Moral Injury and Radical Hope: Part 1

By David S. Prescott, LICSW, and Kieran McCartan, PhD

Note: This is part 1 of a 2 part blog. Kieran.

A clinical director recently shared a concern in a staff meeting about an adolescent on probation. The treatment team had built a program around the youth to address his sexually abusive behavior and general mental health.  Now, the treatment team assessed him as being at low risk and were understandably proud of their contributions to his progress in building a lifestyle incompatible with causing harm to others. Their approach had been team-based, multidisciplinary, and comprehensive. As he neared the end of treatment, his probation officer expressed concerns. “As we all know,” he said, “his seemingly good behavior is a huge red flag that things aren’t right,” which raised concerns about the implications for the youth’s future, as well as their own clinical judgment.

The treatment team found itself in a paradox. If the young man were to behave badly, others would judge him to be in need of treatment. If he behaved well, the natural assumption for some would be that he must be behaving in a secretive manner.  Those working in the field will recognize this as a belief that persists in some quarters despite very strong evidence to the contrary. If your work is simply about managing risk, it’s easy to see risk everywhere.

The impact on the young man’s treatment team was apparent almost in its absence; they had heard this before. Despite a solid base of scientific evidence, it would be difficult to convince others that this young man really was more than the sum of his worst behavior. Although he posed a low risk to abuse again, the team recognized that he was at very high risk to be prevented from living up to his full potential. Concerning to the author who sat in on this team meeting was that the staff had heard this all before. They have spent their careers aware of risks, helping people change, and being merchants of hope for young people in their families, all the while surrounded by people who would not support their efforts.

To be blunt, these experiences of disrespect have a cumulative effect and cause harm to the people who do so much to help others build worthwhile lives and safe communities.  Such experiences beg the question that if we cannot believe people are able to change, then what is the point in treatment? It can feel that we are simply moving the deckchairs around and biding time as the Titanic sinks. Treatment – especially belief in treatment – is fundamental to its process. If we want clients like this young man to cooperate and prosper, then we need to have buy-in throughout the whole multidisciplinary system, not just a few members of staff. Risk management is not simply about containment and control, it’s about skill-building, desistance, and change. When we are caught up in our client’s journeys, then their successes and failures reflect on us. The staff was not acutely burned out yet, but neither were they allowed to work at their best. Instead, they found themselves in an ongoing state of lamenting that so many of their efforts were unrecognized, undervalued, and disrespected.

In 2018, Simon Talbot and Wendy Dean wrote an article on what they termed the “moral injury” of physicians who do not have the opportunity to be as effective as they could be. More recently, they have noted that these professional moral injuries are the precursors to burnout. They state:

“We have come to believe that burnout is the end stage of moral injury, when clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care; when they feel ineffective because too often they have met with immovable barriers to good care; and when they depersonalize patients because emotional investment is intolerable when patient suffering is inevitable as a result of system dysfunction. 

“We believe that moral injury occurs when the basic elements of the medical profession are eroded. These are autonomy, mastery, respect, and fulfillment, which are all focused around the central principle of purpose.”

As the authors note, autonomy is a basic element of training. Whether we are physicians or mental health clinicians, we are taught to think independently when considering diagnoses and to guard against the competing interests of those who may try to sway our treatment decisions away from our patients’ best interests. However, in many facets of our work, we are required to forfeit our autonomy and allow other interests to sway our decisions about care—most commonly for financial reasons. This can be a serious consideration for professionals who feel pressured into ethically questionable actions and whose licenses may be on the line.

When our own autonomy, mastery, fulfillment, and sense of respect are constantly on the line, how can we expect to be at our most effective with clients? Ultimately, this poses its own dilemmas related to public safety.