Humanistic and Critical Psychiatry Flashcards
What is Moral Injury?
A term that originated in the military
Can be defined as the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code
What are the features of a moral injury?
Often strong features of guilt, shame or disgust
Individuals may experience negative thoughts about self or others e.g. I am worthless, my bosses don’t care about people’s lives
Not a mental illness, but may lead to the development of one (depression, PTSD, suicidal ideation)
May alternatively lead to post-traumatic growth - bolstering of resilience, esteem, outlook and values after exposure to highly challenging situations
Outcome will depend on support before, during and after challenging incidents
What are some examples of situations that could lead to moral injury in a healthcare setting?
Following decisions by others that the individual believes were unethical, immoral or against guidance from professional bodies
Change in belief about the necessity or justification for treatment plans or protocols that have affected people’s lives
Putting patients or colleagues in danger because of your inexperience, indecision or working outside your normal competency
Returning from a shift and hearing of seriously worsening health outcomes in the facility in which you were working
Giving clinical orders or establishing protocols that result in the death of colleagues or patients
Feeling let down because you are working with insufficient resources or staffing, especially when you perceive this was avoidable
How can moral injury be prevented?
Prepare staff/students for the possibility/probability of these events occurring, using frank and simple language - theoretical and facilitated experiential methods
Ongoing support - from Balint groups or Schwarz rounds
Targeting individuals who are “too busy” or repeatedly “not available” - as avoidance is a key feature of trauma
No single session debriefing as my cause additional harm
Supportive supervisors are essential but will need support themselves
What is important with aftercare of moral injury?
Supervisors should ensure time is made to reflect on and learn from the experiences
‘Active Monitoring’ - to identify those that start to suffer in a more prolonged way
To accept that something bad has happened, to, with time, vent the negative feelings around it, to be heard and empathised with in doing so will allow individuals to embody the realisation that whilst bad things may have happened as a result of their actions, the intention behind these actions was good - to save the lives of others. Truly knowing this is to heal moral wounds
What is demoralisation syndrome?
A state in which individuals are unable to reformulate a meaningful existence and life direction and so become disappointed, helpless and hopeless
If chronic, is associated with an increased suicide risk
It is an understandable response to loss and/or (serious/chronic) trauma that leaves lasting damage - so conceptualised as such it avoids the medicalisation of metal suffering
It is a process similar to mourning or grief - so notwithstanding the increased suicide risk it can be seen as a manifestation of health
How does demoralisation syndrome differ from depression?
Depression -
Motivation for change is absent or blunted
Somatic symptoms (e.g. sleep and appetite disturbance) present
Anhedonia in the present and cannot foresee positive change in the future
When severe, distortions in reality testing are present (including psychotic phenomena)
Demoralisation -
Individuals cannot act as they are not able to see the direction to take whilst still remaining motivated to make change
Somatic symptoms not often present
No anhedonia of the positive parts of the present but cannot enjoy contemplating the future
Reality testing generally intact - as it is this process of accurately evaluating the severity of ones’s circumstances that leads to this demoralisation + increased suicide risk
How do you work with demoralisation syndrome?
Enabling/encouraging individuals to mourn - this is necessary in order to come to terms with what has happened
Searching for causal explanations e.g. gaining insight into a psychosis diagnosis by understanding formal medical knowledge - this must be understood properly by patients as can risk self-stigmatising
Preventing engulfment = where one’s identity totally coincides with that of being a sick person; internalising negative stereotypes/stigma makes it harder to retain/restore any former sense of dignity
Assisting in areas of meaning making - future prospects, relationships, social belonging, role and dignity - through multiple activities e.g. creative workshops, psychodrama, music therapy, peer support
Fostering hope - not a naive optimism that everything will be fine, but working towards something because it is good
What is ‘Recovery’ in mental health?
“A deeply personal, unique process of changing one’s attitudes, values, feelings,
goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and
contributing life even with limitations caused by illness. Recovery involves the
development of new meaning and purpose in one’s life as one grows beyond
the catastrophic effects of mental illness.”
(Anthony, 1993, p. 15)
What can an existential perspective teach us about wellbeing?
Having ‘meaning’ in life is an ultimate goal an individual - preceding the bottom of Maslow’s hierarchy - loss of this can precipitate hopelessness and diminish the will to actively and positively engage with your existence
As various of losses of meaning are precipitants of multiple formal mental health disorders, this should be an ultimate focus of mental health professionals
Logotherapy (literally “healing through meaning”) was designed by Viktor Frankl to address this directly
CARDS ON GRIEF AND LONELINESS
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