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Professor Neil Greenberg

Between the devil and the deep sea, there lies moral injury

8 minutes read

July 22,2021

The COVID-19 pandemic has pushed our global healthcare systems and workers to their limits. Clinical infrastructure around the world crumbled as waves of the virus swept across countries. Many doctors and nurses have had to make seemingly impossible decisions, including distributing limited resources, choosing which patients to give oxygen to, and which medicines to try, amongst others. Our healthcare front-liners have been in morally ambiguous situations with no 'correct' answers, but decisions still had to be made. By studying past traumatic events, we know that we can expect substantial mental healthcare repercussions in this community due to moral injury unless we act today. It's worth spending a few minutes understanding the history of moral injury, what it means for healthcare workers in the pandemic, and how we can build resilience.

The concept of moral injury has been around for centuries but was highlighted in military contexts during the Vietnam War. American troops found themselves in morally unclear events and were tired, exhausted, and traumatised but, on many occasions, had to act without sufficient information to enable them to properly assess the situation. When they returned home, they experienced psychological distress symptoms linked to events beyond the death and trauma of war, and we observed 'moral injuries'. Many of them who identified as 'family oriented' and 'good, loving parents' began to feel disappointed in themselves for what they had done and wondered whether they could ever be forgiven. They felt betrayed and let down by people who sent them to war and felt they should never have been in that situation in the first place.  

The cycle of mental distress that comes with moral injury was never explicitly considered, even though we had witnessed it before, for example, during the two World Wars. Once we realised that it's not only the death and trauma of war that can cause long term mental health conditions but also moral injuries, we began to look beyond the military. We started understanding the implications of moral injury on mental health in various other professions such as media, policymakers, and healthcare workers.

Unfortunately, moral injury in a situation is often only recognised after it already happens, just like how we found ourselves in the middle of a pandemic. Although healthcare workers regularly deal with uncertainty and ambiguity, the last 15 months have very much changed their meaning. As the volume and intensity of the COVID-19 virus increased, healthcare workers were required to make more judgements in much greater uncertainty without relying on experience. The virus had its own unknowns; its ability to spawn variants, its contagiousness, the efficacy of a vaccine, and much more. The lack of access to manpower, equipment, medicines, and information increased the strain on front-liners to a breaking point. While continuing to exercise judgment with massive uncertainty, many healthcare workers began to feel the distress of moral injury.

There are three ways in which we experience moral injury; (1) acts of commission (things you or other people have done), (2) acts of omission (things you or other people could not or did not do), and (3) betrayal (being let down by people you thought you could trust or who should have been looking out for your welfare). During the first wave in the UK, we surveyed 25,000 healthcare workers and unearthed some interesting data. We found that the most significant impact of moral injury was betrayal. The experience of betrayal in nurses usually manifested in feeling let down by their teams and managers, and for doctors, it manifested as disappointment in society and healthcare systems. So many felt let down that they were doing their best in the worst circumstances. Still, society continued to socialise, refused to wear masks, and indulged freely in concerts, weddings, and other events.

While we see the light at the end of the tunnel, we are still in the middle of a very challenging situation. Therefore, we need to cautiously think about the recovery of ourselves and our healthcare workers.

Examining traumas more generally, we find that there are three stages; pre-trauma, trauma, and post-trauma. The risk of developing long term psychological distress can vary from person to person based on who they were (socioeconomic status, history of mental illness, social support, poor education etc.) in the pre-trauma stage and the intensity of the trauma itself. However, we find that the strongest predictor of mental health repercussions comes from the experience during the post-trauma stage. People who have strong social support, lower exposure to stress, and exhibit help-seeking behaviour early, are much more likely to have a positive outcome than those who don't. This period we are in right now and how we handle it will be the strongest predictor in how our healthcare workers recover from the mental shock of the pandemic. If we can build solid mental health support systems, we may reduce the number of people who have long term mental health conditions while maximising the experience of post-traumatic growth, which describes increases in personal and group resilience as a result of being exposed to adversity.

With healthcare workers likely to be amongst the most impacted, organisations and governments are asking themselves how to prepare for a resilience-building recovery process. First, we need to help people make sense of what has happened so the experience of moral injury doesn't fester. And while there may be a need to increase access to professional support, it's essential to acknowledge that many solutions lie within the individual's team and immediate social circle.

One of the biggest misconceptions of moral injury is to believe it's an illness that only psychiatrists and psychologists can help solve. However, since healthcare is a very team-based profession, we can find many answers within the healthcare community in which the person works. To begin with, individuals mustn't wait for their distress to deepen and intensify before they seek help. This is dangerous for the individual and creates a complex situation for any therapist, who, perhaps, could have intervened more successfully at a much earlier stage. We have observed three things that make a big difference in alleviating moral injury in healthcare teams:

  • Ensuring all supervisors are confident in speaking about mental health and having 'psychologically savvy' conversations to encourage early help-seeking behaviour. We have found that giving a simple one-hour training course on asking the right questions leads to almost a doubling in the proportion of supervisors who feel confident to speak about mental health with their staff.
  • Ensuring that some individuals within the team receive evidence-based peer support training, which allows them to formally check on colleagues who have been exposed to trauma or morally challenging situations. This will enable them to identify if they need support or if they do not recover, whether they have mental health symptoms that may require attention.
  • Practising 'reflection' where the team gets together to try and make sense of the situation they are in and build meaningful narratives so everyone can benefit.

While professional support may be necessary for an important minority of staff, building these three things into healthcare teams can be extremely powerful to reduce the number of people who develop long term illnesses.

There is no doubt that we are living through a global situation which we have not experienced in recent history. We are in the middle of an ongoing and complex traumatic event, and society must decide how to foster post-traumatic growth whilst minimising the chance that healthcare staff will develop mental health disorders. Mass and social media constantly report huge spikes in mental health distress for healthcare front-liners and those who work in critical care, with a large number experiencing symptoms that appear to resemble PTSD. We may have a substantial problem on our hands if we assume that most staff will become unwell and need formal mental healthcare; this is unlikely to be true. By examining past traumatic events, we realise that it is natural to experience many symptoms of distress during the trauma. However, there can be no doubt that as the situation improves, as it hopefully will, most people will recover even with no formal intervention, but we must remain cognizant of the important minority who develop a mental health disorder. Therefore, while we ensure we don't misinterpret conclusions from media reports, we must prepare and educate ourselves and support one another at work and home. We need to encourage people to seek help early when the solutions to the problem are simpler, and they still have their self-esteem, relationships and work to help sustain them through their recovery.

Written By
Professor Neil Greenberg

Professor Neil Greenberg is a consultant academic, occupational and forensic psychiatrist based at King’s College London. Neil served in the United Kingdom Armed Forces for more than 23 years and has deployed, as a psychiatrist and researcher, to a number of hostile environments including Afghanistan and Iraq. At King’s Neil leads on a number of military mental health projects and is a principal investigator within a nationally funded Health Protection Research unit. He also chairs the Royal College of Psychiatrists (RCP) Special Interest Group in Occupational Psychiatry. Neil has published more than 300 scientific papers and book chapters and has been the Secretary of the European Society for Traumatic Stress Studies, the President of the UK Psychological Trauma Society and Specialist Advisor to the House of Commons Defence Select Committee. During the COVID19 pandemic, Neil has worked closely with NHSEI, PHE and has published widely on psychological support for healthcare, and other key workers.

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