Stories - Blogs

By Deb Nofziger

Culturally, we use the word “tired” to describe so much – being mentally and/or emotionally drained, overly frustrated, sleep deprived, physically spent, and lots of stuff in between. These states are not caused or cured by the same thing. But they can basically be divided into two categories – tiredness/sleepiness and fatigue. This difference isn’t something I had ever considered before being diagnosed with Multiple Sclerosis. But, given one of my most prevalent symptoms of MS is fatigue, I soon realized just how much people don’t understand the difference.

What is the difference? Google’s AI overview actually does a good job describing this: “Tiredness makes you feel sleepy; fatigue makes you feel worn out but not necessarily sleepy.” Tiredness/sleepiness is a temporary state fixed by sleep. Fatigue is a more long-lasting feeling of being drained that persists despite adequate sleep/rest. I explain fatigue as that feeling you get after a cross-country airplane trip, or better yet, transatlantic. You get to your final destination and collapse on the hotel bed, absolutely drained. But you aren’t tired, so you aren’t going to sleep. You simply have absolutely no energy left. Regardless of how much the kids want to go to the Disneyland park immediately upon arrival, they are out of luck!

To make matters more interesting in my particular case, insomnia is also widely prevalent with MS. A recent meta-analysis looking at sleep disorders and MS showed that 1 in 2 adults with MS endorsed poor sleep quality and 1 in 5 were diagnosed with insomnia. Many other neurological disorders, from MS to long covid, have higher rates of insomnia along with fatigue. I am one of the unlucky ones who now has both – random bouts of insomnia and chronic, debilitating fatigue. How do I stay functional through the fatigue? A steady dose of stimulants – something that can rapidly mess with my sleep and trigger insomnia. It is an interesting balance that I manage. And a common conundrum faced by many who have both.

As a clinical psychologist, and one of the CDP instructors who teaches CBT for Insomnia, I find it interesting how little we talk about what to do for patients who experience fatigue but not insomnia, or for patients who have both. Many of our patients have underlying medical conditions, from MS to long Covid, and their fatigue and/or tiredness is enmeshed with their other behavioral health symptoms, like depression and anxiety.

I think a starting place for all of us is making sure our assessment is correct in that we are assessing for both tiredness/sleepiness and fatigue and recognizing that these can be caused by different things. The usual tools can be confusing for this. For example, the Insomnia Severity Index (ISI) is widely used to screen for sleep problems and it does a good job for this in general. But it depends on the patient understanding the difference between sleepiness and fatigue, and I’ve found many do not. If I feel drained of energy all day, I might assume that is because my sleep is not good. That would lead me to answer questions on the ISI, or other measures, expressing my dissatisfaction with my sleep and how much that is impairing my life. This, in turn, could lead to a treatment plan including treatment for insomnia, which isn’t going to help general fatigue at all if it is linked to a medical condition.

It becomes even more convoluted when a patient experiences both insomnia and fatigue. Although they aren’t the same thing, the feelings they produce in the body are incredibly similar, if not the same in some cases. So how do we identify which symptom descriptions are linked more to which problem? For example, if I am physically fatigued I feel similar to when I haven’t slept much – weaker and slower in general. If my insomnia is treated and I sleep well, I am still not going to feel rested upon awakening due to my underlying chronic fatigue, so how do I know if I’m “doing better” with better sleep? I’ve noticed that interview forms often mix fatigue and tiredness questions together which is not helpful. True, fatigue can be a symptom of tiredness, but it can also be something completely separate.

The initial challenge for providers is to educate patients on the difference between tiredness and fatigue while they are in the assessment stage and ensure our assessment tools help us distinguish between the two. We must also ask about any medical conditions that may lead to either or both. It is a challenge. Even as a provider with both fatigue and periodic insomnia, I sometimes find it hard to distinguish with patients. But I think the key is to remember this basic truth – if you are tired/sleepy, you can actually lie down and go to sleep. Your sleep drive is high. If you are only fatigued, you won’t sleep because it isn’t linked to your sleep drive.

Treatment planning for tiredness, fatigue, or both is beyond the space I have for this particular blog. But basically, we know that the plan for tiredness will depend on the specific sleep disorder identified (happily, we have good treatments for many of these). The same is true for fatigue – the treatment is going to depend on the underlying medical condition. That is where it gets tricky because there are so many different conditions involved. Medication is a common answer. Behavioral treatments aimed at maximizing and strategically using available energy are also generally used. Unfortunately, behavioral treatments for fatigue are not widely taught or even known about by general providers. They are more utilized within health specialty clinics.

Our starting point is assessment. You have no idea how much rapport and credibility a provider instantly gets from me when, on their own, they acknowledge that tiredness and fatigue are two different things. I instantly think “yes, they get it!” More often than not, however, I am educating my providers on the difference. So please, be sure you are acknowledging the difference. If your patients don’t seem to understand, educate them. That way both of you can explore how to best approach treatment and how to have realistic expectations on treatment outcomes.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Debra Nofziger, Psy.D., is a Senior Military Behavioral Health Psychologist and certified Cognitive Processing Therapy Trainer with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

CITATION:
Zeng, X., Dorstyn, D. S., Edwards, G., & Kneebone, I. (2023). The prevalence of insomnia in multiple sclerosis: A meta-analysis. Sleep Medicine Reviews, 72, Article 101842.
https://doi.org/10.1016/j.smrv.2023.101842

Hopefully, the title hooked you. Now what am I talking about? And who is “us”? The “what” is conversations about firearm safety and suicide prevention. The “who” is healthcare providers. Let’s take a few steps back…

Why Firearm Safety Matters in Suicide Prevention

In the U.S. and military communities, firearms play a uniquely lethal role in suicide:

• Civilian deaths: Firearms account for ~52% of suicide deaths (Centers for Disease Control; CDC, 2024).
• Active-duty service members (Department of Defense; DOD, 2024):
  Firearms: 7% of attempts → 65% of deaths
  Self-poisoning (overdose): 54% of attempts →< 6% of deaths
• Lethality gap:
  Self-poisoning: ~2 in 10 attempts end in death
  Firearms: ~9 in 10 attempts end in death (Johns Hopkins, 2023; Wintemute, 2019)

Takeaway: Even if the number of attempts doesn’t change, reducing firearm access can save lives because of how disproportionately lethal firearms are. That points us toward one of the most effective interventions: Lethal Means Safety Counseling (LMSC), which includes conversations about firearm safety and suicide prevention.

The Trust Problem

If patients don’t trust us to have these conversations, we miss out on one of the most effective strategies to prevent suicide.

How do we know trust is low? Anestis and colleagues (2021) examined which messengers are most and least trusted when discussing firearms and suicide. The most trusted groups: military personnel, veterans, and law enforcement—all communities with firearm experience.

And who’s at the bottom? Us! Physicians and other medical professionals—just above casual acquaintances and celebrities. This pattern was consistent across gender, race, and gun ownership status. In other words, we are only slightly more trusted than strangers!

Other studies echo the theme. For example, half of firearm owners report believing it is never appropriate for healthcare providers to discuss firearms (Betz et al., 2016).

So—what’s driving this lack of trust, and what can we do about it? While we don’t have data explicitly outlining the pitfalls, we can extrapolate based on what we know about how trust is built (and eroded) in interactions with healthcare providers. Below four missteps are illustrated along with how to turn each into a rapport building-conversation.

Common Patient Concerns (and Solutions)

“We judge their choices.”→ Biased Communication
Example: A military spouse shares concerns about being alone at home with her children during her husband’s upcoming deployment. She’s excited about a firearm safety class she just completed in preparation for buying a gun for protection. The provider’s eyes widen:

“Wait—you have three small children at home. Is that really safe?”

Problem: The provider is communicating a biased opinion about gun owners with small children. This assumes that the patient is being inherently unsafe when she is actually discussing proactive steps to be a safe firearm owner. The message the patient hears:

“You are a bad parent; you are putting your children in danger!”

Trust building response:
“I’m glad you’re looking forward to the class. Firearm safety is especially important with kids in the home, and it sounds like you’ve already taken proactive steps, that’s awesome. So when does your husband deploy…”

Solution: Be culturally responsive. As providers, it is our responsibility to not only respect the values and norms of a patient’s culture (e.g., military-connected), but to also be aware of the intersectionality of different aspects of a patient’s identity (e.g., parent, military spouse, gunowner, etc.) within that culture.

Issue: “We want to take their guns.”→ Ignore Patient Autonomy
Example: A service member discloses suicidal thoughts without intent or plan. The provider responds:

“That’s concerning. You’ll need to turn your weapon over to your command until we can be sure you are safe.”

Problem: While reducing access to lethal means may ultimately be necessary, the unilateral approach strips autonomy and discourages future disclosure.

Trust building response:

“Sounds like things have been really difficult. Can you tell me more about what led to those thoughts? From there, we can come up with a plan together to help keep you safe during those tough times.”

Solution: Balance patient safety and autonomy. Conduct a thorough risk assessment with curiosity and concern, then collaborate to develop a Safety Plan with strategies the patient is both willing and able to implement.

Issue: “We don’t know anything about firearms.”→ Lack of Competence
Example: In 2015, an E3 preparing for a Permanent Change of Station (i.e., moving to a new duty station) worries about storing her firearms. The provider shrugs:

“That’s easy, just buy a gun safe and ship it with your household goods” (HHG).

Problem: This overlooks the cost of the safe itself, its weight, and the fact that safes counted against HHG weight allowances at the time—revealing a notable knowledge gap.

Trust building response:

“Let’s start with how you’re storing your firearms now. Then we can check local laws at your new duty station and figure out the best plan together.”

Solution: Be informed. You don’t need to be a firearm expert, but you do need to demonstrate competence in firearm safety basics and relevant regulations/laws. Online courses (e.g., virtual firearm safety, LMSC training) can help, as can familiarity with DoD and local regulations.

Issue: “We act like know-it-alls.”→ Maintaining the Knowledge Gap
Example: A patient says:

“I’m thinking of buying a gun. I don’t feel safe at home.”

The provider replies:

“Trust me, that’s not the way to stay safe. Get a dog instead.”

Problem: The asymmetrical tone conveys “I know better than you—this isn’t up for debate.” It dismisses the patient’s concern, weakens rapport, and misses an opportunity to bridge the knowledge gap between provider and patient.

Trust building response:
Provider:

“No one likes feeling unsafe at home. What’s making you feel this way?”

Patient:

“There’s been more crime in my neighborhood.”

Provider:

“I understand. I do worry about relying on firearms for protection, because research shows that having a gun at home can nearly triple the risk of homicide. Other security options can reduce break-ins without increasing risk of harm. Would you be open to talking through some of those together?”

Solution: Ask, explain, collaborate. Gather more information, share rationale, and avoid assumptions. Provide explanations to reduce asymmetry.

Closing Thought

We may not earn everyone’s trust overnight. But we can take steps—through cultural responsiveness, collaboration, competence, and transparency—to be worthy of the trust we are striving for. The trust it takes to save lives.

Resources
CALM (Counseling on Access to Lethal Means): Training offered by the Suicide Prevention Resource Center that provides information on how to have a discussion with patients about lethal means. (https://sprc.org/online-library/calm-counseling-on-access-to-lethal-means/)

Means Matter: Website from the Harvard T. H. Chan School of Public Health with resources & trainings on the topic of reducing suicidal individuals’ access to lethal means. (https://www.hsph.harvard.edu/means-matter/)

Defense Suicide Prevention Office: Webpage with a suite of lethal means safety tools. (https://www.dspo.mil/Home/Tools/Resource-Library/Lethal-Means-Safety/)

VA Lethal Means Safety & Suicide Prevention: Webpage with resources, including information on secure firearm storage. (https://www.va.gov/reach/lethal-means/)

“Let’s Talk about Your Guns” Podcast: A series of podcasts from the Center for the Study of Traumatic Stress about gun safety. (https://www.cstsonline.org/suicide-prevention-program/podcasts/lets-talk-about-your-guns)

Project Child Safe: Firearm safety education program that offers free educational resources, including gun locks. (https://projectchildsafe.org)

Stanford University - Clinicians and Firearms 2.0: This CME/CE course equips clinicians with the knowledge and communication strategies needed to discuss firearm injury prevention with patients effectively. It includes modules on firearm basics and safe storage. (https://online.stanford.edu/courses/som-ycme0051-clinicians-and-firearms-20-curriculum-firearm-injury-prevention-medical?utm_source=chatgpt.com)

BulletPoints Project - Preventing Firearm Injury: A free, self-paced course that takes about 60 minutes to complete. It provides an opportunity for participants to earn one Continuing Education (CE) credit. The course covers firearm injury prevention and safe storage options. (https://continuingeducation.bulletpointsproject.org/courses/preventing-firearm-injury/)

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Adria Williams, Ph.D., is a Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) with the Uniformed Services University of the Health Sciences. Dr. Williams is a suicide prevention subject matter expert and trainer.

References

• Anestis, M. D., Bond, A. E., Bryan, C. J., Bryan, A. O., & Knox, K. L. (2021). Trust in healthcare providers and willingness to discuss firearm safety: Results from a national survey. Preventive Medicine, 145, 106445. https://doi.org/10.1016/j.ypmed.2020.106445
• Betz, M. E., Miller, M., Barber, C., Beaty, B., & Miller, I. (2016). Lethal means access and assessment among suicidal emergency department patients. Depression and Anxiety, 33(6), 502–511. https://doi.org/10.1002/da.22486
• Centers for Disease Control and Prevention (CDC). (2024). Suicide mortality in the United States, 2000–2022. NCHS Data Brief, No. 509. https://www.cdc.gov/nchs/products/databriefs/db509.htm
• U.S. Department of Defense, Defense Suicide Prevention Office. (2024, November 14). Annual Report on Suicide in the Military, Calendar Year 2023 (ARSM CY 2023). https://www.dspo.mil/Portals/113/2024/documents/annual_report/ARSM_CY23_final_508c.pdf
• Wintemute, G. J. (2019). The epidemiology of firearm violence in the twenty-first century United States. Annual Review of Public Health, 40, 5–19. https://doi.org/10.1146/annurev-publhealth-031914-122535

by Ariana Bazzi and Jaime Rodden

An exciting collaboration between the Uniformed Services University Department of Medical and Clinical Psychology and the Center for Deployment Psychology is investigating a standardized training program for eating disorders within military settings.

About the PreparED Study
The PreparED study centers around a standardized online educational program on eating disorders. The 85 minute course consists of an introduction by Dr. Tanofsky-Kraff describing the unique presentation of eating disorders in military populations followed by modules on Assessment, Medical Complications, Treatment, and Military-Relevant Considerations. Ultimately, the PreparED curriculum is intended to give healthcare providers a clear and comprehensive all-in-one guide to understanding eating disorders in the military.

The Big Picture
Eating disorders appear at higher rates among our service members compared to the general population. This increased vulnerability is often tied to the unique pressures of military life, such as constant exposure to high-stress environments, and the significant impact of conditions including, but not limited to posttraumatic stress disorder and major depressive disorder. To address this critical need, Columbia University Medical Center, has developed a publicly accessible online course and partnered with our study team to train military providers. The curriculum is designed specifically for future healthcare professionals, including students and trainees to provide them with the essential knowledge and practical tools to better understand, identify, and support individuals affected by eating disorders, ultimately aiming to improve care for those who have served.

Participant Eligibility and Study Activities
Medical providers and providers from the Defense Health Agency (DHA) serving as a primary care or other direct care provider to military-connected patients are eligible to participate in the study. Participants are provided with a SurveyMonkey link to take a pre-survey. Participants are then asked to complete the online 70 minute course and post-course survey within a month from completion of the pre-survey.

Get Involved
For more information about the PreparED study, visit our website at https://deploymentpsych.org/Eating-Disorders-Base or reach out to the Research Assistant Ariana at Ariana.Bazzi.ctr@usuhs.edu To participate in the study, review the informed consent document: https://www.surveymonkey.com/r/QXSTNH2

In our suicide prevention trainings at CDP, we discuss current theories of suicide risk, specifically emphasizing those of that fall within the “ideation-to-action framework” (Klonsky & May, 2016). This framework posits that the development of suicidal ideation and the progression from ideation to suicide attempts are distinct processes with distinct explanations. In conjunction with this discussion, we also spend a substantial amount of time talking about risk and protective factors, both in the civilian population and among military-connected individuals.

Given that context, I wanted to share an article I recently read that looks specifically at risk and protective factors distinguishing U.S. veterans with a history of suicidal ideation from those who have made a suicide attempt (Cenker & Zalta, 2025). These authors analyzed data from 620 veterans with a history of suicidal ideation or attempts; this sample was drawn from the Military Health and Well-Being Project, a national survey of approximately 1,500 post-Vietnam U.S. veterans.

Cenker and Zalta found that veterans with a history of past attempts reported higher levels of moral injury, loneliness, and substance use than those who had only experienced suicidal ideation. In addition, those with past attempts also reported lower levels of meaning and purpose in life and lower levels of social support. These findings suggest that the transition from suicidal thoughts to behavior in veterans is associated with more intense psychosocial stressors alongside fewer protective resources.

Last year during Suicide Prevention month, I wrote a blog looking at suicide risk during the transition from military to civilian life. Data has shown that the first year following separation from the military is one of increased risk for Service members (U.S. Department of Veterans Affairs, 2024). During this period of transition, Service members may experience disruptions of personal identity, including a sharp contrast between military and civilian values (Sokol, et al., 2021). They may also experience disruptions to social connections during this period of transition, including a simultaneous loss of military social connections and difficulty rebuilding civilian ones (Sokol, et al., 2021). Thus, Cenker and Zalta’s (2025) findings, which highlight the protective nature of both meaning and purpose in life and social support, provide additional evidence that these are particularly salient clinical targets in this population.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Marjorie Weinstock, Ph.D., is a counseling psychologist currently serving as an Associate Director at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

References:
Cenker, D. P., & Zalto, A. K. (2025). Risk and protective factors that distinguish United States
veterans with a history of suicidal ideation and suicide attempt. Journal of Psychiatric
Research, 188, 126-132. https://doi.org/10.1016/j.jpsychires.2025.05.059
Klonsky, D.E., May, A. M., & Saffer, B. Y. (2016). Suicide, suicide attempts, and suicidal
ideation. Annual Review of Clinical Psychology, 12(1), 307-330.
https://doi.org/10.1146/annurev-clinpsy-021815-093204
Sokol, Y., Gromatsky, M., Edwards, E. R., Greene, A. L., Geraci, J. C., Harris, R. E., & Goodman,
M. (2021). The deadly gap: Understanding suicide among veterans transitioning out of
the military. Psychiatric Research, 300, 113875.
https://doi.org/10.1016/j.psychres.2021.113875
U.S. Department of Veterans Affairs, Office of Suicide Prevention. (2024). 2024 National
veteran suicide prevention annual report: Part 2 of 2: Report findings.
https://www.mentalhealth.va.gov/docs/data-sheets/2024/2024-Annual-Report-Part-2-
of-2_508.pdf

13x
The factor by which "(o)lder men are more likely to die by firearm suicide compared with older women," according to an article in JAMA Network Open -- Sex Differences in Trends of Firearm Suicide Among Older Adults, 2014 to 2023. "However," the article points out, "female gun ownership has surged in recent years, with nearly one-half of all new gun owners being women.

This cross-sectional study reveals an increasing trend of suicide deaths by firearm among older women. Although the firearm suicide rate and FS/S ratio among older men remain high, the trend among older women may have important long-term implications. The proportion of older adults in the US is projected to grow from 17.3% in 2022 to 21.6% by 2040, with women accounting for a larger share of this increase. Research has shown a steady decline in the FS/S ratio among women from 41.5% in 1991 to 35.3% in 2013. However, our analysis of data from 2014 to 2023 highlights a significant upward trend among older women, suggesting a narrowing sex gap in firearm suicide that aligns with changes in gun ownership demographics.

Suicide is a serious public health concern, especially for young adults who have experienced trauma. While a history of trauma can be a risk factor for suicide, we have a limited understanding of the specific mechanisms through which stress responses might contribute to this heightened risk. In a recent study, my colleagues and I investigated the links between suicidal thoughts and behaviors, and how individuals respond emotionally and physically to stress. Ninety-four undergraduate students (Mage​=20.30; 61.7% women) were selected based on their lifetime exposure to at least one DSM-5 defined traumatic event.

The Study’s Approach
To see how participants reacted to stress, they completed two different breathing tasks in a controlled experimental lab setting:

• Voluntary Hyperventilation Challenge: This task involved breathing rapidly for three minutes. It’s designed to bring on physical sensations like fast heart rate or feeling lightheaded, which can sometimes trigger memories of traumatic events.
• Normal Breathing Control Task: This was a comparison task, similar in setup but with a regular calm breathing rate.

Throughout these tasks, we measured:

• Suicidal Thoughts and Behaviors: Participants completed the Suicide Behaviors Questionnaire-Revised at baseline, which asks about four key areas: suicidal thoughts or attempts over their lifetime, suicidal thoughts in the past year, threatening a suicide attempt, and how likely they felt to attempt suicide in the future.
• Self-Reported Psychological and Physiological Reactivity: Participants rated how they felt emotionally (e.g., helplessness, feeling unreal, urge to escape) and physically (e.g., tingling, shaking, chest pain, lightheadedness) using a part of the Panic Attack Questionnaire before and after each breathing task. We created a single "stress score" for each participant by subtracting their symptom change during the normal breathing task from their symptom change during the fast breathing task.

Key Findings

• Emotional Reactions Linked to Suicidal Ideation: Past-year suicidal ideation was significantly and positively associated with self-reported psychological reactivity to stress. This suggests that individuals reporting suicidal thoughts in the past year experienced a greater emotional distress during the stress-inducing task.
• No Clear Link to Physical Reactions: None of the four dimensions of suicidality, including past-year ideation, were associated with self-reported physiological reactivity to stress.

Conclusions
Our findings suggest that more recent suicidal ideation might be uniquely connected to a heightened emotional response to stress. This could be explained by how individuals with current suicidal thoughts interpret or “appraise” stressful events, perhaps seeing them as more threatening or overwhelming. Interestingly, we didn't see a link between suicidal thoughts or behaviors and self-reported physical reactions to stress. One possible explanation for this is a growing body of research on interoceptive deficits, which suggests that people at risk for suicide might have a reduced awareness of their body's internal signals. For example, their heart rate could rise during stress, but they might not consciously notice it as others would. This disconnect between mind and body could be even more pronounced in those who have previously attempted suicide. However, more research is needed, especially using physiological measures to more objectively assess an individual's stress response.

Clinical Takeaway
Understanding these specific patterns of reactivity can aid in developing more focused and effective support programs. This may include prioritizing the assessment of recent suicidal ideation and exploring how individuals interpret everyday stressors. These insights can directly inform treatment planning and guide the selection and development of interventions aimed at improving coping and reducing distress. It also highlights a growing interest in strategies that help people connect with and understand their bodily sensations, especially when they have a reduced awareness of these signals.

Limitations
It’s important to note that this study, like all research, has its limitations. The study's findings are based on self-reported physical reactions, and suicidal thoughts and behaviors were assessed at baseline rather than as a component of the experimental design. The study's population was also limited to trauma-exposed undergraduate students with recent alcohol use (part of a larger project). These characteristics are important to keep in mind when thinking about how broadly these findings apply to other populations.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Linda Thompson, Ph.D., is a Postdoctoral Fellow with the Center for Deployment Psychology. Dr. Thompson earned her doctorate in Behavioral Science, Psychology from the University of North Texas and a master’s degree in Psychology from San Diego State University.

Study Reference
Thompson, L. M., Kearns, N. T., Rafiuddin, H. S., Contractor, A. A., & Blumenthal, H. (2025).
Associations of Suicidal Thoughts and Behaviors with Psychological and Physiological
Reactivity to a Hyperventilation Task Among Trauma-Exposed Emerging Adults.
Archives of Suicide Research, 1–16. https://doi.org/10.1080/13811118.2025.2524414

Additional References
Kearns, N. T., Blumenthal, H., Contractor, A. A., Guillot, C. R., & Rafiuddin, H. (2021). Effects of
bodily arousal on desire to drink alcohol among trauma-exposed college students.
Alcohol, 96, 15–25. https://doi.org/10.1016/j.alcohol.2021.07.002
Norton, G. R., Harrison, B., Hauch, J., & Rhodes, L. (1985). Characteristics of people with
infrequent panic attacks. Journal of Abnormal Psychology, 94(2), 216–221.
https://doi.org/10.1037//0021-843x.94.2.216
Osman, A., Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kopper, B. A., & Barrios, F. X. (2001).
The Suicidal Behaviors Questionnaire-Revised (SBQ-R): Validation with clinical and
nonclinical samples. Assessment, 8(4), 443–454.
https://doi.org/10.1177/107319110100800409

Dr. Rita Brock recently shared her thoughts on moral distress and injury and COVID-19 frontline workers with me. I’m pleased to share parts of that conversation with you below. Dr. Brock has spent much of her career as an academic in philosophy and religion, obtaining her doctorate in this field in 1988. Her interests turned toward moral injury after a 2009 article by Dr. Brett Litz (see below for article citation) “grabbed me and wouldn’t let me go.” As a person who works in religion, ethics, and psychology, she understood how religions address human suffering and believed she could add to the conversation behavioral scientists were beginning to have around moral distress and injury.

Many are familiar with the 2012 book “Soul Repair: Recovering from Moral Injury after War” (citation below), coauthored by Dr. Brock. Besides this and other publications, she was also the Founding Director of the Soul Repair Center at Brite Divinity School, Texas Christian University. In 2017, Dr. Brock began her current position at the Shay Moral Injury Center at Volunteers of America which focuses on developing and implementing moral injury programs at a national level. While the Center initially focused on programs for military veterans, since COVID-19 it has expanded to developing support for front-line workers struggling with moral challenges during this devastating time.

In 2017, the Shay Moral Injury Center developed an evidence-based program called Resilience Strength Training (RST) for combat veterans struggling with moral injury. RST was developed as a peer-facilitated program to decrease the stigma many veterans have about seeking care. Results from a recently published study on the efficacy of this program show it helps veterans working through moral injury, specifically through the development of self-calming strategies, communication skills, self-esteem, improved sleep, and peer-supported communities. For more details about this study (Barth, 2020) and program, go to this link:https://doi.org/10.21061/jvs.v6i2.199. Currently, the Center is adapting the 50-hour program to an online 25-30 hour program. Since the pandemic, they have also adapted elements of the program to a one-hour online support program for COVID-19 care workers, keeping the peer-facilitated model, with the name Resilience Strength Time (ReST).

I asked Dr. Brock what about the peer-facilitated group model she believes is so effective with moral injury. One key healing agent she identified was the validation that occurs when people hear from others experiencing similar situations. People learn they are not alone with their moral struggle. Peer facilitators understand what the person is going through, thus reducing stigma and fear of judgment.

Dr. Brock added that when people have the chance to support others, it allows compassion for self to kick in: “It transforms what you think of yourself to listen to and support others.” Dr. Brock’s experience with the power of peer support groups goes back to her time with a summer camp program for high schoolers dealing with intense issues, ranging from violent crimes to family abuse. Through her work with them, she witnessed the profound impact of group leaders allowing themselves to be vulnerable and share their own experiences – “in that moment, they were peers… people who understood and (the high schoolers) could connect to.” It was this powerful connection that Dr. Brock wanted to carry forward to peer-facilitated moral injury programs to help reduce stigma and allow people to share their pain and work toward healing.

How is the Shay Moral Injury Center adjusting the RST program for COVID-19 ReST for healthcare workers?
The healthcare profession clinicians, especially nursing, have been writing about moral distress and injury faced by professionals for years. Based on this and her own experiences, Dr. Brock knew that the pandemic would place healthcare and frontline workers into a crisis situation around moral injury. In ICU settings, witnessing death is not an uncommon experience. With COVID-19, however, there is much more death, providers are more limited in how they can help, and the patients are dying alone instead of with loved ones. There are more morally challenging decisions and emotional pain involved.

Indeed, Dr. Brock believes these circumstances are similar to what medical providers face in a warzone, something most civilian providers have never experienced. Dr. Brock agrees with other moral injury specialists regarding the importance of people opening up to others who share their moral challenges. People need to talk about their pain and distress in order to process it. To help these providers, Dr. Brock and her colleagues adapted what they learned working with Veterans and the RST program. They started with peer facilitators from the existing veteran RST program and offered open-format online one-hour support group sessions that any COVID-19 healthcare worker could attend.

As the program progressed, the Center trained others to be the peer facilitators guiding the group discussions. These groups are confidential and open to the public. Participants can attend as often as they wish. To access ReST, participants just need register through the VOA/ReST website. Once registered, they are provided with a schedule of upcoming sessions which they can sign up for. Although attendance in prescheduled groups means membership will change session-to-session, arrangements can be made for the same group of people to meet each time. On Mondays at 7 pm Eastern, there is a specific group for military veterans co-facilitated by veterans.

What do you think and hope we will learn from the pandemic about moral injury/distress?
I found Dr. Brock’s answer to this question direct and profound. After reflection, she shared the following hopes for what our society will learn:

• “Moral injury isn’t limited to military Veterans.” Although we have known this, we have been unable in our society to validate this with research until recently.
• “(Moral injury) is also a collective experience.” As a society, we will need to deal with it at larger levels, both in how we recognize it and help those experiencing it.
• “How people feel morally about themselves and society affects how people behave.” This is true both when people are left to continue questioning morality and when they are able to come to an understanding that leaves their morals more strengthened.
• “Moral Injury is the excruciating remnant of goodness in people…. You can’t have a moral injury without a moral conscience.” The struggle with devastating experiences can lead a person to judge themselves or others as bad. In fact, though, to make that judgment requires an inner awareness of what is good, and that awareness is important to recovery.

What do you wish behavioral health providers understood about moral injury?
"Moral emotions like guilt, shame, remorse, humiliation, frustration, anger and all of those feelings are NOT pathologies…. They are appropriate emotions given (a person’s) experience and morals.” I discussed this truth with Dr. Brock, as well as my own observations with military patients both during and after combat deployments. I have been amazed with how many patients, let alone providers, think that the pain and grief involved with moral distress is something that needs to be “fixed” or that these emotions are evidence that there is something wrong with them. The truth is that experiencing moral distress when faced with a morally challenging situation is proof of a person’s goodness and humanity, not proof that they are “broken.” They are suffering, which is why they are feeling pain, and they suffer because they are good.

In our discussion, Dr. Brock shared her own observations of this, acknowledging that although moral injury is understandable, it becomes problematic when it takes over one’s life. Working through a moral injury does not mean the painful emotions are gone. Instead, the intensity of the emotional pain is mitigated so it no longer is in control, and the moral injury becomes a source of information about the self and situations as well as a motivator for action. There will still be emotional pain about the past, but the load is such that it can be carried. As Dr. Brock explains, “You have to sit in the fire until you burn clean (a metaphor she got from Jaques Verduin who works with men in San Quentin Prison). Then you can examine it and learn how it will inform your life.”

Since our interview, I’ve reflected a lot on that last idea and quote about sitting in the fierce fire until you burn clean of it. With the support of others who understand, it is incredible what people can and do get through. My personal fear of a ‘worst outcome’ situation is that those amazing frontline workers doing intensely difficult and emotionally painful, yet necessary, jobs feel they are alone and try to shut down or hide what they are going through. Or, worse yet, they believe they are somehow damaged or “broken” because of how their own morality causes them to feel.

Then there is the second part of Dr. Brock’s statement, that after you burn clean you can sit back, examine what happened and put what you learn into some type of proactive movement in your life, either personally or on a societal level. My sincerest hope is that our world will be able to do just that once this pandemic is under better control, if not over. I am so grateful for support programs like those offered by Dr. Brock and the peer specialists at the Shay Moral Injury Center. I believe they are exactly right about us needing to encourage people to talk about their pain with peers and professionals who can understand and support them through it. In my opinion, the ReST program and other support services like it are what our world needs right now to make sure we come out clean and wiser once this is all over.

More information about the VOA Shay Moral Injury Center and ReST programs can be found at https://www.voa.org/moral-injury-war-inside.

Interviews with Dr. Brock about her work can be found online. These include:

• From WebMD – “COVID-19 and the Threat of Moral Injury” recorded on 22 October 2020. https://www.webmd.com/coronavirus-in-context/video/rita-nakashima-brock
• Dr. Brock and ReST Facilitators explaining program: https://www.youtube.com/watch?v=P4ec31tYxFE
• From Volunteers of America, short video explaining moral injury within combat veterans: https://www.voa.org/the-war-inside
• Recorded webinar “Moral Resiliency for Medical Workers During COVID-19” produced by Volunteers of America:
  • Full webinar (2 hours): https://www.youtube.com/watch?v=wFF8wx6Oqc&list=PLOp3UYSMYFviGIrPLKa_xA_qV7xKUmD_h&index=3&t=2s
  • Shortened edited version (50 minutes): https://www.youtube.com/watch?v=wFF-8wx6Oqc&list=PLOp3UYSMYFviGIrPLKa_xA_qV7xKUmD_h&index=3&t=9s

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Rita Nakashima Brock, Rel.M., M.A., Ph.D., Rev. Dr. Rita Brock is Senior Vice President and Director of the Shay Moral Injury Center at the Volunteers of America.

Debra Nofziger, Psy.D.,is a Senior Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Nofziger is currently located at the Brooke Army Medical Center, TX.

References and Resources:
Barth, T. M., Lord, C. G., Thakkar, V. J., & Brock, R. N. (2020). Effects of Resilience Strength Training on Constructs Associated with Moral Injury among Veterans. Journal of Veterans Studies, 6(2), 101–113. https://doi.org/10.21061/jvs.v6i2.199
Litz B.T., Stein N., Delaney E., Lebowitz L., Nash W.P., Silva C., & Maguen S. (2009). Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. https://doi.org/10.1016/j.cpr.2009.07.003
Brock, R. N. & Lettini, G. (2013). Soul repair: Recovering from moral injury after war. Beacon Press.

The last blog entry on in vivo exposure discussed some strategies to help your client be better prepared to benefit from in vivo exposure. This week I want to talk about “post-in vivo processing”. We don’t usually emphasize processing when we discuss in vivo exposure but it is just as important for in vivo exercises as it is for imaginal exposure. Post-in vivo processing is not merely a check the box activity to make sure the homework was done but instead is an opportunity for a client to reflect on the homework assignment, and extract some understanding or insight from the experience of facing fear and living to tell about it. For some, this may simply mean concluding, “It was easier than I expected it to be!” But for others, it may mean evaluating and dismantling some strongly held beliefs that have kept them “safe” from harm for a long time. Give example?

Many clients will walk into session with in vivo worksheets in hand, ready to discuss their experiences, so I like to ask about homework in the beginning of the session to capitalize on what they just accomplished. Some of my colleagues like to save the processing of homework for the end of session so they can get to the imaginal exposure immediately. Either way can be effective but make sure your client knows what to expect so they don’t feel ignored if you don’t ask about the homework right away. One strategy might be to briefly review the homework at the start of session to provide reinforcement but save the processing and problem solving until the end of session.

Did your client do the assignment?

Begin by finding out whether your client actually did the assignment. If avoidance or a complicated life is preventing him/her from doing the homework, you will spend your processing time trouble shooting those barriers. We could (and maybe we will) write an entire post on troubleshooting barriers, but for now let’s assume that your client did the in vivo assignment and is ready to show you the worksheet. This is your first piece of information to process. What does it tell you?

The most important thing it says is that your client took a step toward getting her life back. She had enough confidence in the treatment, in you, and in herself that she attempted, and perhaps successfully completed the assignment. This is accomplishment number one! She faced her fear!

Lead with the positive

While this accomplishment is certainly rewarding in and of itself, a simple word of praise at this point, from you, will not be wasted.

“You did it!”

“You took the first step. Good for you.”

So perhaps she didn’t stay in the situation as long as you had hoped. Maybe she didn’t do everything exactly as planned, but remember successive approximations from graduate school? This is the process of rewarding small movements or approximations of the target behavior, until the behavior is executed successfully. Shaping behavior in this way takes a few trials so be patient.

It’s not all good, however There may be some problematic aspects to correct for next time, but go ahead and praise what you honestly and sincerely can. Normalize distress and avoidance, and later, after you have extracted all that you can from what went well, constructively discuss the changes that are needed for the next time.

Praise as corrective information

Praise is emotionally rewarding if it is believable, sincerely given and meaningful to the one being praised. But one of the most important things about leading with a bit of praise for effort in this context is that it informs and corrects. For this purpose, it must be descriptive, specific, and timely. One of the biggest problematic beliefs in PTSD is some version of “I am weak for reacting the way I did (having PTSD),” “I should have been able to handle this by myself, ” or “I am incompetent and everyone knows it.” Your specific praise, as well as comments pointing out the evidence against these beliefs is a clear indication that you don’t buy it. On the contrary, you know the treatment is challenging, you appreciate your client’s courage and determination, and you have confidence that she will be able do it. When your praise is targeted in this way, it is not a mindless pat on the head: it actually is corrective information in action.

Broaden your repertoire

PTSD almost always includes many negative, inaccurate thoughts about the self. I hope you take every opportunity to specifically and descriptively comment on, and praise any thought and behavior of your client that disconfirms his deeply held negative beliefs. This means you are going to be praising her a lot, so increase your repertoire of responses. “Great job” is nice to hear a few times, but it starts to sound rote and insincere after awhile. Use humor where it is appropriate.. Tie your praise to the evidence. Look for ways to weave praise into your discussion without fanfare. For example, sometimes a simple statement of fact is a sneaky way to get in some covert praise on the fly.

“You are really working hard.”

“You did it.”

“I can see that you are putting a lot of effort into your homework.”

“You took that one on like nobody’s business.”

“You were like the energizer bunny this week!”

Review the Data

The data begins with the in vivo exposure recording form itself. This form is your client’s experience on paper, and when you go over it together, he can use the recorded data to recall what the experience was like in detail. Most forms use numbers – SUDs - to track the experience, but it is equally valid to use a graphical representation that gives a visual picture, if that is more meaningful for your client. Review the worksheet to get clues about where you might need to focus the discussion. For example, the SUDs data tell you how difficult the assignment was and whether it got easier, or remained distressing throughout the exercise. The number of repetitions tells you about your client’s enthusiasm, commitment to the process, and perhaps something about barriers to doing the treatment, if there are only a few or no repetitions. Perhaps there are notes on the form as well, telling you about your client’s reactions in the moment. Even a sparsely completed form is a clue for follow-up.

Let the client do the talking

While you are reviewing this rich data, resist the urge to open your mouth and start talking, unless you are going to offer praise, or clarify something you don’t understand. Instead gather the data from your client before you start offering your wisdom. Get her impressions of the experience before offering your own. You can use open-ended questions like these:

“How was this experience for you?”

“Did you learn anything new?

“Were your fears confirmed?”

“What are your thoughts?”

“What do you make of the numbers?”

“Was it as bad as you thought?”

“What kept you going? Why were you able to hang in there?”

Normalize PTSD related distress and avoidance

Chances are, even if the assignment went well, your client had some PTSD related distress or avoidance along the way. This is expected, predicted and should be treated as such. Let her know that this is par for the course. Be empathic and compassionate, but accept, and help your client accept, that distress and avoidance are part of PTSD, and confronting them is a planned part of the treatment. Emphasize the opportunity to test out problematic beliefs about distress, its alleged omnipotence, and your client’s ability to have a satisfying life even if distress is sometimes present.

E.g., “Even though it was distressing to be in such a large crowd, you were pleased to be able to attend the graduation ceremony for your daughter. “

Look for habituation, emphasize tolerance

We are always delighted when we see those SUDs numbers going down during the in vivo exercise and across repetitions of the same exercise, right? Look for it, and if you see it, ask about it. Find out how your client views the decrease. Did it get easier, or did she disengage? Did she use distraction or other safety behaviors, or did she habituate?

If the habituation seems credible, celebrate it, but don’t make it your only measure of success because not all the in vivo assignments will follow this pattern. Though some patients successfully habituate to everything on their hierarchy, others do not, and they get better anyway. Sometimes distress tolerance is as important as habituation. And it is a useful skill to highlight and develop because in the end, there will be more distress in life. Learning to tolerate and move through distressing experiences will give your client another way to take care of herself.

Finally, you get to talk

By now, your client may have worked through her experience with your support, of course, and there is nothing left to say except “great job.” But chances are you have noticed some things your client didn’t, so now is the time to ask more pointed, but still open-ended questions. Help your client deconstruct problematic beliefs by asking for more information about her views versus the new information learned in the in vivo. Look for thoughts and beliefs that maintain symptoms and focus the discussion toward these by asking about experiences during the in vivo and at other times that are contradictory.

E.g., “You say that you don’t have control of your temper, but you were able to be civil even though the clerk was rude to you and you felt very angry about it. What do you make of that?”

Now is the time process the safety behaviors or avoidance that may have interfered with learning. What triggered the avoidance? How did the safety behavior function in the exercise? Did it allow your patient to stay when he otherwise would have escaped? Did it prevent him from experiencing distress? Did it help or prevent him from testing his problematic beliefs? Is he willing to drop the safety behavior for the next assignment? Is he willing to stay longer and test the problematic beliefs that maintain avoidance?

Be patient

Resist the urge to sum it all up in a nice little package. Your client may need to do the exercise a few more times before she can come up with more helpful ways of viewing the situation. Let her have that experience. It will teach her so much more than your possibly brilliant but premature summary could do because it will include the nuances of her own life and her own reactions that you cannot possibly know. So be patient. There are times when you will lead your client more directly, but this is always a second line strategy. Let the more powerful strategy of personal experience have a chance to work first.

Do it again

Once you have sufficiently mined the experience for all that it is worth, it is time to collaborate with you client as you plan the next in vivo exercise. Is there more to learn from this item or has it been sufficiently processed? If it is still difficult, or if there are problematic beliefs or safety behaviors still at play, it is important to continue working on it. Does it need tweaking to get at other aspects of the core fear? Are there new questions that need to be tested? Will the corrective information gleaned from this experience easily generalize to other, similar activities, or do you need to change the context to encourage more generalization?You will be aiming to move up the hierarchy as you progress from session to session, but don’t get married to the original hierarchy. New situations may come up as your client gets more active and engaged with his life. Add those new situations as they arise.

While this may seem like a lot to do in homework review, it doesn’t usually take more than a few minutes, and as you model this approach each session, your client might begin processing on her own, making your job even easier. In the end, as with all your interventions, you are not only working through the traumatic experience, you are teaching your client a set of skills, and an approach to life that will serve him well in the future.

Am I the only one who has a hard time keeping my “pearls of wisdom” to myself so the client has a chance to find their own wisdom?

Am I the only one to discover that my fabulous would-be interpretation of the client’s experience was totally off the mark (whew, glad I kept my mouth shut that time!), when he found his own wisdom a few sessions later?

What have you learned helping people process their experiences in therapy?

Staff Voices: Five Strategies to Fortify Your In Vivo Work