Moral Injuries Make the DSM-5 and Nurses Get a Shout-Out!

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

With a little—really a lot—of help from my friends and colleagues, I have learned more about moral injuries. It is the beginning of the Jewish High Holy Days and I was asked to talk about it for our synagogue’s annual Yom Kippur Study Session. Over these 10 days, Jews are supposed to try to improve ourselves individually and collectively, and one way is surely to realize what we do not know that is important and learn. And so, even though we have recently had a series of column on moral injuries, I have been grateful to others for guiding me toward more knowledge: Francis G. Lu, MD; Ronald W. Pies, MD; Vincenzo Di Nicola, MPhil, MD, PhD, FCAHS, DLFAPA, DFCPA, FACPsych, FRSC; John R. Peteet, MD; Alan Fung, MD; Mansoor Malik, MD, MBA; and others.

Every September, our DSM-5-TR gets an update to add on some revisions. As I now understand it, this year that includes adding moral problem to “Other Conditions That May Be a Focus of Clinical Attention.” Those other conditions, which can be expressed as symptoms, have included “Religious or Spiritual Problem,” to now add moral for Moral, Religious, or Spiritual Problem (page18, Z65.8). Moral distress and injury would be among those moral problems for clinicians to pay more attention to with their patients.

I also found out that the modern attention being paid to moral injury even predated the landmark 1994 work of the psychiatrist Jonathan Shay about moral injury in the military from the Vietnam war. Moral injury, it turns out, was already getting attention in health care from nursing,¹ but somehow that did not grab wider attention. Probably the everyday, all day, interaction of nurses with patients in hospitals was getting compromised as for-profit managed care developed.²

Knowing more about moral injury could not come at a more important time in our society, especially the common moral injury that results from broken trust with leaders for important matters. In health care, the trust that we can apply our knowledge to help heal patients has often been blocked by business ethics running our systems of care. Now we must add governmental policies that are reducing our country’s already inadequate mental health care resources, as well as the ongoing wars in the world that present pictures of immense health and mental health suffering.

As the first day of fall begins and its beauty emerges in the Northern Hemisphere, now is the time to address our everyday personal moral injuries and also to try to reinfuse the beauty of providing care to our patients as best as we possibly can before our bone-chilling weather.

Tonight begins Rosh Hashanah, the Jewish New Year, which traditionally was viewed as the birthday of the world. May this year be one when we find ways to reduce our moral injuries and increase our moral goodness.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He presented the third Rabbi Jeffrey B. Stiffman lecture at Congregation Shaare Emeth in St. Louis on Sunday, May 19, 2024. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.

References

1. Jameson A. A Nursing Practice: The Ethical Issues. Prentice Hall; 1984.

2. Moffic HS. The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare. Jossey-Bass; 1997.