Moral Injury in a Broken System
by Scott Chyna, MSW, LCSW
Much has been written about the need for social workers to be mindful of professional burnout. NASW’s Code of Ethics, revised in 2021, pointedly references self-care as a tenet of competent and ethical practice. How, we are often asked, can we be effective practitioners if we neglect our own well-being and emotional balance? Well documented meta analysis (Cieslak et al., 2014) indicates that secondary trauma—the adverse emotional impact that afflicts direct practitioners exposed to the myriad of traumatic first person narratives and experiences—interferes with occupational and personal functioning. The need to regularly engage in self-care practice is vital in preserving the ability to act as stewards of the social work profession and maintain fulfilling relationships and pursuits outside of work. With the advent of trauma research, the shift of incorporating self-care into social work curriculums allows for the development of social workers who proactively address their emotional responses and mitigate potential burnout pitfalls.
Beyond Burnout
Given that self-care has evolved into a standard of professional practice, my recent experience was confusing. I was cognizant of self-care, as I had experienced my fair share of burnout episodically throughout my career. I learned to be preemptive, knowing my caseload of clients was taxing. I made concerted efforts to ensure I was doing what was recommended: daily mindfulness, scheduling “play” time, regular exercise, eating healthy foods, and creating a boundary between time spent at the office and protected personal time. I still felt overwhelmed and defeated, emotionally and physically fatigued. Yes, these were signs of burnout, but it felt different. The last several years have been trying for direct practitioners—a global health pandemic, divisive political discord, rampant violence, and social injustice nationwide—and my feelings took on an air of helplessness, frustration, and anger I had never encountered.
I sought consultation. When I began to examine the underpinnings of my demeanor, I realized what I was experiencing could not be remedied by going to the gym or binge watching my favorite television show. Although the intensity of my caseload didn’t help, it became clear the mental health system in which I was embedded caused an internal dilemma. A moral dilemma.
I was expected to see clients who presented with more acute needs, and resources were scarce. Management focused on billable encounters as opposed to needed services third-party payors refused to reimburse. I felt rushed, often ending an encounter with a client prematurely because another client was waiting in the wings. Client wait lists stretched into the absurd. Once I was able to provide a service to a client, it was challenging to schedule follow-up appointments, given razor thin scheduling opportunities. Conversely, expectations to deliver mental health treatment for clients who were experiencing normal reactions to abnormal circumstances felt as if I was contributing to pathologizing the human condition.
Identifying the Dilemma
The term moral injury, first coined in the early 1990s by clinical psychiatrist Jonathan Shay in his research related to Vietnam veterans and post traumatic stress disorder, describes the inner conflict experienced when betraying an inherent moral code in “high stakes” situations. In acts of war, military personnel following “chain of command” orders in direct conflict with core values, beliefs, and moral codes may experience feelings of shame and despair. Various iterations of moral injury examined in settings beyond the battlefield indicate a prevalence in healthcare settings—particularly during the onset of the COVID-19 pandemic when hospital emergency room staff were faced with the task of determining which patients would receive life-saving treatment (Litam & Balkin, 2021).
The concept that I, as a social worker, was suffering from a moral injury was foreign to me. It seemed almost overly dramatic to consider and, while limited, research indicates that this is an area to examine further. In a sample study of midwestern state child welfare workers, investigation yielded a profession in which workers experienced moral injury within the range of symptoms experienced by military personnel and resulted in high employment dissatisfaction and turnover (Haight et al., 2017).
In employment settings, social workers are tasked with a variety of “orders,” ranging from productivity quotas to utilizing certain F codes in order to secure financial reimbursement. We are constantly faced with proving our viability to stakeholders who have limited understanding of our essential function. Although I was not in literal battle, my emotional upheaval incrementally inflated with every incident that contributed to an inability to provide clients in my charge the sound intervention they desperately needed. What I was tasked to do and what I felt was ethical were in opposition. Subsequently, I questioned my competency. No amount of yoga diminished the feeling.
Taking Care of Oneself
While our NASW Code of Ethics dictates the need for self-care, it is aspirational and not prescriptive in intent. My own remedy for managing moral distress required deliberate acknowledgment of and attunement to my feeling state.
Obtain Support
Beyond professional consultation with a trusted mentor, I sought support from peers and colleagues who felt similarly. There is a profound respite in giving voice to feelings kept internal and having others bear witness. I needed what we impart as helping professionals to our most vulnerable clients—to be heard.
Communicate with Supervisors
If I wasn’t able to recognize moral injury within myself, my supervisor likely wasn’t aware either. Bringing the issue to the forefront can be eye opening for those in leadership. The adage “you don’t know what you don’t know” applies. Starting the conversation can be the seed to ongoing communication, which may necessitate a cultural shift.
Review Options
Reviewing options may be a frightening prospect, because it might lead to uprooting yourself and plummeting into the unknown. When one feels choices are limited, further emotional distress may occur. Reviewing options with a mentor, colleague, or therapist can be empowering and is the first step in potentially reclaiming personal agency.
Advocate Systemic Change
Inherent in every social worker is the belief that inaction is not an option. We are called to advocate. Our mental healthcare system is deeply flawed, and the misallocation of resources perpetuates illness and suffering. Our own unwitting role in this dynamic creates an internal dichotomy. I entered the social work profession to lessen social injustice and avail myself to those in suffering, not to perpetuate harm.
Large system change can be slow-going, yet alterations in how we, as practitioners and organizational leaders, deliver services within a subset of a macro system can mitigate moral injury. In advocating within our own organizations, a culture of “conscious conscience” can take form. Enacting moral courage in social service settings—speaking out against policies and procedures antithetical to the mission of our profession—can reclaim professional identities and, importantly, promote deliberate, sound practice benefitting the most vulnerable we serve.
Invite Everyone to the Table
Those in a decision-making capacity could offset both employee and client dissatisfaction if front-line social workers were invited to regularly give their perspective. And vice versa. There may be a mutual lack of understanding if roles are siloed and separate. Does the executive director fully realize the challenges front-line practitioners face? Does the social worker recognize the entities at play that tend to dictate the provision of services? Determining areas of negotiation and opening up channels of communication can lend to service delivery that doesn’t compromise either party’s integrity. Being an effective leader means immersing yourself in the day-to-day work of employees. And being an informed employee means becoming familiar with larger systems at play.
Reevaluate Productivity Standards
Productivity standards emphasize quantity over quality. The message given to direct practitioners is that they are worthwhile or hard working only if they meet an often ambiguous quota. In my own experience, focusing on a number rather than the quality of an intervention demeans the work performed. Although data is important, focusing on the total number of clients treated loses sight of whether or not a client’s needs are met. Begin formally measuring the efficacy of an intervention as the benchmark of quality. Yes, one may see 10 clients daily, but if half of those clients are marginally assisted, the system remains broken.
If a direct practitioner is evaluated and compensated by positive outcomes, so, too, should an organizational leader. Regular feedback is essential in determining client/provider alliance and achieving client success. The same applies for employer/employee success. Antiquated annual performance evaluations remain steeped in hierarchical advantage and power (e.g., immediate supervisor evaluates subordinate without reciprocation). A 360 review—feedback solicited from subordinates about the job performance of peers and those in management—allows for equitability. Unequal performance standards lend to lack of overall accountability.
Create an Ethical Culture
I tell my graduate students to review the NASW Code of Ethics. Regularly. Religiously. Then review it again. Too often, our professional code is relegated to a cursory glance to fulfill a minimal continuing education requirement. The profession’s code specifically addresses both the agency’s and employee’s responsibility to advocate for a work environment that promotes integrity and a just delivery of services. Unfortunately, the Code of Ethics does not mention the inherent power differential between front-line staff and administrators. How receptive leadership is in inviting discussion focused on moral disconnects can be the difference between a culture of accepted moral impropriety or a culture striving for ethical soundness. Consider creating and utilizing an agency ethics committee as standard operating procedure. Employees who feel vulnerable speaking out may fear retaliation and disciplinary action. Create a culture of intention.
Push for Macro Level Change
It would be negligent not to mention the need to advocate on a level beyond an agency setting. Our profession is rooted in advocating social change. Social services have become politicized; we are faced with the task of political action and advocacy as our profession dictates. It’s a daunting task. If underserved areas lack resources, make yourself known to local community boards, local/state legislators, and stakeholders. Solicit input from others who share similar ideals (and attempt to negotiate with those who don’t).
Facing Difficult Decisions
As a social worker, I am primed to solve problems. There are times, however, when there is no common ground to be had and remaining in a broken system is untenable. In my experience, continuing in a work setting that constantly compromised a value set without any semblance of rectification was not worth the emotional toll. Again, this was not burnout—burnout can be navigated. The daily dilemma of going against the grain of one’s sense of rightness is emotionally devastating. It was a frightening prospect to consider a professional shift. My work was, after all, my livelihood (in more ways than one).
In making a difficult decision, I became reacquainted with the person who entered the social work field many years ago. The person who felt called to a profession that required character and a sense of principle. My past experience provided clarity in future roles. I can establish expectations of myself and others that align with the ideals that initially called me to the social work profession. When considering potential engagement in professional settings, I know what to investigate. And what is non-negotiable.
Scott Chyna, MSW, LCSW, is a graduate of Loyola University Chicago School of Social Work and has more than 25 years of direct practice in psychiatric social work and program management. Scott is a Clinical Assistant Professor at Boise State University School of Social Work.