Kim Howard  00:05

Welcome to the Let’s Talk EMDR podcast brought to you by the EMDR International Association or EMDRIA. I’m your host, Kim Howard. In this episode we are talking with EMDR, certified therapist and consultant. Eva Usadi about EMDR therapy for moral injury. Let’s get started. Today we are speaking with EMDR, certified therapist and consultant Eva Usadi to talk about EMDR therapy and moral injury. Thank you, Eva for being here today. We are so happy that you said yes.

 

Eva Usadi  00:32

Well, thank you, Kim, for having me. It’s a pleasure to be here with you.

 

Kim Howard  00:35

Eva, can you tell us about your path to becoming an EMDR? Therapist?

 

Eva Usadi  00:40

Sure. That’s a great question. I actually I became an EMDR therapist, because I was volunteering at Ground Zero. In New York City after the events of 9/11. I was working with first responders in the big white tent that was, you know, covered many, many blocks, city blocks. And one of the volunteers, we were on the Red Cross disaster mental health team, one of the fellow volunteers that I ended up just doing a few shifts with it. It just happened told me one day that he was an EMDR therapist, and I had heard of this, but I really didn’t I had never met anybody who was and because I respected him. And the work we were doing down there together. I said, Well, you know, can you show me how this works. And so I met with him in his office, he did a little mock thing, I still didn’t really understand it. But that was in, I think, November of 2001. And by December, I had taken the first training. And by April, I had taken second training. And so I just I just went with it, I was you know, really taken aback at the profound shift that happened for me during the training on something that I didn’t even realize was that big. It was just gone. Having worked with somebody who also didn’t know what they were doing, right. And it still had a very powerful impact on me. So my trainer said, he watched me both the first and the second part. And he said, you’re ready to go, just just start using this all the time, took me a long time to get certified, because it just wasn’t that important to me. I had done all the hours, but I just never submitted them took me even longer to get to be a consultant because I’ve been busy. And again, you know, it’s partly because I’ve developed kind of a public face. And I do a lot of speaking that I thought the credential was meaningful. And so I completed it. And the the consultation process was really important because that’s, that’s where I felt like I was refining what I actually do, and how I can teach other people to refine what they’re doing.

 

Kim Howard  02:37

Yeah, absolutely. We always like to ask that question, because we like to know how people found out about EMDR therapy. And a lot of times it’s a class they took or postgraduate, maybe maybe undergraduate or a colleagues, like you said, somebody that they worked with, or somebody that they volunteered with who mentioned that. And so we just are kind of curious how people came to EMDR therapy and how they’ve implemented it. So thank you for sharing that with us.

 

Eva Usadi  03:01

Thanks for asking. And I will say that after 9/11, I was so taken by EMDR. I was working with a lot of firemen, and officers and I treated probably 120 myself through therapy. And yeah, I mean, people people disappeared, because they were done.

 

Kim Howard  03:17

Yeah. But thank goodness that you were you were there and could do that to them to help them heal. So that was a traumatic day for a lot of people, and especially the people who were at point of impact. So thank you for that.

 

Eva Usadi  03:32

Yeah, you’re welcome. And actually it was the day was bad. But it was the weeks and months that followed that were problematic because people got over exposed at the site because the city was not protecting anybody.

 

Kim Howard  03:45

What is your favorite part of working with EMDR therapy?

 

Eva Usadi  03:49

My favorite part is the creativity. You know, I like the trauma processing, but I also do a lot of creative things with resourcing. And you know, I’m of the opinion that sometimes people resource way too long before getting into processing and I, I just weave it in and out because there are times when things come up and resourcing absolutely is organic and make sense. And the other thing is that because I’m also a sensorimotor psychotherapist and a consultant in sensorimotor psychotherapy, I have a greater emphasis on the body than I think that is taught even still in trainings. And so I I integrate the somatic piece is a very big component of EMDR processing.

 

Kim Howard  04:31

Let’s get into why you’re here today. Let’s talk about moral injury. Can you please define what moral injury is?

 

Eva Usadi  04:38

Okay, I’m going to give you my definition. And this is actually a little bit more appropriate to military moral injury, which my team has started to use that term to differentiate what happens to combat veterans than what happens to other people. So I’ll just give you our original definition, which is that it is an existential and or spiritual crisis. that can be the consequence of having been trained to override the intrinsic and instinctive aversion to the taking of human life, that it really is about killing, which is an act that can’t be undone. And that humans are not prepared for the aftermath of that. And it can also be the consequence of having engaged in combat operations, however necessary at the time that create a conflict between between one’s moral code and one’s actions. There is that dissonance between what I was raised to believe what I was taught to believe what I actually do believe, and what I just had to do. And so for other populations outside of military, and I think there are some limited populations that are vulnerable to moral injury, which I’m happy to, to list if you’d like, I think that the only shift in that definition would be, you know, we don’t say combat operations necessarily, but it’s, it’s when people are doing work, where they have to make the level of decision that is so complicated, and so conflicted, the decision itself about, you know, medical personnel during the pandemic, who had to make decisions to remove ventilators from, from people who are still alive, because they knew that somebody else had a greater chance of survival, and there was a scarcity of resources. And so, you know, we think that it’s an I think it’s very much about these life and death decisions, because there’s no undoing of what you just did. And that it, you know, can also be about behavior, you know, which is the case in combat operations may not be about killing necessarily, but it has to do with the way we treat other human beings. And I have found that, primarily an issue with the humanitarian aid workers that I work with, I’ve been a preferred provider for MSF for Doctors Without Borders for about 14 years now, the kind of decisions that they make in the field. Again, it’s very much about how to allocate scarce resources, and also having to, you know, make contact and make agreements with warlords that they know are actually the perpetrators of violence. There are so many times when they have to violate their own moral codes, their moral beliefs, everything that we know about what it means to be human, in order to do their jobs. And so I think that it’s, it’s very much about agency. And that that’s, that’s the piece that I find missing. In a lot of other definitions. I’ve done a lot of presenting on moral injury, as you know, and I did a Google search a while back, and I found something like 40 different definitions of moral injury, you know, everything. Now, I think that makes it even more confusing in a way that I think that we need to narrow and clearly define what it is we’re seeing and what it is, we understand about it so that we can properly process it. I don’t think you can treat but you don’t understand. And so what is missing from a lot of these other definitions is agency is that the person, you know, witnessing something that’s terrible, is traumatic, there’s no question about that. And I might feel morally offended by it. But I think in order to have moral injury, one has to have violated something themself. It can be you know about having done something, it can also be about not having stepped in to prevent something. And that’s also an act. And so I really am focusing on agency, and I’m doing some writing on this now, because I think in a lot of these definitions, it actually is the missing piece that we know that you’ve done wrong. And when some of the veterans and this comes from them, we you know, we didn’t suggest this to them. When people say things like, I feel I’ve sinned, that that’s a much deeper thing than, you know, I don’t like the way my boss treated me or I, you know, I made a mistake at work, or, you know, that that’s a very different level of wounding to the heart and soul. And then people do also talk about soul. And so I think that, that puts this in a different dimension, really, then then other traumas or other ways of understanding the results of behavior.

 

Kim Howard  09:06

Let’s piggyback on what you said about other populations who might be vulnerable to moral injury. So in your view, who do you think is vulnerable to moral injury?

 

09:17

Thank you. I appreciate the question. I think that people who are trying to kill like law enforcement, absolutely; Border Patrol agents, Homeland Security. I did a presentation for a group of Homeland Security people a few years ago, and I really didn’t know about this piece of Homeland Security. But I, I met with people that spend all day long, every day during the week searching for child pornography on their computers, and they get almost no services. And so I think that people who are exposed to that and that they can’t really do anything, you know, they they report it, they document it, you know, and then teams go out and find the perpetrators. But I think that, you know, that is part of law enforcement. So I would say law enforcement, humanitarian aid workers, certainly emergency medical services and medical doctors in certain situations, and war correspondents. I think that what’s going on now in several different places where the world is at war, that war correspondents, journalists, reporters are really suffering, because they, they spend their their days and nights and they make their livelihood by witnessing suffering that they can’t do anything about, in many cases are not permitted to intervene, even if they might be able to they’re not permitted to do that some news agencies require absolute objectivity if that’s even possible, right. And so I have were put some more correspondence and they have significant amount of trauma. And I think also we’re vulnerable. Sure.

 

Kim Howard  10:56

Thank you. So what successes have you seen using EMDR therapy for moral injury?

 

Eva Usadi  11:03

Well, in the program that I run for combat veterans, that is primarily what our approach is in training or our EMDR clinicians who work the program, process moral injury a little bit differently than we process. Other things, I can give some more details about that. But we’ve had people significantly repair we use the word repair because we don’t see moral injury as a disorder, and therefore doesn’t have symptoms in the way that other disorders do. And so we use the term repair as a careful way to make that distinction. And so when we have done repair sessions with EMDR people at the end are really relieved of this burden that they’ve been carrying, that is has been haunting him, in many cases for years or even decades. And we also think that it has a significant impact on reducing suicide among combat veterans. And actually, the U.S. Army agrees with that now they put out a position paper, I think it was in 2019 came out of the chaplaincy, but it was accepted by the U.S. Army suggesting that moral injury is absolutely distinct from PTSD, and that it may be fueling the suicide crisis among our nation’s veterans are some support for that, which is really important.

 

Kim Howard  12:20

Yeah, absolutely. Hey, are there any myths that you would like to bust about working with moral injury?

 

Eva Usadi  12:26

Also a good question. Well, I think that people need to be prepared for what they’re going to hear and need to be able to tolerate it. And one of the things that I teach my team and others who want to learn this is I think that the traditional EMDR with a movement where you’re sitting kind of catty corner to the person, and it takes you out of their vision, right, their visual field, I think that with moral injury repair, people actually have to be in close contact, I think there needs to be eye contact, because the person who is struggling with moral injury needs to be held in a space where they feel seen, and in a way because that really, that’s a good countermeasure for the shame that goes along with this experience, right? They need to be seen and held. And the therapist actually acts as what we call a benevolent witness, being in there with them, so that it’s not something that they have to carry by themselves, because all of these populations that I think are vulnerable to moral injury, they’re public servants, they work for us, you know, we commissioned them, we put them in uniform, we send them to very dangerous places. And I think we have a responsibility to help them come back from that. And that puts us as an active, the benevolent witnesses, not a silent witness or an observer, they actually become part of the story. And so then it becomes a shared experience, which overcomes isolation. And, you know, people feel that they have to struggle with this by themselves. So I think that people who are going to do moral injury repair, at least the way that I’ve learned to do it, need to be able to tolerate hearing the story. And, you know, I know EMDR therapist know how to do this, but we also still tell people that for EMDR to work, you don’t have to tell what happened or what you did, you know, that processes anyway. And I think with this, it’s a little bit different. And it’s a little bit about or not a little bit, it’s a lot about being able to say what you did, and hold it as real and not a perceived negative cognition, but a real act that I did, and that I have to learn to live with, which is beyond taking responsibility. It’s coming to terms with achieving some peace with that with what I did, and so when I repair moral injury, I do get people to say what they actually did. You know, whether it was I killed somebody or I raped somebody which you know, I processed a very powerful piece is with a, an Army veteran who had been carrying the story for I think, 37 years where he had raped one of his fellow soldiers soldiers deployed. And so, you know, we did a moral injury piece about that, because he, he did that it was some that he, he couldn’t come back from. And so I think that people need to in this, with this process need to actually be able to say what they are. And that in part, you know, we know that when we say things, it also reduces shame. And then it becomes a sharing rather than something that they have to hide, because it can’t be talked about. And, you know, just one little caveat, we know that with law enforcement and special forces, and you know, people that do things in places where we’re not supposed to be and they can’t talk about it, they can still say what they did, they just don’t have to say who they were with, or where they were, they can say what they did and how they feel. And I think that that’s an important segue, in a way or maybe an expansion of how we understand traditionally EMDR therapy.

 

Kim Howard  16:05

That’s a good point that you raised, not necessarily just about the secrecy of what kind of mission they were on. But the perception among certain people in the military, or certain people in public service, like law enforcement agencies, where there, there’s this machismo kind of attitude about what they’re doing, and they’re so tough, and they’re supposed to be this warrior. And they’re not supposed to talk about their feelings. And, you know, they’re, they’re weak because they have a problem. So what would you say to somebody who might be struggling with a moral injury? Who fights would you have for that person to come forward and try to get some help? It’s not easy for anybody to go to therapy. But I think there are certain types of people within society, it’s, it’s a little bit tougher for them. And so how would you encourage them to reach out?

 

Eva Usadi  16:54

Yeah, that’s a great question, Kim. I think, unfortunately, there’s not too many therapists who really understand how to work with this. So there may not be enough places to go yet. But I also think that for uniform personnel, whether they’re working domestically or on foreign soil, the problem really comes from the top has to be more work to overcome the stigma. Because even though you know, the military says, Yeah, everybody can go get help. And it’s a sign of strength, not weakness, the stigma remains, people don’t actually believe that that’s true. And in the police departments, at least, you know, all that I know of, once you report for, for help you lose your badge and gun. So who’s gonna do that, right? You have to be some changes on command level, where services are available, people are encouraged to go and they don’t get punished for going. Because that, that still happens. Yeah. So I am, I will just add one more piece to that, which is that I think a lot of people are struggling with this. And they don’t know that’s what’s wrong with them. And that that was one of the comments at a program a number of years ago, where I, we’re doing more education and our program, we’re teaching them, you know, what, to help them understand what’s happened to them, and why they feel the way they do. And one veteran just he, he was astounded when I talked about moral injury. And he said, it was at a community meeting. And he said, Why is nobody ever told me this before? This is what’s wrong with me? Why doesn’t the V.A. know this? And I said, Well, they do know it. They just don’t know what to do with it, you know, there’s not agreement, you know, around what kind of treatment is, or repair or whatever, you know, so they don’t quite know what to do with it. And the other piece, and this was true with New York City, firefighters and police after 9/11, their departments don’t want to take responsibility for what happens to their people, when they’re doing what they’re supposed to be doing, you know, following rules of engagement following, you know, police protocol, or whatever. They’re doing what is lawfully sanctioned, but they still feel like they don’t deserve to live. So departments don’t really want to take responsibility for that same way. They don’t want to take responsibility for people having PTSD, you know, can still be a career ender.

 

Kim Howard  19:05

Yes.

 

Eva Usadi  19:06

So. I think that it’s a tremendous burden to put on individuals to have to find help for this. When there’s not even still, even after all these decades of work with PTSD. There’s still not really recognition that that’s treatable. People can get through it, they can still have their jobs. You know, it’s almost an immediate render. And in fact, what I heard recently, this is quite disturbing. I heard this from a police officer in New York, that the departments are when they’re hiring military veterans, anybody who was flagged with PTSD has a problem getting on the force. And, yeah, so this continues to be an issue and I think, certainly more education, but the other thing that my organization has done, I’m talking about trauma and resiliency resources. We created our own moral injury scale because the ones that exist. They’re confusing, we use the main one, it’s called the Moral Injury Event Scale. And it was created by researchers from the Navy and from V.A. And it was helpful to have it initially. But what was happening with us is that we were used to scale the first day the program, we do it again, at the end, there was no real change. And that’s because most of the questions in that scale are about exposure. And so we created our own scale, we’ve used it at multiple programs, and we’re having it evaluated, because we haven’t done that piece yet. And it’s administered face to face with every veteran who comes to our program. And the questions are really impactful. And so when clinicians, you know, are able to be taught to us that it’s not a validated scale yet, you know, we’re working on that. But the more people that can be taught to integrate that into their practice, people probably have clients and their practice has already come maybe more. And they may not have identified that. Because the client themselves is not the one that’s going to be able to put the words to that the clinician has to know what to listen for the right questions, and then, you know, provide some assurance that they know how to work with it.

 

Kim Howard  21:14

Right. And or they may be treating them for PTSD, which they might likely have. But plus one of that is, well, I have PTSD, but I also have moral injury because of this incident that happened. And it’s all connected to what I was doing for a living. And so that might it might be sort of hiding under the PTSD net, and either the patient or client or the therapist recognizes that. So that’s probably what’s happening.

 

Eva Usadi  21:41

Yeah, exactly right. And a few years ago, I was walking in, in New York City, and I bumped into an old trainer for my gym, who I hadn’t seen for a while. He’s an Army veteran. And he, we just ended up having a 45 minute conversation on the street. And I really wish I could have recorded it. Because he had been following my organization. He’d read some things we were writing about moral injury. And he said, ‘You’re spot on. He said, for years, people, my family, my wife, telling me to go to the VA and get treatment for PTSD. And I don’t think that’s what’s wrong with me. You know, I’m not having sleep problems, I’m not having all the things that they can, you know, that are part of that diagnosis, said, but what I am haunted by is the stuff I did in combat that I’ve never been able to talk to about with anyone.’ And so, you know, I honestly, I wish I had pulled up my phone and said, ‘Can we go we record this?’ You know, there’s the evidence right there that people really do understand that if there being an agreed people have both in a minute, but if you’re being, you know, sent to treatment for PTSD, and nobody asks them these other questions, and they feel like they can’t raise it, because they were following lawful order. So why do I feel like this?

 

Kim Howard  22:56

Right.

 

Eva Usadi  22:57

Right. And yeah, then they’re, they’re kind of lost?

 

Kim Howard  23:00

Yeah. All right. Let’s switch gears a little bit. How do you practice cultural humility as an EMDR therapist?

 

Eva Usadi  23:07

Well, I think as any therapist, you have to practice cultural humility, you know, and what I learned from one of my teachers, I was trained by Salvador Minuchin, many years ago, and structural family therapy. And he basically said, if your client says something you don’t understand, you have to ask, you know, what, what do you mean by that? Or what does that term mean? Or what is this practice for you, and be open to listening and have a dialogue about it, so that if you’re working with somebody who’s from a different culture, or a different, you know, race, or ethnic group or anything, you have to be open to listening to what they say, not from a position of power and dominance, but like, I really need to understand what you meant by that, so that I can integrate it into what we’re doing here, you know, in my population, you know, veterans is one of the most integrated, you know, the DOD, our armed forces are very integrated, not at the top, there’s still a lot of hierarchy problems in terms of people being promoted. Still very white leadership. But I think that there’s such a mix of races and cultures, that one has to be able to integrate that into practice. And, you know, I also had the benefit of having lived in New York most of my life, so I’m quite used to hearing 15 languages on the subway and right, you know, signs in multiple languages. And, you know, you call the operator you get somebody to translate for you. You know, there’s a lot of things that are set up in some parts of the country, which won’t be as available.

 

Kim Howard  24:38

Yeah. Ialways tell the story, if you’ve heard it on the podcast before, my apologies for being repetitive, but I was a military brat, and I grew up on a military base and you learn at a very young age because the military is so integrated, especially at the – my Dad was an NCO – especially at that level, that if you don’t learn to play with other kids who don’t look like you, or maybe didn’t come from where you grew up, you’re gonna be a lonely kid. You know, I grew up across the street from the Korean lady who was married to the Mexican guy who was in the Army who lived next door to the Iranian couple who lived across the street from the Black couple who lived next door to us, right there, there was a huge melting pot of people, and they’re your neighbors, and they’re your friends and you your kids play together. And so you learn, you just, it just sort of is almost natural in that setting. But not everybody grows up that way. And a lot of people won’t get exposed maybe till they go to high school, or maybe really, quite frankly, if they go to college, or they get out to the workplace. And then they are a little more exposed based on where they go to school or where they have an ID of working. So thanks for answering that. It’s not an easy question. But we’d like to ask it anyway. So that people are aware that that’s part of, you know, the practice, that’s part of being a therapist is being aware that people are going to come to you and they’re not always going to be like you. So you have to kind of be prepared to be inquisitive about about them. Do you have a favorite free EMDR related resource he would suggest either for the public or other EMDR therapists?

 

Eva Usadi  26:12

Yeah, honestly, I thought about that question. And my favorite video is one that was produced by CBS News, I think it’s about 15 years old at this point, it’s called ‘EMDR and PTSD.’ I still send it to clients and have it, it’s on our website, as well. And I think it’s a really clear description of, you know, the benefits and the power of EMDR. It’s actually a story about a Marine veteran, who got re traumatized in his own community. And in it is Sarah Gilman, from, you know, our community doing a beautiful job explaining EMDR. And also Daniel Amon, showing this, you know, marine, the MRI of his brain, which shows, you know, what areas are lit up, and what happens at the end of EMDR, that all of that is settled. It’s a very scientifically done presentation. And, you know, I still think it’s one of the best things out there.

 

Kim Howard  27:06

What would you like people outside of the EMDR communities to know about EMDR therapy and moral injury?

 

Eva Usadi  27:11

Well, I would say that it is a tool that can be very effective and healing for people. I think that as I’ve said a little bit earlier, there are some adjustments that can be made in the way that we conduct EMDR sessions with clients who are morally injured, but those are really easy for me to teach people and, you know, very effective, sometimes we think that we can just operate as usual. And I think that some adjustments do need to be made when repairing this particular thing. And so I think that it will help people to watch, you know, some of the available resources, and to go to trainings and to, you know, attend to this as a kind of an a new, it’s not a it’s not really one population, there are multiple populations that are vulnerable to moral injury. But I think that learning, you know, a specific way of processing this can be very helpful to people, because there are some changes in the way we understand negative cognition, how to go from negative to positive, but so there’s some nuances, I guess, is what I’m trying to say in working with EMDR with a mortally injured person.

 

Kim Howard  28:17

Thank you. Eva, if you weren’t an EMDR therapist, what would you be?

 

Eva Usadi  28:21

Wow, I probably I would be mostly doing sensorimotor psychotherapy. And I would be working mostly in the arena with horses. I have not integrated my work with horses and EMDR. Although occasionally I’ve done some resourcing with EMDR after a powerful session with the horses, but that’s really my love. EMDR has very much enhanced and changed my practice over these 23 years. And I won’t stop using it. But I have some other modalities that I also really enjoy.

 

Kim Howard  28:51

All right. Good answer. There’s no right or wrong answer. Is there anything else you’d like to add?

 

Eva Usadi  28:57

I don’t think so. I think we’ve covered a lot of ground.

 

Kim Howard  28:59

All right. Thats it. Thank you. This has been the Let’s Talk EMDR podcast with our guest Eva usati. Visit www.emdria.org for more information about EMDR therapy, or to use our Find an EMDR Therapist Directory with more than 15,000 therapists available. Like what you hear, make sure you subscribe to this free podcast wherever you listen. Thanks for being here today.