The Clinician in the Room: Projection, Power, and Moral Injury in Psychosis Care
- 5-5:30pm Unrecognized and Untreated: Moral Injury Associated With Psychiatric Hospitalization - James Black, MD PhD, Wendy Haight, PhD
- 5:30-6pm Whose Insight Is it Anyway? Therapist Projection and the Folly of Targeting Anosognosia - Lionel Wininger, PhD
Unrecognized and Untreated: Moral Injury Associated With Psychiatric Hospitalization - James Black, MD PhD, Wendy Haight, PhD
Moral injury (MI) is the lasting distress caused by violations of core ethical values. It affects combat veterans, healthcare workers, and other populations, significantly increasing suffering, dysfunction, and suicide risk. Psychiatric hospitalization can violate core ethical values MI in many ways and with lasting harm, yet moral injury remains unstudied despite in both patients and clinicians. MI is associated with moral cognition and emotions, whereas PTSD is associated with danger and fear, and different brain mechanisms are involved.We describe MI in 32 hospitalized patients with severe mental illness. While some MI stemmed from behaviors during illness or experiences of stigma, the hospital experience itself frequently caused profound ethical violations: involuntary holds, physical restraints, forced medication, and civil commitment have traumatized patients, who perceived these as assaults on dignity and autonomy. Healthcare professionals administering coercive treatments also suffer MI, caught between therapeutic duties and causing harm.Patients experienced lasting distress from loss of bodily autonomy, betrayal by trusted clinicians, challenges to identity, and powerlessness. Some patients showed limited distress regarding violations, revealing MI's heterogeneity among people with different brains and experiences. Despite the apparently high prevalence and severity, psychiatric institutions neither recognize nor treat MI in patients or staff.This case series demonstrates that: (1) psychiatric hospitalization frequently inflicts MI through necessary but coercive care; (2) this can cause severe, unaddressed suffering; (3) both patients and professionals can be deeply affected; and (4) current practice ignores the ethical dimension of trauma. These findings establish an urgent need for developing evidence-based methods for recognizing and treating moral injury in a psychiatric hospital.
Whose Insight Is it Anyway? Therapist Projection and the Folly of Targeting Anosognosia - Lionel Wininger, PhD
The concept of insight occupies a central role in psychosis treatment, yet its clinical meaning is rarely examined with the scrutiny it deserves. This presentation draws on psychoanalytic frameworks to examine two underexplored dimensions of the therapist-patient relationship in psychosis care: 1) psychological contagion, the unconscious fear therapists harbor about being "infected" by severe mental states; and 2) the clinical risks of targeting anosognosia as a treatment goal when therapist and patient unknowingly collude around harmful, simplistic, or stigmatized narratives of psychosis.
