Staff Perspective: Lean Into Your Moral Pain
Several years ago, I was co-facilitating a group Cognitive Processing Therapy (CPT) session with several BIPOC (Black, Indiginous, People of Color), Vietnam Veterans. During agenda setting, one of the Veterans in the group wanted to discuss a Challenging Beliefs Worksheet (CBW) that he had completed during the past week. I acknowledged his request, and, since he didn’t often speak about his practice assignments, I asked the group if we could start with his agenda item. The rest of the group agreed.
Once the agenda had been set, I went to the dry erase board in the front of the group room, looked toward the veteran who had requested to discuss his practice assignment, and said, “Ok, let’s get started with our first CBW. What did you write down as your activating event?”
Veteran: “A cop pulled me over on the highway”
Me: “Ok (writing) ‘a cop pulled me over on the highway.’ And what was your Stuck Point?”
Veteran: “He pulled me over because I am Black.”
At this point, I felt my heart rate increased, and I started to sweat. As the only white person in the room, I was standing at the front of a therapy group in a position of authority about to lead a group of BIPOC Veterans in doing what we do in CPT: identify and challenge inaccurate and/or unhelpful beliefs.
Me: “And what did you write in ‘C,’ emotions?”
Veteran: “I was angry. Really angry”
Me: “How intense was that emotion?”
Veteran: “100% I wasn’t doing anything wrong except speeding a little. It wasn’t right”
Me: “Great. Let’s start looking at those challenging questions. What was the evidence that you were pulled over because you are black?”
And this is where I screwed up. I followed the CPT protocol instead of putting down my marker, sitting down at the table, and really listening. In this situation, following the protocol was cowardly. I was hiding behind “treatment fidelity” to avoid my own discomfort and ignorance and to protect myself from the possibility that my biases, as much as I would have liked to believe that they didn’t exist, would be exposed.
This is just one example of many times in the past when I have acted from a place of white privilege and bias. Having the choice not to think about systemic racism is the definition of white privilege. Most of these times, my actions were subtle, more on the level of microaggressions. Microaggressions are short, often casual, expressions that communicate hostile, derogatory, or negative racial slights and insults to an oppressed target person or group. Microaggressions can be verbal or non-verbal, and they can be intentional or non-intentional (Pierce, 1970). However, there were a few times that my actions weren’t so subtle. It’s very painful to think about these memories. It’s even more painful to acknowledge that I continue, at times, to act from a place of bias and privilege despite my efforts to stop. My pain isn’t the point here, though. This blog isn’t about, “Andy feels bad about being an idiot,” or confession of my past wrongs to make myself feel better. This isn’t about getting anyone to say that I’m “brave” because I admitted to doing incredibly messed up things that likely hurt other human beings and perpetuated systemic racism. No, I don’t deserve sympathy or kudos. As Cardinal Lomberto says to Michael Corleone in Godfather 3, “Your sins are terrible, and it is just that you suffer.” I’m glad this is painful, to be honest.
The concepts of moral pain and moral injury have been front and center this month at CDP. During this past month, several of my colleagues at the Center for Deployment Psychology have created some wonderful resources related to moral injury. These include an outstanding blog by Dr. Jeff Mann and a panel discussion with several leading experts in moral injury hosted by Dr. Paula Domenici. Much of the discussion, rightly so, has been about conceptualizing and recognizing the manifestation of moral injury in our military clients and developing effective interventions to address moral injury. This is necessary and important work. In my opinion, there is also important work for us as clinicians (and human beings) to do on ourselves.
My colleague Wyatt Evans spoke about the difference between moral pain and moral injury during the webinar I mentioned in the last paragraph (you can watch it here), and he and I spoke a bit about the differences between moral injury and PTSD in a previous vlog post (you can watch that here). Moral pain or moral emotions are the emotions we feel when either we act in a way that violates our most deeply held values or we experience a situation in which those values are violated by others. The intensity of these emotions can vary widely from a sense of mild embarrassment or irritation to strong feelings of shame and rage depending on the values violation. These emotions, while painful, are also normal and can be adaptive. When something is painful, it’s human nature to want to turn away. Pain is usually a signal that something is either presently causing “damage” or has the potential to do so. In many cases, avoiding pain is good judgement. Reducing or eliminating pain is rarified in our culture. In fact, we often define health, whether physical or psychological, as the absence of pain. However, cutting off our emotional reactions, especially when it comes to moral pain, also cuts off our capacity to connect with some of our most deeply held values. Caring hurts, it turns out. Allowing ourselves to experience moral pain and to learn from it can be a powerful way to reorient ourselves towards what matters. Although it is natural to want to distance ourselves from the pain of racism experienced by our clients, doing so robs us of the opportunity to stand with them and bear witness to the injustices in their lives.
Knowing that I can’t ever go back in time to that moment in the CPT group and actually “show up” to do the work that was there to be done will continue to cause pain. I feel shame, sadness, and anger. It doesn’t feel good. That shame tells me that what I did wasn’t right. The sadness tells me that I wish that I hadn’t hurt those men. The anger tells me that something needs to change.
If I could go back, I would have liked to do something like this:
Veteran: “A cop pulled me over on the highway”
Me: “Ok (writing) ‘a cop pulled me over on the highway.’ And what was your Stuck Point?”
Veteran: “He pulled me over because I am black.”
Me: “Guys, I know we have kind of a routine when walking through these CBWs, but if it’s ok with you all, I’d like to put my marker down and sit with you at the table. If you are willing, I’d like to know more about what it was like for you (to the veteran who shared his CBW) and anyone else who has experienced being pulled over by the police. Would that be ok?”
Then I would sit down and shut up. I would make room for my anxiety and shame. I would make eye contact. I would listen. I would ask permission to ask more questions and listen some more. I would be brave, ask questions that showed my ignorance, and I would do my best to be teachable. I would also invite group members to talk about what it's like to have this discussion with a white person in a position of authority. I would remember that my “job” in that moment wasn’t to play the role of “therapist.” I would try not to be doing a “job” at all. I would work as hard as I could to be a human being sitting with other human beings, coming from a place of not-knowing so that I could truly bear witness.
Of course, it’s nice to fantasize about the way we would like things to have been. That isn’t nearly enough. That said, introspection can be a good place to start. It can help us to genuinely and honestly take ownership of where we are and where we would like to be. I don’t pretend to be an expert when it comes to cultural competence. I’d like to lay out a small set of simple rules or guidelines to follow to be more competent when it comes to responding to situations like the one I shared above. Even if I could, that wouldn’t necessarily make you want to do anything different. It wouldn’t necessarily motivate you to make the changes that you need to make.
Instead, I am offering you this: allow yourself to engage with your most painful memories of clinical (and personal) failures when it comes to issues of race and discrimination. Lean into that moral pain, if you are willing. See what that pain has to tell you about what matters. Listen deeply. Stay. Learning to bear witness to your own experiences of moral pain can help you to create a space where you can be willing to bear witness to the moral pain that your clients experience. This can be a creative, reorienting experience.
*Note: It’s very important for me to say clearly and directly that I am in no way trying to compare my experience of moral pain with those who have experienced significant moral injuries. Moral pain lies on a spectrum. If you’ve experienced moral injury and have intense levels of moral pain, please take care of yourself by speaking with a professional.
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.
Andy Santanello, Psy.D., is a licensed, clinical psychologist and Military Behavioral Health Psychologist at the Center for Deployment Psychology. Dr. Santanello joined CDP after over a decade of service in the Veterans Health Administration where he was a staff psychologist in the Trauma Recovery Program.
References
Borges, L.M. (2019). A Service Member's experience of Acceptance and Commitment Therapy for Moral Injury (ACT-MI) via telehealth:“Learning to accept my pain and injury by reconnecting with my values and starting to live a meaningful life”. Journal of Contextual Behavioral Science, 13, 134-140.
Farnsworth, J.K., Drescher, K.D., Evans, W.R., & Walser, R.D. (2017). A functional approach to understanding and treating military-related moral injury. Journal of Contextual Behavioral Science, 6(4), 391-397.
Nieuwsma, J.A., Walser, R.D., Farnsworth, J.K., Drescher, K.D., Meador, K.G, & Nash, W. (2015). Possibilities within acceptance and commitment therapy for approaching moral injury. Current Psychiatry Reviews, 11(3), 193-206.
Pierce C. Offensive mechanisms. In: Barbour F, editor. The Black Seventies. Boston: Porter Sargent; 1970. p. 265–82. 29.
Several years ago, I was co-facilitating a group Cognitive Processing Therapy (CPT) session with several BIPOC (Black, Indiginous, People of Color), Vietnam Veterans. During agenda setting, one of the Veterans in the group wanted to discuss a Challenging Beliefs Worksheet (CBW) that he had completed during the past week. I acknowledged his request, and, since he didn’t often speak about his practice assignments, I asked the group if we could start with his agenda item. The rest of the group agreed.
Once the agenda had been set, I went to the dry erase board in the front of the group room, looked toward the veteran who had requested to discuss his practice assignment, and said, “Ok, let’s get started with our first CBW. What did you write down as your activating event?”
Veteran: “A cop pulled me over on the highway”
Me: “Ok (writing) ‘a cop pulled me over on the highway.’ And what was your Stuck Point?”
Veteran: “He pulled me over because I am Black.”
At this point, I felt my heart rate increased, and I started to sweat. As the only white person in the room, I was standing at the front of a therapy group in a position of authority about to lead a group of BIPOC Veterans in doing what we do in CPT: identify and challenge inaccurate and/or unhelpful beliefs.
Me: “And what did you write in ‘C,’ emotions?”
Veteran: “I was angry. Really angry”
Me: “How intense was that emotion?”
Veteran: “100% I wasn’t doing anything wrong except speeding a little. It wasn’t right”
Me: “Great. Let’s start looking at those challenging questions. What was the evidence that you were pulled over because you are black?”
And this is where I screwed up. I followed the CPT protocol instead of putting down my marker, sitting down at the table, and really listening. In this situation, following the protocol was cowardly. I was hiding behind “treatment fidelity” to avoid my own discomfort and ignorance and to protect myself from the possibility that my biases, as much as I would have liked to believe that they didn’t exist, would be exposed.
This is just one example of many times in the past when I have acted from a place of white privilege and bias. Having the choice not to think about systemic racism is the definition of white privilege. Most of these times, my actions were subtle, more on the level of microaggressions. Microaggressions are short, often casual, expressions that communicate hostile, derogatory, or negative racial slights and insults to an oppressed target person or group. Microaggressions can be verbal or non-verbal, and they can be intentional or non-intentional (Pierce, 1970). However, there were a few times that my actions weren’t so subtle. It’s very painful to think about these memories. It’s even more painful to acknowledge that I continue, at times, to act from a place of bias and privilege despite my efforts to stop. My pain isn’t the point here, though. This blog isn’t about, “Andy feels bad about being an idiot,” or confession of my past wrongs to make myself feel better. This isn’t about getting anyone to say that I’m “brave” because I admitted to doing incredibly messed up things that likely hurt other human beings and perpetuated systemic racism. No, I don’t deserve sympathy or kudos. As Cardinal Lomberto says to Michael Corleone in Godfather 3, “Your sins are terrible, and it is just that you suffer.” I’m glad this is painful, to be honest.
The concepts of moral pain and moral injury have been front and center this month at CDP. During this past month, several of my colleagues at the Center for Deployment Psychology have created some wonderful resources related to moral injury. These include an outstanding blog by Dr. Jeff Mann and a panel discussion with several leading experts in moral injury hosted by Dr. Paula Domenici. Much of the discussion, rightly so, has been about conceptualizing and recognizing the manifestation of moral injury in our military clients and developing effective interventions to address moral injury. This is necessary and important work. In my opinion, there is also important work for us as clinicians (and human beings) to do on ourselves.
My colleague Wyatt Evans spoke about the difference between moral pain and moral injury during the webinar I mentioned in the last paragraph (you can watch it here), and he and I spoke a bit about the differences between moral injury and PTSD in a previous vlog post (you can watch that here). Moral pain or moral emotions are the emotions we feel when either we act in a way that violates our most deeply held values or we experience a situation in which those values are violated by others. The intensity of these emotions can vary widely from a sense of mild embarrassment or irritation to strong feelings of shame and rage depending on the values violation. These emotions, while painful, are also normal and can be adaptive. When something is painful, it’s human nature to want to turn away. Pain is usually a signal that something is either presently causing “damage” or has the potential to do so. In many cases, avoiding pain is good judgement. Reducing or eliminating pain is rarified in our culture. In fact, we often define health, whether physical or psychological, as the absence of pain. However, cutting off our emotional reactions, especially when it comes to moral pain, also cuts off our capacity to connect with some of our most deeply held values. Caring hurts, it turns out. Allowing ourselves to experience moral pain and to learn from it can be a powerful way to reorient ourselves towards what matters. Although it is natural to want to distance ourselves from the pain of racism experienced by our clients, doing so robs us of the opportunity to stand with them and bear witness to the injustices in their lives.
Knowing that I can’t ever go back in time to that moment in the CPT group and actually “show up” to do the work that was there to be done will continue to cause pain. I feel shame, sadness, and anger. It doesn’t feel good. That shame tells me that what I did wasn’t right. The sadness tells me that I wish that I hadn’t hurt those men. The anger tells me that something needs to change.
If I could go back, I would have liked to do something like this:
Veteran: “A cop pulled me over on the highway”
Me: “Ok (writing) ‘a cop pulled me over on the highway.’ And what was your Stuck Point?”
Veteran: “He pulled me over because I am black.”
Me: “Guys, I know we have kind of a routine when walking through these CBWs, but if it’s ok with you all, I’d like to put my marker down and sit with you at the table. If you are willing, I’d like to know more about what it was like for you (to the veteran who shared his CBW) and anyone else who has experienced being pulled over by the police. Would that be ok?”
Then I would sit down and shut up. I would make room for my anxiety and shame. I would make eye contact. I would listen. I would ask permission to ask more questions and listen some more. I would be brave, ask questions that showed my ignorance, and I would do my best to be teachable. I would also invite group members to talk about what it's like to have this discussion with a white person in a position of authority. I would remember that my “job” in that moment wasn’t to play the role of “therapist.” I would try not to be doing a “job” at all. I would work as hard as I could to be a human being sitting with other human beings, coming from a place of not-knowing so that I could truly bear witness.
Of course, it’s nice to fantasize about the way we would like things to have been. That isn’t nearly enough. That said, introspection can be a good place to start. It can help us to genuinely and honestly take ownership of where we are and where we would like to be. I don’t pretend to be an expert when it comes to cultural competence. I’d like to lay out a small set of simple rules or guidelines to follow to be more competent when it comes to responding to situations like the one I shared above. Even if I could, that wouldn’t necessarily make you want to do anything different. It wouldn’t necessarily motivate you to make the changes that you need to make.
Instead, I am offering you this: allow yourself to engage with your most painful memories of clinical (and personal) failures when it comes to issues of race and discrimination. Lean into that moral pain, if you are willing. See what that pain has to tell you about what matters. Listen deeply. Stay. Learning to bear witness to your own experiences of moral pain can help you to create a space where you can be willing to bear witness to the moral pain that your clients experience. This can be a creative, reorienting experience.
*Note: It’s very important for me to say clearly and directly that I am in no way trying to compare my experience of moral pain with those who have experienced significant moral injuries. Moral pain lies on a spectrum. If you’ve experienced moral injury and have intense levels of moral pain, please take care of yourself by speaking with a professional.
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.
Andy Santanello, Psy.D., is a licensed, clinical psychologist and Military Behavioral Health Psychologist at the Center for Deployment Psychology. Dr. Santanello joined CDP after over a decade of service in the Veterans Health Administration where he was a staff psychologist in the Trauma Recovery Program.
References
Borges, L.M. (2019). A Service Member's experience of Acceptance and Commitment Therapy for Moral Injury (ACT-MI) via telehealth:“Learning to accept my pain and injury by reconnecting with my values and starting to live a meaningful life”. Journal of Contextual Behavioral Science, 13, 134-140.
Farnsworth, J.K., Drescher, K.D., Evans, W.R., & Walser, R.D. (2017). A functional approach to understanding and treating military-related moral injury. Journal of Contextual Behavioral Science, 6(4), 391-397.
Nieuwsma, J.A., Walser, R.D., Farnsworth, J.K., Drescher, K.D., Meador, K.G, & Nash, W. (2015). Possibilities within acceptance and commitment therapy for approaching moral injury. Current Psychiatry Reviews, 11(3), 193-206.
Pierce C. Offensive mechanisms. In: Barbour F, editor. The Black Seventies. Boston: Porter Sargent; 1970. p. 265–82. 29.