Stories
Staff Perspective: A Discussion with Dr. Rita Nakashima Brock on Moral Distress and Helping COVID-19 Healthcare Workers
March 31, 2021
Dr. Rita Brock recently shared her thoughts on moral distress and injury and COVID-19 frontline workers with me. I’m pleased to share parts of that conversation with you below. Dr. Brock has spent much of her career as an academic in philosophy and religion, obtaining her doctorate in this field in 1988. Her interests turned toward moral injury after a 2009 article by Dr. Brett Litz (see below for article citation) “grabbed me and wouldn’t let me go.” As a person who works in religion, ethics, and psychology, she understood how religions address human suffering and believed she could add to the conversation behavioral scientists were beginning to have around moral distress and injury.
Many are familiar with the 2012 book “Soul Repair: Recovering from Moral Injury after War” (citation below), coauthored by Dr. Brock. Besides this and other publications, she was also the Founding Director of the Soul Repair Center at Brite Divinity School, Texas Christian University. In 2017, Dr. Brock began her current position at the Shay Moral Injury Center at Volunteers of America which focuses on developing and implementing moral injury programs at a national level. While the Center initially focused on programs for military veterans, since COVID-19 it has expanded to developing support for front-line workers struggling with moral challenges during this devastating time.
In 2017, the Shay Moral Injury Center developed an evidence-based program called Resilience Strength Training (RST) for combat veterans struggling with moral injury. RST was developed as a peer-facilitated program to decrease the stigma many veterans have about seeking care. Results from a recently published study on the efficacy of this program show it helps veterans working through moral injury, specifically through the development of self-calming strategies, communication skills, self-esteem, improved sleep, and peer-supported communities. For more details about this study (Barth, 2020) and program, go to this link:https://doi.org/10.21061/jvs.v6i2.199. Currently, the Center is adapting the 50-hour program to an online 25-30 hour program. Since the pandemic, they have also adapted elements of the program to a one-hour online support program for COVID-19 care workers, keeping the peer-facilitated model, with the name Resilience Strength Time (ReST).
I asked Dr. Brock what about the peer-facilitated group model she believes is so effective with moral injury. One key healing agent she identified was the validation that occurs when people hear from others experiencing similar situations. People learn they are not alone with their moral struggle. Peer facilitators understand what the person is going through, thus reducing stigma and fear of judgment.
Dr. Brock added that when people have the chance to support others, it allows compassion for self to kick in: “It transforms what you think of yourself to listen to and support others.” Dr. Brock’s experience with the power of peer support groups goes back to her time with a summer camp program for high schoolers dealing with intense issues, ranging from violent crimes to family abuse. Through her work with them, she witnessed the profound impact of group leaders allowing themselves to be vulnerable and share their own experiences – “in that moment, they were peers… people who understood and (the high schoolers) could connect to.” It was this powerful connection that Dr. Brock wanted to carry forward to peer-facilitated moral injury programs to help reduce stigma and allow people to share their pain and work toward healing.
How is the Shay Moral Injury Center adjusting the RST program for COVID-19 ReST for healthcare workers?
The healthcare profession clinicians, especially nursing, have been writing about moral distress and injury faced by professionals for years. Based on this and her own experiences, Dr. Brock knew that the pandemic would place healthcare and frontline workers into a crisis situation around moral injury. In ICU settings, witnessing death is not an uncommon experience. With COVID-19, however, there is much more death, providers are more limited in how they can help, and the patients are dying alone instead of with loved ones. There are more morally challenging decisions and emotional pain involved.
Indeed, Dr. Brock believes these circumstances are similar to what medical providers face in a warzone, something most civilian providers have never experienced. Dr. Brock agrees with other moral injury specialists regarding the importance of people opening up to others who share their moral challenges. People need to talk about their pain and distress in order to process it. To help these providers, Dr. Brock and her colleagues adapted what they learned working with Veterans and the RST program. They started with peer facilitators from the existing veteran RST program and offered open-format online one-hour support group sessions that any COVID-19 healthcare worker could attend.
As the program progressed, the Center trained others to be the peer facilitators guiding the group discussions. These groups are confidential and open to the public. Participants can attend as often as they wish. To access ReST, participants just need register through the VOA/ReST website. Once registered, they are provided with a schedule of upcoming sessions which they can sign up for. Although attendance in prescheduled groups means membership will change session-to-session, arrangements can be made for the same group of people to meet each time. On Mondays at 7 pm Eastern, there is a specific group for military veterans co-facilitated by veterans.
What do you think and hope we will learn from the pandemic about moral injury/distress?
I found Dr. Brock’s answer to this question direct and profound. After reflection, she shared the following hopes for what our society will learn:
- “Moral injury isn’t limited to military Veterans.” Although we have known this, we have been unable in our society to validate this with research until recently.
- “(Moral injury) is also a collective experience.” As a society, we will need to deal with it at larger levels, both in how we recognize it and help those experiencing it.
- “How people feel morally about themselves and society affects how people behave.” This is true both when people are left to continue questioning morality and when they are able to come to an understanding that leaves their morals more strengthened.
- “Moral Injury is the excruciating remnant of goodness in people…. You can’t have a moral injury without a moral conscience.” The struggle with devastating experiences can lead a person to judge themselves or others as bad. In fact, though, to make that judgment requires an inner awareness of what is good, and that awareness is important to recovery.
What do you wish behavioral health providers understood about moral injury?
"Moral emotions like guilt, shame, remorse, humiliation, frustration, anger and all of those feelings are NOT pathologies…. They are appropriate emotions given (a person’s) experience and morals.” I discussed this truth with Dr. Brock, as well as my own observations with military patients both during and after combat deployments. I have been amazed with how many patients, let alone providers, think that the pain and grief involved with moral distress is something that needs to be “fixed” or that these emotions are evidence that there is something wrong with them. The truth is that experiencing moral distress when faced with a morally challenging situation is proof of a person’s goodness and humanity, not proof that they are “broken.” They are suffering, which is why they are feeling pain, and they suffer because they are good.
In our discussion, Dr. Brock shared her own observations of this, acknowledging that although moral injury is understandable, it becomes problematic when it takes over one’s life. Working through a moral injury does not mean the painful emotions are gone. Instead, the intensity of the emotional pain is mitigated so it no longer is in control, and the moral injury becomes a source of information about the self and situations as well as a motivator for action. There will still be emotional pain about the past, but the load is such that it can be carried. As Dr. Brock explains, “You have to sit in the fire until you burn clean (a metaphor she got from Jaques Verduin who works with men in San Quentin Prison). Then you can examine it and learn how it will inform your life.”
Since our interview, I’ve reflected a lot on that last idea and quote about sitting in the fierce fire until you burn clean of it. With the support of others who understand, it is incredible what people can and do get through. My personal fear of a ‘worst outcome’ situation is that those amazing frontline workers doing intensely difficult and emotionally painful, yet necessary, jobs feel they are alone and try to shut down or hide what they are going through. Or, worse yet, they believe they are somehow damaged or “broken” because of how their own morality causes them to feel.
Then there is the second part of Dr. Brock’s statement, that after you burn clean you can sit back, examine what happened and put what you learn into some type of proactive movement in your life, either personally or on a societal level. My sincerest hope is that our world will be able to do just that once this pandemic is under better control, if not over. I am so grateful for support programs like those offered by Dr. Brock and the peer specialists at the Shay Moral Injury Center. I believe they are exactly right about us needing to encourage people to talk about their pain with peers and professionals who can understand and support them through it. In my opinion, the ReST program and other support services like it are what our world needs right now to make sure we come out clean and wiser once this is all over.
More information about the VOA Shay Moral Injury Center and ReST programs can be found at https://www.voa.org/moral-injury-war-inside.
Interviews with Dr. Brock about her work can be found online. These include:
- From WebMD – “COVID-19 and the Threat of Moral Injury” recorded on 22 October 2020. https://www.webmd.com/coronavirus-in-context/video/rita-nakashima-brock
- Dr. Brock and ReST Facilitators explaining program: https://www.youtube.com/watch?v=P4ec31tYxFE
- From Volunteers of America, short video explaining moral injury within combat veterans: https://www.voa.org/the-war-inside
- Recorded webinar “Moral Resiliency for Medical Workers During COVID-19” produced by Volunteers of America:
- Full webinar (2 hours): https://www.youtube.com/watch?v=wFF8wx6Oqc&list=PLOp3UYSMYFviGIrPLKa_xA_qV7xKUmD_h&index=3&t=2s
- Shortened edited version (50 minutes): https://www.youtube.com/watch?v=wFF-8wx6Oqc&list=PLOp3UYSMYFviGIrPLKa_xA_qV7xKUmD_h&index=3&t=9s
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Rita Nakashima Brock, Rel.M., M.A., Ph.D., Rev. Dr. Rita Brock is Senior Vice President and Director of the Shay Moral Injury Center at the Volunteers of America.
Debra Nofziger, Psy.D.,is a Senior Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Nofziger is currently located at the Brooke Army Medical Center, TX.
References and Resources:
Barth, T. M., Lord, C. G., Thakkar, V. J., & Brock, R. N. (2020). Effects of Resilience Strength Training on Constructs Associated with Moral Injury among Veterans. Journal of Veterans Studies, 6(2), 101–113. https://doi.org/10.21061/jvs.v6i2.199
Litz B.T., Stein N., Delaney E., Lebowitz L., Nash W.P., Silva C., & Maguen S. (2009). Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. https://doi.org/10.1016/j.cpr.2009.07.003
Brock, R. N. & Lettini, G. (2013). Soul repair: Recovering from moral injury after war. Beacon Press.
Staff Perspective: Cracking the Code of Sleep Log Scoring
August 16, 2017
By Dr. Diana Dolan
Providers of behavioral treatment of sleep disorders, such as Cognitive Behavioral Therapy for Insomnia (CBT-I) or Brief Behavioral Therapy for Insomnia (BBTI), need to score sleep logs efficiently and accurately to implement strategies. Moreover, we must teach patients how to score their own logs so that they in turn can implement sleep schedule adjustments without our guidance. It’s not surprising, then, that a frequent topic that arises in consultations concerns the use of sleep logs, specifically, learning steps for how to score logs and getting experience doing so.
To help provide additional practice, here is an actual de-identified patient log with two weeks’ of baseline data. You can score one or both weeks. Then, check out the videos above, which show step-by-step scoring of the log to check your calculations. You may have some scoring questions of your own after this practice, so feel free to run them by us by email or join the weekly Consultation Call!
Staff Voices - Productive Processing of In Vivo Exposure
June 20, 2012
The last blog entry on in vivo exposure discussed some strategies to help your client be better prepared to benefit from in vivo exposure. This week I want to talk about “post-in vivo processing”. We don’t usually emphasize processing when we discuss in vivo exposure but it is just as important for in vivo exercises as it is for imaginal exposure. Post-in vivo processing is not merely a check the box activity to make sure the homework was done but instead is an opportunity for a client to reflect on the homework assignment, and extract some understanding or insight from the experience of facing fear and living to tell about it. For some, this may simply mean concluding, “It was easier than I expected it to be!” But for others, it may mean evaluating and dismantling some strongly held beliefs that have kept them “safe” from harm for a long time. Give example?
Many clients will walk into session with in vivo worksheets in hand, ready to discuss their experiences, so I like to ask about homework in the beginning of the session to capitalize on what they just accomplished. Some of my colleagues like to save the processing of homework for the end of session so they can get to the imaginal exposure immediately. Either way can be effective but make sure your client knows what to expect so they don’t feel ignored if you don’t ask about the homework right away. One strategy might be to briefly review the homework at the start of session to provide reinforcement but save the processing and problem solving until the end of session.
Did your client do the assignment?
Begin by finding out whether your client actually did the assignment. If avoidance or a complicated life is preventing him/her from doing the homework, you will spend your processing time trouble shooting those barriers. We could (and maybe we will) write an entire post on troubleshooting barriers, but for now let’s assume that your client did the in vivo assignment and is ready to show you the worksheet. This is your first piece of information to process. What does it tell you?
The most important thing it says is that your client took a step toward getting her life back. She had enough confidence in the treatment, in you, and in herself that she attempted, and perhaps successfully completed the assignment. This is accomplishment number one! She faced her fear!
Lead with the positive
While this accomplishment is certainly rewarding in and of itself, a simple word of praise at this point, from you, will not be wasted.
“You did it!”
“You took the first step. Good for you.”
So perhaps she didn’t stay in the situation as long as you had hoped. Maybe she didn’t do everything exactly as planned, but remember successive approximations from graduate school? This is the process of rewarding small movements or approximations of the target behavior, until the behavior is executed successfully. Shaping behavior in this way takes a few trials so be patient.
It’s not all good, however There may be some problematic aspects to correct for next time, but go ahead and praise what you honestly and sincerely can. Normalize distress and avoidance, and later, after you have extracted all that you can from what went well, constructively discuss the changes that are needed for the next time.
Praise as corrective information
Praise is emotionally rewarding if it is believable, sincerely given and meaningful to the one being praised. But one of the most important things about leading with a bit of praise for effort in this context is that it informs and corrects. For this purpose, it must be descriptive, specific, and timely. One of the biggest problematic beliefs in PTSD is some version of “I am weak for reacting the way I did (having PTSD),” “I should have been able to handle this by myself, ” or “I am incompetent and everyone knows it.” Your specific praise, as well as comments pointing out the evidence against these beliefs is a clear indication that you don’t buy it. On the contrary, you know the treatment is challenging, you appreciate your client’s courage and determination, and you have confidence that she will be able do it. When your praise is targeted in this way, it is not a mindless pat on the head: it actually is corrective information in action.
Broaden your repertoire
PTSD almost always includes many negative, inaccurate thoughts about the self. I hope you take every opportunity to specifically and descriptively comment on, and praise any thought and behavior of your client that disconfirms his deeply held negative beliefs. This means you are going to be praising her a lot, so increase your repertoire of responses. “Great job” is nice to hear a few times, but it starts to sound rote and insincere after awhile. Use humor where it is appropriate.. Tie your praise to the evidence. Look for ways to weave praise into your discussion without fanfare. For example, sometimes a simple statement of fact is a sneaky way to get in some covert praise on the fly.
“You are really working hard.”
“You did it.”
“I can see that you are putting a lot of effort into your homework.”
“You took that one on like nobody’s business.”
“You were like the energizer bunny this week!”
Review the Data
The data begins with the in vivo exposure recording form itself. This form is your client’s experience on paper, and when you go over it together, he can use the recorded data to recall what the experience was like in detail. Most forms use numbers – SUDs - to track the experience, but it is equally valid to use a graphical representation that gives a visual picture, if that is more meaningful for your client. Review the worksheet to get clues about where you might need to focus the discussion. For example, the SUDs data tell you how difficult the assignment was and whether it got easier, or remained distressing throughout the exercise. The number of repetitions tells you about your client’s enthusiasm, commitment to the process, and perhaps something about barriers to doing the treatment, if there are only a few or no repetitions. Perhaps there are notes on the form as well, telling you about your client’s reactions in the moment. Even a sparsely completed form is a clue for follow-up.
Let the client do the talking
While you are reviewing this rich data, resist the urge to open your mouth and start talking, unless you are going to offer praise, or clarify something you don’t understand. Instead gather the data from your client before you start offering your wisdom. Get her impressions of the experience before offering your own. You can use open-ended questions like these:
“How was this experience for you?”
“Did you learn anything new?
“Were your fears confirmed?”
“What are your thoughts?”
“What do you make of the numbers?”
“Was it as bad as you thought?”
“What kept you going? Why were you able to hang in there?”
Normalize PTSD related distress and avoidance
Chances are, even if the assignment went well, your client had some PTSD related distress or avoidance along the way. This is expected, predicted and should be treated as such. Let her know that this is par for the course. Be empathic and compassionate, but accept, and help your client accept, that distress and avoidance are part of PTSD, and confronting them is a planned part of the treatment. Emphasize the opportunity to test out problematic beliefs about distress, its alleged omnipotence, and your client’s ability to have a satisfying life even if distress is sometimes present.
E.g., “Even though it was distressing to be in such a large crowd, you were pleased to be able to attend the graduation ceremony for your daughter. “
Look for habituation, emphasize tolerance
We are always delighted when we see those SUDs numbers going down during the in vivo exercise and across repetitions of the same exercise, right? Look for it, and if you see it, ask about it. Find out how your client views the decrease. Did it get easier, or did she disengage? Did she use distraction or other safety behaviors, or did she habituate?
If the habituation seems credible, celebrate it, but don’t make it your only measure of success because not all the in vivo assignments will follow this pattern. Though some patients successfully habituate to everything on their hierarchy, others do not, and they get better anyway. Sometimes distress tolerance is as important as habituation. And it is a useful skill to highlight and develop because in the end, there will be more distress in life. Learning to tolerate and move through distressing experiences will give your client another way to take care of herself.
Finally, you get to talk
By now, your client may have worked through her experience with your support, of course, and there is nothing left to say except “great job.” But chances are you have noticed some things your client didn’t, so now is the time to ask more pointed, but still open-ended questions. Help your client deconstruct problematic beliefs by asking for more information about her views versus the new information learned in the in vivo. Look for thoughts and beliefs that maintain symptoms and focus the discussion toward these by asking about experiences during the in vivo and at other times that are contradictory.
E.g., “You say that you don’t have control of your temper, but you were able to be civil even though the clerk was rude to you and you felt very angry about it. What do you make of that?”
Now is the time process the safety behaviors or avoidance that may have interfered with learning. What triggered the avoidance? How did the safety behavior function in the exercise? Did it allow your patient to stay when he otherwise would have escaped? Did it prevent him from experiencing distress? Did it help or prevent him from testing his problematic beliefs? Is he willing to drop the safety behavior for the next assignment? Is he willing to stay longer and test the problematic beliefs that maintain avoidance?
Be patient
Resist the urge to sum it all up in a nice little package. Your client may need to do the exercise a few more times before she can come up with more helpful ways of viewing the situation. Let her have that experience. It will teach her so much more than your possibly brilliant but premature summary could do because it will include the nuances of her own life and her own reactions that you cannot possibly know. So be patient. There are times when you will lead your client more directly, but this is always a second line strategy. Let the more powerful strategy of personal experience have a chance to work first.
Do it again
Once you have sufficiently mined the experience for all that it is worth, it is time to collaborate with you client as you plan the next in vivo exercise. Is there more to learn from this item or has it been sufficiently processed? If it is still difficult, or if there are problematic beliefs or safety behaviors still at play, it is important to continue working on it. Does it need tweaking to get at other aspects of the core fear? Are there new questions that need to be tested? Will the corrective information gleaned from this experience easily generalize to other, similar activities, or do you need to change the context to encourage more generalization?You will be aiming to move up the hierarchy as you progress from session to session, but don’t get married to the original hierarchy. New situations may come up as your client gets more active and engaged with his life. Add those new situations as they arise.
While this may seem like a lot to do in homework review, it doesn’t usually take more than a few minutes, and as you model this approach each session, your client might begin processing on her own, making your job even easier. In the end, as with all your interventions, you are not only working through the traumatic experience, you are teaching your client a set of skills, and an approach to life that will serve him well in the future.
Am I the only one who has a hard time keeping my “pearls of wisdom” to myself so the client has a chance to find their own wisdom?
Am I the only one to discover that my fabulous would-be interpretation of the client’s experience was totally off the mark (whew, glad I kept my mouth shut that time!), when he found his own wisdom a few sessions later?
What have you learned helping people process their experiences in therapy?