The COVID-19 pandemic has put immense strain on healthcare workers around the world.
They’ve had to make impossible decisions, work in unsafe conditions, and often still feel like they didn’t do enough to help.
For some frontliners, they will emerge from the pandemic with moral injuries similar to what we see in soldiers who’ve been to war.
That’s why we talked to Ruth Lanius, MD, PhD to find out how she approaches moral injury. She’ll share how she worked with a Vietnam veteran, including the word she uses with clients suffering moral injury that is often the first step in healing.
How have you worked with clients who suffered from moral injury? Please share your experience in the comments below.
If you found this helpful, here are a few more resources you might be interested in:
Treating Trauma: How to Work with the Shame of Moral Injury
[Infographic] Shame vs. Guilt – A Client Handout
What Can Help COVID-19 Frontliners Who Are Exhausted and Overwhelmed?
Very helpful to hear moral injury described in this way. It gives me an opportunity to work with the shame the client has experienced working in an environment that does not provide much opportunity for positive outcomes such as in combat or working with Covid-19.
Thank you for posting!
Thank you for bringing up the future need to help the frontline workers with their PTS that will arise within them when the dust settles. To avoid these feelings from becoming a disorder we need to offer support.
I think it is important to consider the differences with this and military war experieince. These individuals were face to face with death of innocent people with loved ones holding on for them distantly. The crushing loss of one stranger had echoes through their family. With no one there to carry the burden-the density of the loss was heavier.
War has an enemy. PTSD of soldeirs increased with the Vietnam War when the enemy was not identified by uniform. This “war” with invisible viral enemy and no concensus on response make the battle so much more difficult. Patients struggling for last free words or gulps of air before you paralyze/intubate them perhaps into their last days alive is a death stare beyond the dying last breaths of a battle comrade. Wanting to win, wanting to save life and losing can crush a medical professional. Just being in the midst of so much struggling in isolation and feeling “not enough” will linger in the medial professionals souls for ever.
I am preparing to help with the increased moral injury of the frontline workers but is not the same and we need to respect that if we are to help.
I am now wondering how many of the world’s political leaders will be impacted. Comparing how prepared and efficient Thailand and New Zealand (for example) were to the apparent unpreparednesss and slow actions of European and American countries suggests the potential for extensive guilt and shame. I fear for our leadership.
Im not sure NZ was particularly well prepared. After decades of underfunding hospitals ( which resulted in Invercargill Hospital, which serves 100000 people in Southland being reduced to having only one intensive care bed) Jacinda Ardern announced that patients would not be transferred to other regions if they had Covid 19. So the first person to get it badly would have a chance to live while everyone else would die. New Zealand HAD TO close their borders because healthcare access is almost unavailable, in my opinion.
Thank you for bringing up this topic. I loved Ruth’s approach, through and through. It heartens me to know that Moral Injury awareness is growing, and that counselors and therapists will be helping to address it.
I am a palliative care social worker and find myself dealing with my own moral injury during this pandemic but also the one supporting the ICU docs and nurses as they deal with theirs. We are learning a lot together. Thank you, this was a great insight
Watching this was the best supervision I’ve had in a while. Thank you for clear and thoughtful guidance on how to help frontline workers.
and just a small step to Dick Schwartz’ IFS idea of self-leadership.
Please define what a “moral injury” is.
Thanks for the food for thought as I have missed that from NICABM lately. I totally understand those words, especially the eyes having a stron connection when we are getting through and they are awakening. Need to really ponder the word leadership as I know a career navy now will benefit from that word this next week and help put in in perspective. Thank for alerting to the words that are powerful for you. What I also learned it made me weap for our role in this healing process. So much or work is done under the privacy laws and makes a total repression if you have done this work most of ones life. I think that has gotten to me more than anything lately and makes me want to weep for all the years we supervise, deal with group consults when we think of our own role in the process. I long for the time of the old specialist who spoke often of transference and counter transference which feels rampant in our roles more than ever before due to this pandemic. Thanks for the food for thought. It nourishes me.
Not knowing what, or how we are going to be impacted by the covid-19 makes for a disconnect for many clients who already struggle with moral injury. I am reminded that we need to be in the moment with the client, help them to feel grounded in the moment and to breath.
Hence, the importance of group work for the resolution of self-isolation and the accompanying shame. As an aside, there is an abundance of shaming going on in these times and the morally injurious stance that so many take about what is unfolding nationally and globally related to the Covid pandemic. The emphasis of our humanity and how precious it is needs to prevail. I LOVED the video and the use of terms, humanity, leadership, and working with gaze, “the eyes.”
Beautiful!
Thank you!
This was excellent – so succinct and helpful. Thank you.
I have been doing charity work helping Care Homes prepare for supporting staff reporting high levels of suffering post-COVID.
Many of the workers have English as a second language and have no previous experience of working psychologically, so the challenge is huge.
(It is possible that staff may not report the symptoms, depending on their culture).
After COVID, I have volunteered at a large local hospital to work with any front-line workers. Interesting that you said how useful group work is, Ruth. Do you think that it follows individual assessment and preliminary work? Can you foresee senior doctors participating in a group with ward cleaners?
Any advice would be welcome.
Thank you
Dr. Nikki Scheiner
Consultant Psychologist
London
I’ve wondered for a while how to work with shame in people who actually have done something morally wrong in the past (or who think they have out of a strong and reasoned moral conviction that you don’t share but don’t want to invalidate). It’s certainly easier when you can go “you have nothing to be ashamed of, lots of people have been through the same thing as you and it wasn’t your fault,” but when it’s more complicated than that, it’s a challenge. Good to see that others are working on this issue because we have all done wrong things and it isn’t just the morally pure who deserve to heal. (In fact, I’d argue that healing from shame is crucial to not doing wrong things in the future — contrary to what our society seems to believe!)
40+ years of doing crisis clients… what you term as “moral injury” I call “ethics trauma” is the number one cause of internalized self imposed isolation that leads to suicide/homicide /addiction. When it escalates to self imposed excommunication, homelessness is the typical indicator. The scarred ones isolate the self in public roles that demand sacrificing every relationship in the name of wealth, dominance, corruption.
This topic is so important, because it can lead so easily to self-punishment and self-isolation. The person with an immutable moral compass is in the same boat as the perfectionist: it’s impossible for a human to always meet the standards 100%.
1) Helping the client understand context and constraints and the pressured time frame of emergency decisions, can help quite a lot. I help them process that awful experience of pressure itself- how difficult and accelerating and challenging that can be for anyone.
2) As for the outcome clients may blame themselves for, thousands of diverse factors of chance and decision, personality, health history, cultural pressures, others’ actions, etc. etc. play into any moment of injury, battle, disease or death. Mapping some of these can help the client start to see that their role was just ONE tiny piece of a giant jigsaw puzzle of time, place, and circumstance.
3) Above all, acceptance. I tell all my clients that I may not know everything about them, but I know one thing for sure: There are very good reasons for them to be and act exactly as they are.
4) I agree totally with the presenter. I had a client that engaged in inappropriate sexual behavior as a young adolescent, and later expressed to me shame, self-disgust and remorse. I noted to him the large incidence of sexual abuse and assault throughout our country, with the low percentage of those abusers expressing remorse. I congratulated him on being one of the brave and moral few who had processed what had happened in a real way, had worked to control his triggers, to change his behavior, to ask forgiveness and make amends as appropriate. To me, his very guilt was a sign of great and unusual honor.
Excellent video I am a counsellor ( but not working in that area right now) but also a care worker/Giver with the elderly. Yes I get the moral injury bit but know we are all doing the best we can do right now. Defiantly the support of the close team is Critical like your friends with in your tears , almost in a way to check out “ is it ok to feel this way” I am a very strong person and have had days when I’ve had tearful moments concerned with our clients I work with some amazing elderly over 100! But yes it does take its tole to be sure. But it gives such a lot back that you can feel you can protect them from the outside world . As care givers we live in one moment the world of the client inside their safe homes carrying on with normal care , laughter , but now doing their hair , tiding there gardens literally running their homes wt zero visitors apart from us.still privileged to still share special moments contrasting and comparing them in the Second World War and this Corona war homes ! and at the same time we step into a silent street when all we see is a police car or ambulance for 8 weeks. ! Learning to “ Stepping “you get used to but if you keep mindful it’s easier you can see other Carers that are confused with this dual confusion and very highly stressed. With all injuries and dents in our souls we are ever healing getting more used to how the world is “ right now” as well as being mindful of what will become the “ new normal” in contrary to providing the stable normal for our wonderful elderly clients !
Not only the health care workers, but families that have to leave loved ones alone in hospitals, some who die without them and all those providing care and making decisions about seeking medical help— am I doing enough, should I have done something sooner , etc. are also Suffering and there will be many more. Thanks, Ruth This was very helpful for our Mental Health toolkits!
When in traumatic circumstances people make decisions and behave in ways they would never do or have to do in ordinary circumstances. It’s important for people to distinguish the environment in which these so called “choices “ occur. Context is a vital consideration. Healing shame requires acknowledgment of all aspects of the experience both internal and external and necessary forgiveness of self in relation to the experience. Trained trauma therapists need to help clients grieve the circumstances and behaviors that occurred and repair the self image, moral and emotional injury of the survivors. Trauma therapy can include group therapy, EMDR, IFS, etc. and a loving, accepting therapist who understands that need for repair of the heart, body, and beliefs of the survivor. That reset takes time depending on the depth of the loss of self that occurred during the event or events. Calling someone a “leader” might be helpful but it is not enough. Therapists have to help the survivors regain a sense of self lost in the traumatic events, mourn what occurred, and recover their belief in themselves.
Profound! Thank you very much for sharing your knowledge and wisdom. You packed a lot of helpful and worthwhile info into a few short minutes. Very digestible, useful, and applicable info I can apply at once in my work with clients. Btw, your presence exudes tremendous compassion. Your embodied self, in and of itself, I can see as very healing combined with the power and significance of choice of words. Wow, powerful stuff! Thank you.
Thank you Dr. Ruth for sharing your work.
I love the fact that you highlight the use of the “Leadership” strength, when working with individuals. Many use their leadership strength without the title or rank.
This Covid pandemic is an added burden to the prevalence of the existing burdens of empathy overload, compassion fatigue, and burnout in health care providers.
Do you think this could tie in with Survivors Guilt? Thinking about this in terms of Whakaari here in NZ in December. The guides that survived for example. They were leaders in more way than one. Also their possible fear of how They may be perceived/judged having survived when many others did not.
As counselor, spiritual director and confessor, I find it very important to develop the richness of the experience of forgiveness, asking forgiveness, and extending forgiveness. A great help to people who feel they are in some way morally at fault, or injured by what they have done (or believe they have done), is to assist them in distinguishing the relative degree of their own responsibility from the conditioning and the pressure under which they committed the acts they now regret.
good answer. thanks