Psychological Trauma: Theory, Research, Practice, and Policy Psychological Trauma and Moral Injury in Religious Leaders During COVID-19 Talya Greene, Michael A. P. Bloomfield, and Jo Billings Online First Publication, June 15, 2020. http://dx.doi.org/10.1037/tra0000641

CITATION Greene, T., Bloomfield, M. A. P., & Billings, J. (2020, June 15). Psychological Trauma and Moral Injury in Religious Leaders During COVID-19. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000641

Psychological Trauma and Moral Injury in Religious Leaders During COVID-19

Talya Greene University of Haifa and University College London

Michael A. P. Bloomfield University College London and Camden and Islington NHS

Foundation Trust, London, United Kingdom

Jo Billings University College London

Religious leaders are at risk of psychological trauma and moral injury during the COVID-19 pandemic. This article highlights potentially traumatic or morally injurious experiences for religious leaders and provides evidence-based recommendations for mitigating their impact.

Keywords: PTSD, coronavirus, stress, burnout, mental health

Since the outbreak of the COVID-19 pandemic, considerable media and academic attention has been directed toward the mental health impact on various high-risk groups, particularly “frontline” workers—those who are key to the treatment of individuals with COVID-19 (Chen et al., 2020; Lai et al., 2020). Another group of frontline workers at high risk of psychological distress, but who have largely been overlooked are religious leaders of faith-based communities. Although they are not involved in the medical care of people, they play a key role in supporting individuals, families, and communities in coping with the pandemic and especially so for those who are ill or bereaved by COVID-19. Due to the implementation of quarantine and other social distancing mea- sures, there has been a huge shift in the daily work practices of religious leaders, some of which increase the risk of negative mental health outcomes (Lewis, Turton, & Francis, 2007), and in particular for moral injury.

Being part of a faith-based community can be a protective factor for mental health following disasters and crises (Milstein, 2019). This is partly due to the sense of belonging and the emotional and

material support derived from being part of a community. It is clear, however, that religious leaders are key, because community members may turn to them for comfort and advice in getting through difficult times. Although this role can be deeply reward- ing, it also comes with risks.

Previous studies have highlighted the risk of burnout in religious leaders, noting that they tend to not prioritize self-care and often experience work overload, emotional isolation, and the feeling they are permanently on call (Jackson-Jordan, 2013, Lewis et al., 2007). Furthermore, religious leaders can suffer distress as result of their exposure to other people’s traumatic experiences, often referred to as secondary or vicarious trauma (Hendron, Irving, & Taylor, 2014). These negative mental health outcomes are likely to occur more frequently during the COVID-19 pandemic and may be compounded by the fact that religious leaders and their com- munity have a shared experience of the trauma stressor. In some respects this may be helpful, but it also poses risks because religious leaders have to actively cope with their own experiences while also helping others (Baum, 2014).

One area that has not yet been addressed in the academic literature, but may be particularly relevant in the COVID-19 pan- demic, is that of moral injury in religious leaders. Moral injury has been defined as the psychological distress caused by actions, or their omission, that violate an individual’s moral code (Litz et al., 2009). Although moral injury is not in itself a mental disorder, it has been associated with a range of mental health problems, including posttraumatic stress disorder (PTSD), depression, anxi- ety, and suicidality (Griffin et al., 2019; Williamson, Stevelink, & Greenberg, 2018). Moral injury has generally been studied in the context of military experiences. Although there are studies of moral injury in other occupational groups, such as teachers, jour- nalists, and health care workers (Griffin et al., 2019; Williamson, Murphy, & Greenberg, 2020; Williamson et al., 2018), there has not yet been any focus on religious leaders.

Potentially morally injurious events (PMIEs) refer to acts that an individual has done or failed to do (transgressions of self; Nash et

Editor’s Note. This commentary received rapid review due to the time- sensitive nature of the content. It was reviewed by the journal editor.— KKT

X Talya Greene, Department of Community Mental Health, University of Haifa, and Division of Psychiatry, University College London; X Michael A. P. Bloomfield, Division of Psychiatry, University College London, and the Traumatic Stress Clinic, St Pancras Hospital, Camden and Islington NHS Foundation Trust, London, United Kingdom; X Jo Billings, Division of Psychiatry, University College London.

Correspondence concerning this article should be addressed to Talya Greene, Department of Community Mental Health, University of Haifa, 199 Aba Houshy Avenue, Haifa 3498838, Israel. E-mail: tgreene@ univ.haifa.ac.il

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Psychological Trauma: Theory, Research, Practice, and Policy

https://orcid.org/0000-0002-3044-2841

https://orcid.org/0000-0002-1972-4610

https://orcid.org/0000-0003-1238-2440

mailto:[email protected]

http://dx.doi.org/10.1037/tra0000641

al., 2013) or has observed other people do or fail to do (transgres- sions of others). Additionally, people may feel that they have been betrayed by those in positions of authority or even a sense of theological challenge (Fontana & Rosenheck, 2004; Koenig, Youssef, & Pearce, 2019). In the following text we highlight some PMIEs for religious leaders that may arise during the COVID-19 pandemic.

Due to restrictions implemented in many countries, religious leaders are not able to conduct in-person meetings or make hos- pital or home visits and are prohibited from gathering their com- munities together. In addition, religious leaders are not able to conduct weddings, christenings, and many other joyful lifecycle events, which may feel like a loss and give a sense of “imbalance” in the work they are doing. Although the public health reasons for doing so are clear, religious leaders may find themselves strug- gling with not being able to provide support and comfort to their congregation in the ways that they are accustomed to and feel distressed by this act of omission. In other words, failing to do what they feel morally obliged to do, which may feel like a transgression of self.

Another area that is likely to be particularly problematic con- cerns death and mourning. The normal rituals that religious leaders perform are being interfered with. Religious leaders are prohibited from visiting those dying from COVID-19 and providing direct in-person comfort and end-of-life religious rituals. In many coun- tries, mourners at funerals are limited to immediate family (re- gardless of the cause of death), and sometimes not even that; if any of the mourners have symptoms of COVID-19, they will not be allowed to attend. Open-coffin funerals are not allowed for those who died from COVID-19, nor is ritual cleaning of the body of the deceased, as undertaken by some religions. Religious leaders may find themselves conflicted because they have no choice but to follow these instructions, which are potentially devastating to both the mourners and indeed the religious leaders themselves and may cause a sense of betrayal; leaders may even believe that they themselves have committed a religious transgression.

Recommendations

Given the risks relating to moral injury, and more broadly to burnout, and secondary trauma, what does the literature suggest regarding protective factors? Below is a list of recommendations based on existing knowledge regarding psychological stressors for religious leaders, as well as drawing from evidence based on other occupational groups (Billings et al., 2020; Greenberg, Docherty, Gnanapragasam, & Wessely, 2020; Ludick & Figley, 2017; Wil- liamson et al., 2020, 2018).

Self-Care

It is important for religious leaders to attend to self-care. This means taking regular breaks and trying to schedule time away from professional tasks. Try to eat, drink, and sleep properly.

Spirituality

Self-care for religious leaders includes not only physical and mental but also spiritual aspects. This is an unprecedented situation that may be theologically challenging for some. Setting aside time to focus on spirituality can help with processing this.

Acknowledge Moral Conflicts

It is important to acknowledge the moral conflicts that will likely emerge. Discussing them with colleagues and being pre- pared for some of the possible responses may facilitate coping and acceptance of distress.

Purpose

Religious leaders should try to maintain a strong sense of purpose. Although it is difficult to do work in conditions that are far from ideal, it plays a critical role in comforting people in difficult times.

Supervision and Peer Support

Try to implement supervision, mentoring, and peer-to-peer sup- port. Religious leaders can often find themselves isolated and depleted by their role. If such structures already exist, it is not sufficient just to have them but vital to actively make use of them.

Social Support

Staying in touch with family and friends is a key buffer of distress and can be a great source of strength.

Professional Support

Religious leaders should be aware of the professional support that is available. This can include general psychological support. For some denominational groups, there are bespoke counseling services for their leaders. Religious leaders should know how to access this support and be prepared to do so if needed.

Conclusion

It is important that religious leaders keep in mind that they are doing important work but are also living through difficult times along with everyone else. Furthermore, they will experience some stressors unique to their role. Attending to self-care, sharing dif- ficult experiences with colleagues, accepting the likelihood of moral conflict, and getting professional help when needed can all facilitate coping with the unique challenges brought by the COVID-19 pandemic.

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Received April 16, 2020 Revision received May 14, 2020

Accepted May 18, 2020 �

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