Moral Injury - Esther Murray
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Dr Murray is a Chartered and Registered Health Psychologist with an interest in social inequalities in health, wellbeing in medical students and doctors, and doctor patient communication. She has a long-standing interest in the wellbeing of healthcare professionals and since starting work at Barts and the London she has been developing her research in the area of moral injury. As well us undertaking research on this issue, she works with NHS staff to develop workshops and seminars which focus on psychological wellbeing and moral injury. Her early research was in chronic pain and its effect on doctor-patient communication and she has a background in psychological intervention in cardiac care and training NHS staff in communication skills. She Health Psychology to MBBS students and Physician Associates at Barts and she is course leader for the iBSc in Medical Education.
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Moral Injury - Esther Murray
- 1. The neuroscience of moral injury Dr Esther Murray and Dr Charlotte Krahé @EM_HealthPsych
- 2. What’s coming up • Concept of moral injury • Implications for critical care – teams and individuals • Current research and interventions
- 3. What do we know – critical care? • Levels of burnout are high across staff groupings, LOTS of research on burnout in critical care settings (see esp American Journal of Critical Care) • There is a paucity of research into the long term effects on healthcare practitioners of witnessing trauma in a professional context (see for e.g. Firth-Cozens et al., 1999; Bennett et al., 2004) • Not all of those affected will present with diagnosable mental disorders (Benedek et al., 2007)
- 4. What is ‘moral injury’? • A concept linked to Post Traumatic Stress Disorder • Emerging from research with combat veterans • In veterans results from being involved in or witnessing events which transgress one’s moral code ▫ Killing/attempting to kill enemy combatants ▫ Seeing human remains/having to handle human remains ▫ Seeing ill or wounded women and children and being unable to help (Litz et al., 2009)
- 5. Why would moral injury occur? • Emotional processing models – avoidance and emotional numbing mean event isn’t assimilated and so can’t be extinguished • Meaning making (Park, 2010) – can all or part of the experience be made sense of? • Cognitive models – data driven processing, stuck in sensory details – failure to see context (Litz 2009, Currier 2015)
- 6. What are the implications for teams? • Symptoms such as social withdrawal (as a result of shame) affect team coherence • Emotional numbing will affect expressions of empathy and ability to offer and receive social support • Re-experiencing increases cognitive load • Eventually we will see burnouts and substance abuse in some cases
- 7. What are the neural processes involved in witnessing pain in others and how are they affected by context and experience?
- 8. Witnessing and understanding others’ pain
- 9. Empathy for pain ▫ participants experienced pain and also watched a loved one experience pain ▫ brain regions involved in pain processing activated just when watching someone in pain ▫ specifically regions processing affective-motivational dimension of pain ▫ brain activation correlated with empathy scores Singer et al. (2004)
- 10. Physicians • Physicians did not show brain activity in pain processing regions when watching people being pricked with needles (Cheng et al., 2007) • Physicians did not show early Event Related Pain Response differentiation between pain and no pain (Decety et al., 2010) • But does dampening of neural responses and possible freeing up of emotion regulatory processes translate into less distress for doctors?
- 11. Impact of available cognitive resources • Vicarious pain responses reduced when under low vs. high cognitive load (Cui et al., 2017) – though not physicians! • When more resources are available, less affective arousal and sensitivity to other’s pain • So less empathy, but also less distress?
- 12. Physicians, empathy and burnout • More experienced physicians rated < pain in others than less experienced physicians BUT groups did not differ on personal distress (Gleichgerrcht & Decety, 2014) – but cross-sectional! • “practicing medicine for a longer time does not seem to give physicians a direct advantage in learning how to down-regulate the costs of empathy (i.e. compassion fatigue)” (Gleichgerrcht & Decety, 2014)
- 13. Limitations and future directions • Most studies ▫ cross-sectional - research on links between empathy and long term impact in terms of empathic distress and empathic concern needed ▫ use picture stimuli and deplete cognitive resources by means of holding in mind digit strings – limited ecological validity BUT also limited by ethical concerns ▫ what about giving people capacity to act, rather than witness only? Behavioural responses should be measured
- 14. Beginnings…conversations with PCP and PHM students
- 15. Student Experiences of trauma cases ‘’mechanism’ makes it worse’ ‘the tiny little things’ Debrief has to be straight away ‘Looking with medical eyes’ Being able to help It matters who you debrief with Filling in the gaps
- 16. ‘the tiny little things’ “it’s the subtle things that preoccupy you, …the casualty might be making noises as you’re compressing. All of these things stay with you a while afterwards…” “…there were just loads of little children looking out of the windows over it (the scene) and I don’t know why but that sticks with me.”
- 17. Debrief “In order for you to do it (talk) you have to accept that something stressed you out or affected you…for me that was quite a big step.” “It needs to be spoken about on the day, otherwise I have the niggly feeling that it’s going to come out.” “I think speaking and getting it out of your head and either on to paper as a reflection or speaking is very helpful.”
- 18. What makes it worse? “The mechanism behind what happened.” “she (the girlfriend) was just screaming, it was the middle of the night and all the neighbours were out and it was just horrible.” “it’s always the ones with the violent connotations which are the hardest to process afterwards…when it’s a violent attack there’s an air about it of ‘God, someone else has done this and it’s up to us to reverse it.’”
- 19. ‘Medical eyes’: what experience does… “I’m not just seeing (the scenes) as ‘this is horrific’ I’m seeing them as ‘this is your injury pattern’ and it changes for me the way the scenes feel.” “I think it is easier for them (experienced doctors) to deal with these cases because they have a lot more medical knowledge, they’re prepared for it…they look at the scenes with medical eyes and they’ve got their algorithms.”
- 20. “I have worried that this year has exposed me psychologically to a bit too much a bit too soon in my career. But I haven’t gone through my career yet so I don’t know whether it’s going to make me better… and if I have this really early on exposure to trauma and say ‘urgh it’s been really rubbish how can I make it better for myself?’, will it help me in the long run… Or is it, the earlier you get exposed to this stuff, the earlier you burn out?”
- 21. What next? • Capitalising on support systems which already exist. Are new systems needed? • Understanding experiences and needs at different points on the career path • Taking care of practitioners in order to ensure their wellbeing – staff generated ‘Psychological Wellbeing in Theatres’ morning. What works for whom? • Longitudinal research – observing behavioural responses, the role of experience in sense making, neural changes.
- 22. We need your help to carry out this research. Please get in touch.
Editor's Notes
- Like PTSD it can result in feelings of distress such as demoralization and guilt Manifests as Intrusive re-experiencing Avoidance Emotional numbing Social withdrawal
- The concern being with regard to the dose – response effect – are we burning out, literally? Draw parallels with the concussion research.
- Since moral injury can occur as a result of ‘bearing witness to the aftermath of violence and human carnage’ (Litz 2009) witnessing human suffering, or failing to prevent outcomes which transgress deeply held beliefs, such as the rights of a child to be protected by their parents, it can be conjectured that doctors and other first responders could be at risk of such injury. Witnessing suffering e.g., seeing someone in acute pain Research in the field of social cognitive neuroscience has examined neural responses to witnessing, understanding, and sharing another person’s emotional state, in short what has been defined as empathy. Empathy has diff components…and here bc of our focus on moral injury, we focus here on the left side of the panel, so on self-oriented feelings of distress when witnessing pain, which can lead to withdrawal and difficulties coping. Of course empathic concern is vital in providing sensitive and compassionate care. But really, a balance needs to be struck, need to be able to manage feelings of personal distress for empathic concern to arise. Pain as we know is an unpleasant emotional state. It hurts, it’s associated with fear and the motivation to escape these feelings. Pain can also be experimentally induced in the lab e.g., brief laser pluses, and we can look at brain regions active when we experience pain using functional neuroimaging techniques, and we can also measure evoked brain potentials following noxious stimuli using EEG. Of course it is nothing like what people experience in an accident or other trauma, but it means we can look at pain in the lab. Now as well as studying brain reponses when experiencing pain first hand, we can also measure responses to witnessing pain. Empathy in the scanner: common paradigm is to watch or imagine someone else experience something and then experience it yourself.
- Singer et al. (2004): participants received pain and also watched a loved one receive pain when they observed their loved one in pain, brain regions involved in processing pain were activated – so just seeing pain activates similar regions to those which process pain experienced first hand Specially, regions such as the AI and dACC, involved in processing the affective, unpleasant dimension of the pain experience Regions involved in processing pain intensity, on the other hand, e.g., posterior insula/secondary somatosensory cortex, the sensorimotor cortex (SI/MI), were specific to receiving pain first hand So parts of the pain matrix were activated just when watching someone in pain empathy! But as the sensory dimension is missing when you are not directly experiencing pain yourself, only the affective parts of the network of regions involved in pain processing are active AI and ACC activation correlated with individual empathy scores! So individual differences here…the more empathic people rated themselves, the greater the brain activation
- And speaking of individual differences, we move on to looking at empathy specifically in physicians. Cheng et al. (2007): Physicians had experience in acupuncture vs control participants control participants showed activation in brain regions involved in processing pain, when viewing others being pricked by needles these regions (i.e., the ACC, insula, and PAG) were not activated in the expert group and experts rated these situations as significantly less unpleasant and painful than did the control participants. Experts regulate their emotions by relying on higher cognitive processes involving knowledge in working memory, long-term memory Not adaptive to extend empathy to all. If feel too much empathic distress, not able to perform. excessively empathic responses may be costly, leading to burnout, emotional and physical exhaustion and professional self-devaluation Decety et al. (2010): physicians and control shown pics of pain and no pain controls showed early differentiation between pain and no pain (N110 component) over the frontal cortex, indicating negative arousal. Physicians did not show this instead constrain incoming sensory info dampening negative response leaves more room for higher brain structures involved in regulating behaviours. Event related potential (ERP) – an evoked pain response e.g. when someone pricks yr hand with a needle. Non-physicians show an early differentiation when looking at painful pics. Non-physicians don’t have the ERP to painful pics – dampening. Habituation.
- To regulate your own distress you need cog resources available. If not it all the emotion comes flooding in. What‘s happening to WM and available for processing? We don‘t yet know. Come back to that but first just want to focus on this idea of the level of cognitive resources available being involved in modulating levels of empathy And this experiment directly modulated cognitive resources by asking participants to hold in mind strings of digits to induce a cognitive load. A small load = 2 digits; a high load = 6 digits, whilst watching pictures showing a person’s hands/forearms/feet in painful or non-painful situations, which have been used in previous ERP studies High WM load increased affective arousal and emotional sharing in the observer and increased the sensitivity to other’s pain; so when reduced cog resources available to regulate emos, show more empathy ie greater vicarious responses But again does this translate into distress felt? Many studies don‘t directly ask this question!
- Helps understand BURNOUT. So back to some behav data and now taking a step away from cognitive resources and looking more generally at the association between level of empathy and distress reported. And here a study compared more and less experienced physicians who rated video clips with facial expressions of pain. And more experienced physicians rated < pain in others than less experienced physicians BUT groups did not differ on personal distress But cross-sectional: Longitudinal studies mixed – some report decrease in empathy over the course of medical education; some no change and some increase (see Quince, 2016) – no brain data! Need to understand long term impact! Participants grouped into either a less or a more experienced group based on whether their individual years of medical practice were above (n = 580) or below (n = 619) the sample’s mean
- So will hand back to Esther, but… ** one study in adolescents found that greater empathic reponses (at a neural level) when witnessing emotional pain translated into them sending more prosocial emails How better simulate cognitive load? Stress people out? Cog load purely cognitive but better to introduce emotional component as well? What about situations – witnessing pain one thing but how about doing nothing? Or if don‘t have enough resources?
- There is evidence to suggest that medical students in any specialty can suffer secondary traumatic stress, that is, traumatic stress symptoms as a result of working with patients experiencing the diagnosis of, or treatment for, a serious illness. This may be because students, in contrast with experienced staff, have fewer resources and less experience to deal with witnessing suffering (Crumpei and Dafinoiu 2012) The proposed research is the first in a series of studies, then, which will explore the relevance of the concept of moral injury to providers of pre-hospital medicine. The current project will explore the perceptions of students involved in pre-hospital care and pre-hospital medicine of the possible effects, both short and long term of witnessing trauma and the systems, formal and informal, which they feel are in place to support them. It leads us to ask the following key questions… - Does the way students talk about their experiences in emergency medicine resonate with the symptoms of moral injury? - If social support can be protective, to what degree to students feel they have access to this support and want to use it? Talk about methods here…..