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Moral Injury and Being Trauma-Aware

While trauma comes from the experience of a threat to our physical or psychological safety or that of others, moral injury is when we believe we or others have been responsible for unmet moral or ethical obligations.  Repeated or unresolved issues of moral concern can develop to become moral injury, which is not a recognised mental health condition yet but can lead to PTSD, depression, suicidal ideation, and suicidal completion. Exposure to morally injurious events does not necessarily lead to moral injury nor trauma. Psychiatrists now recognise that most people manage the shock of an adverse event by talking about and exploring their experiences with people they are close to or who were involved in the same or similar traumatic events.  

RK Papadopolous (2020) described people who experience feelings of moral injury as being “Troubled by the unpredictable and catastrophic turn of events and facing the life-shattering consequences of the experienced adversities, they are shaken to the core of their being, and in deep anguish they struggle to make sense of what has befallen them and to reassess most aspects of their lives.”  

In the pandemic the specific experiences of black and minority ethnic communities, the early shortages of PPE, news about public figures breaking COVID rules without accountability or ‘moral address’ will all have added to the potential for individuals to feel moral injury.  This includes the unique risk of moral injury or vicarious moral injury to NHS leaders who were responding to the demands of the pandemic, making thousands of decisions for the best possible provision of health care. 

Supporting those staff who have experienced moral injury has not yet been well researched in the civilian population. There are suggestions below from a Lancet Psychiatry 2021 article based on the experience of work with military veterans, from reports from veterans themselves, and also from Dr Dominic Murphy, Head of Research at Combat Stress and Professor at King’s Centre for Military Health Research. 

What will work well? 

  • Strong leadership which legitimises the space to experience trauma and manage psychological distress and reduces the stigma of help seeking.  
  • Acknowledging the existence of the feelings of trauma and or moral injury without judgment. 
  • Work towards repairing moral injury by recognizing the continuing existence of shared ethical and moral norms even if they have been violated.  
  • Taking responsibility for that which you are responsible. 
  • Establishing trained peer support networks that are not staffed by mental health specialists. 
  • Setting up long term peer support for leaders. This could be an arrangement across trusts to protect confidentiality. 
  • Arranging supervision. For everyone to regain some equilibrium and to protect themselves from long term ill health, psychological contracts (implicit expectations and mutual obligations held between an employee and employer) may need to be reassessed and potentially renegotiated because of the changed working practices that have been experienced. Through research, supervision has been shown to be the ‘critical juncture’ for building psychological contracts backed up by organisational behaviour.  
  • Considering attending Acceptance and Commitment Therapy (ACT) session. The aim of ACT is to promote non-judgemental acceptance of internal experiences and committed action towards value-congruent behaviour. Research carried out in 2019 for the International Society of Traumatic Stress Studies, confirmed positive qualitative outcomes from a small study on the attendance at Acceptance and Commitment Therapy sessions. 

Self-care at times of moral distress or trauma and in preparation for ongoing adversity 

(Based on Combat Stress and work by Cynda H Rushton PhD, MSN, RN, Prof of Ethics at John Hopkins University) 

  • Have a plan to commit to healthy practices: nutrient rich eating, practising sleep hygiene, rest, exercise. 
  • Connect with ‘nurturing’ people when you can. 
  • Limit your access to news, media and other sources of negative information. 
  • Avoid alcohol as a means of relaxing – it has a depressive effect and gets in the way of the body processing any stress or trauma it has experienced and increases the risk of developing PTSD. 
  • Cultivate the emotional intelligence that goes along with unselfish, altruistic behaviour appreciating your intentions to do your best for everyone.   
  • Try to avoid identifying with others too deeply as this increases the risks of vicarious moral distress or injury. We are separate bodies and keeping our own identity allows us to show more compassion. 
  • Use grounding or somatic (body awareness) based strategies to help you notice your body’s instinctive responses to moral or ethical challenge and your ability to manage them e.g. mindfulness body scans, 4-7-8 breathing (4 counts in, hold for 7, exhale for 8). 
  • Build a personal ‘zone of resilience’. Pause and breathe calmly before entering a challenging situation. 
  • Foster situations where you can safely explore moral or ethical dilemmas with others before or after the event. 
  • Practice self-forgiveness. Institutions and people fall short all the time, and our expectations are often not met. As a result, we can become resentful, feel futile or we freeze into inaction and numbness. Recognise the difficulties in your role and be forgiven. Appreciate your limitations with compassion. Remember you have been and are doing the absolute best you can, at all times.  

References: 

Shale S. (2020) Moral injury and the COVID-19 pandemic: reframing what it is, who it affects and how care leaders can manage it. BMJ Leader 2020;4:224-227. 

Papadopoulos RK (2020) Moral injury and beyond: understanding human anguish and healing traumatic wounds.  Routledge, 1st edition. 

Williamson, V., Murphy, D., Phelps, A. Forbes, D. and Greenberg, N. (2021). Moral injury: the effect on mental health and implications for treatment. The Lancet Psychiatry, [Online]. Published March 17, 2021, 1-2. Available at https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(21)00113-9/fulltext [Accessed 28 March 2021].  

Aujla, R. (2020) How to Heal a Moral Injury – Helping Healthcare Workers Heal Mental Wounds in the Aftermath of Coronavirus with Dr Dominic Murphy. The Doctor’s Kitchen Podcast. [Podcast]. [Accessed 23 March 2021]. Available from: https://thedoctorskitchen.com/mental-health/51-how-to-heal-a-moral-injury-helping-healthcare-workers-heal-mental-wounds-in-the-aftermath-of-coronavirus-with-dr-dominic-murphy 

Wainwright, Delia & Sambrook, Sally. (2012). Managing the Psychological Contract in Health and Social Care: The Role of Policy. 10.1057/9780230355026_3. 

Weberg, D., 2021. Episode 50: Building resilience in the face of moral suffering. The Handoff Podcast. [Podcast]. [Accessed 28 March 2021]. Available from: https://www.trustedhealth.com/the-handoff-podcast/cynda-rushton