Torree McGowan hoped the worst of the Pandemic was behind her. She and her colleagues wore layers of protection before seeing patients, but they were still able to keep things running smoothly. The central Oregon region, which was ringed by snow-capped mountains, had largely escaped the first wave of COVID waves.
The Delta variant of the virus wreaked havoc in central Oregon. She had to tell many patients that she was powerless to help them because she didn't have any drugs that worked late in the disease. It feels terrible. It is not what we signed up for.
It wasn't just patients who couldn't help. Everyone else was also a part of it. People still approach health care emergencies with the expectation that they'll be taken care of quickly. There were no beds in the middle of the surge. She doesn't have a helicopter that can fly between her hospital and the next one because they're all full. A patient with a suspected colon cancer showed up in the ER bleeding from behind, and she needed to be admitted immediately for testing. The patient had to be sent home because there weren't any beds left.
She needed to abandon her standards and watch people die. More and more patients stopped caring about her or anyone else. She assumed that she and her patients played by the same rules and that they would support her or at least treat her fairly.
The moral calculus turned on its head as the virus increased in strength. Patients without vaccine walked into the exam room. They cursed her because she told them they had a disease. Many people don't care if they make someone sick or kill them. Their ruthlessness frightened her because of her husband's illness. I do hours and hours of continuing education monthly. Every patient that I have made a mistake on, I can tell you about it. When I place so much value on someone's life, it's a lot to carry.
When people face situations that violate their conscience or threaten their core values, it's called moral injury. It can be difficult for those who wrestle with it to forgive themselves or others. Millions of people are affected by the condition. Doctors have to admit a few patients and turn away many others. Soldiers kill civilians to finish their assignments. When no one wants to adopt an animal, it's time to put it down.
Most people don't realize that the trauma is much worse than they think. Wendy Dean says that it is clear to her that it is all over the place. Social workers, teachers, lawyers are what it is. Survey studies in the U.S. and Europe show that many teachers and doctors have faced morally injurious situations. More than half of K–12 professionals, including teachers, moderately or strongly agree that they have faced morally injurious situations involving others, and about half of physicians have been exposed to potentially morally injurious events at high levels. Many people don't have the vocabulary to describe what is happening to them, so artificially low figures are possible. The mental health effects are huge. The meta-analysis found that moral injury was associated with higher rates of depression and suicidal impulses.
The moral injury crisis became more pressing as ethical wrenching dilemmas became the new normal for frontline workers. Store employees had to put their lives at risk to make a living. It's nearly impossible for lawyers to represent clients adequately if they can't meet them in person. No matter how hard you work, you are always going to be falling short.
There is a growing belief that moral injury is a different condition than depression or post-traumatic stress disorder. The moral injury treatments aim to help people deal with ethical traumas. They stress the importance of community support in long-term recovery and encourage people to face moral conflicts head-on rather than blotting them out. Some clients make plans to make up for harms committed.
Scientists and clinicians agree that a key step in healing morally injured people is grasping the true nature of their situation. They aren't "bad seeds" or "irredeemable" They can't fit the criteria for a mental illness. They are suffering from a lack of connection between their moral principles and reality. The sense of who you are as a person has been brought into question in moral injury.
The term "moral injury" was first used by Jonathan Shay in the 1990's. In the ancient Greek epic The Iliad, the hero Achilles lost his best friend Patroclus in battle and then tortured himself because he failed to protect him. The term "battle fatigued" was used when world wars broke out in the 20th century. Many of them were tortured not by shell shock but by war crimes. According to Andrew Jameton, moral distress was not limited to the military realm. He wrote that constraints made it nearly impossible to pursue the right course of action.
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The waves of U.S. soldiers returning from the Vietnam War inspired the first rigorous study of moral injury. The Department of Veterans Affairs Boston healthcare system saw a lot of struggling vets who weren't responding well to counseling during the deployment. They seemed to be stuck in a state of grief over what they had done. Litz was reminded of one of his past therapists who was detached from the room. Litz discovered why after the fact. He killed a child that was just biking down the road when he opened his car door. He was shattered as can be. I saw what that was.
Litz thought he was seeing a different type of condition than depression and post-traumatic stress disorder. When someone's life or safety is in danger, it's a good time to start getting Post Traumatic Stress Disorder. Most of the trauma Litz saw in vets had nothing to do with threats. He says it was related to mounting guilt and hopelessness, as well as the lack of meaning and participation in grotesque war things. At least they were pariahs.
Litz decided to develop a working concept of moral injury so that researchers could study it in more detail and figure out how to treat it. He thought there would be broad impacts and that the culture would be affected. It was necessary to bring science to the table. It was necessary to define the terms.
In 2009, Litz and his colleagues published a comprehensive paper on moral injury, detailing common moral struggles veterans were facing and suggesting a treatment approach that involved making personally meaningful reparations for harm done. Not all morally injurious events cause moral injury. You might not experience moral injury if you kill someone and feel justified in doing so. When you have a vision of the world as fundamentally fair and good, things can destroy that vision.
Rita Nakashima Brock was a visiting scholar at the Starr King School for the Ministry in Berkeley. Brock was going to convene the Truth Commission on Conscience in War, an event where returned soldiers would testify about the moral impact of engaging in battle.
The personal roots of Brock's antiwar activism could be seen. Her father left his family after returning from Vietnam. He lashed out when he spoke to his family. She says that her father was so different that she didn't want to be at home anymore. Brock's cousin helped her piece together more of his story. A young woman was tortured and killed while he worked with a guide. He was horrified at what had happened, and he knew his ties to the guide could have put her at risk.
Something clicked when Brock read Litz's paper. She says that when she and her colleague read it, they exclaimed, "Oh, my God, this is what the whole thing is about." We told everyone to read it.
Her committee set out to create programs to inform the public about moral injury. Brock received a grant from the Lilly Endowment to establish a moral injury research program. Brock arranged a meeting with Mike King, CEO of the national nonprofit Volunteers of America, after Tommy Potter mentioned his work to him.
VOA had long focused on helping marginalized populations, and when Brock described the moral injury concept to King, "it just instantly resonated with every area of our work" The place is profoundly there with veterans. I can see it in our work with people coming out of prison. VOA funded the creation of the Shay Moral Injury Center in Alexandria, Va., named for Jonathan Shay. Brock headed up research and training programs to understand and treat moral injury.
The moral injury research at Litz was beginning to take off. A measure of exposure to events that can cause moral injury was tested by Litz and his health care colleagues. The scale gauged how much people felt they had violated their morals, how much they felt others had betrayed important values and how much distress they felt as a result. In a study of five VA clinics across the U.S., people who had experienced moral injury were more likely to commit suicide.
There is new research that supports Litz's idea that moral injury is different from post-traumatic stress disorder. According to a study done by researchers at the Salisbury VA healthcare system in North Carolina, people with moral injury have more activity in the brain than those who only have post-traumatic stress disorder. According to a 2016 study by researchers at the University of Texas Health Science Center at San Antonio, people who suffer moral trauma show different brain metabolism patterns than people who don't. Theories about moral injury are supported by the results.
Margaret Kibben, the current chaplain at the U.S. House of Representatives, was one of the people Brock forged connections with. One of Kibben's recent talks was about morality. Brock reports that the event drew more members than usual and they all wanted to talk about their experience. A growing trend in the study of moral injury is collaboration between scholars and clergy members who want to help people through it. Anna Harwood-Gross says that moral injury brings together a lot of disciplines. It's rare to see articles written by psychologists and chaplains.
From 2020 onward, moral injury research and inquiry took a different turn. Dean and her colleagues at the George Washington University School of Medicine and Health Sciences published a journal article that urged employers to monitor moral injury's effects. They said they needed time, energy and intellectual capacity to make peace.
Dean sees a lot of moral injury in health care. She says providers are dying by a thousand cuts because they have to give people subpar care or nothing at all. They don't think they're good. They think they're not good enough. No one is saying, 'You don't suck.' This is a moral problem. The Physician Support Line was founded by a Psychiatrist. Is I really a failure? I wonder if I failed my call. Am I no longer a person?
Those words would make him feel good. An ambulance pulls out of the parking lot as she approaches the hospital during a COVID surge. It is most likely another transfer, according to McGowan. Someone claiming one of the few available COVID beds in the region means someone else may have to do without. There are warning signs of other moral compromises ahead, according to the ER. There is a critical shortage of green top tubes. There is no blue tops for 0 days. She may not be able to order blood tests for patients when the tubes run out.
The outside world feels disturbingly normal on many days during the Pandemic Surge because of the dislocation of shuttling between the ER and the outside world. She wonders how people can casually chat and sip coffee when a person is sent home. The larger world is spinning with barely a wobble while her own moral world is knocked off- axis.
She says seeing a therapist has helped her deal with the situations she has faced. She continues to wrestle with moral dilemma, reflecting a growing consensus that traditional therapy may not always be enough to help morally injured people get past demons. Basic cognitive-behavioral therapy is the gold standard for insurers. Some researchers believe that cognitive behavioral therapy is enough to treat moral injury.
One sticking point is that the focus of the program is to correct distorted thought patterns. Harwood-Gross says ethical distress is genuine for people with moral injury who have experienced wrenching events that upend their value system. People with moral injury may not be satisfied if they try to retrain their thoughts.
In Harwood-Gross's experience, therapies for post traumatic stress disorder can fall short for morally injured patients. The exposure approach doesn't help clients resolve ethical conflicts because it doesn't teach them how to adapt to traumatictriggers. Harwood-Gross says that effective moral injury counseling is more about the process. There has to be a movement that asks how to see it for what it is and what to do with it. The approach is a more spiritual one.
Litz has created therapies that more directly address clients' needs. adaptive disclosure was pioneered by Litz and other providers. A pastoral narrative disclosure approach has been developed by researchers at Australia's La Trobe University. Discuss moral issues with a spiritual adviser instead of a doctor.
The therapies stress the importance of morality. They encourage their clients to accept uncomfortable truths. It is possible for counselors to help clients develop strategies for making amends or pursuing closure after an accident.
There is early evidence that these approaches make progress where others can't. In Litz's initial trial of adaptive disclosure, participants' negative beliefs about themselves and the world decreased. The therapy helped resolve their moral issues, according to most.
A 173 person clinical trial of adaptive disclosure has just finished at VA sites in Boston, San Diego, Calif., Minneapolis, San Francisco and central Texas. According to Litz, adaptive disclosure boosted participants' levels of functioning over time. Litz wants to restore people's ability to thrive rather than wipe their moral slate clean. When you think about what happened, you will always feel bad. The new normal will be that. There is a question about how to rehabilitate and live a good life.
Brock's VOA team uses a suite of peer support programs. The Shay Moral Injury Center's core group offering, Resilience Strength Training (RST), is a 60-hour, in-person program where people with moral injury share about events that spurred it, engage in talks about forgiveness (for themselves or others) and do exercises to help them define their The VOA program participants scored an average of 46 percent higher on a scale of post-traumatic growth and 19 percent higher on a scale of perceived meaning in life than they had before beginning the program. Plans to restart the in-person program are currently under way.
VOA developed an online version of RST for health workers. Attendees can sign up for as many sessions as they'd like.
Several people in a recent ReST video meeting talked about their moral challenges on the health care front lines. A nurse spoke about how she felt powerless as a patient abused her. The leaders of the peer session, both war vets, listened closely to each attendee's dilemma and empathised with them. The invisible enemy is what frontline workers are experiencing, Wong said. You might feel like you let other people down. You can observe people engaging in bad behavior. You're not the only one. We are here to lend a hand.
There is a marked power differential between therapist and client. VOA has groups where members and facilitators take turns being vulnerable. Brock says that this openness builds bonds that support people's recovery. She says that the people who know them well are the ones who matter. You have an identity crisis whenMoral Injury is a relationship break. You have to make new friends.
Austrian psychologist Viktor Frankl believed that a personal search for meaning could fuel trauma recovery and developed therapies that bolster clients' sense of purpose. Frankl focused on his love for his wife and his commitment to rewrite a research manuscript when he was in the death camp. Frankl wrote, "everything can be taken from a man but one thing, to choose one's attitude in any set of circumstances, to choose one's own way." Frankl created a treatment approach called logotherapy which emphasized a clear sense of purpose to help people endure the suffering.
Litz and Harwood-Gross encourage clients to accept the depth of inhumanity in the world rather than try to hide it. In the midst of what has happened and what is still happening, how can I find meaning in life was Frankl's question.
Brock says partnerships between clinicians and religious leaders help facilitate the search for meaning. The role of the professional in mental health treatment is not to be personal. Clergy are great at connecting with morally injured people who have doubts about their own humanity. According to Brock, complaints don't bill by the hour. They are spending time with people.
There is a need for moral injury treatments for people who are fighting guilt. Old hands on the front lines note that nudging the morally injured toward self-repair is only part of the solution. If your employer doesn't hire more staff or provide more resources, you'll have to keep making decisions that violate your ethics, compounding your trauma. A lot of problems that cause moral injury need systemic solutions.
Many organizations are leaving the easy way out. Instead of launching systemic reforms that could help head off moral injury, they're offering "wellness solutions" such as massage and meditation tips, which can amount to putting a Band-Aid on a canker sore. New York City ER doctor Jane Kim says she will throw up if she has to listen to another person talk. In-depth, system-wide conversations about what frontline workers need to do in order to do their jobs ethically would be better. She believes that the reforms would benefit both workers and those they serve. She says they care for others. How can we help other people if we are broken ourselves?
Similar thoughts come to mind as the Pandemic drags on. There aren't enough providers to give patients adequate treatment because workers have quit in droves I compare it to the death march. There is no ending in sight. She has a plaque on her bookshelf that says "You never know how strong you are until being strong is the only choice you have."
McGowan's husband grew just a fraction of his usual hay crop last year because of the dry weather. They face the same dilemma when forces beyond their control affect their intentions.
She tries to focus on the good things she has been able to do. She is a lieutenant colonel in the Oregon Air National Guard and her unit has immunized more than 100,000 people against Covid.
She has had a lot of dead-end choices and regrets, but mentoring other doctors has made her feel better. It has helped me to be a bit more compassionate to myself. I try to repeat to myself the same words that I say to them. She exhales and hesitates. You are a great doctor. I would allow you to look after my family.
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