Responding to Moral Distress, a Phenomenon of our Time and Finding our Courage to Act

Rebecca, a social worker and mother of three, wakes up at 4 am, turns over and over in her bed, unable to fall back to sleep. Images of scared children peeking through the wire-fences of a detention camp arise in her mind. California’s Adelanto Detention Center is less than 100 miles away from Rebecca’s home where she and her family are living in a modest but comfortable house. Knowing the discrepancy between the safety and comfort of her home and the dangers of the detention camp, she is outraged, and at the same time, hopeless. Even though she feels strongly about the injustice of this situation, she experiences powerlessness to effect any change.

Steven, a young oncology resident feels outraged and hopeless about his 27-year-old patient Shawna, whose treatment of Stage IV Melanoma has been delayed because of health insurance complications. Steven wrote a letter on Shawna’s behalf, yet to no avail. The bureaucratic red tape is making it increasingly unlikely that Steven will be able to save Shawna’s young life.

Don, an environmental science teacher at a Midwestern high-school feels gloomy and disheartened when he learns that coal mines have been re-opened in his town. Requests to re- train the miners for alternate careers have been voted down by the city government. Don knows how badly his students’ fathers do need these jobs, yet he is at the same time all too 2 aware of the detrimental influence of fossil fuels on climate change. He feels paralyzed, unable to act.

Recently, I was asked to write about burn-out, secondary traumatization and Moral Distress disorder in a book on self-care for nurses and other health-care providers. When I read the invitation, the word Moral Distress jumped out at me, landing right on my heart. This syndrome is described in the nursing literature: “Moral Distress occurs when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”

I immediately recognized that this phenomenon, so clearly described in the medical literature, is naming an experience that is endemic to our culture. Liz Stokes, a professor of nursing from the University Kentucky writes:” …this conundrum, dubbed ‘Moral Distress,’ can make nurses feel powerless, anxious, and even depressed.”

Clearly, it is not only nurses who feel morally troubled when they can’t give the care they know is right because of institutional constraints. Like Rebecca, Steven and Don, many millions of us feel disheartened when the vulnerable among us and at our borders are treated without compassion and respect, and big institutions or the current government seem to make it impossible for us to take right action.

The term Moral Distress names an often-unrecognized source of demoralization and paralysis in our society. Our feeling of powerlessness leaves us riddled with self-doubt, and without a sense of agency. Symptoms of Moral Distress, as described in the medical literature, include anxiety and depression as well as gastrointestinal problems, insomnia, headaches and 3 nightmares. As I reflect on Moral Distress, I remember accounts from friends about how they feel nauseous when listening to the news, how they wake up at night worried that our democracy is crumbling, leaving countless people un-safe and un-cared for. As a psychologist, I work with my clients’ nightmares about trying to escape from detention camps, from autocratic armies or environmental catastrophes. A psychiatrist friend told me, “Most of my clients can deal with life, but the unpredictability and lack of safety in the social situation feels like a bad flu that does not go away.”

Stokes’ recommendations for nurses grappling with Moral Distress can be beneficial for the broader community. “Once nurses identify Moral Distress,” Stokes writes,” they’re better equipped to overcome it.” Many of us are not aware of the degree of our upset and moral angst over what is happening to the vulnerable in our country. While nightmares and physical symptoms sometimes express how we feel inside, we push our upset away, distract ourselves and deny our feelings. I have come to see that simply acknowledging how we really feel, as Stokes suggests, allows us to find ground under our feet again. Rebecca felt less atypical and eccentric in her feelings about the children in detention camps, when she knew what she was experiencing: Moral Distress.

Stokes writes: “Coping with moral distress includes cultivating both moral courage and resilience.” The cultivation of moral courage that is recommended to nurses involves developing the strength to speak up despite the fear of repercussions. Moral resilience is the internal capacity that nurses have to learn in order to restore and sustain their personal integrity in response to Moral Distress.

Imagine, if a majority of us would stand up and voice exactly what we feel, without fear of being criticized, excluded, or of being impolite or uncool. What if we truly allowed ourselves to feel what we feel? Imagine, if Rebecca allowed herself to feel true pain and outrage when she got to know about the fate of the children in the detention camp nearby as well as about her own powerlessness and inability to help. Imagine, if she could have calmly driven to the Adelante Detention Center and would have found the courage to speak out on the behalf of those incarcerated children. Who knows? Possibly some officers might have responded with understanding and allowed her and others to come in to support those children in finding appropriate care and in reconnecting with their parents. If all of us were able to act in accordance with our inner integrity in response to what feels wrong, I believe our world would be a very different place.

Stokes tells us further: “When nurses experience Moral Distress, it’s important that they feel supported. They have to be able to address the issue in a safe and nonjudgmental space.” As I see it, we need safe public spaces where we can reflect, think and feel together, spaces that allow us to feel a sense of belonging instead of isolation, of respect instead of ridicule. I am reminded of my grandparents and parents in Hitler’s Germany, where it was unsafe to share one’s feelings with each other, and where people were hiding timidly and scared in their homes. We are not in Hitler’s Germany, but so many of us do not feel comfortable and free enough to voice our sentiments openly. Imagine if people in health- care settings and in our various communities were encouraged to speak out on behalf of those vulnerable. Imagine an environment where such acts of bravery would be rewarded 5 and respected?

Stokes proposes what she calls “Four A’s” to those in healthcare settings. Like nurses, we all can be helped by these four A’s. The first A is Ask: We ask ourselves, “Am I feeling distressed or am I showing signs of suffering?” This is an important issue, as at times we feel sadness and grief about the information and images of pain that come towards us, such as a stranded orca or a child hit by a car. Our suffering becomes distress when we feel powerless about sorrow and anguish that we would love to have prevented. Don, the environmental science teacher from the Mid-west, was asked by his primary care doctor at his last yearly visit, if “he was OK.” The doctor worried about Don’s haggard look. Don confided in him his great worries about climate change, about the future of his own children and his students. He revealed that he was suffering from bad dreams and that he found it hard to eat. “I don’t know what I can do,” he told his doctor, I feel completely powerless.” So, a first step is recognizing one’s own distress.

The second A is to Affirm our experience: You may say to yourself, “Yes, I’m feeling this distress and I’m going to make a commitment to address it.” Imagine Hitler’s Germany. What would have happened if the majority of the adult population would have made a commitment to act on their outrage about injustice and violence happening in their midst. Or if in our time, thousands would demonstrate in front of detention centers, refusing to leave until the last child was released to her family.

The third A is Assess: “Assess your ability to make a change. Ask yourself, ‘What can I do personally? How can I contribute to my organization to try to mitigate moral distress?’ Do a 6 deep dive to understand the root causes of the distress.” I find the last sentence of this recommendation especially important. Yes, let’s find the root-causes of our unease. Let’s understand deeply the range of social and spiritual causes that contribute to our moral distress. The rules and regulations and social forces that allow greedy individuals to harm others? The I, me, mine culture that shapes us to think of ourselves first and foremost before considering the welfare of others? Our own inability to ponder our meaning and purpose in life, and our lack of connection to a wider perspective?

The last A encourages us to Act. Stokes urges nurses to take personal responsibility and try to implement the changes that they desire. When more people act, then acting becomes the normal thing to do. Then our culture becomes one that is alive, caring and creative. Then we feel good to live in our own skin. Imagine if oncology resident Steven had continued to write letters on behalf of Shawna to the higher echelons of power in the healthcare system. It is possible this could have been effective, helping her receive immediate treatment, and may have allowed her to continue her life being healthy and productive. Regardless of her treatment outcome, Steven would have felt confident within himself, and he would have continued his career with a sense of agency and hope. This might have encouraged him to stand up for of his patients in the future and may have led to him becoming an important agent of justice, compassion and change.

Building on Stokes’ four A’s, I suggest we meet our moral distress with the power of Bodhicitta, a term from Buddhist teachings. Bodhicitta is the wish for all beings to be well, to be happy, and to be free. The Dalai Lama has said, “Bodhicitta is the medicine which receives and gives life to every sentient being who even hears of it. When you fulfill the needs of others, 7 your own needs are fulfilled as a byproduct.” When we act on our wish to share our riches such as knowledge, insight, happiness or wealth with others who are less fortunate, we are acting with the motivation of Bodhicitta. Bodhicitta allows us to have an attitude that is bigger than our self-doubt, more powerful than our hate or our wish for revenge and deeper than our despondency and depression.

Bodhicitta is a term that has become highly relevant to me in my frequent travels to attend teachings of the Dalai Lama in Dharamshala, a community of Tibetan refuges in Northern India. How do the Dalai Lama and these exiled people manage to live with such equanimity and kindness in the wake of immense trauma and Moral Distress, having experienced and witnessed capture and torture by Chinese officials while being powerless to help and intervene on behalf of friends and relatives?

Day after day, the Dalai Lama listens with a caring ear to the horrific stories of countless refugees confiding in him. I am guessing that it is Bodhicitta that allows him to maintain an attitude of engagement, open-heartedness and presence with each person who approaches him. The Dalai Lama has explained, “I trust in the sincerity of my heart’s intention.”

One vehicle for cultivating an attitude of Bodhicitta as well as for healing Moral Distress is the practice of mindfulness and compassion. Mindful Awareness, can be understood as “Being aware with acceptance and caring intent, on purpose, with compassionate judgement, in the present moment” (Integral Mindfulness, Witt, Keith, Integral Publishers, 2014). When we practice mindfulness, our minds calm and our hearts open, allowing us to 8 recognize the quiet voice of Bodhicitta within us. Compassion is the movement of our hearts and the caring that arises when we witness the suffering of others. Compassion practice allows us to grow our ability to respond to others with a sense of caring and gentleness, spontaneity and relevance. Mindfulness and Compassion together allow us to be present with our own or another’s Moral Distress in a tender and loving way.

After the 2016 election, my husband Michael and I started a monthly town-hall meeting at a local church where we present and promote reflection and discussion about common areas of suffering and concern in our Santa Barbara community. After a beginning mindfulness and compassion meditation, a panel of speakers reflects together with the audience. Themes of such evenings have been: “Compassion as Refuge and as Response,” “Connecting to Love in a Time of Fear,” “How Bodhicitta can help us be Engaged in Uncertain Times,” and “Responding to Moral Distress.” These evenings have helped Michael and I feel a greater sense of agency and meaning. Our fear, even though still present, is more manageable now.

Recently, Patricia, a local therapist, spearheaded teaching mindfulness and compassion in a local High School. After a traumatic winter when two students committed suicide, discouragement and general anxiety were running rampant. Patricia grieved deeply over the loss of the two boys. The Moral Distress she experienced by being a helpless bystander in the face of those boys’ and so many of their school mates’ misery gave way to her being more able to feel her own deep distress. From that experience grew moral resilience and courage which in turn made it possible for her to organize a Mindfulness and Compassion 9 school program. This new project allowed her to experience herself as having a greater sense of agency and to act as a force for health in our community.

Lynne, a local accountant, felt helpless and exhausted when witnessing our community devastated by fires and mudslides. In the company of a few close friends, she allowed herself to feel her sorrow. Then she began to experience the energy and courage to lift herself out of her paralysis. She made a commitment to act, and with a small group of peers she started a non-profit through which courses on health, wellness and resilience are now affordable to everyone who needs them.

How is Bodhicitta a response to Moral Distress?

As we hold an intention that is greater than our own comfort and concerns, we learn to surrender even our sense of outrage to a greater vision, the welfare of all. This does not mean that we become inactive and compliant; instead it might mean that we speak out from the basis of a wider foundation than our own. We speak out as ourselves and as emissaries of all humankind and of universal goodness. Bodhicitta springs from the insight that we are all interdependent and interconnected. If we deeply understand what Zen Master Thich Nhat Hanh calls our interbeing, then compassion and acting on behalf of each other is the natural next step.

As we act with the intention to help others to be more at ease, healthy, or safe, we notice that we ourselves become happier. Then we feel a greater sense of belonging, we feel more confident in ourselves and our symptoms of Moral Distress recede. Our longing for 10 connection, and our desire to see others well and happy become intertwined with our own happiness, meaning and purpose. We may continue to know that we cannot easily change the system. However, we can feel part of something life-giving, and we can act with kindness, hoping that this will relieve some suffering, bring comfort, and inspire others to discover their courage to act.

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