UKPTS President Prof Dominic Murphy welcomed delegates to the Great Hall in King’s College London for the first in-person conference since the COVID-19 pandemic was declared at which Complex PTSD and Moral Injury were the focus of two-days of keynotes, panels and workshops.  Both key themes were particularly pertinent in the context of the broadening interest in the pandemic’s widespread impact on varying occupational frontlines.

When morally injurious events happen….they don’t only affect us emotionally, physically and socially, they affect people in deeply spiritual ways.
– Joseph Currier

It was regarding the centrality of violations of a personal code and sense of morality that Prof Joseph Currier (Day 1; keynote) made a compelling case for clinicians and researchers to consider the often overlooked role that religious belief or spirituality can play in the trajectory of moral injury.  Powerful and linked to core areas of diversity, identity and psychosocial functioning, spirituality and religious beliefs can be both a help and a hindrance in promoting positive health outcomes.  Indeed, Prof Currier stated that sometimes it is those with the strongest faith who can show the most pain and suffering as moral transgression cuts particularly deep, and can lead to a disavowing of previous faith with widespread ripple effects.  ‘Being spiritually literate’ and openly asking about beliefs – whether present or not – allows clinicians and practitioners to work within a patient’s own definitions and system of meaning-making that is key to the concept of moral injury itself.

The impact and influence of higher powers of a more managerial type was explored by Dr Jo Billings, Dr Danielle Lamb and Mr Jeremy Reynolds (Day 1) who combined research and lived experience to evocatively illustrate the enormous and ongoing toll the pandemic has wrought on frontline healthcare workers.

Dr Billings identified a number of factors as particularly salient in contributing to distress, including separation from family and friends, redeployment and isolation, and the double-edged sword of the media portrayal of healthcare workers that swung with ease from lionisation to vilification.  She reported that although the public’s perception of healthcare workers as heroes itself could be seen as initially welcome, it was also often regarded as unhelpfully framing healthcare work in terms of ‘sacrifice’.  As such, this was could have the effect of minimising or ignoring systematic shortcomings and concerns that many healthcare workers felt need addressing such as a pay, equipment, and working conditions.

We are being asked to go to the frontline and not being given the tools to do it.
– Jeremy Reynolds

This was graphically illustrated by Mr Reynolds who described a sense of betrayal amongst NHS staff during the pandemic as a result of continued and long-standing failures in leadership, lack of PPE and poor governance across the health service.  He described widespread burnout, and the NHS as being ‘beyond crisis point’ with the emphasis on catching-up with growing waiting lists as the next major pressure.

Leadership failure was picked up by Dr Lamb, who reported NHS staff did not point to COVID-19 ‘breaking the system’, rather it was a cumulative impact of ‘pressures on pressures and cuts on cuts’ over the years.  She reported preliminary results from NHS CHECK, the UK’s largest survey of the mental health and wellbeing of all NHS staff during COVID-19 and beyond, which made for sobering listening.  Amongst almost 13,000 respondents, 29% reported experiencing at least one potentially morally injurious event.   Although challenges remain in defining moral injury and its measurement, it does not sit apart from established and identified psychological disorders such as PTSD and Complex PTSD as much ongoing research is uncovering.  NHS CHECK data confirmed this, with the odds of meeting the threshold for a range of mental health conditions reported to be up to three times greater than for those who didn’t experience a potentially morally injurious event.

It was considered that many incidences of ‘classic textbook trauma’ have a morally injurious component, that moral injury may be a barrier to recovery from other conditions, and thus any therapeutic intervention should reflect this.  The panel identified that what happens between exposure to a potentially morally injurious event and the aftermath may be key to mitigating any further distress or illness, and it was to this theme Prof Neil Greenberg turned (Day 1; keynote).

We should be thinking more about how we use what has happened to foster post traumatic growth
– Neil Greenberg

The ability to sustain staff at work was contingent on a number of elements: a buddy-buddy system of colleagues who share similar experiences partnering and looking out for each other; peer support networks to identify and direct those at risk to appropriate help; and fostering trust in superiors and supervisors.  This final element also includes ensuring superiors have the tools and experience themselves to feel equipped to deal with staff trauma and distress.  Prof Greenberg proposed that a ‘forward mental health supervision and support’ model could be adopted for acute distress that drew on the forward psychiatry model developed during the First World War.  With thought and planning, staff support could move forwards from preventing or mitigating illness, to fostering post traumatic growth.  The key to getting buy-in from those in power according to Prof Greenberg, was to frame such support in terms of operational effectiveness rather than staff wellbeing.

All speakers identified the significant work that is still required to codify, measure and treat moral injury, and the considerable overlaps with CPTSD, PTSD and other common mental health conditions.  Rachel Ashwick (Day 2; workshop) identified the perils of and pitfalls of codifying post traumatic symptoms and responses in general, whilst Prof Murphy, Dr Victoria Williamson and Amanda Bonson (Day 1; workshop) combined to detail an innovative trial of treatment for moral injury in UK military veterans.

I can’t take away their pain and reactions, but I can help them deal with the nightmares and given them the tools to deal with it a bit better
– William Yule

Whilst worldwide attention may have been recently focused on the pandemic, Dr Derek Indoe (Day 1; workshop) explored the intersection of CPTSD, moral injury and human rights violations, and drew attention to the traumatic consequences of those on the frontline of the ongoing climate emergency; a crisis long in evidence but only comparatively recently garnering the attention it merits.  So too, the war in Ukraine which has grabbed headlines since February but has been an active conflict for eight years.  Prof William Yule (Day 2; keynote) recounted the development of his Teaching Recovery Techniques (TRT) approach to helping children caught up in disasters, war and violence.  First developed over 20 years ago and currently being scaled-up to support children in Ukraine, TRT focuses not on treatment but on recovery and management.  He explained that the goal is to help children develop an understanding that their reactions are normal and give them skills to regain control over their thought and feelings, and remember events without being overwhelmed.  He stated that it is of central importance to decentralise healthcare, get skills out of the hospital and on the ground to anyone who interacts positively with children.

The focus of childhood PTSD research needs to shift to those communities and countries where the need is highest
– Sarah Halligan

Child trauma and treatment was also the focus for Prof Richard Meiser-Stedman (Day 1; workshop) and Prof Sarah Halligan (Day 1).  Prof Halligan highlighted that whilst the models and treatment for PTSD in adults fit the child population reasonably well, some adaptation is required.  In this respect, parental input and context including how the child and parent view a traumatic event, appear to be particularly important.  Whilst a body of research has been conducted with children presenting at hospital emergency departments in high income countries as a result of single incident traumas, an impassioned plea was made for more research to be conducted in middle or low income countries or communities.  It is in these communities that prevalence and number of experiences is expected to be higher and where the need is greatest.

Dr Eileen Walsh echoed the call for real world studies of populations who may benefit from therapeutic care, specifically highlighting a lack of research into effective treatment for survivors of human trafficking.  For them, the traumas can be multiple, potentially complicated by ongoing social and legal problems.  A feasibility study of Narrative Exposure Therapy (NET) identified a number of themes of moral injury in trafficking survivors including both witnessing the harm and exploitation of others, but also ‘participating’ in a system that led to harm in others.  Dr Walsh reported that the study showed promising results, and that whilst ongoing complex socio-legal problems may not serve as a barrier to therapeutic intervention, they do need to be considered.

Moral injury is a useful concept, as it might open up more conversations about the moral impact of the work we do, but why we also want to continue doing it
– Sian Williams

Sharing the various frontlines with the groups detailed throughout Conference, are journalists and media workers.  Both Prof Peter Lee (Day 2) and Dr Sian Williams (Day 2) made transitions from previous occupations in the military and journalism respectively to traumatology, and shared personal accounts of lived experience at the intersection of occupational exposure to trauma both direct and vicarious, research and treatment.  In addition to Gavin Rees (Day 2; workshop), Dr Williams recounted the myriad challenges journalists face in their exposure to vicarious trauma, the pressure of deadlines, and their non-interventionist stance.  She explained that often the transition between bearing witness to trauma and returning to a comfortable existence at home or quickly moving on to the next assignment, can open up the ‘wound on one’s soul’ of moral injury.  In drawing similarities between ICU nurses and journalists, she echoed earlier speakers’ comments about the importance of a sense of purpose or understanding of the world.  Whether guided by a desire to care, bear witness, or serve a higher spiritual power, in the face of challenging circumstances or ineffective leadership these personal motivators can be the point at which morally injurious conflict can occur, but also a significant protective factor to continue to want to do one’s work.

As researchers and practitioners of various hues all immersed in the field of psychological trauma, Dr Williams said it is incumbent on us all to reflect and remember that offering compassion is easy; accepting it ourselves is much harder.

Selected highlights from the Conference are available on the @UKPTS Twitter feed or by searching #UKPTS2022.
UKPTS Members can download materials presented at Conference in our Member Area.