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This Stress Awareness Month, MQ supporter Sophie Brigden kindly lends us her words to explain more about Moral Stress and Moral Injury. Our huge thanks to Sophie for writing so eloquently and informatively.

And the Moral of the Story Is…

In this blog I want to explore a different perspective to explain the ‘why’ of our current modern day stress epidemic and for the increase in employee resignations that some sectors are experiencing.

Unlike workplace burnout which can be experienced as feelings of exhaustion and disengagement and focusses on individualised solutions such as resilience training, wellness apps and if you are lucky, time off to recoup, I want to talk about a potential reason underlying burnout, Moral Stress. Unlike burnout this isn’t an individual issue but generates from a systemic one and its impact, health wise, can be harder to overcome.

What I talk about stems from my own experience of Moral Injury (MI) which led to Post-Traumatic Stress Disorder (PTSD) and what I learnt to make sense of everything, on my journey through recovery.

I will be using what was initially coined by Jonathan Shay in military research as MI before it gained relevance in society and in business context under the term Moral Stress, to explain the symptoms experienced from working in toxic work environments where extreme moral issues are rife. Some argue that Moral Injury and Moral Stress are separate terms, in this blog though they are used interchangeably.

What is Moral Injury/Stress?

MI is a trauma response which includes feelings such as injustice, anger, guilt, shock or shame, cognitive responses such as intrusive thoughts, social withdraw, loss of trust and avoidant behaviours after experiencing events which contradict your ethical beliefs and rock your self-identity and semblance of the world. If experiences aren’t integrated, it can lead to cognitive dissonance and if the situations continue, in the long-term, it can lead to mental health implications and outcomes such as PTSD.

MI gained further relevance in the healthcare sector during COVID to explain the distress experienced as professionals were left conflicted between their reality and the level of care desired and MI has also been found to be prevalent in other institutional hierarchical environments where there have been clear abuses of power.

My Own Experience

I was posted out to Afghanistan as the only female attached initially to an infantry battalion (800 men) where from the onset of arriving in the battlespace, I experienced extreme humiliation & bullying, the betrayal of leadership, sexism and at worst, I was sexually assaulted by an Afghan National Army (ANA) Officer I was training.  When I reported the assault to my Commanding Officer (CO) I was told, I would go back and train ANA officer but this time, I should take a pistol with me. At that point, it dawned on me I really was alone, a mere object in his agenda of keeping the ANA happy and onside and this took precedence over his humanity.

As these events piled up it became more and more apparent that no-one else had my back which was one of my biggest lessons; always have your own. But why didn’t I speak up sooner? Partly because I feared the consequences of speaking up on my career, of being seen as a failure and of the backlash by peers especially when this was all happening in a war zone. It is amazing what a person will put up with to fit in or survive but I wish I had spoken up earlier. My advice to anyone now would be nip things in the bud, even if the outcome is difficult and not what you want, because putting up with their behaviour enables it to continue and caused me so much pain. Eventually I did call the CO out and when people heard about it, I was ostracised but at this point I had given up caring.

At the end of the tour, I was posted back on my own, straight onto a new job, whilst those on tour came back together and had 2 weeks in Cyprus to ‘decompress’. When invites went out to those on tour to be awarded their medals at ceremony, my medal was sent to me in the post. No-one checked on me and trying desperately to forget what had happened, I tried to push the memories and hurt down but, this was a massive mistake. Funnily enough it wasn’t the incidents that led to me losing my career but the fall out of the emotional pain I felt. I now know you can’t get rid of hurt by running away from it, you have to face it, but it would take me spiralling slowly down to a rock bottom before I figured out what was wrong and how to help myself.

Causes of Moral Injury/ Moral Stress

Events don’t need to be catastrophic to cause MI but can include the gradual build-up of transgressions. MI is present in certain conditions and affects people in different locations within an event(s). This includes the person who carries out, witnesses, fails to prevent, or encounters betrayal by those in a position of power. In these situations, a person’s deeply held core beliefs are violated and ultimately this leads to adverse outcomes for self or others. This might look like witnessing unfair redundancies in your company, an inability to deliver the appropriate level of care to a patient due to resource shortages, toxic bullying environments and a leadership that look the other way or unwritten recruitment rules to hire for ‘high energy’ that is really, blatant ageism.

MI can affect anyone at any level, from the frontline worker to every layer of leadership in situations that leave us feeling powerless and lacking agency. Sometimes the distress we experience is happening because it isn’t as simple as weighing up what is the right thing to do and then acting because ethically, you already know what the right thing to do is. You may feel torn though because the situation could involve someone higher up the chain, speaking up could be costly for your career, the family you support or the organisation. Perhaps your values are in direct conflict with others’ wishes and at the same time as all of this, not speaking up can mean you become complicit to the problem.

In my case how I was treated violated my deeply held beliefs of equality, humaneness and respect. It rocked my sense of self, I lost my trust in others and of feeling safe in the world, I internalised and personalised the experiences thinking I was a failure and there must be something wrong with me. Ruminating on all of this and wrestling with insidious shame, deep feelings of anger and injustice at being left with the consequences of something that was never my fault, I struggled to make peace with what had happened to me. Little did I know that this continued struggle psychologically would lead to me developing PTSD.

How do we deal with Moral Injury/Stress?

Individuals: Having experienced MI myself and being clueless to what I was experiencing, my first piece of advice is don’t ignore how circumstances are impacting your emotional health.

Find allies at work and even if uncomfortable nip situations like bullying in the bud.

Reflect on whether you might be suited in an organisation more aligned with your values but I would suggest working through what happened to you first, because you might carry the residue of the impact on to your next job.

Get the help you need to work things through and gain perspective which might look like getting help from a Trauma-Informed Coach like me.

My experience and everyone’s healing journey is different but, it wasn’t resilience training or mental health Apps that helped me heal but the love of one person who stood by me through out and gave me my faith back in humanity. Find healthy and supportive relationships where you are accepted so you can trust once again.

Organisations:  Embed ethical behaviours and decision making through policies, reinforcing through communication and consistent action.

Shift perceptions in the culture around actions like whistleblowing to one of emotional courage and authenticity and through leaders responding in ways that demonstrate the value of those that speak up.

Encourage reflective group discussions where taboo subjects are talked about and hold honest discussions about the gap between their ideals and the reality of practises observed and experienced.

The post Moral Stress: what is it and how do we deal with it? first appeared on MQ Mental Health Research.

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