In this section:
Moral injury from the COVID-19 crisis
Invisible losses: Secondary trauma and survivor guilt
Help for UCSF employees
In addition to the section on grief below, please also see the short video about grief from our Resilence and Emotional Well-Being video series.
When we face acute traumatic stressors like a pandemic or climate disaster, we are experiencing a direct threat to our life or the lives of others we know. We are all either vicariously witnessing trauma, through media or through supporting others, or directly experiencing trauma, by becoming ill, isolated, or experiencing the plight of close others. We all know, in some vague way, that “normal” has changed and the world will never be the same.
Even more, frontline providers and essential workers are at risk of developing traumatic stress symptoms. These acute stress reactions are natural, but it is important to promote self-care, social support, and sleep, in order to prevent prolonged psychological consequences such as post-traumatic stress disorder and depression. These serious reactions are more likely to occur in people with a history of trauma, especially childhood trauma, but we can take steps to protect ourselves and minimize the negative consequences. Resilience and healing from trauma is something that happens best in the context of supportive relationships.
Loss can occur in many different ways. You may experience the death of a loved one, family member, or friend. Perhaps you lost a relationship, friendship, or career. In global crises where you experience sudden change (such as the COVID-19 pandemic), you may experience a communal sense of grief at the loss of how things were, and anticipatory grief at the threat of loss of life.
When experiencing a crisis, you may feel what is called "moral distress." This is an expression of anger at witnessing injustice. These emotions are natural and common. However, it can lead to shaming and blaming, and is not necessarily helpful to the person suffering.
Moral injury is also common in both personal or global loss. This is when an individual witnesses or cannot prevent acts that transgress their moral beliefs. In these intense states, we feel our integrity is violated. This phenomenon is described well by the humanitarian Joan Halifax (who also has tips for coping with moral distress). In this section, we have asked several acclaimed experts in these sensitive and critical issues to share helpful education and tips."
For coping with all of these issues, we emphasize ‘trauma informed” strategies:
- Use strategies to reduce stress throughout the day, including statements that support a resilient mindset (radical acceptance, self compassion, positive challenge appraisals), as well as mind-body exercises that reduce stress reactions such as breathing exercises, meditation, physical activities, and social support.
- Recognize and reduce traumatic reactions. During a webinar, UCSF's Alica Lieberman, PhD, and Edward Machtinger, MD, described traumatic stress—including how it is different from typical life stress, how it can lead to avoidance and emotional numbness and shame, and how to manage it. It is important to help patients, providers, and staff feel safe. Encouraging the early seeking of care is crucial.
- Understand organizational and community perspectives. It is helpful to realize that in response to large scale disasters and traumatic events, solutions must be communal and not just individual (like one-on-one therapy). As noted by Jack Saul, PhD, communal perspective provides outlets such as community peer support groups, ritual, art expression, and safe environments. Trauma-informed practices and principles help make people feel safe and thus more regulated. It includes prioritizing relationships (as social support and connection can buffer stress responses), creating physical safety (a safe environment decreases the stress response and ensures rational thinking, judgement and attentional control can occur), and emotional safety (to help staff understand what to expect).
Moral injury from the COVID-19 crisis
Moral injury is a new term to most. It is defined as the psychosocial and spiritual burden caused by an act that goes against one’s own or shared morals and values. UCSF professor Shira Maguen, PhD, is an expert in moral injury in war veterans, who has shared the following to help us think about its role in our mental health.
Moral injury is an important framework to help understand the mental health impact associated with the current coronavirus pandemic. Moral injury has most frequently been studied in combat veterans following deployment to war. For example, killing or feeling responsible for the death of another in war has important downstream effects on mental health, functioning, and well-being. Health care workers may experience moral injury when they feel responsible for the death of others in situations where impossible choices need to be made about distribution of life-sustaining equipment.
We can learn from medics who go to war. They have taught us what it is like to make impossible choices, to not be able to save everyone needing help, to hold a dying patient in their arms while being shot at during a battle, and to suffer from moral injury when the war is over and they have to live with the memories of those they could not save as a constant reminder.
Some of the identifiable symptoms of moral injury include demoralization, inability to self-forgive, guilt, shame, and self-punishing behaviors. Individuals may struggle with feeling like their morals and values conflict with the choices they have to make during a crisis; terrible thoughts and images may continue to haunt them.
Moral injury can happen both from actions and inaction. For example, not being able to be at a loved one’s bedside when they fall ill. Witnessing upsetting situations and not being able to help may also result in moral injury (e.g., witnessing loved ones get sick and not being able to intervene with love or support due to risk of contagion; being a patient in a hospital and feeling helpless while hearing others around you in distress).
The bottom line is you can experience moral injury when you are not able to act in ways that are in line with their core values, whether that is due to a global or personal crisis. It is important to watch for symptoms of moral injury and reach out for support if you or someone you care about is experiencing some of these symptoms.
Recognize moral injury and associated grief. Even when it seems impossible to tend to our psychological well-being due to exhaustion or isolation, it is crucial. Starting with your family and loved ones, making sure that each individual is tending not only to their physical health, but also their mental health, is important. If some loved ones are isolated, try to reach out, offer support, and check in about mental well-being.
What to expect when experiencing loss and grief
There are a range of emotional responses including grief, loss, and mourning. UCSF distinguished professor of psychiatry and author of "Grieving as Well as Possible" Mardi Horowitz, MD, has shared here the process of grief.
You may find that you grapple with all kinds of emotions. These are all within the normal range of experiences and not under anyone’s full conscious control. It is not a matter of will power to prevent your mind from clouding with unwanted emotions, or to force a cleansing bout of weeping at a funeral service. Rather, as with grief in general, it is a matter of courage and stamina to endure what must be tolerated, and to make easier those difficulties that can be made a bit more manageable without too much emotional cost to others.
The grief period after a loss can be lightened, but not eliminated. Each individual’s personal experiences differ, even in the same household. Each person must negotiate their own darkened passage with the help of their community supports. For a time after a loss, you may experience feelings of apathy, insomnia, poor or increased appetite, anxiety, irritability and weight loss or gain. These symptoms are often associated with feeling deeply sad and having severe worries. But do not be surprised if there is a stage of feeling numb and a bit unreal or not yourself. There are stages of reaction and not all affected parties to a loss of loved one go through the phases at the same time.
Take pride in taking care of yourself and others. Pay attention to feelings and keep up with social activities as much as you can. If you have suicidal impulses or cannot function, you are probably suffering from a complicated grief reaction and/or a clinical depression, and you should promptly seek professional help.
UCSF palliative care physicians B.J. Miller, MD, and Mike Rabow, MD, share guidance for those of you suffering from grief below, including a chapter on grief from Miller's 2019 book "The Beginners Guide to the End." Words are not enough—they never are. Still, here are a few thoughts to help us find a way through the terrible pain of grief.
Grief is the pain of loss: Losses can occur in multiple ways and can feel nearly overwhelming. We all know what it is like to lose something. We all know the ache of being at odds with our own lives. We all know vulnerability. We all know loss. Some losses are of people: family, lovers, friends, neighbors. But losses can be other important things too: loss of connection, certainty, predictability, blissful ignorance, or normalcy. Some losses are for a certain amount of time, some are gone forever. Each person’s grief is personal, true, and incomparable to another’s. There is no ranking of loss, just what it means to each of us to go without, to miss, be separated, be disappointed, and to feel alone and bereft.
Grief has to be, because we love: Grief is normal. We grieve the loss of what we care about. If you are hoping to avoid grief, then you’d have to avoid love. Noting this connection can help soften the sting of these hard feelings. In this way, grief is something of value and is worth protecting. Hence, many cultures and societies have long ritualized the mourning period. Ritual reminds us that we have lost what we love and points us to the comfort of community, honor, and meaning.
Grief is how loss heals: Grief is necessary. Grief is a powerful, painful, and deep experience of how we deal with loss. Understanding what you’re feeling is itself therapeutic, even though it means sitting with the discomfort and pain we all inevitably feel. There is no right way to grieve, there is just the process that each of us must go through to integrate our losses into our lives. Grief is the human process of metabolizing and accommodating loss.
There are a few things to know about grief:
First, grief is an amalgam of emotions. Grief can feel like impossible sadness, but it can also be expressed as anger, numbness, or discombobulation. Even odd giddiness can be grief “talking.” Grief rarely presents itself as any single emotion for very long.
Second, grief is dynamic. That means that grief comes and it also goes. It’s important to note that whatever you are feeling will not last forever in the same way or at the same intensity. Furthermore, a hallmark of emotion is that it cannot be easily controlled. We’ve met many mourners ashamed of unwanted feelings (guilt, anger, relief, indifference), even though such feelings are normal. Our advice is to ride grief’s waves rather than try to command them. It can be helpful to cultivate positive states during this time as well.
Third, there is no particular timing to grief. In fact, grief can begin even in anticipation of loss (anticipatory grief), or it might be delayed for some time. When taking into account how grief shifts shape over time, it is important to recognize that we are never “done” with it, just as we are not done with whomever or whatever we have lost.
Even so, grief can trip into depression. We tend to distinguish the two based on severity and time since the loss was incurred. We strongly recommend you seek professional counseling if you simply want help or are struggling for long periods of time. There is nothing pathological about wanting help, and therapy—whether individual or group sessions, online or from six feet away—can be helpful along the way.
Finally, even the words of a great poet pale in the profound pain and the fundamental diminishment of our losses. But, perhaps, simple words can offer some small solace in our new lives.
Resources for dealing with grief
From author and UCSF grief counselor Claire Bidwell Smith, MS
- Modern Loss: Online community for all grievers
- Dougy Center: For grieving children
- Compassionate Friends: For grieving parents
- Motherless Daughters: For women who have lost a mom
- Soaring Spirits International: For widows and widowers
- Where's the Grief?
- What's Your Grief?
- Grief Out Loud
- Terrible, Thanks for Asking
- Grief Works
- GeriPal Podcast: "What is Emotional PPE for Front-Line Providers?"
- "On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss" by Elisabeth Kubler-Ross and David Kessler
- "It's OK That You're Not OK: Meeting Grief and Loss in a Culture That Doesn't Understand" by Megan Devine
- "Bearing the Unbearable: Love, Loss, and the Heartbreaking Path of Grief" by Joanne Cacciatore
- "Permission to Mourn: A New Way to Do Grief" by Tom Zuba
- "Anxiety the Missing Stage of Grief" by Claire Bidwell Smith
- Extremely Loud and Incredibly Close
- One More Time with Feeling
- Truly Madly Deeply
- P.S. I Love You
Coping with loss and virtual funerals
- Nurture.co: Provides various resources for those looking for support with loss under COVID-19 circumstances. A webinar on having a virtual funeral led by CEO Sierra Campbell is also available.
- GatheringUs: A Brooklyn-based startup that helps make virtual funerals simple and free for lasting communal space to celebrate the lives of ones you love.
- Tribute.Co: Makes it easy to create a collaborative video montage that you can share for virtual funerals or any important occasion. (Free during COVID-19)
- Handouts created by Kaethe Weingarten, PhD, offering guidance to help with workplace and general moral distress:
- Virtual Grieving: Is There Closure if There is No Goodbye?: An article by Shoshana Ungerleider, MD, that provides insight and resources on loss due to COVID-19.
Invisible losses: Secondary trauma and survivor guilt
From Michael W. Rabow, MD, and David Bullard, PhD
We can be hurt by what we bear witness to in others. In caring for others in a crisis, we can experience secondary trauma. Repeatedly seeing and hearing about, working to ameliorate or treat the traumatic losses experienced by others, we are at risk of being traumatized ourselves, going beyond just empathy for another’s pain to an actual vicarious experience of suffering and trauma.
Numbing and compassion fatigue are when emotional and physical exhaustion sap our ability to empathize or to feel compassion. Compassion fatigue can be the unwanted, uninvited cost of caring. Repeatedly now in the time of COVID-19, we are advised (appropriately so) by a series of platitudes that are, nonetheless, absolutely true: “put on our oxygen mask first,” “prioritize on self-care,” especially as we reckon with the fact that “this is a marathon, not a sprint.” We must sustain for the long haul, or at least refuel for the next wave.
We can be hurt by what we bear witness to in others. In caring for our patients, we can experience secondary trauma. Repeatedly seeing and hearing about, working to ameliorate or treat the traumatic losses experienced by others, we are at risk of being traumatized ourselves, going beyond just empathy for another’s pain to an actual vicarious experience of suffering and trauma.
Survivor guilt is an unfounded sense that we have done something wrong by surviving a tragic event. We are hurt by what has not hurt us. This feeling can be both rational and irrational, conscious and unconscious. We can feel this way by watching close family, siblings, friends, or lovers suffer from what we have escaped. Or, we can feel this way by watching people we don't know, parents, or children across the globe struggle from what we have survived (ex: a deadly virus, climate disasters, etc.).
We can even experience an invisible but well-documented version of this emotional response called unconscious survivor guilt. Some manifestations of this can be one's thoughts acting as tools for self-punishment. This is a common response to the perception that we have fallen short of our natural and even hyper sense of responsibility for the lives of others. Rumination and worry are exaggerations of thoughtful self-reflection, and contribute to feelings of unease and depression, distorting the natural sadness and grieving that are inherent in our humanity, and robbing us of joy and delight in our own present moments of precious living.
And here again, the advice is repeated. Though it has become commonplace, even cliché, it remains true: recognize your feelings are normal (and common); realize you are not exempt and there will be time still for us all to feel losses that we might deem big enough; and, if you can, pay it forward. If you have had good fortune, you can dedicate yourself to having your life and work be an honor to those who have not had such luck. Let yourself find moments of peace, connection, joy and love; they can be valuable treatments for the wide world of pain and suffering.
Ultimately, be gentle with yourself. Be compassionate to yourself for the losses that anyone might see in your life, for the invisible suffering only you can feel, and for your place in the misery of what has befallen us all in a million inexplicable ways.
Whether on the frontlines or the sidelines, kindness and taking care of yourself allow you to be compassionate with and to provide deep help to others. Kindness and self-care, most of all, allow us to see the sacrifices and contributions that we and so many are making and to feel our connection to all humankind.
A poem about what we can and cannot do
As sheltering-in-place was starting on March 17, 2020, poet Jane Hirshfield wrote a poem, “Today, When I Could Do Nothing.”
Help for UCSF employees
The UCSF Department of Psychiatry and Behavioral Sciences, in partnership with UCSF Human Resources and the Center for Digital Health Innovation, has launched a program specifically for UCSF faculty, staff, and trainees to provide additional mental health assessment, treatment, and referral resources to our valued colleagues who are experiencing distress related to the COVID-19 pandemic. These services are available to all UCSF employees, regardless of their personal health insurance carrier or status.
The UCSF Employee Coping and Resiliency Program uses a simple and confidential online screening tool to connect UCSF employees with a wide array of emotional support services. Employees requesting assessment and ongoing care through the program will have the option to be treated by UCSF mental health clinicians or, if they prefer, to be connected with their existing health provider.
In addition, employees seeking help with substance use issues will be connected with Bright Heart Health, a telehealth treatment program not affiliated with UCSF. (Please note that this a referral only; UCSF does not control costs or ensure insurance coverage for services provided by Bright Health Health.)
To utilize the program, UCSF faculty, staff, and trainees should visit tiny.ucsf.edu/cope or text COPE to 83973.