Beyond Resilience: Addressing Moral Distress During the COVID-19 Pandemic

Beyond Resilience: Addressing Moral Distress During the COVID-19 Pandemic

by Melissa Abraham, PhD & Rachel E. Smith, MS, PA-C
In the coming months, psychotherapists will need to work knowledgeably and compassionately with clients wrestling with moral distress. 


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Rachel Smith was deployed to Iraq as a nurse at the height of the war in 2003. When she returned to the States, she recognized she was changed by the war, but didn't speak to anyone about her experiences. She closed off that part of herself and began to question the purpose of her deployment. Rachel did not believe she had PTSD — she wasn't plagued by flashbacks or hypervigilance, but she did feel sad, guilty and helpless over what she experienced. She went on to become a physician assistant and pushed her memories of war to the back of her mind. In 2018, an article in STAT about people in healthcare suffering from moral injury went viral.
Rachel had never heard the term “moral injury” before
Rachel had never heard the term “moral injury” before, and read this article several times – the concept resonated on a deep level, describing how she felt about both her military experience and her current struggles providing care in a broken system as a physician assistant. She felt a sense of freedom and relief to finally have the vocabulary to describe what she was feeling, and this gave her the starting point to begin processing what she had experienced.

Moral Distress

Right now, everywhere we look, there are articles, both popular and professional, about how to manage, cope and reduce stress. Mental health providers are dispatched to COVID treatment sites to help care providers with the crisis they are experiencing. Apps such as Calm or Headspace, which focus on self-care and breathing, have come into focus to help with the overwhelmingly stressful situations that frontline healthcare workers find themselves in. This is crucial and important primary prevention, but it is only a starting point, not a solution. The challenge is not only about handling acute trauma. The COVID experiences of healthcare workers are slow-moving and life-altering, with important moral features.

By the time healthcare workers finally visit a therapist’s office (for those who do), therapists need to be prepared for more than helping people manage acute anxiety and addressing trauma. They will need to recognize the vocabulary of moral distress and to have internalized its meaning.

Distress is not new to healthcare workers. It is part of their normal routine and work; they experience days where people are sick and cannot be cured, and witness pain, suffering and death. They expect this as part of their role and are accustomed to its happening and to witnessing it. They often feel a sense of privilege at being able to be there for people during these challenging moments of grief, pain and loss.

With COVID, there are unexpected experiences. People around COVID patients suffer, but the resources to which they are accustomed are simply not there. There is not enough equipment or staff. Patients are alone when they die. Healthcare workers may be charged with triage decisions that make them feel they are “playing God,” or they may be following protocols to make those life-or-death decisions that constrain them from making a different choice, resulting in feelings of powerlessness or self-blame. Furthermore, the lack of personal protective equipment or leadership support can result in feelings of anger or of being sacrificial, even disposable. Because of COVID’s unpredictable and devastating nature,
working in a healthcare role right now can lead to more helpless or sad feelings than usual, and potentially a questioning of purpose. When these feelings are associated with one’s belief that he or she is participating in moral wrongdoing, this is “moral distress.”
working in a healthcare role right now can lead to more helpless or sad feelings than usual, and potentially a questioning of purpose. When these feelings are associated with one’s belief that he or she is participating in moral wrongdoing, this is “moral distress.”

It is not too early for therapists to get a head start on learning about moral distress. This is what many healthcare workers will be experiencing. We can learn more, and professional organizations can educate their constituents to avoid the potential problems that can happen if we ignore this aspect of what is coming down the pike.

Another concept, “moral injury”, is typically discussed in the context of military populations who had field experiences where they perpetrated, failed to prevent, and/or bore witness to acts that were transgressive and that went against their deeply held moral beliefs. Although such events may additionally give rise to post-traumatic stress symptoms or disorder, moral injury is not a psychiatric disorder.

The concept of moral distress, on the other hand, first arose in the field of nursing literature and has now been discussed in relation to other healthcare professions. In general, the term moral distress has been used to describe one’s inability, due to perceived constraints, to fulfill the moral obligations that those in healing roles assume to others. As a result, one’s core values and duties are violated. Within the nursing profession, some uses of the term reflect experiences of working within traditional hierarchies of decision-making. For example, in some cases, nurses are certain of the right thing to do, but feel constrained to carry out physicians’ orders or abide by other policies which make it impossible to pursue the actions they feel are morally right. Others in healthcare, in addition to nurses, may experience constraints due to power differentials or other obstacles. When any healthcare worker is not certain about the rightness of an action (for example, taking someone off life support), the decision is morally hard as well, and deep distress can arise out of having to make these decisions. Allocation of resources in the healthcare setting can at times lead to problems with unsafe staffing, unsafe practices and sometimes subsequent codes of silence in speaking out or reporting mistakes. These factors may all contribute to moral distress.

Like moral injury, moral distress is a not a psychiatric disorder
Like moral injury, moral distress is a not a psychiatric disorder. It is a psychological experience or state, a response to situations that are morally challenging. It is a disorienting feeling, a way one might feel that what they are doing does not fit in with their role as a caregiver, a healer, a health professional. Importantly, moral distress not only occurs at the moment of the morally challenging situation, but can linger for an indefinite period of time after the initial triggering event passes. Those who experience moral distress can be impacted for some time. It is and will become increasingly important for psychotherapists to appreciate the complexities of working with clients experiencing moral distress.

Suggestions for Amelioration of Moral Distress

1. Our primary goal is not to “fix” moral distress. Not only is this impossible, it overlooks something important for the person. Instead, we need to help them integrate their experience into their life and see it as life-altering but not life-impairing, in some ways similar to how we work with other losses and death. Don’t tell someone that you are sure you know what will help. No one knows exactly. But say what you do know — that therapy can give one the opportunity to better understand one’s thoughts, feelings and behavior and to gain insight into our pasts and futures.

2. Early recognition is important. When someone seeks help acutely, we must help them with general wellness in body and mind, and also acknowledge that they may need to make sense of this entire experience later on. Some people may think they are depressed — and in some cases there will be clinical depression or other significant psychiatric symptoms — but there is risk in not also incorporating the concept of moral distress.

3. Be cautious about diagnosis. Don’t make assumptions or over-pathologize moral distress. Depression and PTSD are psychiatric conditions. Burnout is a constellation of symptoms that correlates with psychiatric illness. But moral distress might in some cases resonate better with patients who don’t feel distorted in their thinking, feeling or behavior. In fact, some people might experience the stresses during COVID and attribute their experiences to “doing their job” or an “occupational hazard” and not feel distress, instead coming for other reasons to therapy. The same experiences might cause deep, abiding distress in others.
For some, COVID may be amplifying something they already felt, while for others it is an entirely new set of feelings to contend with.
For some, COVID may be amplifying something they already felt, while for others it is an entirely new set of feelings to contend with.

4. Use what you already know. Don’t over-specialize the emotional states of moral distress on one hand, yet at the same time recognize the particulars of it as unprecedented. Sit with a patient to listen and understand what happened to them. Develop a narrative that makes sense by revisiting facts and experiences about moral events, particularly those that engendered shame, self-blame, sadness or anger; and ask what else they could have done in those moments or not, to help them move toward the future. This is different for every person and depends on their own individual values and priorities. They can adapt and incorporate what happened and move forward.

5. Use compassion. Bearing witness, being non-judgmental, sitting with intense feelings and acknowledging normal human reactions are important tools to keep the individual well and better able to handle the reactions and feelings they have.

6. All theoretical orientations are welcome. We all practice from different theoretical perspectives: psychodynamic, cognitive-behavioral, relational, mindfulness-based. All of these can be helpful. We also know how to ask people about experiences where they felt powerless, harmed, abandoned, mistreated, overwhelmed, or witnessed others’ suffering. But it is important we have language to discuss what we see, and that patients have some language to use as well. We do not need to be trauma specialists to provide excellent care to healthcare workers and others with moral distress coming to terms with how COVID has affected them.

7. Avoid saying “I know how you feel.” Psychotherapists can relate to some aspects of this. When healthcare systems put in place decisions we might otherwise not make, we may feel our efficacy is undermined by not being able to provide high quality or even adequate care. This can literally feel “demoralizing” to the individual. But here, it is important not to say you know what it is like to be trying to save someone dying from severe hypoxemia while others also need your attention, while at the same time being terrified of catching the virus. Instead, focus on reflecting and supporting, and encouraging people to debrief and connect with trusted colleagues who share their lived experience.

8. Make room for non COVID-related experiences as well. 
Healthcare workers seeking help in the coming months are not only about COVID — their lives bring context
Healthcare workers seeking help in the coming months are not only about COVID — their lives bring context. Some may come for psychotherapy for the same reasons many others will — to deal with general worry, sadness, questions about life and relationships, even to seek care for mental health concerns that predate COVID — so we can’t make assumptions that all will experience moral distress.

9. Pursue Purpose and Meaning. Finally, it is important to recognize that our work is not only about making someone feel better, though this is important. But to address moral distress we also need to make room for meaning-making and cultivating the sense of purpose that brought people to healthcare in the first place. Rachel found this by moving into the field of patient safety and quality improvement in health care. At Ariadne Labs, she works on developing solutions to improving healthcare delivery. She is completing a doctorate in Public Health, which will give her the ability to improve the care of patients on a large scale. For some, being able to address the system and effect change in some way is very therapeutic, and attempts to change structures to prevent morally distressing situations in health care systems in the future can help people heal.


We need more understanding about what best “treats” moral distress across situations and people, and there is great need to invest in research. We need to ask people over time what helped them or would have helped them. But for now, at least, we psychotherapists have the tools we need to carefully listen to our patients affected by COVID and can avoid mistakes if we keep these concepts in mind in the coming months.

© 2020, LLC
Melissa Abraham, PhD & Rachel E. Smith, MS, PA-C Melissa Abraham, PhD, is a licensed clinical psychologist and Assistant Professor of Psychiatry, Harvard Medical School, Department of Psychiatry, Massachusetts General Hospital and in private practice in Boston. She is Associate Faculty at the Center for Bioethics at Harvard Medical School and a Faculty Associate at Ariadne Labs.  

Rachel E. Smith, MS, PA-C is a physician assistant and clinical implementation specialist at Ariadne Labs, a joint health innovation center at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health. She is a Doctor of Public Health candidate at Johns Hopkins Bloomberg School of Public Health.