Moral Stress in Mental Health Practice and Research

By: Adam Fried, Ph.D.

Mental health practice, assessment and research can be highly fulfilling, but also emotionally demanding. In recent years, the field of psychology has made a concerted effort to educate psychologists about the effects of various types of caregiver stress (including secondary traumatic stress and vicarious traumatization in which the professional internalizes or is otherwise personally affected by the trauma experienced by those with whom the professional works) on their mental health and professional work (Collins & Long, 2003; Figley, 2002). Extreme cases can lead to a phenomenon known as compassion stress/fatigue (Figley, 2002), which can often be accompanied by a decrease in professional self-efficacy and a reduced willingness to help (Figley, 2002; Newell & MacNeill, 2010).

Stress can take many forms. One type that has received increased attention occurs when professional, institutional or legal rules and constraints prevent the practitioner from doing what they believe is right or most beneficial for the client/patient. Known as moral stress, these experiences describe ethical and emotional impasses experienced by professionals who may feel unable to provide the assistance they believe is truly necessary to address the client’s issues while also maintaining appropriate boundaries and adhering to ethics codes and laws.

Originally developed within the nursing community (Jameton,1984), this type of stress has been studied across many “helping” professions, including social workers, psychologists, and palliative care providers. Within psychology, it isn’t difficult to imagine a variety of moral stress situations within practice, assessment and research settings, although the nature of moral stress may differ in terms of the role of the professional, the setting and the nature of the mental health condition or focus of intervention.

The psychologist who is not able to provide much-needed treatment due to client health insurance limitations or costs, the evaluator who hesitates about making a mandatory child abuse report because they fear the investigation may do more harm than good, the therapist who contemplates lending a destitute client money to pay for groceries, and the clinical trainee who believes that the intervention a supervisor has mandated will be ineffective or harmful have in all likelihood experienced this type of stress.

These situations are not limited to practice and assessment. Researchers are also confronted with similar and unique moral stress dilemmas. These particular moral challenges come into play when research staff want to do what they believe is right but may be prevented by their role responsibilities, job description, or organizational rules. For example, in many instances, research staff are required to follow standardized or manualized treatment protocols that are focused on a particular symptom or area of focus, but that may prevent them from addressing the a participant’s more pressing clinical needs.

A recent study of mental health research workers (Fried & Fisher, in press) identified several moral stress concerns within their work, including experiences where they weren’t able to provide participants with the services or referrals they felt were truly needed and endorsed beliefs that participants ignored research risks in order to receive compensation.

These situations can be difficult to resolve, and may place the professional at ethical and legal risk. The psychologist’s intended goal of “doing good” can lead to behaviors that conflict with ethical codes, state laws, or other rules of conduct, and can thus be dangerous to one’s professional standing. As emphasized by Austin et al. (2005), psychologist awareness and recognition of a situation as morally stressful is critical. This echoes several ethical decision-making models, where the first step is often recognizing that the dilemma or question is an ethical one, likely requiring considerable deliberation, consultation with colleagues and other sources (such as laws and ethics standards) and consideration of stakeholder perspectives as well as the role and responsibilities of the professional.

The risks of not addressing chronic stress are significant, especially given the multidimensional effects of the relationship between chronic stress and burnout (which can include professional ineffectiveness). In order to provide effective services, psychologists have an ethical obligation to ensure that their own personal problems and conditions do not negatively affect their work and possibly harm individuals with whom they work (Principle A: Beneficence & Non-maleficence; 2.06 Personal Problems and Conflicts; 3.04 Avoiding Harm; APA, 2010).

Drawing on the growing self-care literature that has proliferated among psychologists to address work-related stress, the American Psychological Association’s Board of Professional Affairs’ Advisory Committee on Colleague Assistance has developed a number of resources and suggested interventions, including developing a peer consultation group for social support and to process dilemmas, self-assessment of stress and vulnerabilities to occupational stress, and developing and implementing personalized stress-reducing techniques.

Stress is also affected by workplace policies, climate and expectations. Perceptions of positive workplace support, policies and resources have been found to serve as protective factors against workplace distress, staff turnover and unethical behaviors in high stress professions, such as nursing (Hart, 2005; Lutzen et al., 2010; Olson, 1998; Pauley et al., 2009) and there has been recognition of the importance of working environments that are respectful and that promote discussion of work-related stress (Gelsema et al., 2005). Recent studies of community-based drug use research workers have echoed these findings, with lower levels of organizational support associated with higher levels of moral stress (Fisher et al, 2013).

Stress, including moral stress, can affect all mental health professionals regardless of experience, but there is reason to believe that those with less experience, including interns, clinical trainees and research workers may be at particularly high risk. For example, research suggests that younger, rather than older research staff are more likely to experience moral stress and burnout (Fried & Fisher, in press).

Stress in new and aspiring professionals may also be compounded by a lack of experience, professional self-doubt, and fewer opportunities to learn and use self-care strategies (Cushway, 1992; Pakeham & Stafford Brown, 2012). These factors underscore the responsibilities of supervisors to recognize and address stress among trainees. Supervisors can work to ensure that trainees, interns and assistants are afforded opportunities to process moral and other types of work-related stress, including outlets for trainees and staff to discuss stressful work-related situations, such as debriefing sessions, supervision, or on-site counseling provided by trained outside professionals.

As psychologists and psychologists in training, it’s critical to recognize that our work may place us at increased risk for workplace stress. In our attempts to “do good” and care for our clients, we may be confronted with difficult moral stress dilemmas where what we think is “right” may be constrained by professional rules, boundaries, and obligations. Although there are no easy answers to these types of moral stress dilemmas, acknowledging the tension, affirming our professional commitments, and working to process the stress through self-care strategies may be critical strategies in minimizing any negative impact on professional work.

Dr. Adam Fried is the Assistant Director of the Fordham University Center for Ethics Education, and the Director of the M.A. in Ethics & Society and Interdisciplinary Bioethics Minor.

This column originally appeared in the Winter 2015 edition of the The Clinical Psychologist.

References

American Psychological Association (2010). Ethical Principles of Psychologist and Code of Conduct with the 2010 Amendments. Retrieved from http://www.apa. org/ethics/

American Psychological Association’s Board of Professional Affairs’ Advisory Committee on Colleague Assistance (http://www.apapracticecentral.org/ce/self- care/)

Austin, W., Rankel, M., Kagan, L., Bergum, V., & Lemermeyer, G. (2005). To stay or to go, to speak or stay silent, to act or not to act: Moral distress as experienced by psychologists. Ethics & Behavior, 15, 197-212.

Collins, S., & Long, A. (2003). Working with the psychological effects of trauma: Consequences for mental health-care workers – a literature review. Journal of Psychiatric and Mental Health Nursing, 10(4), 417-424.

Cushway, D. (1992). Stress in clinical psychology trainees. British Journal of Clinical Psychology, 31, 169–179.

Figley, C. R. (Ed.). (2002). Treating compassion fatigue. New York: Brunner-Rutledge.

Fisher, C.B., True, G., Alexander, L., & Fried, A.L. (2013). Moral stress, moral practice, and ethical climate in community-based drug-use research: View from the front line. AJOB Primary Research, 4 (3), 27-38.

Fried, A.L., & Fisher, C.B. (in press). Moral stress and job burnout among frontline staff conducting clinical research on affective and anxiety disorders. Professional Psychology: Research and Practice.

Gelsema, T.I., van der Doef, M., Maes, S., Akerboom, S., & Verhoeven, C. (2005). Job stress in the nursing profession: The influence of organizational and environmental conditions and job characteristics. International Journal of Stress Management, 12 (3), 222-240.

Hart, S. (2005). Hospital ethical climates and registered nurses’ turnover intentions. Journal of Nursing Scholarship, 37(2), 173–177.

Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice Hall.

Lutzen, K., Blom, T., Ewalds-Kvist, B. and Winch, S. (2010). Moral stress, moral climate and moral sensitivity among psychiatric professionals. Nursing Ethics, 17(2), 213–224.

Newell, J. M., & MacNeil, G. (2011). Professional burnout, secondary traumatic stress, and compassion fatigue: A review of theoretical terms, risk factors, and preventive methods for clinicians. Best Practices in Mental Health: An International Journal, 6(2), 57-68.

Olson, L. L. (1998). Hospital nurses’ perceptions of the ethical climate of their work setting. Image: Journal of Nursing Scholarship, 30(4), 345–349.

Pakenham, K.I., & Stafford-Brown, J. (2012). Stress in clinical psychology trainees: A review of current research and future directions. Australian Psychologist, 47, 147-155.

Pauley, B., Varcoe, C., Storch, J., & Newton, L. (2009). Registered nurses’ perceptions of moral distress and ethical climate. Nursing Ethics, 16(5), 561–573.

Written By Fordham University Center for Ethics Education

Moral Stress in Mental Health Practice and Research was originally published @ Ethics and Society and has been syndicated with permission.