Experiencing healing after moral injury
To build compassionate healthcare organisations we need to care for the caregivers. In 2011 Dr. Jasmine Brown (not her real name) heard I was trying out a way to support health and social care professionals through the moral turmoil that we would now call ‘moral injury’.
Some six months after completing her work with me Jasmine was interviewed by award-winning medical journalist Jane Feinman about how it had helped her. Although I no longer offer structured one to one support (in an approach I called ‘Restorative Review’) I have continued to write about moral injury and how it might be addressed. I hope that Jasmine’s story will give some insight into how we might support people feeling morally injured.
Jasmine became a doctor in the 1990s. During her specialty training, she was held captive by an armed patient. After the event she received counselling for Post Traumatic Stress Disorder and appeared to have fully recovered. She eventually left medicine, using her medical knowledge to establish a successful business, and built a happy family life. But inwardly Jasmine continued to suffer great anguish. She feared she would never be free from the painful feelings associated with this event and its aftermath.
A long moral crisis
“Nearly fourteen years ago I was held at knifepoint for two hours in a hospital interview room. I was unable to get to the panic button, and at times I feared for my life. I eventually escaped only by gaining the patient’s trust, and convincing him that if he allowed me to leave the room I would return voluntarily and alone. Instead, I informed hospital staff about what had happened. When they called the police, I watched my patient being held at gunpoint. I even believed for several moments that he was going to be shot.
“In the aftermath of the incident, I was treated for Post Traumatic Stress Disorder (PTSD). I was awarded damages by the hospital, for failing in their duty to keep me safe. But I realised slowly that I had lost confidence in being alone with patients, and two years after the incident made the decision to abandon my medical career.
“While I appeared to be managing well, I continued to feel a deep connection to what had happened. It became a constant painful burden and one that I feared would never be resolved.
“I was offered more PTSD counselling. But I knew that I’d dealt with the fall-out of the trauma and that this was something else. I now understand that I was experiencing a mix of destructive feelings: resentment and anger that the hospital had never fully acknowledged responsibility for what had happened; a feeling of being cheapened by my acceptance of financial compensation; a sense of shame that I’d been forced to give up medicine. And above all a strong sense that I had betrayed a patient who relied on me.
“I could never have put this into words at the time, but I was suffering a moral crisis.
Seeing a way forward
“It was only when I met Suzanne in 2011, that I began to see a way forward. I was immediately drawn to Suzanne’s description of the work she was developing. I recognised that I needed to investigate how I felt I should have behaved and been treated; and how far I had failed to treat others, and be treated myself, in a way that I believed should have happened. I had a strong sense that Suzanne understood what I needed. She “got it”. I felt that she had the ability to hold everything together and take it forward so that it was safe to open up.
“In the work we did, there were obvious parallels with both counselling and coaching. We had regular ninety-minute sessions. Suzanne was a hospice bereavement counsellor for several years and has trained as a mediator. She brought skills from this work to our interaction.
“But there are important differences in Restorative Review, partly because of Suzanne herself. Alongside her considerable intelligence, she has a natural inquisitiveness and a need to make sense of things in a very practical way. Most important though, is her quite exceptional ability to listen.
“In our discussions, she’d frequently see connections that I hadn’t seen and would draw them to my attention. I had the sense that we were working side by side, more than in the normal one-to-one counselling relationship.
“Further, we had a clear, shared goal in sight: the restoration of trust and confidence. This single-minded aspiration puts Restorative Review in quite a different space from coaching. The background to our conversation at every point was moral: an opportunity to come to terms with the harm, and betrayal of trust, that I had suffered myself, as well as caused to others.
“I came to realise that this ethical viewpoint or standard is exactly what people need in managing the personal crises that are caused by inadvertent or avoidable harm in the healthcare setting.
Making moral sense
“Suzanne is hyper-alert to words that suggest the moral background to any relationship or event. By picking up on such words, she was able to show me how much I value the moral qualities of trust, reliability and dependability. That’s how I talked about my attraction to my husband, for instance. I used the same kind of words when I talked about why I went into medicine and how I wanted to use my work as a doctor to make up for events where trust and reliability were absent in my childhood.
“It was hardly surprising, Suzanne pointed out, that an event involving my employer failing to keep me safe and where I’d also had to break a promise to my patient in order to keep myself safe, had such resonance.
“Suzanne also insisted on taking however much time and effort was needed to achieve precision in the language we used to examine the issues behind my anxiety. I recall vividly the session where we looked at my decision to leave medicine, spending much of it framing the words to ask the right question about why this decision had become so painful for me. It was an important session – and by the end, my whole perspective suddenly changed. I could make sense of what I had decided, accepting fully that it was difficult but absolutely necessary, that I can accept my loss, trust my intuition and learn from the experience.
“Six months down the line, Restorative Review has left me with an immense sense of peace, of forgiving and being forgiven.”
What can we learn from Jasmine’s experience?
There has been a growing focus on moral injury during the Covid19 pandemic. Jasmine’s experience suggests how important it is to differentiate moral injury from PTSD, and respect how people suffering a sense of moral injury yearn for a moral conversation. This can be hard because significant moral concepts – such as resentment, betrayal, trust, and shame – come heavily loaded with explosive emotional resonance.
There is no ‘qualification’ in moral conversations, nor specialists who will tell us how to do it. So this calls for all of us, particularly leaders in care, to be attentive to these moral needs. The temptation is to smother the moral elements in a conversation with managerial or psychological insight. We need to remain open to hearing the pain associated with moral injury, and truly listen to the moral anxiety that people want us to hear.