With the ongoing demands of the pandemic, the constructs of moral distress and injury have drawn increasing attention. This has been particularly salient amongst health care workers but can be considered pertinent for everyone who has lived through this extraordinary series of experiences.

The Australian Red Cross have published guidelines to support communities before, during and after Collective Trauma Events. One of the authors Kate Brady wrote an article at the conclusion of Melbourne’s first extended lockdown in 2020 that argued the pandemic and its associated impacts could be considered Collective Trauma Events (CTE’s).

Traditionally, these have been understood to be disasters such as bushfire, flood, or mass trauma events linked to violence. A CTE is defined as an event which irrespective of the hazard, results in a blow to the basic tissues of social life that damages the bonds between people and impairs the prevailing sense of community. Critically, they must have an impact on the broader community and challenge peoples’ typical understanding of the way the world works (Brady, Randrianarisoa & Richardson, 2018).

This in turn requires us to consider the continuum of impact experienced by individuals. It  has been well documented that Covid19 has disproportionately affected those already more disadvantaged in society. The recent differentials in stay at home orders in Sydney highlighted the varied lockdown impact by local geographic area. Women have been reported to have shouldered greater burden from care provision and home schooling and young peoples’ increased levels of psychological distress has been well documented. In contrast, in some states the interruptions have been far less disruptive. Thus, whilst there are simultaneous impacts which are complex and compounding, disasters affect people differently. Brady et al., (2021) have written of the hierarchies of affectedness after disasters which are determined externally but also by the differing perspectives of groups of individuals who experienced them. Rob Gordon’s research on social bonding and de-bonding following a disaster is also relevant.

This same lens can be applied to moral injury defined as the psychological, social and spiritual impact of events involving betrayal or transgression of one’s own deeply held moral beliefs and values occurring in high stakes situations (Phoenix, 2020). This too exists on a spectrum. Whilst all moral stressors violate a person’s beliefs about what is right and just
or wrong and unjust, and all give rise to moral emotions, their potential for enduring harm or impairment are a function of severity.  Moral challenges tend to be common, frustrating but convey minimal harm or impairment, whereas moral distress occurs less frequently but has a moderate risk of harm. Moral injury, whilst rare carries a high risk of potential harm and can result in PTSD symptoms. Fortunately, not all individuals who experience moral distress or injury will develop PTSD as some with the provision of Psychological First Aid and good personal and organisational support will sufficiently process their experience. It is also possible that for some this experience may result in increased moral strength and post traumatic growth where useful learnings can be embedded in future practice.

However, the negative impacts of moral injury include feelings of guilt, shame, anger and disgust together with reduced empathy. There can be intrapersonal outcomes such as lowered self esteem resulting in beliefs about being bad, damaged, unworthy or weak. Interpersonal outcomes include loss of faith in people, withdrawal, avoidance and lack of trust, anger and blame. Existential and spiritual outcomes such as a loss of faith or belief in the ‘just world’ can occur and the individual can experience difficulty in occupational functioning, motivation and sense of purpose.  There are clearly parallels in the above expressions which are commonly seen in stuck points highlighted by people undertaking CPT for PTSD.

This prompts the query as to the applicability of CPT to treat PTSD arising from moral injury. Much of the existing research has emerged from the military setting and combat related PTSD which is also where moral injury was initially described. Griffin et al., (2019) conducted an integrative review of the literature on moral injury. They report mixed evidence as to the degree in which morally injurious outcomes are associated with specific PTSD symptom clusters. However, they cited the work of Bryan et al., (2017) who suggested a PTSD profile which included startle reflex, memory loss, flashbacks, nightmares and insomnia, where the moral injury profile included guilt, shame, anger particularly where perceived betrayal was present, anhedonia and social alienation.

The review considered the application of Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) as treatment for moral injury. Whilst CPT was not specifically designed for this application, it is considered that its focus on accepting naturally occurring emotions, challenging unrealistic cognitions and using socratic questioning may assist in providing a context for the event and promote perspective taking. There remains debate in the pre- pandemic literature as to the best way to define moral injury in addition or separate to PTSD and how best to apply the existing evidence based treatment modalities. However, it does appear that the constructs as described by Bryan et al., are common to those addressed by CPT which would position it well as treatment option in this area.

A recently published review in PTSD Quarterly by Maguen and Norman (2021) considered the dearth of research outside of the military setting,  and the need for clearer definitions of the constructs and assessment tools and longitudinal studies. Hines et al., (2021) reported on trends in moral injury, distress and resilience factors among healthcare workers at the beginning of the Covid-19 pandemic. Findings included that the improvement of workplace support and lowering of workplace stress may protect healthcare workers from adverse emotional outcomes.

It remains to be seen how much of the current reported psychological distress amongst healthcare workers will require formal intervention as opposed to psychological first aid which has been recommended as a first line approach. It is pleasing to see that in response to the pandemic challenges, many health networks in Victoria have set up staff wellbeing supports and normalized access of mental health support for both individuals and teams to mitigate the very real impacts of moral challenge and distress consistently being encountered.

References

Brady, K. 2020 . Dear Australia, Your sympathy helps but you can’t quite understand Melbourne’s lockdown experience. The Conversation, online article, Oct 2020.

Brady, K, Randrianarisoa, A & Richardson, J 2018 Best practice guidelines: Supporting communities before, during and after collective trauma events. Australian Red Cross. Carlton, VIC

Bryan, C. J ., Bryan, A.O., Roberge, E., Leifker, F.R. & Rozek, D.C. (2017) Moral injury, posttruatic stress disorder and suicidal behaviour among national guard personnel.. Psychological Trauma: Theory, Research, Practice and Policy, 10, 36-45.

Griffin, B.J., Purcell, N., Burkman, K., Litz, B.T., Bryan, C.J., Schmitz, M., Villierme, C., Walsh, J., Maguen, S. (2019) Moral Injury: An Integrative Review. Journal of Traumatic Stress, 32, 350-362.

Gordon, R. (2004) The social system as site of disaster impact and resource for recovery. The Australian Journal of Emergency Management (19)4

Hines,S.E., Chin, K.H., Glick, D.R. & Wickwire, E.M. (2021) Trends in moral injury, distress, and resilience factors among healthcare workers wat the beginning of the Covid-19 pandemic. International Journal of Environmental Research and Public Health, 18, 488

Maguen, S. & Norman, S.B (2021) Moral Injury. PTSD Quarterly, 32(5)

Phoenix Australia – Centre for Posttraumatic Mental Health and the Canadian Centre for Excellence – PTSD (2020).  Moral Stress Amongst Healthcare Workers During Covid19: A Guide to Moral Injury

Smallwood,N., Karimi.L., Bismark,M., Lutland.M., Johnson,D., Dharmage,S.C., Barson,E., Atkin,N., Long,C., Ng,I., Holland,A., Munro,J.E., Thevarajan,I., Moore, C., McGillon,A., Sandford,D & Willis,K. (2021) High levels of psychosocial distress among Australian frontline healthcare workers during the Covid19 pandemic: a cross-sectional survey. General Psychiatry, 34.

Smallwood, N., Pascoe,A., Karimi,L & Willis,K. (2021) Moral Distress and perceived community views are associated with mental health symptoms in frontline health workers during the Covid-19 pandemic. International Journal of Environmental Research and Public Health,18,8723.

Wachen, J.S., Dondanville, K.A. & Resick, P.A (2017) Correcting misperceptions about Cognitive Processing Therapy to treat Moral Injury: A Response to Gray and Colleagues. Cognitive and Behavioural Practice, 24, 388-392.