Moral Injury – From Combat To Counselling

Mental health is not a destination, but a process. It’s about how you drive, not where you’re going. -Noam Shpancer

These are difficult times brought out by a severe pandemic and the psychological impacts of which are beginning to show on medical and non-medical health personnel, especially the frontline workers. Moral Injury is comparatively a new concept though it has been around since ancient times. “Moral injury” or “moral distress” occurs when someone engages in, fails to prevent or witnesses acts that conflict with their values or beliefs. It usually involves experiences that contradict an individual’s personal or shared values, expectations, or such as having to make decisions that affect the survival of others. They will have to make decisions where all options will lead to a negative outcome, engaging in an act of wrongdoing, failing to prevent serious unethical behaviour, witnessing or learning about such an act, or betrayal by trusted others (Norman & Maguen, 2020; Campbell, et. al, 2018). Most often, healthcare workers do not experience significant distress from difficult situations at work because of the training and preparation that they have received. However, in unprecedented contexts, such as a pandemic like the current COVID-19, some may have difficulty with unfamiliar and potentially distressing work experiences (Norman & Maguen, 2020). Moral injury can weaken the trust in one’s self, others, and the world. They can shatter a person’s sense of moral identity and challenge their belief in the goodness of others or one’s self.

Potentially Morally Injurious Events And Stressors:

Since moral injury results from participation in or observation of action/s that challenge one’s core values, risk can be characterized in terms of potentially morally injurious events (Griffin et. al, 2019;“Preventing and Addressing Moral Injury Affecting Healthcare Workers During the COVID-19 Pandemic,”(2020)). Events that place healthcare workers at risk and act as stressors may include the following (Williamson, et. al, 2020):

• Loss of a vulnerable person (e.g., an elder or child).
• Situations where death may have been the result of insufficient resources or staffing, or issuing directions that result in the death of a patient particularly when these issues are perceived to have been preventable.
• Having to save one patient over another due to limited equipment or resources.
• Following clinical instructions that the worker feels are immoral.
• Confusion about the illness and how to manage it.
• The constant change in the ways of treatment due to the lack of effective treatment.
• Lack of clarity around the indication of use of PPEs and shortage of PPEs.
• Worry about being unskilled and untrained. 
• Fear of transmitting the virus to other patients, colleagues or loved ones.
• Inadequate testing to diagnose the virus in a timely manner. 
• Incidents of hostility and aggression towards healthcare providers especially medical staff.
• Isolation from family and other support.
• Intense scrutiny of media.
• The workload with an increasing number of suspected and confirmed cases.
• Progressively depleted workforce due to illness and isolation of staff.

Even those who are dealing with non- COVID patients are at risk of moral injury. They have a constant fear of attending a genuine patient and the fear of contracting the virus. Apart from that the financial stress of keeping their services open, paying their staff, paying bills, and adding on the extra expenses of buying PPEs and other safety kits. 

According to Talbot and Dean (2018), moral injury is a significant factor behind high rates of burnout and suicide among physicians. For healthcare workers, there is a violation of one’s sense of “what’s right” along with fear and anxiety as they are in direct contact with the people who have been infected by COVID- 19. 

Symptoms:

Unlike several mental health conditions such as depression or post-traumatic stress disorder, moral injury is not a mental illness (Greenberg et.al, 2020). According to Norman & Maguen (2020) and “Preventing and Addressing Moral Injury Affecting Healthcare Workers During the COVID-19 Pandemic,”(2020) however, there are feelings or symptoms such as –

• Experiencing difficult emotions like guilt, shame, anger, sadness, anxiety, and disgust
• Sense of betrayal
• Negative thoughts about themselves or others
• Loss of meaning and purpose
• Loss of faith in people and avoidance of intimacy
• Loss of religious faith or loss of faith in a just world
• Beliefs about being bad, damaged or unworthy
• Disturbing and upsetting thoughts and images that may result from moral injury.

However, if moral injury goes unaddressed, it may progress beyond the symptoms mentioned above and result in significant and persistent negative changes in behavior or habits. According to Norman & Maguen (2020) and “Preventing and Addressing Moral Injury Affecting Healthcare Workers During the COVID-19 Pandemic,”(2020), some individuals may develop, or simultaneously experience, mental health disorders such as depression, anxiety, PTSD and/or few other symptoms mentioned below:

• Self-isolation
• Hypervigilance
• Social problems
• Drastic changes in worldview
• maladaptive behavior (e.g., overworking, overeating)
• Intrusive memories
• Demoralization
• Difficulties in concentrating
• Self-harming behaviors and/or suicidal ideations
• Changes in sleep
• Not feeling as much empathy or compassion as one usually feels etc.

Intervention Strategies:

Given that the current COVID-19 environment poses the potential for mental health impacts and moral injury, it is crucial to implement a preventative and early intervention approach to reduce risks and maximize protective factors for healthcare workers. It is crucial to take care of our psychological well-being even though it seems difficult and impossible in this situation. We can start with our family by making sure that each individual is managing not only their physical health but also their mental health. If someone in the family is in isolation, it is important to try to communicate in safe ways (phone or online), offer support, and check in about mental well-being.

What are some of the ways positive self- care can be practiced?

1. Engage in positive self-care both within and outside of work.
2. Engage in positive self-talk, as well as manage both personal and external expectations as it helps prevent the onset of symptoms from moral injury.
3. Model healthy sleep, proper nutrition, regular exercise, and stress management techniques. 
4. Engage in brief problem-solving exercises that will help identify the barriers and talking actions towards midying them for a better attainment of goal. For example, making phone / video calls to family incase healthcare workers are unable to meet them;  expressing simple gratitude to colleagues by asking about their day; reaching out to co workers by listening / sharing out feelings; confiding with the coworkers and sharing casual conversations with them (Williams et.al.,2020)
5. Practicing mindfulness can help promote emotion regulation and reduce depression and anxiety (Hempel et al., 2014)
6. Identify physical quiet spaces to decompress and recharge during shift breaks that would help normalize amid stressful working conditions (Williams et.al.,2020)
7. Engage oneself in online courses to help medical staff manage common psychological problems
8. Make use of self-help apps to encourage meditation, positive self-talk, relaxation techniques
9. Seek professional support if needed by contacting dedicated mental health helplines that are predominantly staffed by mental health professionals to provide emotional and psychological support to those experiencing psychological distress or seek help from mental health professionals that are stationed at staff rest areas that provide face-to-face support. 

Strategies a supervisor can adopt to initiate self- care in the team?

Being a supervisor, one can follow a few strategies to help reduce the workplace stressors, ensuring enough support to the general welfare as well as psychological support for healthcare staff. Few of those strategies may be:

1. Initiating Peer support programs,
2. Providing designated break times for staff
3. Pairing staff with “Battle Buddies” to ensure that everyone is provided with a key and immediate layer of support (Smith, 2020),
4. Alternating shift system to allow frontline workers periods of rest,
5. Provision of adequate information on stress management, identification of burnout and available support services for staff,
6. The adequate facility of accommodation can be made available to staff to temporarily isolate themselves from their family and reduce concerns around transmitting the virus, etc.

The importance of seeking therapy by clinicians / mental health professionals:

Additionally, clinicians or other professionals who provide care for moral injuries and other associated mental illnesses should also be clearly aware of the potential to refuse to talk about guilt and shame and instead, focus on other stressful factors during therapy. This avoidance in therapy may lead to even poorer outcomes (Greenberg et.al, 2020; Salkovskis et. al., 1999).

How SWAASTHI can help?

For healthcare workers, this situation is a cocktail of issues for which they lack solutions. As long as the COVID-19 outbreak does not subside, many healthcare workers may encounter situations where their helplessness owing to a lack of resources will succumb to their spirits, causing a great deal of psychological damage to the individual. Despite the fact that not all staff will be adversely affected by the challenges lying ahead, no one really is invulnerable. This pandemic situation will not only take a physical toll but also a tremendous psychological toll.

Being a frontline worker, if you’re feeling overwhelmed or if someone you care about or know is experiencing some of the symptoms mentioned above, reach out for support and help at SWAASTHI. This psychosocial helpline provides for professional counseling and emotional support and is a dedicated helpline for frontline health workers. It addresses psychosocial concerns faced by healthcare staff and provides mental health and psychosocial support. Having a sensitive, affirmative, supportive, confidential space can be greatly helpful in the process of managing the pain. SWAASTHI is run by a trained and qualified team of counselors. It is a completely anonymous and confidential service that can be availed free of cost over the telephone by reaching out to the number: 9152987824 between Monday and Saturday from 10 am to 06 pm. telephonic counseling services at SWAASTHI can be availed in six different languages: English, Hindi, Marathi, Bengali, Malayalam, and Kannada.

A phone call may be just what one needs as the first step towards a healthier mind in this difficult time.

References :

Campbell, S. M., Ulrich, C. M., & Grady, C. (2018). A broader understanding of moral distress. In Moral Distress in the Health Professions (pp. 59-77). Springer, Cham.

Chen, Q.; Liang, M.; Li, Y.; Guo, J.; Fei, D.; Wang, L; He, L.; Sheng, C.; Cai, Y.; Li, X.; Wang, J. & Zhang, Z. (2020). Mental health care for medical staff in China during the COVID-19 outbreak. The Lancet Psychiatry 7(4),e15-16. DOI: https://doi.org/10.1016/S2215-0366(20)30078-X

Preventing and Addressing Moral Injury Affecting Healthcare Workers During the COVID-19 Pandemic. (2020).  COVID-19 Healthcare Resilience Task Force. Retrieved from https://files.asprtracie.hhs.gov/documents/bh-addressing-moral-injury-for-healthcare-workers.pdf 

Dewey, C.; Hingle, S.; Goelz, E. & Linzer, M. (2020). Supporting Clinicians During the COVID-19 Pandemic. Annals of Internal Medicine, 172:11, 752-753.

Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ, m1211. https://doi.org/10.1136/bmj.m1211

Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., … & Maguen, S. (2019). Moral injury: An integrative review. Journal of traumatic stress, 32(3), 350-362.

Hempel, S.; Taylor, S. L; Marshall, N. J.; Miake-Lye, I. M.; Beroes, J. M.; Shanman, R.; Solloway, M. R. & Shekelle, P. G. (2014). Evidence map of mindfulness. VA-ESP Project #05-226. Health Services Research & Development Services, Department of Veterans Affairs.

Kang, L.; Li, Y.; Hu, S.; Chen, M.; Yang, C.; Yang, B. X.; Wang, Y.; Hu, J.; Lai, J.; Ma, X.; Chen, J.; Guan, L.; Wang, G.; Ma, H. & Liu, Z. (2020). The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. The Lancet Psychiatry, 7(3), e14. DOI: https://doi.org/10.1016/S2215-0366(20)30047-X

Norman,S. B. & Maguen, S.(2020). Moral Injury. U.S. Department of Veterans Affairs, National Center for PTSD. Revived from  https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp

Salkovskis,  P. M.; Clark, D.M.; Hackmann, A.; Wells, A. & Gelder, M.G.(1999). An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia. Behaviour Research and Therapy; 37:559-74. DOI: 10.1016/S0005-7967(98)00153-3 10372469

Smith, R. S. (2020). Lessons from a different war for preventing moral injury among clinicians treating Covid-19. STAT. Revived from https://www.statnews.com/2020/04/01/lessons-different-war-protecting-clinicians-moral-injury/

Talbot, S. G. & Dean, W. (2018). Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT. Retrieved from  https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/

Moral Injury in healthcare Workers on the Frontlines of the Coronavirus (COVID-19) Outbreak (2020). U.S. Department of Veterans Affairs, National Center for PTSD.  Revived from https://www.theschwartzcenter.org/media/Moral-Injury-Covid-19-Fact-Sheet-040420_JH.pdf

Watson, P.; Norman, S. B; Maguen, S.; & Hamblen, J. (2020). Moral Injury in Health Care Workers. U.S. Department of Veterans Affairs, National Center for PTSD. Revived from https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury_hcw.asp

Williamson, V.; Stevelink, S. & Greenberg, N. (2018). Occupational moral injury and mental health: Systematic review and meta-analysis. The British Journal of Psychiatry, 212(6), 339-346. DOI: https://doi.org/10.1192/bjp.2018.55.

Williamson, V., Murphy, D., & Greenberg, N. (2020). COVID-19 and experiences of moral injury in front-line key workers. Occupational Medicine, 70(5), 317–319. DOI: https://doi.org/10.1093/occmed/kqaa052

Williams, R. D., Brundage, J. A., & Williams, E. B. (2020). Moral Injury in Times of COVID-19. Journal of health service psychology, 1–5. Advance online publication. DOI: https://doi.org/10.1007/s42843-020-00011-4