Healing Moral Injury in the Age of COVID-19

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By Clint Hougen, Ph.D., Robert M. Gordon, Psy.D., and Carolyn M. Springer

Much has been written about the experience of moral distress among healthcare workers during the COVID-19 pandemic. While there has been considerable emphasis on frontline workers, including physicians, nurses, and hospital staff, it is also important to consider the mental healthcare workers, who found themselves at similar risk of moral distress or injury.

Psychologists and mental healthcare workers have been drawn into many roles throughout the pandemic. Some psychologists were called upon to provide psychological first aid to their frontline peers or operate hotlines when doors closed during the initial throes of the virus. Others had to quickly learn the intricacies of telehealth service delivery and the ever-changing terrain of insurance coverage.

We all juggled the dangers to our health and well-being, as well as the health and well-being of friends and family, with the struggles of maintaining continuity of care with our patients and managing growing waitlists of individuals seeking mental healthcare.

Furthermore, given the intimate nature of our work, we absorbed challenging stories of disability and death, different political views, and the unequal way in which social determinants of health disproportionately impacted many of our patients. Given the unique way in which mental healthcare workers moved through the pandemic, it is imperative to acknowledge and better understand the role of moral distress in our experience and healing.

Understanding Moral Injury

Jonathan Shay (2010) coined the term “moral injury” in 1994 as a betrayal of “what is right” by someone in legitimate authority in a high-stakes military situation. Litz et al. (2009) defined moral injury as “the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”

Nash and colleagues argued for a stress continuum model of moral stressors and their outcomes where moral injury is conceptualized as a “wound to the mind, brain, body, and spirit inflicted by a life event that violates deeply held moral expectations of oneself and the world” (Nash, 2019). Stressors may foment moral dilemmas, lead to moral distress, or escalate the wound of moral injury. The wound then needs repair and healing.

Stress, Appraisal, and Coping Model

Farnsworth (2019) argued against the biomedical model, which in his view pathologized an individual’s responses to social and political injustices. Instead, he asserts that in moral injury, the core problem is the adoption of inaccurate self and other condemning beliefs around culpability, which conjure painful moral emotions, such as guilt, shame, and anger.

He added that avoidance of these painful emotions allows the emotions to intensify resulting in higher levels of distress and dysfunction. In morality-based appraisals, cognitive distortions come in the form of what should have happened (Farnsforth, 2019).

Moral Injury and Mental Health Outcomes

Moral injury has been associated with adverse mental health outcomes and is a transdiagnostic feature of many manifestations of psychological anguish. It is related to an increased risk of suicide (Nieuwsma, 2021) and has been shown to worsen the severity of PTSD (Bryan et al., 2013), depression, and anxiety symptoms (Currier et al., 2017). Chronic pain and alcohol and other substance misuse are also associated with higher rates of moral injury (Nieuwsma et al., 2021).

Moral Distress Injury and COVID-19

In light of COVID-19, interest in moral distress and injury among healthcare workers has picked up pace, and measures of moral injury have been developed to study this population (Mantri et al., 2020). During the pandemic, mental healthcare workers navigated countless potentially morally injurious dilemmas (Figley et al., 2023).

Clinicians were vulnerable to moral distress when feeling pressured to make decisions inconsistent with their core therapeutic and personal values (Williams et al. 2020). For example, how to counsel a patient in isolation when we know the essential nature of social contact for well-being? How to keep the business of private practice afloat while also serving those disproportionately impacted by the pandemic and least able to pay full fees? How to navigate political ideas incongruent with public health in sessions? How to cope with the disembodied nature of telehealth? When to return to the office? “How to deal with patients who did not comply with vaccines, distancing, and wearing masks?”

Moral Injury Essential Reads

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Prolonged distress can evolve into moral injury, which involves a lack of trust in oneself, leadership, and the organization.

As mental health clinicians, we had difficult choices to make when tending to our own safety and self-care versus our patients’ needs. It has been challenging to reflect on one’s perceived or actual omissions and commissions that may have led to moral injury, while simultaneously maintaining self-compassion and not internalizing systemic deficiencies.

Tips on Healing Moral Injury in the Age of COVID

• Acknowledge your feelings of moral distress and injury and share your feelings of pressure, conflict, and sacrifice with trusted colleagues (Williams et al., 2020).
• Maintain a connection with the most cherished and valued parts of yourself as a way to ameliorate the sense that you are no longer the same person you once felt yourself to be due to perceived and/or actual breaches of your moral code. (J. Plotkin-Bornstein, personal communication, August 30, 2023). Embrace the feedback from respected others regarding this.
• Seek out a mentor for guidance in processing these complex challenges including systemic and societal contributing factors.
• Aspire to maintain integrity by monitoring how your words, actions, and decisions align with your values and the person you want to be.
• In striving for integrity, ask yourself the following questions: “What do I stand for?” and do “I embrace difficult, or potentially unknowable, questions (Rushton, 2018)?”

Concluding Thoughts

Experiencing moral distress or injury is not a sign of weakness or a character flaw, but rather is a reflection of one’s humanity and moral conscience. Examining the reasons for our moral distress may provide insight into how we can advocate for our patients and live life with greater integrity, purpose, meaning, and self-compassion. Reflecting on our values is an opportunity for growth and change.

Clint Hougen, Ph.D., is currently a postdoctoral fellow in the Department of Neurology at the Icahn School of Medicine, Mount Sinai Health System.

Robert M. Gordon, Psy.D., is a Clinical Associate Professor at the NYU Grossman School of Medicine.

Carolyn M. Springer, Ph.D., is an Associate Professor in the Gordon F. Derner School of Psychology at Adelphi University and Director of the Center for African, Black, and Caribbean Studies.