A clinician’s guide: how to manage morally distressing situations

Leaves in a stream

Most health care providers are used to dealing with a daily range of stressful and distressing situations. However, some experiences can weigh on us even after they’ve passed ― consuming our thoughts, heightening our emotions and triggering our nervous system. These feelings can be difficult to shed.

When we experience a deeply upsetting event and there’s very little we can do to change it, it’s common to mull it over. Since the experience is unresolved, our brain continues to work through it. As a result, we might struggle to keep our thoughts focused on what’s happening in the moment. The more we stay stuck in these thoughts, the stronger this memory or emotional experience can become.

These feelings are heightened when the situation results in moral distress or a moral injury. This occurs when we find ourselves facing a situation we can’t change, and that is at odds with our personal and/or professional value system. Examples include situations where our concerns went unheard, we didn’t have the tools or resources we needed, or we arrived too late to make a difference.

While you can’t avoid every situation that causes moral distress, there are strategies to decrease their impact on your well-being and help you feel more in control when these feelings resurface.

 

How to calm your nervous system

When we experience stress or think about a deeply disturbing memory, our bodies enter fight-flight-freeze mode: our heart races, our breathing becomes shallow, our muscles tense and our attention heightens. That’s because our brain senses danger or a threat and is preparing us to do whatever we need to stay safe. To help our bodies get out of danger mode, we must signal to our brain that it can “turn off” the stress response and “turn on” the system responsible for relaxation. Here are two exercises to try:

Boxed breathing (physiological system)

Start by finding a square-shaped object to look at such as a window, pillow or book. Focus your gaze on one corner. Take deep, slow inhales and exhales as you begin tracing each side of the square with your gaze. Keep going until you find a nice, paced rhythm with your breathing, or until you notice your body beginning to relax. The more you practise this exercise, the more effective it becomes in stressful situations.

Tips:

  1. Extending the length of your exhale can help increase your body’s calming response.
  2. If breathing deeply is difficult for you, focus on taking smooth and even breaths.

 

Drop anchor (emotional system)

Begin by planting your feet on the floor. Push them down — notice the floor beneath you, supporting you. Notice the muscle tension in your legs. Notice your entire body — the feeling of gravity flowing down through your head, spine and legs into your feet. Now look around and notice what you can see and hear around you. Notice where you are. Once you feel more grounded (or anchored), you can transition back to what you were doing before.

 

How to free yourself from sticky thoughts (cognitive system)

Sometimes we call distressing or intrusive thoughts sticky ― when we get jolted out of the present moment and stuck in certain thoughts or images. To free ourselves or get “unstuck”, we need to step back from our thoughts. In this strategy, called cognitive diffusion, we take a step back to observe our thoughts and decide what we will do with them as they occur. As a result, we can better control our thoughts and be more open to what’s happening in the present moment. Here are two exercises to try:

Leaves on a stream

Start by visualizing a flowing stream with leaves floating along the surface. Take each thought that enters your mind, place it on a leaf and let it float by. Do this with each thought ― whether it’s pleasurable, painful or neutral. If your thoughts stop, continue to watch the stream until they start up again. It helps to be open and curious as you watch your thoughts come and go and to be patient with those that hang around a bit longer.

 

Spot and shift

Follow these three steps:

  1. Spot the Thought: identify and name the thought, e.g., “My family’s health.”
  2. Shift to Thinker: say to yourself, “I’m having this thought about my family’s health.”
  3. Shift to Observer: say to yourself, “I notice I’m having this thought about my family’s health.” It can help to say these phrases out loud, but if this is not possible, simply note them mentally.

 

How to reconnect with your values

Values give our lives direction and meaning; they reflect what we care for most deeply. But sometimes situations arise, especially in extraordinary circumstances, where we’re unable to act in a way that’s aligned with our personal or professional value system. As we move away from our values, our distress intensifies. One way to manage the impact of a distressing event is to engage in behaviours that are in line with what we value ― it doesn’t change the situation, but it can help us reconnect to who we are as people.

Choice point

Life is full of choice points ― where we must decide what our behaviours are going to be. When you realize you’re in a distressing situation, tapping into your choice points can be helpful. Here are some examples to help you notice, reflect and act based on your values:

“I don’t have the stamina to care for my family and perform well at work.”

  1. Notice the difficult feeling or thought (e.g., guilt or sadness);
  2. Ask yourself: What can I do to maintain my value — connection — in my current situation? (e.g., compassion for myself and smaller moments of connection);
  3. Take action: Tell myself: I am doing the best I can; I am not alone in this experience; it’s ok to do small things to keep the connection with my family rather than trying to keep up with everything everyone is asking from me).

“My patient is not able to have visitors and is very isolated.”

  1. Notice the difficult feeling or thought (e.g., sadness or pain watching someone else suffer);
  2. Ask yourself: What do I value that I can provide in this current situation? (e.g., compassion and kindness toward others);
  3. Take action: Validate and normalize how hard this is for your patient; remind yourself how hard it is for you to experience this as well; when you connect and show kindness to this patient, give yourself a moment to pay particular attention to this feeling of connection).

“I don’t feel I have the resources to provide the best care to my patient.”

  1. Notice the difficult feeling or thought (e.g., moral distress, anger, anxiety)
  2. Ask yourself: What are the risk/benefits with each possible decision? What systems are available to support my well-being?
  3. Take action: reach out for system and/or personal support; find one small thing you can do to take care of yourself.

 

If you’re experiencing moral distress or a difficult situation, it’s ok to seek help through peer support, a consultation with your ethics team and/or professional mental health support. Here are some resources to get you started:

 

Written in collaboration with Gillian Potter, Psychology Resident and Dr. Kerri Ritchie, C.Psych.

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This material is for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. The opinions stated by the authors are made in a personal capacity and do not necessarily reflect those of the Canadian Medical Association and its subsidiaries including Joule.  Feel passionate about this topic? Please connect with us at jouleinquiries@cma.ca.

About the author

Dr. Caroline Gérin-Lajoie

Dr. Caroline Gérin-Lajoie is a psychiatrist and the vice-president of physician health and wellness at the Canadian Medical Association.

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