Moral Injury and Locus of Control

For years I was haunted by the memory of the dead Afghan infant.?

The event occurred on my first tour of Afghanistan. We had successfully completed a vehicle mounted mission and were extracting back to base, when we had one of our fighting vehicles bogged in a river crossing in a rural area.?

The situation was benign and as our element was working out how to skull-drag the vehicle out of the river, a group of interested Afghan locals from a nearby village approached.?

One of the Afghan men was carrying a small package wrapped in cloth and, through our interpreter, he asked if there was anyone medically trained who might be able to help. I approached as the man unwrapped the package to reveal a lifeless infant girl. Her closed eyes were sunk into their sockets and her skin was pale. Her tiny hands were cold, and she didn’t move as I examined her.?

At first, I thought she was already dead but on closer examination I detected a faint heartbeat and almost imperceptibly shallow breathing.?

The history suggested that she had been suffering from gastro for the past few days and hadn’t been able to keep any food or fluids down. She was critically dehydrated, and her body was shutting down. She was hours from death.?

Using a device known as an intraosseous, we inserted a metal cannula into the bone marrow of her shin and infused some lifesaving fluids and antibiotics. Slowly at first, but then with increasing animation, the infant began to move and then cry. It was a good sign, but she wasn’t out of the woods. She would need days of management to rehydrate her and get some nutrition back into her failing system.?

Through the interpreter I discussed her ongoing management with her father. He unconvincingly assured me that they could get the girl to a hospital in the nearest town, some 50 kilometres away. During that discussion, word came that our bogged vehicle had been recovered and we needed to move.?

Blood flow had returned to the little girl’s veins, allowing us to place a small drop in the back of her hand and remove the metal cannula from her shin. I hastily gave instructions to the father on how to give further intravenous fluids and antibiotics, and left supplies of both for ongoing treatment prior to them getting to hospital.?

As I was packing my medical kit to leave, the commander of the mission approached and asked if I felt we should take the girl and her dad back to base with us for medical review at a military hospital. In the moment I was dismissive of the idea. Although unconvincing, the father had indicated that he could get the child to hospital. Furthermore, it was my first trip to Afghanistan and my mindset was very much fixated on medical care for my own teammates. I hadn’t spent much time considering where the boundaries were for medical management of local nationals. On subsequent rotations I would begin to appreciate the significance of providing medical care to local nationals as part of a counterinsurgency operation, but at that time it was lost on me. We mounted our vehicles and left the girl behind.?

Passing through the same village a couple of weeks later I learned the little girl had never made it to hospital and had died the day after I treated her.?

Reflecting on the conversation with the mission commander on the day left me feeling wracked with guilt. Why had I been so dismissive? Would the child have lived if we took her with us??

Of course, the questions were moot, the outcome was fixed. But that didn’t stop the scenario playing on regular loop in my mind for years and occasionally creeping into my dreams.?

Moral Injury

What I was experiencing is known as moral injury, which can be defined as:

“…an injury to an individual’s moral conscience and values resulting from an act of perceived moral transgression on the part of themselves of others[1]” leading to “…profound feelings of guilt or shame, moral disorientation, and societal alienation[2]”.?

Moral injury often occurs because of an act of omission rather than commission. Something you didn’t do (or couldn’t do), rather than something you did do.?

The issue that I was hung up on was the fact that I could have done something different and didn’t. I had the opportunity to act and failed to.?

Over the years I’ve heard many stories of moral injury from military members, police, and other first responders, and often it’s clear that they couldn’t have acted and yet they carry the burden of moral injury for bad outcomes.?

Among those stories were those of a paramedic stuck ramped in their ambulance at a hospital as a call came through for a man having a heart attack nearby. Unable to respond in a timely fashion, the patient died, leaving the paramedic feeling the guilt of not being able to attend and most likely save the man.?

One police officer I spoke with had attended a domestic disturbance, and although his sixth sense told him something was wrong, there was no grounds for arrest or intervention. Later that night, the man he had responded to went on to kill his partner.?

I spoke with a firefighter who was off shift when he attended a house fire in his neighbourhood in the middle of the night. By the time he was on scene, the house was well alight, and the fire was burning with such ferocity that windows were exploding out of the house. He learned that there was a teenage girl trapped in the house but was unable to act. While his rational mind told him that there was nothing he could have done, his emotional mind was still running the “what ifs” on loop.?

Locus of Control

A useful place to start in trying to make sense of a moral injury situation is the concept of locus of control. Locus of control refers to the degree to which we believe we have control or influence over the outcomes of events in our lives. The important word in this definition is believe as it can often be a false belief, leading to an unrealistic impression of what we could have controlled or influenced.?

Locus of control exists on a spectrum. At the negative end of the spectrum is External Locus of Control, where one feels that everything is outside of their control and that they are along for the ride and a victim of circumstance. On the positive end is Internal Locus of Control, where one feels like their actions can have a direct impact on the outcome of a situation.?

In any given situation our locus of control will exist somewhere on this spectrum and as a generalisation, we want to try to push things towards the internal locus of control end.?

That said, a falsely elevated impression of our ability to control or influence the outcome of certain situations can worsen moral injury. Sometimes it’s healthier to accept that we had little to no ability to influence the outcome of a situation, as this can allow us to process events that might have occurred without as much self-judgement.?

The author of Seven Habits of Highly Effective People, Stephen Covey, offers another model that’s useful in rationally determining whether we can realistically impact on the outcomes of situations.?

Covey uses a model of three concentric circles, being:

· ?Circle of Control – as the name suggests, these are things we can absolutely control and can and should be held accountable for. Included here are our thoughts, behaviours, attitudes, and responses to situations.?

· ?Circle of Influence – in this circle are people or situations that we can interact with to try to have an influence but, ultimately, we can’t be held accountable for the outcome.?

· ?Circle of Concern – These are things that are of concern to us, but that realistically we have no control or influence over.?

This is not new wisdom (the Stoics were practicing it thousands of years ago!) but it’s critically important to identify, and try to let go of, stressors in our circle of concern. The issue with ruminating on these stressors is that there is no solution. We can’t do anything to control or influence them, so any emotional energy invested here is wasted. That emotional energy is best spent focused on things we can control or influence.?

I think most readers will agree that in the case studies of the paramedic, police officer, and firefighter that I mentioned above, none of them could have controlled or influenced the outcomes in their respective situations.?

The problem I faced in the scenario involving the Afghan infant is that I had the opportunity to act in a different fashion and didn’t.?

To some extent, I could have influenced that situation further and failed to. This then led to rumination on the negative outcome, driven by a human bias known as negativity bias.

?Negativity bias causes us to fixate on the negative, driving an emotional reaction and coming at the expense of considering any positives in a situation. It can lead to maladaptive rumination, which is the loop of thought that is focused on the bad outcome.?

After-Action Reviews

A strategy that can help give a more balanced interpretation of a situation is known as an After-Action Review (AAR). One of the key aspects of a good AAR is that it needs to be emotionless and blame-free. It is a cold, calculated review of an event.?

Three questions need to be answered in an AAR:

1. ?What happened? Remember, there’s no utility for emotion here. This is about capturing an accurate timeline of the situation from start to finish with key events along the way.?

2. ?What went well? Have the discipline to ask yourself this question next. Otherwise, the tendency will be to jump straight to the negative and go deep into that rabbit hole! Even in the worst of situations, there’s likely to be a few good points that can be brought out.?

3. ?What didn’t go well? Once again, this isn’t about blame and try to leave emotion out of it. Start with the big picture of what didn’t go well and then do a Root Cause Analysis (RCA) to get to the bottom of the situation. An RCA involves continuing to ask the question “why” until the root cause of the problem is identified.?

Map the outcome of the RCA against Covey’s Circles and realistically assess whether you could have controlled or influenced the outcome of the situation or not.?

If the answer is no; that the root cause of the outcome was in the circle of Concern, then hopefully that helps in allowing you to rationalise that the outcome was outside of your control or influence and help reduce rumination and self-judgement for the outcome.?

If the answer is yes; that the root cause was within your circle of Control or Influence, then this is the starting point for how you can do better next time.?

No amount of rumination will change the outcome of the previous event; however it can be used to prepare you to do things better in the future to avoid a repeat episode in similar situations. In effect, you are becoming future-focused and using the past negative outcome as a fuel for a more positive future outcome. You’re finding the silver lining to the otherwise dark cloud.?

This was the process I eventually was able to use to break the cycle of rumination on the bad outcome with the Afghan infant.?

A snapshot of the balanced AAR from the event (done in my journal years after the event) looked like this:

What Happened?

· ?Vehicle bogged during exfiltration from a vehicle mounted mission

· ?During recovery of vehicle, locals presented with critically unwell child

· ?Responded with appropriate initial fluid resuscitation and antibiotic management

· ?Stabilised child in immediate setting – improved vital signs

· ?Established action plan for ongoing management with fluids and antibiotics through father

· ?Established with father his intent to take child to hospital and stressed importance of this

· ?Dismissed option to take child and father with us to base hospital

· ?Provided father with a supply of ongoing intravenous fluids and antibiotic and instructions for use

· ?Left scene and returned to base

· ?Later learned that child didn’t get taken to hospital and died the following day

What went well?

· ?Positive choice to engage in the treatment of the child

· ?Effective communication with father through interpreter to gain informed consent for medical treatment

· ?Effective and timely insertion of intraosseous cannula in critically shocked child

· ?Appropriate administration of fluids and antibiotics with rapid improvement of clinical state

· ?Effective insertion of an intravenous cannula allowing removal of intraosseous

· ?Effective communication with father to:

??????????o ?Stress importance of hospital review and management

??????????o ?Educate in ongoing fluid and antibiotic administration prior to getting to hospital

??????????o ?Establish father’s intent to take child to hospital

· ?Management done in a timely fashion in austere conditions

· ?Good validation of training in paediatric resuscitation?

· ?Good validation of kit load and layout to respond to paediatric patients in the field

What didn’t go well?

· ?Prematurely dismissive of the concept of taking the child and father with us to hospital (noting that there was no guarantee that they would have come with us)

· ?Child never attended hospital and ultimately died the day after our management

When done properly, this AAR allowed for a far more balanced interpretation of the situation that my previous tendency to go straight to the negative ruminative thoughts of regret for not taking the child with us, and my perceived failure to save her.?

It’s possible that the child would have died anyway, however it’s reasonable for me to believe that a stint in hospital on intravenous fluids and antibiotics could have saved her.?

The AAR allowed me to realise that the failure of the child to get to hospital was not solely my responsibility. Through the interpreter I had informed the father of my assessment that the child needed hospital management and I had confirmed his understanding of this. Furthermore, he had indicated an intent to take the girl to hospital.?

There remained the fact that I hadn’t even offered to take her with us, however the root cause for the failure of the child to reach hospital was shared between me not offering a solution and the father indicating he would take the child to hospital and then failing to do so (for whatever reason).

The AAR also allowed me a far more balanced review, and therefore memory, of the situation. Some good points were highlighted and reinforced, and the one key negative point, being the failure to offer a ride to hospital, served as a learning point.?

To prevent moral injury in any future similar situation, I would ensure that I considered all reasonable options to facilitate the optimal management of a patient and communicate them clearly to the appropriate people. In doing so, I would do everything I could withing my circles of control and influence, and any bad outcomes would then exist in my circle of concern and be easier to rationalise without critical self-judgement.?

For those out there struggling with moral injury, I encourage you to revisit it using the model outlined here:

1. ?Without emotion, do a balanced After-Action Review of the situation.?

a. ?What happened??

b. ?What went well?

c. ?What didn’t go well??

2. ?Take what didn’t go well and do a Root Cause Analysis – keep asking the question why until you get to the root cause of the situation.?

3. ?When you establish the root cause of what didn’t go well, apply Covey’s Circles to establish whether it was within your control or influence, or whether it was in your circle of Concern and there was realistically nothing more you could have done.?

4. ?If the root cause of the bad outcome was in your circle of Concern, do your best to apply Stoic wisdom and soften your feelings of self-judgement for the outcome

5. ?If the root cause of the bad outcome is in your circle of Control or Influence, use this as the starting point to build strategies to do things better next time. No amount of beating yourself up is going to change the past, but you can use the previous negative outcome in a positive fashion to fuel self-improvement and minimise the chance of a repeat negative outcome in the future.?

A word of warning in wrapping this newsletter up, some of this reflection is heavy stuff. If you’re carrying moral injury that needs processing, this work is best done with the guidance of an appropriate psychologist or counsellor. No military member or first responder would face a high-threat situation alone, they would do it with their team. Facing personal demons is no different, build your team (including appropriately trained mental health professionals) and tackle the demons together.?

Thanks for reading! If you want to support my content and get a signed copy of one of my books in the process, please subscribe to my brand new Patreon page.

Until next Friday, stay safe, and don’t forget to have some fun!

Cheers,

Dr Dan Pronk

References

[1] Litz, Brett T.; Stein, Nathan; Delaney, Eileen; Lebowitz, Leslie; Nash, William P.; Silva, Caroline; Maguen, Shira (December 2009). "Moral injury and moral repair in war veterans: A preliminary model and intervention strategy". Clinical Psychology Review. 29 (8): 695–706.

[2] Molendijk, Tine (2018). "Toward an Interdisciplinary Conceptualization of Moral Injury: From Unequivocal Guilt and Anger to Moral Conflict and Disorientation". New Ideas in Psychology. 51: 1–8.

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