There is a sweet parable of an older man taking a morning walk on the beach, who sees a young boy frantically picking up and throwing starfish back into the ocean to save them before the sun rises and the tide goes out. The older man remarks that because there are thousands of starfish, his efforts would not make much of a difference. Undeterred, the boy picks up and throws another starfish back. Turning toward the man, he says, “It made a difference for that one.”

Behavioral health clinicians have worked tirelessly these past 15 months to meet the explosion of need in their communities, and often within their organizations. Despite exhaustion and awareness that their capacity has been exceeded, setting boundaries and saying no to patients is often exceedingly hard. The need is simply too great and the desire to be of service has prevailed. I am reminded almost daily of Mamatha Ghandi’s persuasion: “The best way to find yourself is to lose yourself in the service of others.”

While this type of service before self can inspire, energize, and resonate with our core values in the short term, there are notable risks with this approach. The chronicity of the COVID-19 pandemic demands modifying this core value to sustain the work over time. The risk of burnout – which is the opposite of engagement but often follows intense periods of (over)engagement – is very real for individual clinicians and detrimental to the mental health system at large. Vaccine rollout and the lifting of mask mandates may signal some resolution to the medical crisis of COVID-19, but this is not the end of the mental health crisis. In fact, behavioral and mental health needs are likely to soar in the next several years.

How can behavioral health clinicians stay on the beach, throwing starfish back into the ocean, while staying whole and well themselves?

First, we can adjust our expectations about pandemic recovery…

The tail of mental health sequelae from the pandemic is going to be substantial by all available metrics. Additionally, much of this suffering will manifest outside traditional diagnostic categories. Burnout and exhaustion are not mental health disorders and should not be labeled as such; however, they can and should still be helped with the mental healthcare armamentarium. Although we might be required to label a patient with an adjustment disorder or a trauma/stressor-related disorder for the purpose of insurance reimbursement, we should be clear in our use of non-pathologizing language when educating patients, and in our approaches to and documentation of treatment. Over the past 15 months, we have seen many ordinary responses to extraordinary circumstances and will continue to see more of this.

It is important to remember that we have not all experienced the same pandemic. People need time and space to tell their story. Humility, curiosity, and remembering to amplify existing strengths will serve us well. As mental health practitioners, we are well-trained to evoke and honor people’s stories without pathologizing the associated distress. We should expect to spend the next few years continuing to hear these stories and inquire about people’s pandemic experiences. We will also need to recognize our own desire to “move on” as another manifestation of pandemic-related stress, and acknowledge that desire without succumbing to it.

Second, we can name our own pandemic experience…

Moral suffering captures several types of suffering common in human services work. Such suffering arises from breaches in expected social order and norms, and violations of our expectations and desires for basic human goodness. Common examples include:1

  • Moral Injury – a psychological wound from witnessing or participating in morally transgressive acts
  • Moral Distress – awareness of a moral problem and remedy but feeling unable to act because of internal or external constraints
  • Moral Outrage – outward expression of indignation toward systems or others who have violated a social norm
  • Moral Apathy – lack of care to know or denial about situations that cause harm
  • Moral Residue – painful emotional residue after a violation of one’s integrity

Most mental health practitioners have experienced moral suffering during the pandemic, most notably moral distress and moral outrage. Personally, I have experienced moral distress when hearing about work conditions and expectations placed on some of my patients, which has led to preventable COVID-19 infections and other adverse outcomes. I also have experienced moral outrage toward leaders whose decisions have contributed to these conditions.

How can we manage moral suffering – and model such management for our patients – with more authenticity, grace, and fluidity? I believe it starts with naming how hard it has been for many of us to bear witness to the injustices, inequities, poor leadership, and harms that many of our patients are describing and that we ourselves may have experienced. This process can include breaking the fourth wall at times, naming moral suffering with patients directly.

I’ve long described my clinical work as “listening to stories no one else wants to hear.” I hold space for and bear witness to previously unexpressed pain, heartache, confusion, and self-doubt. In the words of Roshi Joan Halifax, this work requires a “soft front and a strong back.1 She uses this phrase to describe the capacity to be fully present and open to another human being’s pain, along with the strength and fortitude to resist succumbing to it by turning away, trying to fix the unfixable, or holding it internally. Being this present is not a skill taught in graduate training, or easily taught at all. This way of being with oneself and others is meant to be infused within your day and your work to meet abounding moral suffering.

Being present and open to others is not a typical self-care prescription, the latter of which involves things we do when not at work or actively performing our craft. Because we all had our own struggles with the pandemic, it is uniquely demanding to stay open and curious about other people’s experiences without comparisons, judgments (of others or self), unskillful self-disclosure, or amplification of the distress being shared.

Instead, we must be aware of any internal reactions by paying attention to our bodies, in real time. Staying curious and naming our own experience can be sufficient in the short term, but naming it to others – a colleague, supervisor, or your own therapist – can help mitigate the impact of moral suffering even more. This vulnerable truth has supported my equanimity despite the vast moral suffering – my patients’ and my own – throughout the pandemic.

Third, we can acknowledge the resilience and meaningful achievement that exists alongside suffering and loss…

Being open to the inherent bittersweetness of life is quite different from ineffective encouragement to “look on the bright side.” Instead, I am reminded of a colleague’s work with a medical provider who had returned from a combat zone. This clinician knew the exact number of the many people who died in their care, and felt haunted by those people’s faces and last words.

As my colleague clinicians explored the clinician’s story of tremendous loss, they discovered that there was another number: the people they helped save, more than twice the number who perished. The calculus of human suffering and loss is not zero-sum: the people who lived did not “make up for” those who died, and those saved were neither more nor less valuable than those who could not be. They were simply equally valuable, and this provider’s experience was one of both tragedy and remarkable fortitude and efficacy under sustained duress.

Fourth, we can practice forgiveness, mainly toward ourselves…

I have treated hundreds of healthcare professionals in the past 15 months and there are two themes I hear most often. The first is intense frustration toward people not following guidelines, putting themselves and others at risk, and seeing this laxity result in illness or death. The second is about providers’ own inability to do, help, and be more. While seemingly contradictory, these themes are inextricably linked – if other people were not as careless, I would not have to feel so ineffective. The pain stems from not being able to curb enough human suffering.

I have felt this myself countless times during the pandemic. When I catch this pain quickly enough, I can meet the moment with compassion for myself and others in the spirit of forgiveness. Whatever causes us pain tells us what truly matters to us: my anger about how things “should be” or “should have been” points to my deeply held belief in universal human worth and dignity, and a desire to alleviate suffering. This guiding light for my own work is what allows me to show up day after day, however imperfectly.

My moral outrage is a reminder of these values and my moments of exhaustion are a reflection of my purpose, and of the joy I find in my work. I have learned that if pain becomes too intense, valued action becomes difficult; thus, protecting our connection with our values sometimes requires us to take a step back, at least momentarily, from situations causing the most distress. But mostly, I forgive myself repeatedly for things left undone or done imperfectly, and forgive others for the same. I cannot save all the starfish on the beach, but I can personally make a difference for a few and that feels like enough right now.

 The author would like to acknowledge Julia Mackaronis, PhD, for her contribution to this article.

Last Updated: Jun 29, 2021