The PTSD-like Affliction That’s Traumatizing Health Care Workers

The invisible wounds of moral injury run deep for those on the front lines

Photo: San Francisco Chronicle/Hearst Newspapers/Getty Images

“Some experiences imprint themselves beyond where language can speak.” These are the words of psychiatrist and trauma expert Bessel van der Kolk. This is also the experience of many health care workers ensnared in the Covid-19 pandemic.

“I just can’t… can’t find the words… there simply are none,” whispered a doctor friend working in a hospital in New York City’s viral epicenter. We were Zooming — both of our backgrounds dark. Through the screen’s dim glow, I watched her head fall into her hands and rock back and forth. Her shoulders slumped forward, and she started to shake.

Marie, I’ll call her, and I had worked together in California’s Bay Area when I was doing palliative care chaplaincy and clinical ethics work. She was never at a loss for words. In fact, to call her highly verbal would be an understatement. And yet what she has recently witnessed, been forced to do, and could not prevent on the Covid-19 front line has brought about some kind of internal preternatural silence. “It’s as if part of my soul had been shredded with a knife,” she told me when she finally could speak; “the part that holds me in relation to my Hippocratic oath and personal values.”

Marie, like many health care workers, entered the field of medicine because, as she would say, she cares about doing good and not doing bad. From the day she started medical school, she had a clear vision of who she was and how she could serve humanity. But after “death by a thousand cuts” from a pandemic that has made her betray her vow to “do no harm,” she’s now questioning who she is, who other people are, and what life is all about — generally speaking. Some might call this experience a loss of innocence — a recognition that the world is more of a babel of bad than Marie originally believed. What I also know is that this suffering is a moral injury.

Moral injury is a transgression of conscience. It is what happens when a person’s deeply held values, beliefs, or ways of being in the world are violated. That violation could result from things the person did themselves, things they experienced, things they were made to do against their will or better judgment, or things they couldn’t stop from happening. And it’s more prevalent than many would think. Of the 2.7 million service people who served in Afghanistan and Iraq, reports show that roughly the same number who were diagnosed with post-traumatic stress disorder (11% to 20%) were also coping with moral injury.

But moral injury is not unique to veterans. Moral injury is a pall that has blanketed individuals, families, and communities throughout time and across cultures. It can be found on the battlefield; at the front line of disaster; behind closed doors of churches and temples; in hospitals, bars, brothels, prisons, refugee tents, abortion clinics, soup kitchens, unemployment lines; at borders and in detention centers; on school playgrounds and social media; and even in the unsuspecting house or office next door. This is because wherever human beings are, so too dwells moral injury.

Moral injury is a transgression of conscience. It is what happens when a person’s deeply held values, beliefs, or ways of being in the world are violated.

We are, as a species, hardwired to embody goodness, love, compassion, empathy, and a sense of right and wrong. Moral expectations are at the heart of who we are as people and societies. But human beings are also imperfect and limited. We can’t always meet our own moral expectations nor can others always meet them. Sometimes life throws us into situations where the stakes are high and no outcome is good, and we or others act, doing what we or they otherwise know to be bad, aware that harm will come in one way or another to ourselves or to another. Sometimes that is simply life.

Some have likened PTSD and moral injury. And while intrusive images of the past are similar in each experience, with moral injury, memories don’t trigger fear. Instead, they beget shame, guilt, rage, disgust, emptiness, and despair. With PTSD, the primary concern is physical safety. With moral injury, it is existential safety — or trust. Moral injury makes a person question themselves, others, life, or their God. It makes them question their or others’ ability to do right or be good. Moral injury deteriorates one’s character, ideals, ambitions, and attachments. It leaves people feeling contaminated in their being or that something they once held dear has been sullied. “Unworthy,” “beyond redemption,” “gone forever,” and “emotionally dead” are how many people have described the experience. “A soul divided against itself” is how Rita Brock, an author and the director of the Shay Moral Injury Center, defines it.

“How can I be a saver of life and a monster in scrubs at the same time?” Marie asked, her eyes distant and dark. “We’re all killing ourselves to save everyone we can, and yet we have to play God and decide who lives and dies. Who am I — or any one of us, for that matter — to make such a call?”

Anyone who has listened to the news in the last few months knows well the issue of limited personal protective equipment (PPE) and ventilators in this country: There simply weren’t enough. While politicians and talking heads debated the veracity of need, people like Marie were wading through jam-packed ER wards as if they were minefields, donning soiled or homemade masks. For the first time in their careers, many health care workers had to determine not if a patient needed a ventilator but rather who would get the high-value, vital air.

“How can you look anyone in the eye … gasping patients, pleading family members, knowing that your decisions will send many to their graves … or more like the make-shift morgue in the U-Haul van outside? I struggle to look at myself in the mirror, let alone at any of the people I’m trying to help.”

Marie mentioned that the sound of a cough is beginning to be what fireworks were to her Vietnam veteran father — a PTSD response. But the nausea in her belly — the sickness that comes from disgust at the situation — is the making of moral injury. Shortages of equipment, overloaded hospitals, overburdened staff, and insufficient testing made the U.S. Covid-19 response an ill-fated mission from the start. Having to be surrogate mothers, fathers, sons, and daughters for dying patients — holding up cellphones for family members to say their final goodbyes — was a task beyond medical training. Not being able to hold or breastfeed an infant child or tuck a scared youngster into bed at night because their essential work took precedence over essential familial love was felt by many to be a dereliction of duty.

The “invisible wounds” that are injuring Covid-19 front line workers bear the markings of a system equally scarred. “A betrayal of what is right, by a person who holds legitimate authority, in a high stakes situation,” is how psychiatrist and author Jonathan Shay first defined moral injury when he coined the phrase in the 1990s.

In the months since Covid-19 first reared its ugly head in the U.S., we have witnessed repeated stall tactics by leaders in the upper echelons of the government despite dire warnings from around the globe. We’ve heard the virus called a “hoax” and minimized in severity and threat. We’ve seen safety guidelines for the general public developed by respected public health officials and then flouted by the very leaders who employ said officials. We’ve heard the virus was contained when it wasn’t. We’ve discovered the organizations that ought to have been prepared for such a pandemic actually weren’t. We’ve endured a lack of testing and faulty testing. We’ve been exposed to inefficiencies and inequities in our health system. We’ve witnessed hospital administrations put finances above safety.

We are, as a species, hardwired to embody goodness, love, compassion, empathy, and a sense of right and wrong.

While no one person is to blame for the “injuries” that many are now suffering and while much is finally being done to stem the Covid-19 tide and get our society back on track, the above “betrayals” can also be summed up as widespread asystemic thinking and disorganization.

Whatever the labyrinthine conditions and events that created the current morally injurious climate for Covid-19 health care workers, we, as a society, must do better to help them heal — because, as research shows, once the acute phase of a situation like this subsides, it is the following period that is often the hardest for people to come to terms with. While the rest of society hastens to return to normal life, shifting their attention from stories of the front line to the economy and getting kids reintegrated in school, there will be swaths of people like Marie feeling the weight of all their decisions, questioning how this all could have happened, overwhelmed by guilt, shame, anger, disgust, emptiness, and despair.

Brock pointed out in a recent BBC article that the fight against the coronavirus is similar to battlefield medicine: “desperate and unrelenting encounters with patients, an environment of high personal risk, an unseen lethal enemy, extreme physical and mental fatigue, inadequate resources and unending accumulations of the dead.”

I wouldn’t pretend to know the demons that Dr. Lorna Breen, the medical director of the emergency department at New York-Presbyterian Allen Hospital in Manhattan, was wrestling with when she took her own life after fighting Covid-19 herself and fighting against it on behalf of her patients. But I do know — and research with veterans shows — that moral injury is associated with increased suicide risk.

Covid-19 health care workers are putting their lives on the line, and in some cases sacrificing their lives, so that others can live. We cannot allow the lives lost to be for naught nor the future of those who survived to be put at further risk or sacrificed because we, as a society, got distracted by our desire for normalcy and exhaustion with discomfort. Healing from moral injury requires a person to reconcile many difficult truths and to transform in difficult yet often unexpected ways. But it also requires communities and systems of shared values to support them. We all must do that now.

To the women and men who were courageous enough to serve on the Covid-19 front, we thank you and honor your experience. To those struggling to heal from the wounds of moral injury, either now or in the future, please know you’re not alone.

If you or someone you know is suffering from moral injury, here is a wealth of resources. If you are in crisis and in need urgent of help, please contact the National Suicide Prevention Lifeline at (800) 273-8255.

Award-winning writer, therapist, clinical ethicist, and researcher specializing in moral injury. I talk about the stuff many won’t. micheledemarco.com

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