Staff Perspective: A Discussion with Dr. Rita Nakashima Brock on Moral Distress and Helping COVID-19 Healthcare Workers
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.
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.