Moral Injury and Mental Health Clinicians

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The COVID-19 pandemic strained the nation’s healthcare system. And that strain is perhaps no more obvious than when we consider the difficult ethical decision-making dilemmas clinicians have experienced.

A lot of attention has been paid to front-line workers— and rightly so. With demands for service exceeding capacity, a scarcity of necessary equipment, and inadequate staffing, many healthcare providers have faced unprecedented moral dilemmas. As a result, an accumulation of moral distress can lead to “moral injury,” the spiritual harm that arises from a betrayal of one’s core values, is becoming a sad and serious hallmark of this pandemic.

Beyond the plight of doctors and nurses on the front lines, COVID-19 disrupted healthcare services in mental health. While off-site modalities, like telehealth, did fill an important gap during the height of the pandemic, virtual mental healthcare can’t solve the mental health crisis, which the pandemic has only exacerbated.

What is moral injury?

Moral injury in medicine “occurs when clinicians are repeatedly expected, in the course of providing care, to make choices that transgress their longstanding, deeply held commitment to healing.” While moral injury may be related to other mental health concerns, such as burnout, adjustment disorders, depression, and PTSD, it is distinct from them.

Moral injury is not classified as a mental disorder. However, it undermines clinicians’ capacity for well-being, confidence in meeting challenges, feelings of belonging and meaning, and overall sense of self. Moral injury occurs when clinicians know what care patients need but are unable to provide it due to constraints that are beyond their control. The key to moral injury is that it is associated with guilt and shame, and leads to behavioral effects such as the withdrawal from everyday routines.

Although mental health professionals have been discussing moral injury in the context of the military and combat situations for decades (starting with this groundbreaking paper by Brett Litz, et. al.), the current crisis has exposed the depth and breadth of moral injury’s potential impact upon entire networks of healthcare workers.

For those on the front lines of the pandemic, studies have shown that transitioning from ordinary standards of care to crisis standards of care can provide a framework for making ethically difficult decisions and alleviate some moral injury. One question is whether a similar mindset shift could also help mental health clinicians deal with moral injury.

Moral Injury and Mental Health Clinicians

A silver lining of the COVID-19 pandemic is that patients from remote and historically underserved communities have been able to access mental health care for the first time via video therapy sessions. Still, while teletherapy has meant first-time or easier access for many people, there are instances where an in-office visit is still needed.

For patients that have domestic situations that require safety and privacy, for example, the clinician’s office is a safe space where they can speak candidly. In their own home, however, patients understandably find it more difficult, or, in some instances, dangerous to talk openly about their situation.

Teletherapy can also be difficult for kids seeking privacy from their parents. Mental health clinicians have reported parents listening in or even interjecting during their child’s therapy session. If a child is confiding in their clinician about having trouble with a parent and that parent walks into the room, clinicians have extremely limited options to protect their patient.

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Issues surrounding teletherapy and client safety raise the prospect of moral injury for mental health clinicians. Although satisfaction with telehealth has been high, barriers such as technical issues, certain elements of risk assessment and establishing therapeutically beneficial relationships in certain patient populations may be challenging. While many of the challenges may have relatively easy solutions, in the midst of the chaos of the pandemic, the uncertainty about legality or insurance policies, among others, left many clinicians in the lurch.

Additionally, teletherapy can’t solve the biggest problem: the clinician shortage. The National Center for Health Workforce Analysis estimates that, by 2025, there will be shortages of psychiatrists, clinical counseling, marriage and family therapists, school counselors, and mental health and substance abuse social workers numbering in the tens of thousands.

Teletherapy may allow some clinicians to see more patients, but there’s only so much we can squeeze out of the current mental healthcare workforce.

How to prevent moral injury for mental health clinicians in the workplace

Until we have a clear set of guidelines and a well-thought-through plan for dealing with the above issues, mental health clinicians will continue to suffer moral injury over what they can't do for their patients. Still, there is a significant role that organizations and leaders can play in mitigating the impact on mental health clinicians.

The American Psychiatric Association issued guidance on moral injury during the COVID-19 pandemic. Following are some of the major recommendations that would help mental health clinicians in particular:

• Start a conversation about moral injury: The objective here would be to allow clinicians time to voice their concerns, consider moral dilemmas, and discuss how to promote resilience.
• Provide support for ethically challenging decisions: This would include making sure all decisions have supervisory support and ensuring that there are processes in place to take the burden of such decisions off of individual clinicians.
• Identifying resources for dealing with moral injury: These could be spiritual, emotional, or psychological.
• Ensuring prompt and easy access to ethics consultation: In situations where it seems that any action might violate a core value of healing professionals, medical ethicists should be made available and continuous consultation should be provided.
• Ensuring that messaging and actions from leadership consistently reflect an understanding of moral injury and a genuine concern for the well-being of clinicians: Contradictory, inconsistent, or punitive messages and decisions undermine the morale of mental healthcare workers and can increase the risk of moral injury.

As the shape of mental healthcare continues to shift, it is within our power to make sure the transition doesn’t leave irreversible scars on our clinicians. Moral distress and moral injury are urgent concerns for those doing the heavy lifting here. Let’s address this reality, even as we deal with the strain on other parts of our healthcare system.