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Articles: 

Coping with moral injury in mental healthcare 

By Tamika Damond, Ph.D.

How Gestalt Therapy  impacts client awareness

By Ken Hutchinson, Ph.D. 

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Coping with moral injury in mental healthcare

 By Tamika Damond, Ph.D.

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      In the mental health world, there is a term we should know: moral injury. It is all about the emotional struggles mental health helpers go through when faced with tough or morally conflictual situations. Psychologists and other therapists play a crucial role in comprehending this complex concept and supporting not only their clients but also themselves and their colleagues who may be grappling with it.

     Moral injury is not about physical pain; it is more about a deep internal struggle when someone sees or does things that go against what they believe is right. Think of it as a crack in the soul—a strong sense of guilt, shame, or feeling like they let themselves or others down. This type of experience transcends the regular stress of the workplace. Typically, the person’s moral compass feels broken as they struggle between their professional duty and deeply-held personal values.

    Consider a therapist who finds themselves torn between disclosing a client's serious substance issues to their family, risking the vital trust in their therapeutic relationship, or keeping it confidential, potentially endangering the client. Or think about a healthcare worker having to make tough choices during a crisis, deciding who gets help because of insufficient resources. There are also those situations where therapists feel betrayed by their organization when a lack of transparency results in displacement or hardship for their clients. These are scenarios where moral injury can develop as therapists question whether they made the right choices for the greater good of their clients. Of course, no definitive example completely represents situations that bring about moral injury. Numerous factors in each situation include cultural, sociological, spiritual, political, societal, and injustice dynamics.

     Recognizing the signs of moral injury is crucial for early intervention and support. Symptoms might show up as intense guilt, anger, or blaming oneself. Mental health helpers might distance themselves from friends and family or feel down and anxious. They may experience a sense of isolation, finding it challenging to connect with friends and family due to their internal conflict. Sleep disturbances, such as insomnia or restless nights, can compound the emotional toll, exacerbating feelings of distress. Sometimes, they might turn to unhealthy ways of coping, such as substance abuse, workaholism, compulsive behavior, or refusing to acknowledge or address the emotional struggle associated with conflicting values and actions.

    Distinguishing moral injury from other mental health challenges like burnout and PTSD

is crucial to understand. Burnout typically involves prolonged exposure to chronic workplace

stress, like organizational constraints, resulting in feelings of powerlessness and heightened

frustration. PTSD often arises from exposure to life-threatening events eliciting symptoms

of intrusive thoughts, hypervigilance, and mood changes. Moral injury goes beyond feelings

of disillusionment in a job setting or effects after traumatic experiences; instead, it manifests

as a profound internal struggle and questions one's moral integrity. Moral injury is characterized

by the depth of inner conflict, existential questioning, and emotional turmoil experienced, often

leading to a fundamental shift in one's worldview or identity. 

    For those suffering from moral injury, creating a safe space to share experiences is essential. Having a loved one or colleague listen without judging allows a chance to express emotions and start to feel better. The addition of self-compassion is also vital in maintaining a healthy self-image. Therapies, including cognitive-behavioral therapy (CBT) or mindfulness practices, can help change distressing thoughts and handle difficult feelings. Group therapy is also effective, creating an opportunity to connect with others who have been through similar experiences. Additionally, organizations and schools can teach about confronting moral dilemmas and how to make good decisions.

    Self-care acts as a preventative measure. As mental health professionals, dealing with other people's challenging experiences can be demanding. Taking care of yourself ensures you can continue to provide the best support to others. Seeking support and engaging in meaningful activities outside the work environment can create fulfillment that keeps you mentally healthy. Getting back a sense of purpose is useful in building resilience. Engaging in activities that match personal values or giving back to the community can help restore that sense of moral balance.

    Remember, dealing with moral injury isn't about erasing the past. It's about facing the pain, working toward healing, and regaining a sense of moral strength. Understanding and kindness can be the guiding light to rebuilding confidence, mending broken beliefs, and guiding toward a fresh start filled with purpose and meaning.

    In the end, creating an environment that encourages talking openly about moral struggles can help mental health helpers deal with complex situations related to moral injury.

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Tamika Damond, Ph.D., is a licensed psychologist in California. She specializes in culturally competent therapeutic services for clients with diverse identities.

She may be reached by email at dr.damond@believepsychology.com

How Gestalt Therapy  impacts client awareness

By Ken Hutchinson, Ph.D.

     Gestalt therapy was developed in reaction to the rigidity of Analytic approaches that dominated the 1940s and 1950s when Gestalt therapy was being conceptualized. Gestalt therapy shifted the focus from the past to present functioning, from “insight” to “awareness” processes that were integrating and healing.

     

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     It altered the therapeutic relationship from" disengaged analyst as expert" to a cocreated and very personal

dyadic interaction. It shifted the power to the from the therapist’s knowledge of health to trusting the inherent organismic capacity to self-regulate and knowing what is best for us. It saw “defenses” not as inaccessible unconscious processes but as physical and somatic manifestations of our adaptations to life challenges. Gestalt saw the projections of the client onto the therapist (transference) as a co-created phenomenon rather than a pathology of the client and understood “self” not as a fixed entity but as an emergent phenomenon related to the context of the situation in which “self” is aroused.

    Gestalt therapy owes much to psychoanalysis, existentialism, field theory, phenomenology, Buber’s “I-Thou” understanding of relationships, and Gestalt psychology, which understood the processes of figure/ground formation, closure, holism, and other integrating processes.

The I-Thou Relationship

           Gestalt therapy, as Fritz Perls practiced it, did not initially look like it does today. While powerful and dramatic, Perls put aside some of the principles discussed in his 1951 book ‘Gestalt Therapy, Excitement and Growth in the Human Personality.” Current gestalt therapy sees a therapeutic relationship as co-created (field theory). There has been a great recent emphasis on the understanding that the therapeutic relationship is a 2-way street, and the client is best met when the therapist is present, real, and engaged, which Perls seemed to overlook.

Transference and Countertransference as part of a co-created dynamic in the therapy

     Current Gestalt therapy sees the importance of the therapist recognizing that they participate in and somehow trigger transference issues for the client. When the therapist begins to recognize that something they did or said in therapy is part of the client’s reaction, the therapist can own this and support the client (and themselves if needed) in deepening an experience to increase awareness of what was triggered.

Awareness, not insight

    The Gestalt approach has always distinguished itself from psychoanalytic thinking with the recognition that in- sight alone does not lead to change. Instead, the focus is on supporting the client in bringing the unaware to aware- ness to move from operating out of habit to out of choicefulness. Choice is a “superpower” of the human being.

Safe Emergency

​     Gestalt therapy recognizes that clients are somehow stuck. We do not think it is useful to “blast through” defenses and resistances; instead, we provide just enough support for the client to take the next step in their growth edge. We set up experiences in sessions that a client tends to avoid in real life to support them in finding some clarity, safety, and comfort in taking the next step for themselves.

Content to process

​     Gestalt therapy, unlike many approaches, is much less focused on a client’s story and more focused on the emotional impact of the story. We often direct clients to attend to their breathing, somatic experiences, and musculature to broaden awareness of how the “story” is experienced and how meanings are given to the story. Focusing on inner experience rather than words opens deeper levels of emotional experiencing and awareness.

Meaning giving

    As humans, we tend to give meaning to our lives in ways we don’t think other animals do. We have an experience, judge it for ourselves in one way or another, and create a story around it. The story's meaning remains fixed unless deeper emotional experience is uncovered, experienced, and reintegrated. Integration occurs most deeply after the emotional experiences are processed so that new meanings can emerge.

Self-talk

​     We all do this. While not a great focus of Gestalt therapy, our stories, our self-judgments,

and our histories, including the messages we received from parents, siblings, and friends,

all impact our emotional processes. More about this will be discussed below.

Deepening emotional process

​     We recognize the importance and centrality of our emotions in giving meaning, directing our behavior, and impacting our inner sense of distress or peacefulness. When working with clients who become stuck in emotional processing, we may ask things like: “As you breathe right now, what do you notice in your body (chest, stomach, muscles, breath?” “Finish this sentence: ‘Right now my body is telling me’…” “Right now, I want…” “Right now, I need…”

Empty chair work

​     Ambivalence: The empty chair can be used to assess the client’s ambivalence in life decision-making. A client can investigate each side of a decision by separately embodying each part and having a dialogue between the parts. A skilled therapist will be able to guide this toward the client’s deeper sense of the direction they wish to go.

    Unfinished Business: When a client has a figure from the past or present that they have been unable to address directly, they may find some sense of release, clarity, emotional depth, or understanding by having a “conversation” with this person in the empty chair. This promotes a safe way to unravel the thoughts, feelings, and behaviors that the client has suppressed. Again, a skilled and experienced therapist can work with a client on deeply intense experiences, moving the client toward better closure.

    Inner Splits: We briefly discussed self-talk earlier. A skilled therapist will be able to work with a client to clarify the nature of the client’s self-talk and what messages clients have “introjected” from others in their lives. The therapist will also support the client in reevaluating these messages. We have all grown up with messages from others, such as “If you do that, you’re going to hell.” As adults, we have the capacity to “re-digest” this kind of internalized message in our adult minds rather than living with this belief without deeper examination. The empty chair can help us evaluate the current relevancy of these kinds of messages. Also, an inner split is the part that judges us and the part that resists (Top Dog, Underdog).

     An example of this can be seen in procrastination. Part of a person’s self wants and intends to complete a task; the other part finds anything but this to do. We’ve all seen this and probably done this! The empty chair dialogue between these aspects of self can lead to better integration.

Dreamwork

​     Gestalt therapy is a very expressive, potentially dramatic, and powerful approach to supporting a client to understand their dreams. This occurs through an embodiment of the relevant aspects of the dream and noting where the conflicts and energies reside. Again, it takes a skilled and experienced therapist to do this impactfully. Clients are often surprised by the directions and meanings they may glean from this work.

    Something not well understood outside of Gestalt therapy is the theory of self. In Gestalt therapy theory, there is not a “fixed” self, but one that emerges and configures itself in the context of what is current. As self-adapts to life, sometimes fixed patterns of response occur. These fixities lead to automatic reactions rather than aware, chosen responses to life. When working with any of the processes discussed above, we typically work with some fixed sense of self that has become maladaptive, though it served a client well when adopted. Gestalt therapists seek to help clients free themselves from fixed aspects of self that are no longer adaptive. Again, a perceptive, experienced therapist will note these fixities and support the client in more spontaneous and free living.

National Psychologist CE Quiz

Ken Hutchinson, Ph.D., is a licensed clinical psychologist in CA. and N.M. He currently lives in Albuquerque, N.M. and is “mostly retired” but continues to see a few clients each week. He runs a therapy group for therapists and conducts Gestalt therapy training. His email address is khutch@zianet.com.

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