Monday, May 07, 2018

HARVEY and MORAL INJURY by ed cooper

Harvey is a 1950 comedy-drama film based on Mary Chase's play of the same name, directed by Henry Koster, and starring James Stewart and Josephine Hull. The story is about a man whose best friend is a a six-foot, three-and-a-half-inch tall invisible rabbit named Harvey.  Due to his insistence that he has an invisible six foot-tall rabbit for a best friend, a whimsical middle-aged man is thought by his family to be insane - but he may be wiser than anyone knows.

Let us begin with the above facts.  It would help if you have seen either the play or movie, but even if you have not we will use it to explore some issues of modern therapy.  How does one approach helping a person with an invisible best friend?

First,  if the person’s friend isn’t causing any major issues in the person’s life then there is not a need to do anything.  Most people are living their lives based on unprovable assumptions, untruths and world views established on all sorts of sinking and shifting sands.

Second, if one decides to try to help there are some basic principles to follow if you want to use a first-person approach.  (I do not use person-centered because it is so widely used it has become meaningless) The First-Person Approach simply means the person is in charge.  They get to make “I” decisions.  No “we” decisions.  No “third-person” decisions in their “best interest.”  In other words force and coercion is not part of first-person.  That means even if you do not see Harvey you do not say he is not there.  You can say I do not see him because truth is important.

Third, if Harvey is a problem then the goal is not to try to medicate Harvey’s death, but rather to build a trusting relationship so strong with the person that Harvey is no longer needed.

Harvey may be present because of moral injury.  “Moral injury is damage to the soul of the individual. War is one of, but not the only thing that can cause this damage. Abuse, rape, and violence cause the same type of damage. “Soul repair” and “soul wound” are terms already in use by researchers and institutions in the United States who are exploring moral injury and paths to recovery.”

I started with this quote because of the need to understand the full scope of moral injury.  In 1968, I found myself at Fort Jackson, SC starting basic training.  I went to my company commander and told him I wanted to apply for conscientious objector status.  I got six notarized statements about my having been raised on a mission station in Zimbabwe (Rhodesia), Africa and my starting preaching at village churches at thirteen years of age.  In addition the notarized letters testified to my having been the minister of a church in Kentucky before entering the Army.  The company commander did not let my request or papers out of the company area.  He told me he was “going to make my father proud of me.”  I spent an entire cycle and a cycle break and then another eight weeks in the same unit before completing basic training. The “soul wound” is still here and I am almost 70.

Active duty military personnel are subjected to abuse, rape and violence not directly related to war.  Therefore, no one other than the person can know the real cause or causes of moral injury.  No one other than the person can determine the nature or direction of the healing journey needed to restore a shattered soul to some sort of livable balance.  We should not always be talking about folks recovering.  We might consider talking in terms of how to give lifelong support to help folks on the journey they decide to endeavor to travel.

I should define some terms so I am not misunderstood.  I know that biopsychosocial is a term rather well accepted today.  In 1988, I started using the term bio-psycho-social-spiritual to try and point out that some of the mental health discussions were very reductionistic.  There isn’t any disputing that we have a part of us wanting to be rooted in something larger and far beyond ourselves.  Dallas Albert Willard (1935-2013), a philosopher, theologian, minister and author,  defines the soul as what “encompasses and organizes the whole person, interrelating all the other dimensions of the self so that they form one person functioning in a flow of life.”  It does not matter for the purposes of this discussions if I or you think the soul is eternal and given to us by one God.  The only thing that matters here is what the person thinks.

“We live in a culture that has, for centuries now, cultivated the idea that the skeptical person is always smarter than one who believes. You can almost be as stupid as a cabbage as long as you doubt.”  Culture- Hearing God: Developing a Conversational Relationship with God, Dallas Willard

The Veterans Administration needs to ask itself how person-centered the VA approaches to PTSD and moral injury truly are?  I do not intend to make a long drawn out academic argument here, but Prolonged Exposure Therapy and Cognitive Processing Therapy do not seem to meet the criteria of the psychologist who came up with person-centered therapy.  Impact of Killing in War of course would not even be appropriate for all of the moral injury causes listed above.  Adaptive Disclosure  “AD is an experiential exposure-based approach.”

The following is a summary of what one psychologist thinks is needed to create a “climate to be growth promoting.”

“Carl R. Rogers in his book A Way Of Being gives a very simple and clear explanation of what he means when he uses the term person-centered approach.  This is the last in a three part blog series trying to cover the three main conditions that Carl Rogers says must be present to create a “climate to be growth promoting.” (CR)  I highly recommend reading this book.  It was copyrighted in 1980 seven years before his death in 1987.  It shows his development of thought and his call for a more person-centered and humane future.

The first condition is “genuineness, realness, or congruence.”  He says a person wishing to help another must not put up any “professional front or personal facade.”

The second condition is what he called “unconditional positive regard.”  He first says if you want to help facilitate growth, healing and recovery you have to be real and then he adds you have to accept and prize the person you are walking beside just as they are.

The third facilitative condition is “empathic understanding.”

The question becomes how does one acquire an empathic understanding of another person?  It does not occur from matching observed or reported symptoms to a list in DSM-5 and arriving at a diagnosis and then saying I know this person.  He is Ed, Bipolar I.  You also cannot use any profiling techniques to arrive at an empathic understanding of a person.  In fact, the truth be known, you may not even have an empathic understanding of yourself.

To acquire an empathic understanding of a person you must be one of those rare individuals who can listen to another person.  Really listen.  Sometimes it is called active or deep listening.  It cannot be done with your mouth open or your mind elsewhere.  It cannot be done if you are already planning on how to fix the person you are listening to.  That is why the second condition is so important.  To truly listen you must accept and prize the person.

The pieces fit together like this.  If I can see you are being real and that you see me as a person and value me enough to truly listen to me, then I will start to see some value in myself and begin a journey I might never have started if no one had ever convinced me I was worth truly listening to.

Person-centered approaches only work if the person comes to believe they are thought of and seen and heard as a person.  Rogers boils down the steps to helping another human see they are truly a person with a self worthy of being.  These three conditions are the basic building blocks of any person-centered approach.”

© Ed Cooper, January 10, 2015, Stoney Creek, Tennessee
All rights reserved”

So my problem with the information about how to help folks with wounded souls found on the VA PTSD web page is very simple.  They do not sound like person-centered approaches to me.  They sound like therapy approaches developed by people with the fix-it syndrome.  Understanding and supporting the person does not appear to be the top agenda here, but rather fix them in eight sessions and rid them of their shame and get them to make amends.  Stop!  It may be shame for my country I am suffering from.  How do I write a letter to make amends for that?

My first proposition is the VA needs to adopt a true FIRST-PERSON approach to therapy that is non-directive and uses active/deep listening at its core to truly be useful in the healing process of folks suffering from shattered souls/ moral injury.

My second proposition is the use of veterans with a primary mental health diagnosis to be trained as co-leaders of the groups.  ( There has been a national issue of folks with addictions backgrounds filling the consumer employment slots. It will be important to prevent this in this program.) They can be volunteers or paid staff.  The point being that trust is an issue.  Professionals have all the power and most have never served.  It is hard to relate and be fully forthcoming with a person you do not think has a clue about your situation.

My third proposition is that the person can come and go from group as needed.  This may require setting up groups in the community with trained volunteers to include  ministers, veterans and mental health professionals all under the supervision of the VA.

Wayne Edward Oates (24 June 1917 – 21 October 1999) was an American psychologist and religious educator. He studied at Mars Hill Junior College, Wake Forest University, Southern Baptist Theological Seminary, Union Theological Seminary, and the University of Louisville School of Medicine. After graduating from Southern with a PhD in Psychology of Religion, Oates joined the School of Theology in 1947 as professor of psychology of religion and pastoral care. He held the post until he joined the University of Louisville Medical School in 1974.

Oates' cross-disciplinary approach combined psychological models with pastoral sensitivity, and biblical teaching. The result changed conventional attitudes to counselling to yield the modern pastoral care movement. Oates developed the 'trialogue' form of pastoral counseling: a conversation between counselor, counselee, and the Holy Spirit.
In 1984 the American Psychiatric Association granted Oates the Oskar Pfister Award for his contributions to the relationship between psychiatry and religion.

 © Ed Cooper, 5/7/2018, Stoney Creek, TN
All rights reserved

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