Update from Witness to Witness: Pivoting to Virtual Peer Support for Clinicians Experiencing Moral Injury During Pandemic

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[Editor’s Note: Last week was the two-year anniversary of Witness to Witness [2]! In just two short years, Witness to Witness has supported over 3,000 frontline workers like pro-bono attorneys working at the US-Mexico border, clinicians in Paradise, California after the Camp Fire, and outreach workers at Ventanilla de Salud offices around the US during this COVID-19 pandemic. Kaethe Weingarten, PhD, the founder of Witness to Witness, gave us a brief update on how far W2W has come, and where it’s going next -- along with some interesting notes on the changing language and research on what clinicians are experiencing on the frontlines of COVID-19. This interview has been edited for clarity and brevity.]  

For decades, Kaethe Weingarten, PhD, has explored how witnesses to violence are affected by that witnessing. Several years ago, Dr. Weingarten began to wonder how the helpers – like pro-bono attorneys at the US-Mexico border supporting refugees, or frontline clinicians limited in their ability to help patients after a major disaster – cope with what they see every day at work. She found they encountered traumatized clients or patients and significant barriers to effectively help them heal. Two years ago, Dr. Weingarten launched a new initiative to support these frontline workers who experience empathic distress when working with survivors of primary trauma. Witness to Witness [2] began as a volunteer initiative wherein therapists provide one-on-one conversations with frontline workers to support their own healing; since then, it has provided numerous additional support components including print resources, peer support, organizational consultation, and webinars. Earlier this year, W2W became a program of Migrant Clinicians Network, where it has continued to expand. Last month, we caught up with Dr. Weingarten to hear what W2W is doing now, and what’s on the horizon.

What happened when COVID-19 struck?

There were a number of things that coincided. The partnership with Migrant Clinicians Network had started barely three weeks before the lockdown for us in California. We had 38 volunteers [who provided one-on-one support through W2W], many of whom have young children, and are managing older parents. They were in isolation, had children at home, and had clinical work to do, had to catch up with telehealth – integrating volunteer work for W2W was not possible. The other part that not only W2W had noticed but others as well, is that request for individual-based services had declined. My guess is that’s only going to be time-limited... People are in ‘stun’ mode, and the idea of adding attention to self is incompatible with what people believe is beneficial to them.

Peer support is the most efficient way to help people through difficult times – and research evidence supports this. We had been running peer support groups, and it seemed to me that it was possible to use W2W webinars as a way to bolster the interactive component. [MCN Senior Program Manager] Alma Galván, MHC was instrumental in helping me think it through. The first Spanish-language webinar, on April 15th (Manejo del estrés durante tiempos inciertos [3]: la "esperanza razonable" como herramienta para Ventanillas de Salud en el tiempo de COVID-19) really demonstrated that if you use the chat integrated with the presentation you can create a temporary peer support group during the time of the webinar itself. Also, the chat itself became a source of ideas about what was on peoples’ minds, and therefore what webinars we needed to offer. In sequence, there was a general webinar on how to manage stress in the time of COVID (Managing Stress in Uncertain Times: How Clinicians Can Stay Resilient in the Time of COVID-19 [4]), and during that webinar, information about grief came up, and we started seeing that, at least in some sectors of MCN’s constituency, people were getting sick and dying – and grief was definitely an issue, so we offered a webinar on grief (Grief in the Time of COVID;19: Loss, Connection, and Hope [5]).

Another feature was figuring out – again, Alma was instrumental in this – how to not just translate the English-language material, but how to make it culturally robust and linguistically usable for a variety of Spanish-speaking audiences. The adaptation of the first webinar for Puerto Rico really addressed the trifecta they are dealing with: Hurricane Maria, the earthquakes, and COVID (Manejo del estrés durante tiempos inciertos: proveedores de salud y trabajadores en Puerto Rico [6]). The people who worked on that webinar, Vanessa Ibarmea, MA, and Lorena Torres, PsyD, were adept at making it resonant with those three issues that people were having to cope with.   So, the pivot had to do with figuring out ways that the interactive webinars could become ‘virtual support communities’ -- we used that language in the description for the second webinar.

What type of response have you had to this pivot to virtual support communities?

Since COVID, there have been 2,700 people who have at least registered for a webinar. This is astonishing to me. In one 90-minute webinar, there were 350 unique comments in the chat. One of the wonderful things that happened was that there was cross-talk on the chat. It turned out to be a really successful format. We expressly said that we were going to be working together to build a community, virtual and temporary though it may be, to support each other. And people dug in. They put in very moving comments in the chat, and people responded to them. Moderators were able to feed back chat responses to me, not as ‘this person has a question’ but ‘this is what’s coming up’, or ‘this is what people are talking about on the chat,’ and I was able to engage in conversation and dialogue. It was interactional, relational, and emphasized the material as it was emerging in the conversation -- I was high as a kite. It was really exciting to see that.

From that webinar, I wanted to do another on how to support a friend, family member, or colleague who was suffering, because people were saying it was overwhelming to figure out how to be effective in helping somebody while sheltering in place. 

From that, I understood the real value of virtual support communities, and the possibility that in some cases it actually may be more effective to create small groups of people who are not working in the same health care setting, but across health care settings. The internal office dynamics in many settings are sometimes challenging and it’s possible that people lend themselves more to support strangers.

What else have you had to adapt for these COVID-19 times?

Celia Jaes Falicov, PhD, Coordinator of Spanish Language Programs for W2W, suggested I read a book by a colleague of hers. In the context of COVID, it didn’t make sense to translate it word-by-word. It had to be opened up and expanded around what the impact of COVID on Latinx community has been, which we definitely saw in the grief webinar that we offered for [coordinators of] the Ventanillas de Salud (Manejo del estrés durante tiempos inciertos [3]: la "esperanza razonable" como herramienta para VdS en el tiempo de COVID-19).  One of the big issues there – which had to be integrated in the handouts – was the impact of layers of systemic oppression that are interfering with people managing with what, under any circumstances, would be very difficult.  We heard in the chat that their loved ones were not being taken care of in the way they would have been had they been white, or if their immigration status were different. And mourning rituals are very different – people would have preferred to send their loved ones’ bodies back to the country of origin, but can’t do that.

What have you learned over the last two years that is influencing your approach now?

One year into W2W we began to make peer support groups. People were using the language of ‘burnout’ but from my perspective it was moral injury – and that had not come out in the first year’s notes [from volunteers doing one-on-one sessions]. So, I did a session around moral distress and moral injury and I asked people to put in the notes if moral injury was the category they were really talking about – and we got flooded with painful, rich examples. It became really clear that moral injury was the dominant experience that people were having.

But ‘burnout’ continues to be the primary language in the nationwide conversation about health care workers during COVID-19.

The conversation has definitely moved very rapidly. ‘Burnout’ is a construct that, technically, if you look at the burnout literature, it suggests that it occurs because of conditions in the workplace. It’s not primarily a construct that is used when, let’s say, an individual is deficient in being able to manage the work environment.  But when someone says, ‘I am burnt out,’ it’s linguistically reflexive, and it seems to say something about a deficit or deficiency of the individual. A lot of the solutions for ‘burnout’ also use the term ‘self care,’ which again seems to suggest or imply that the problem is with the individual. 

And moral injury is very relevant right now, particularly with health care workers on the frontlines of COVID-19, right?

There are two definitions of moral injury, one of which also has a potentially problematic implication, in that it suggests that a person has done something that has violated his or her moral values, whereas the original definition, which was put forward by psychologist Jonathan Shay, says very clearly that there’s an aspect of moral injury that has to do with a betrayal by an authority.

Say you’re a nurse in a health care setting, and your manager says, ‘we don’t have enough PPE, I want you to go into Mrs. So & So’s room, using this cloth mask that you’ve made, or here’s a surgical mask, you will be fine.’ But the nurse believes that the science is suggesting that, inadvertently, she might infect her patient, and she's being asked to do something that violates her sense of what’s right or good. Over time, you can imagine the dilemma for that person, needing to make the choice to stay in the job – because of income, or devotion to patients – and at the same time, drawing a line in the sand and saying, ‘no, this is wrong’.

I think a couple of years ago was the first time I read an article suggesting that burnout would be better understood as moral injury – but I didn’t really see it taken up much. But absolutely, now, many organizations are using ‘moral injury’.

And where does ‘compassion fatigue’ fit in?

I’m allergic to that phrase. I think there is now neurological evidence to suggest that the parts of the brain that light up when we feel compassion, versus when we feel empathy, are different.  I’m not a neuroscientist, so this is something that I believe and then I’ve looked for sources that support my belief -- I’m not doing the hard science myself -- but I do think that we know that empathy has a pro-social dimension, but it also has an avoidance dimension. I have grandchildren, four little girls and a boy, and I can see developmentally with my grandchildren: they're all really empathic, but when they are young, they feel so empathic that they get overwhelmed and sometimes they turn their attention to themselves to take care of themselves. Of course, that’s an experience that adults have also. For example, let’s say there is a tragedy in a family, and people you thought were really close friends are avoiding the family -- maybe because they experience personal distress, and they avoid the family to take care of themselves.  That’s pretty common.

Compassion works differently and I don’t think it fatigues. Something I try to help people with is how they can move from one form of empathy where you imagine how you would feel in another’s place... But if you do that continually over time, you’re going to tax yourself, you’re going to develop empathic fatigue. Whereas, if you imagine how the other person feels, that’s a different process.  Likewise, compassion has been contained within the construct that you’re feeling for the other person’s suffering and imagining the action you can take to relieve that suffering. It has an action component built into it. And my model is about being aware and empowered. Compassion is about being aware and empowered -- a sense of what you will do to help the other person. I have never really heard of anybody for whom once they have an action component, that their ability to feel compassion erodes or gives up on them, I don’t think that happens.

It’s what we can’t do that exhausts us. That’s what’s exhausting.

Where are you going next?

I think melding what W2W does with an explicit anti-racist conceptual frame is important.  We need to provide the best kinds of services to groups and agencies with whom we collaborate... [through] innovation, collaboration, anti-racism, and resilience. I don’t know what it’s going to look like, but I think we’re going to be in ‘virtual reality’ for a long time, and I think that the longer-term consequences of the physical distancing, isolation, unemployment, grief and the awareness of peoples’ responsibility for racist practices are going to produce significant and consequential distress for individuals and communities. I hope that MCN and W2W will be active in addressing the nexus of issues that we’re facing.

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