Wes Fleming, BCC, a clinical chaplain for the Veterans Administration in Syracuse, NY, recently spoke to Vision editor David Lewellen about the similarities in moral injury between combat veterans and healthcare workers. Below is a slightly condensed version of their conversation. (We plan to run another article next week about Wes’ experiences in the worst of the pandemic.) 
Q. What’s the difference between PTSD and moral injury?
A. PTSD is a physiological response, the result of biological mechanisms in the brain and nervous system that release stress hormones, and we can treat the symptoms with medication and therapy. Moral injury was noticed by researchers as presenting features that weren’t ameliorated by PTSD treatment. The ways people react to the emotional pain of a moral violation, in this case moral pain, can include emotional distress, substance abuse, and self-harming behaviors—all sorts of avoidance and maladaptive coping. Chaplains can provide an accepting space where veterans can find a safe place to look at the moral violation, ways to either deconstruct it or see it for what it is, and accept what happened. They can acknowledge their own personal trespass, or forgive others who betrayed them, such as institutions. That can happen in a group, which has been highly successful for us, or individual pastoral care. Sometimes it helps them move into committed action or do something in life that can sometimes look like atonement—like ways of serving that try and make it right.
Q. How did you become interested in moral injury?
A. I became aware of it around 2009, when articles started coming out that separated it from PTSD. On a personal level, my father was a combat veteran. Sometimes he would tell me he dreamed of cities on fire, and he felt terrible about the innocent lives he took as B-29 navigator over Japan. He carried a lot of moral residue – guilt, anger, and a sense of betrayal by the government.
Q. What was it like to start seeing the same thing in the pandemic?
A. Not being able to hold a patient’s hand felt wrong to me. That began to ring a bell. I said oh my goodness, this is moral pain, a violation of what I hold to be true and good. And moral stressors like these were felt hospital-wide among nurses, and by administrators who needed to design and enforce visitor policies that disrupt human connection for the sake of infection control. You see it popping up everywhere.
Q. Not being allowed visitors caused moral injury two years ago. What about now?
A. Visitor policies have opened up a bit. The big thing now is staff vacancy. Loyal workers are getting hammered. They’re looking at early retirement, the stress is so great, and there’s a moral dilemma about leaving their colleagues, but also the stress they bring home to their families. Nurse managers are trying to plug holes and hire people without a lot of experience, and the sense of team on the unit has been broken. I’m offering a group to nurse managers, a kind of debriefing, half an hour, not to problem solve or work on fixing anything within the organization, but a chance to share in a confidential environment the stressors they’re experiencing. We do it with veterans right now, and it’s very successful, but now we’ll try it in the hospital setting.
Q. What’s your role in the group?
A. We don’t minimize a person’s sense of transgression. I’m not going to tell someone it’s not that bad, or you’re just doing your duty. They need to take the feeling of a violated conscience very seriously. It’s a chance to share out loud their story, and in that environment provide acceptance, affirmation, and understanding, and heal one another. Working with combat veterans for 10 years, the types of treatments that I’ve learned about apply so naturally to what we’re seeing here among healthcare professionals. It gets me excited about offering staff more opportunities to find relief.
