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Arquette C, Peicher V, Ajayi A, Alvarez D, Mao A, Nguyen T, Sawyer A, Sears CM, Carragee EJ, Floyd B, Mahanay B, Blankenburg R. Moral Injury: How It Affects Us and Tools to Combat It. MedEdPORTAL 2023; 19:11357. [PMID: 37927405 PMCID: PMC10622333 DOI: 10.15766/mep_2374-8265.11357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 08/03/2023] [Indexed: 11/07/2023]
Abstract
Introduction Moral injury comprises feelings of guilt, despair, shame, and/or helplessness from having one's morals transgressed. Those underrepresented in health care are more likely to experience moral injury arising from micro- and macroaggressions. This workshop was designed for interprofessional health care providers ranging from students to program leadership to raise awareness about moral injury and provide tools to combat it. Methods This 75-minute interactive workshop explored moral injury through a health care lens. It included components of lecture, case-based learning, small-group discussion, and individual reflection. Participants completed anonymous postworkshop evaluations, providing data on satisfaction and intention to change practice. We used descriptive statistics to analyze the quantitative data and applied content analysis to the qualitative data. Results The workshop was presented at two local academic conferences. Data were collected from 34 out of 60 participants, for a response rate of 57%. Ninety-seven percent of participants felt the workshop helped them define and identify moral injury and was a valuable use of their time, as well as indicating they would apply the information learned in their daily life. One hundred percent would recommend the workshop to a friend or colleague. Almost half felt they could implement strategies to address moral injury after participating in the workshop. Discussion This workshop proved to be a valuable tool to define and discuss moral injury. The materials can be adapted to a broad audience.
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Affiliation(s)
- Connor Arquette
- Fourth-Year Resident, Department of Plastic Surgery, Stanford University School of Medicine
| | - Valerie Peicher
- Postdoctoral Fellow, Department of Pediatrics, Stanford University School of Medicine
| | - Antonette Ajayi
- Fellow, Department of Pediatrics, Stanford University School of Medicine
| | - Dora Alvarez
- Third-Year Resident, Department of Pediatrics, Stanford University School of Medicine
| | - Alice Mao
- Fellow, Department of Medicine, Stanford University School of Medicine
| | - Tram Nguyen
- Fellow, Department of Medicine, Stanford University School of Medicine
| | - Anthony Sawyer
- Fourth-Year Resident, Department of Anesthesia, Stanford University School of Medicine
| | - Connie Martin Sears
- Fourth-Year Resident, Department of Ophthalmology, Stanford University School of Medicine
| | - Eugene J. Carragee
- Professor, Department of Orthopedic Surgery, Stanford University School of Medicine
| | - Baraka Floyd
- Assistant Professor, Department of Pediatrics, Stanford University School of Medicine
| | - Bernadett Mahanay
- Fellowship Programs Manager, Department of Anesthesia, Stanford University School of Medicine
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Fleming WH. The Moral Injury Experience Wheel: An Instrument for Identifying Moral Emotions and Conceptualizing the Mechanisms of Moral Injury. J Relig Health 2023; 62:194-227. [PMID: 36224299 DOI: 10.1007/s10943-022-01676-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 06/16/2023]
Abstract
This paper introduces an infographic tool called The Moral Injury Experience Wheel, designed to help users accurately label moral emotions and conceptualize the mechanisms of moral injury (MI). Feeling wheels have been used by therapists and clinical chaplains to increase emotional literacy since the 1980s. The literature on the skill of emotion differentiation shows a causal relationship between identifying emotions with specificity and emotional and behavioral regulation. Emerging research in moral psychology indicates that differentiating moral emotions with precision is related to similar regulatory effects. Based on this evidence, it is proposed that increasing moral emotional awareness through use of an instrument that visually depicts moral emotions and their causal links to MI will enhance appraisal and flexible thinking skills recognized to reduce the persistent dissonance and maladaptive coping related to MI. Design of the wheel is empirically grounded in MI definitional and scale studies. Iterative evaluative feedback from Veterans with features of MI offers initial qualitative evidence of validity. Two case studies will show utility of the wheel in clinical settings and present preliminary evidence of efficacy.
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Affiliation(s)
- Wesley H Fleming
- Clinical Chaplain, Syracuse VAMC, 800 Irving Ave, Syracuse, NY, 13210, USA.
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Hess A, Porter M, Byerly S. Environmental Factors Impacting Wellness in the Trauma Provider. Curr Trauma Rep 2023; 9:10-17. [PMID: 36591543 PMCID: PMC9791636 DOI: 10.1007/s40719-022-00246-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2022] [Indexed: 12/27/2022]
Abstract
Purpose of Review The purpose of this review is to evaluate the recent literature on environmental factors impacting wellness for the acute care surgeon. This includes factors influencing physical, mental, and emotional well-being. Recent Findings Recent studies have identified challenges to surgeon wellness including increased incidence of sleep deprivation, musculoskeletal pain and injuries, pregnancy complications, moral injury, posttraumatic stress disorder (PTSD), and burnout. Qualitative studies have characterized the surgeon's emotional response to occupational stress, adverse events, and surgical complications. Further descriptive studies offer interventions to prevent moral injury after adverse events and to improve surgeon work environment. Summary Acute care surgeons are at increased risk of sleep deprivation, musculoskeletal pain and injury, pregnancy complications, moral injury, PTSD, and burnout. Surgeons experience feelings of isolation and personal devaluation after adverse events or complications, and this may lead to practice limitation and progression to PTSD and/or burnout. Interventions to provide mentorship, peer support, and education may help surgeons recover after adverse events. Further study is necessary to evaluate institution-driven interventional opportunities to improve surgeon well-being and to foster an inclusive and supportive environment.
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Affiliation(s)
- Alexis Hess
- grid.267301.10000 0004 0386 9246Department of General Surgery, University of Tennessee Health Science Center, 920 Madison Avenue, Memphis, TN 38163 USA
| | - Maddison Porter
- grid.267301.10000 0004 0386 9246Department of General Surgery, University of Tennessee Health Science Center, 920 Madison Avenue, Memphis, TN 38163 USA
| | - Saskya Byerly
- grid.267301.10000 0004 0386 9246Department of General Surgery, University of Tennessee Health Science Center, 920 Madison Avenue, Memphis, TN 38163 USA
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Brémault-Phillips S, Cherwick T, Smith-MacDonald LA, Huh J, Vermetten E. Forgiveness: A Key Component of Healing From Moral Injury? Front Psychiatry 2022; 13:906945. [PMID: 35911220 PMCID: PMC9328408 DOI: 10.3389/fpsyt.2022.906945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Service members and veterans can be exposed to potentially traumatic and morally injurious experiences (PMIEs) including participating in, witnessing, or failing to prevent an act(s) that transgresses their core beliefs. Violation of one's deeply held morals and values can be profoundly distressing and shatter one's sense of self at the deepest level. Relationships with self, others, the world, and for some, the Sacred, can also be fractured. Post-Traumatic Stress Disorder (PTSD) and/or Moral Injury (MI) can result. Left unresolved, MI can leave individuals struggling with guilt, shame, cognitive dissonance, and negative self-attributions. A holistic approach that addresses the psychological and spiritual harm associated with MI is warranted. We wonder if forgiveness can help individuals struggling with MI to address the harm caused by actions or inactions, release negative emotions, and mend relationships. Commonly used by Spiritual/Religious (S/R) Leaders, forgiveness practices are increasingly being explored by Mental Health Professionals as a complement to evidence-based treatment approaches. This article provides case examples that illustrate the use of forgiveness practices that promote recovery and identifies programs used in clinical practice that incorporate forgiveness. Research is yet needed to better understand the importance of forgiveness in the treatment and healing of PTSD and/or MI. This requires an interdisciplinary discourse between Mental Health Professionals and S/R Leaders working in the field of MI. Such engagement and integrated use of forgiveness practices may yield improved outcomes not only for service members and veterans, but for all those struggling as a result of PTSD and/or MI.
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Affiliation(s)
- Suzette Brémault-Phillips
- Faculty of Rehabilitation Medicine, Department of Occupational Therapy, University of Alberta, Edmonton, AB, Canada.,HiMARC, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Terry Cherwick
- Royal Canadian Chaplain Service, Department of National Defence, Edmonton, AB, Canada
| | - Lorraine Alison Smith-MacDonald
- Faculty of Rehabilitation Medicine, Department of Occupational Therapy, University of Alberta, Edmonton, AB, Canada.,HiMARC, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - John Huh
- Royal Canadian Chaplain Service, Department of National Defence, Edmonton, AB, Canada
| | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands
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Buhagar DC. The Forgiveness Interview Protocol: A Narrative Therapy Writing-Process Model for the Treatment of Moral Injury. J Relig Health 2021; 60:3100-3129. [PMID: 34487295 DOI: 10.1007/s10943-021-01395-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/09/2021] [Indexed: 05/25/2023]
Abstract
During psychotherapy assessments clinicians may recognize that some of their injured and traumatized clients may be wrestling with issues related to a lack of forgiveness linked to Moral Injury (MI). This paper presents the Forgiveness Interview Protocol (FIP), a narrative therapy writing-process model for the treatment of Moral Injury, drawing upon the philosophical work of Margaret Holmgren: "Forgiveness and the Intrinsic Value of Persons" (1993) now linked to a variety of evidence-based psychological sources. The FIP utilizes three distinct theoretical and clinical disciplines to arrive at a semi-structured interview intended for mental health counseling, and religious and spiritual care.
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Affiliation(s)
- Desmond C Buhagar
- Department of Practical Theology, Regis College, The Jesuit School of Theology in Canada, Affiliated with the University of Toronto, 100 Wellesley St. West, Toronto, ON, M5S 2Z5, Canada.
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Abstract
Introduction Much has changed in healthcare during the coronavirus disease (COVID)-19 pandemic. Medicine, a profession of traditional principles and virtues, has faced unprecedented challenges in the light of scarce and unequal distribution of ventilators, testing, and personal protective equipment. Healthcare workers have been- and are increasingly likely to be- forced into situations that require difficult decision making under life-and-death conditions. Concepts of "medical necessity" and "maximum benefit" challenge healthcare systems that already struggle to manage unequal treatment and access to services, giving rise to moral distress and moral injury on the front lines. Methods This article focuses on moral injury in the context of coronavirus disease (COVID)-19 pandemic. I review recent literature to highlight the psychological impact of many morally-injurious events that have been reported during the COVID-19 pandemic. With the help of a clinical vignette, I point out how healthcare systems adopt many utilitarian policies in times of excessive healthcare burden. A viewpoint is offered that many morally injurious events happen when healthcare workers, traditionally practicing Kantian and virtue ethics, are forced to follow utilitarian policies of healthcare system. Conclusion One form of moral injury may arise from inherent conflicts between individual deontological moral judgments and organizational utilitarian moral judgments. More research is needed to validate the philosophical viewpoint as well as to explore whether increased awareness and education of key principles within moral philosophy can better equip healthcare workers in situations when public health takes precedence over individual health.
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Affiliation(s)
- F Akram
- Saint-Elizabeths Hospital/DC Department of Behavioral Health, Washington, DC, USA
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Weingarten K, Galván‐Durán AR, D’Urso S, Garcia D. The Witness to Witness Program: Helping the Helpers in the Context of the COVID-19 Pandemic. Fam Process 2020; 59:883-897. [PMID: 32621761 PMCID: PMC7361603 DOI: 10.1111/famp.12580] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
The Witness to Witness Program (W2W), based on Weingarten's witnessing model (2000, 2003, 2004), began in July 2018 and originally was established to support healthcare workers and attorneys (our partners) who were experiencing empathic distress working with people involved in various stages of the detention process. The W2W program evolved to offer four primary components: clinician listening sessions geared to deep understanding of the person's story of their work and its challenges; an inventory of the person's current internal and external resources both in the present and in the past; help with removal of barriers to those resources; and development of a personal toolkit to handle stress. Additional services available to partners and their organizations included psycho-educational webinars, facilitated peer support groups, and organizational consultations to foster trauma-sensitive and resilience-hardy work environments. In March, after lockdowns due to the coronavirus pandemic, W2W pivoted to focus on handouts and webinars addressing how to cope with distress and moral injury, maintaining resilience, coping with grief, and dealing with multiple losses caused by the pandemic. Disaster sparked collaboration and innovation. A train the trainer model was developed to reach more community health workers providing services to the Latinx community dealing with losses similar to those experienced by the clients they serve. W2W continues to create virtual communities of support. In doing so we practice doing reasonable hope together (Weingarten, Family Process, 2010, 49, 5).
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Affiliation(s)
| | | | - Sol D’Urso
- MFT Program USD and Private PracticeSan DiegoCAUSA
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Richardson CB, Chesnut RP, Morgan NR, Bleser JA, Perkins DF, Vogt D, Copeland LA, Finley E. Examining the Factor Structure of the Moral Injury Events Scale in a Veteran Sample. Mil Med 2020; 185:e75-e83. [PMID: 31184715 DOI: 10.1093/milmed/usz129] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/13/2019] [Accepted: 05/15/2019] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Interest in moral injury has burgeoned over the last decade as an increasing number of professionals recognize that current conceptualizations of trauma are not sufficient to explain some of the challenges that military service members face. The Moral Injury Events Scale (MIES) was the first instrument developed to measure exposure to military events that could produce moral injury (Nash et al., 2013). Two previously published validation studies that focused on service members still in uniform reveal some discrepancies regarding the scale's factor structure. Bryan and colleagues (2016) documented a three-factor solution (i.e., transgressions-others, transgressions-self, and betrayal), while Nash and colleagues (2013) noted a two-factor solution (i.e., perceived transgressions and perceived betrayals). MATERIALS AND METHODS With an interest in further scale validation, the present study utilized survey data from a group of veterans recently separated from service, to test the fitness of the two- or three-factor model and to examine the invariance of the scale across gender and branch. The investigators followed the policies governing the protection of human subjects as prescribed by ICF Institutional Review Board. RESULTS Findings revealed a two-factor structure that differed from previous factor solutions (transgressions-self and transgressions-others) and was invariant across gender and branch. High intercorrelations among the MIES items that addressed exposure and reaction to events suggested that these experiences tend to co-occur. Removal of the event items did not significantly impact model fit. CONCLUSIONS The factor structure identified in the present study aligns with current theoretical conceptualizations of moral injury. The inability to distinguish between event and reaction items and the lack of impact on the factor structure when event items were removed from the model suggest the MIES is more accurately described as a measure of moral pain as compared to a measure of potentially morally injurious experiences (PMIEs). Given that all events associated with moral injury have impinged upon welfare, justice, rights, and fairness considerations, one could argue that little would be gained by focusing attention on the development of a measure of PMIEs. Given the lack of convergence in factor structure across samples, future directions may profit from a focus on further clarifying the temporal stability of the MIES factor structure.
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Affiliation(s)
- Cameron B Richardson
- Clearinghouse for Military Family Readiness at Penn State, The Pennsylvania State University, 402 Marion Place, University Park, PA 16802
| | - Ryan P Chesnut
- Clearinghouse for Military Family Readiness at Penn State, The Pennsylvania State University, 402 Marion Place, University Park, PA 16802
| | - Nicole R Morgan
- Clearinghouse for Military Family Readiness at Penn State, The Pennsylvania State University, 402 Marion Place, University Park, PA 16802
| | - Julia A Bleser
- Clearinghouse for Military Family Readiness at Penn State, The Pennsylvania State University, 402 Marion Place, University Park, PA 16802
| | - Daniel F Perkins
- Clearinghouse for Military Family Readiness at Penn State, The Pennsylvania State University, 402 Marion Place, University Park, PA 16802.,Social Science Research Institute, Pennsylvania State University, University Park, PA 16802.,Department of Agricultural Economics, Sociology and Education, The Pennsylvania State University, 107 Ferguson Bldg, University Park, PA 16802
| | - Dawne Vogt
- Women's Health Sciences Division, National Center for PTSD (116B-3), VA Boston Healthcare System, Boston, MA 02118.,Department of Psychiatry, Boston University School of Medicine, Boston, MA 02130
| | | | - Erin Finley
- Veterans Evidence-Based Research Dissemination and Implementation Center (VERDICT), South Texas Veterans Health Care System, 7400 Merton Minter Blvd. (11C6), San Antonio, TX 78229
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Held P, Klassen BJ, Brennan MB, Zalta AK. Using Prolonged Exposure and Cognitive Processing Therapy to Treat Veterans with Moral Injury-Based PTSD: Two Case Examples. Cogn Behav Pract 2017; 25:377-390. [PMID: 30147290 DOI: 10.1016/j.cbpra.2017.09.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Moral injury refers to acts of commission or omission that violate individuals' moral or ethical standards. Morally injurious events are often synonymous with psychological trauma, especially in combat situations; thus, morally injurious events are often implicated in the development of PTSD for military service members and veterans. Although Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) have been well-established as effective treatments for veterans who are struggling with posttraumatic stress disorder (PTSD), it has been suggested that these two evidence-based therapies may not be sufficient for treating veterans whose PTSD resulted from morally injurious events. The purpose of this manuscript is to detail how the underlying theories of PE and CPT can account for moral-injury based PTSD and to describe two case examples of veterans with PTSD stemming from morally injurious events who were successfully treated with PE and CPT. The manuscript concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.
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Affiliation(s)
- Philip Held
- Department of Psychiatry, Rush University Medical Center
| | | | | | - Alyson K Zalta
- Department of Psychiatry, Rush University Medical Center
- Department of Behavioral Sciences, Rush University Medical Center
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