Macro Level Moral Injury Within the SUD Care System – Our Unaddressed Imperative

Authors note – I first wrote on this topic in Recovery Review in 2021. It was also picked up by Treatment Magazine. Since then, overall overdose mortality rates have decreased slightly which is being reported quite broadly despite the fact that they are dramatically increasing in African American communities. Alcohol death rates have increased at a rate unprecedented in history. Do those deaths matter? We are grappling in our systems of care with survivors of hypoxic brain injury and substance use related dementia, facets that have largely been ignored for a generation. We have a beleaguered workforce with astronomically high turnover rates and tanking morale who are quitting the field at higher than the required replacement rate to even sustain current demands, let alone increased demands for help. What is going on here? Are there unaddressed facets at the core of our challenges?

The first time I heard the term moral injury around 2020, It was in the context of military combat situations. Soldiers  witnessed involved in events that wound their very souls. In recent years the concept has been extended to human service and medical care settings. The Wikipedia definition of moral injury refers to an injury to an individual’s moral conscience and values resulting from an act of perceived moral transgression. This produces profound emotional guilt and shame, and in some cases also a sense of betrayal, anger and deep “moral disorientation.”

It is termed Occupational Moral Wounding as noted in this 2020 British Medical Journal piece, as “arising during work when people carry out, fail to prevent, or become aware of, human actions that violate deep moral commitments. Occupational moral injury is often associated with psychological distress, and moral responses including guilt, anger and disgust.” This resonates with many of us working within the SUD field that outsiders, including policy makers working far from the front lines have no frame of reference for. We cannot change things we do not acknowledge.

Unless we do so with intent as a care system, we may not be able to effectively address our profound and growing service system challenges . Occupational moral injury associated with SUD care work is likely  routine and contributes to high levels of turnover in our workforce. Many abandon the field as a result of this phenomena, at least anecdotally from hundreds of conversations I have had with people who left the field over the course of years.

How bad is our workforce turnover rate? The Legislative Analysis and Public Policy Association, in collaboration with the Oneill Institute at Georgetown University recently released a Model for Building the Substance Use Disorder Workforce for the Future Report. They note that our turnover rate is more than twice the average of 13.5% for the entire national workforce and 32% for the SUD workforce. The report offers excellent and constructive policy recommendations similar to ones made a generation ago, yet long unheeded. Methods aimed at building the SUD workforce like many such reports across the generations. Perhaps we will make them. Yet, it is also possible that we will be making the same ones in the next decade. Even then, changes may not occur as society tends to view punishment for having a substance use condition more favorably than helping people, which itself is a form of moral wounding for our field and those we serve.

What most analysis of the SUD challenges relates to factors like increasing compensation and reducing administrative burden, this may not be at the heart of the problem. What we never seem to get to are the underling care system design flaws on the macro level that relate to the failure of our care system to routinely deliver the care and support people need to heal over the long term. Care that affirms the efforts both for those served and the workforce dedicated to helping them heal. This is at the heart of our problem. As I noted in the original piece on Moral Injury in the SUD care system. A 2006 article from Journal of Social Work Research Personal and Occupational Factors in Burnout Among Practicing Social Workers found that within the helping professions there is a lifetime burnout rate of 75%.

If the turnover rate is higher in SUD settings than other areas of Social Work, what is the lifetime burnout rate for SUD workers? Three out of four workers experiencing harm in Social Work is not something we should ask of anyone, but we may be asking even more from our SUD workforce, burnout rates perhaps closer to 100%. This points to systemic challenges and a deep disconnect between what our care system provides and what people need to heal experienced relatively universally. It is not just a few bad apples operating ineffective programs but rather profound and systemic challenges that must be addressed. We have a rotten system that fails to meet the needs of communities in all of their diversity despite a great deal of effort by many people for a very long time to build and deliver better care across America.   

We are seeing efforts on the mezzo (or organizational level) to address occupational moral injury. A May 2023 paper, the Occupational Moral Injury Scale (OMIS) – Development and Validation in Frontline Health and First Responder Workers explores the OMIS scale (Page 25). The authors of the paper found that the OMIS offers a reliable and validated tool for capturing the experience of moral injury in occupational settings. The screening tool incorporates screening across five domains including Betrayal, Commission with Agency, Commission Under Duress, Act of Omission and Witnessing that include twenty questions to participants.

The screening tool includes among the twenty questions, statements that are measured across the five domains:

• The way my workplace had failed to look after me makes me question my career.
• Choosing to act against my own moral values in my job has made it hard for me to find meaning in my work.
• I am ashamed of myself because of things I’m pressured to do at work that go against my conscience.
• I am angry that I haven’t chosen to stand up against the things that go against my beliefs about right or wrong at work.
• Witnessing unethical behavior at work without being able to change it has broken the sense of purpose I used to have.

As referenced earlier, there is a tendency to see these challenges in the light of poorly managed treatment programs run by managers who do not care about the outcomes of the services and instead are focused on the bottom line or perhaps nothing at all beyond their paycheck. Of course, this happens in our care system, but we would be remiss if we scapegoat such situations as the root of the challenge. To continue to ignore the fact that our systems are designed in a way that exacerbates occupational moral injury across the entire care system, even in well run, ethically grounded programming. Unless we address these fundamental challenges, we will continue to have inordinately high turnover rates. We will fail to sustain a stable, proficient and dedicated workforce over the long term. It is likely that we are at a crucial point in time in respect to these issues, a fact I have considered a Tipping Point from which it may be hard to even return to what we have now in respect to our SUD care system.

My observations as a person who has run treatment and recovery community organizations and worked closely with organizational leaders in the public sector over the decades is that care often becomes in essence a “Hail Mary” against all the odds as a direct result of our system design. There was a myriad of circumstances in these instances when as a leader I was unable to provide the people in the programs I was overseeing the things that they needed to heal. There were weeks in which the decision was between multiple staff members spending most of the week trying to get the proper care from funders for the services one person required balanced against the needs of all the other clients who would not get properly served if we committed the hours required to squeeze what a single person needed out of the vast machinery of care denial. Situations in which persons we were working with needed a lot more than we could provide for longer durations of care but ended up referred to us through a level of care assessment process that did not properly account for their needs but was instead designed as a cost containment tool. Our systems tend to push people down to lower levels of care than their needs require to save a few bucks in the short term for their bottom line. This costs society more in the long run but that is not part of the measures we use. We can and must do better.

These dynamics are the norm for so many programs I have encountered across the whole care system, in my state and beyond. Instead of providing what the people we care for need, the decision ends up being a Hobson’s choice to provide them with what little we could even when it was not what they needed because otherwise they would get even less of what they required to heal. Our care system is simply not designed to provide what people need for heal. And in ways that replicate family dysfunction, even if all the members do not have all the facts, they feel that this is what is occurring, and they experience a form of moral wounding. They then burn out or quit. This is why moral wounding is endemic to our field and at the center of our workforce challenges.  It is a huge facet of our field’s astronomically high turnover rate. To effectively address it , we must first acknowledge this truth and address moral wounding in our field systemically and not just in the trenches but within the government, insurance systems and beyond.

Authentic Recovery Oriented Care: the Antithesis of a Fieldwide Endemic Moral Wounding

Imagine what our field would need to do to shift the statements of occupational moral wounding above so that our workforce could routinely state them in the affirmative as measures of resilency. What it might look like:

• The way my workplace had looked after me validates my career choice.
• My job affirms my own moral values in ways that I find meaning in the work.
• I am proud of myself because of things I’m able to do at work consistent with my conscience.
• I am validated when I am able to stand up for my beliefs about right or wrong in my field.
• Witnessing unethical behavior on the job and being able to change it has strengthened my sense of purpose.

It becomes clear that to shift from occupational moral wounding to systems of care that are moral affirming would necessitate change well beyond the programmatic level. Almost no attention goes to changing how care is funded to support long term healing and to create channels to address these needs in a meaningful way.

We need a system redesign focused on long-term recovery.

That is what we must change.

Ultimately, people who get into this field do so out of a deep dedication to helping people heal from substance use conditions. Pervasive occupational moral wounding is indicative of systemic failure to focus on this outcome. When we think about our workforce challenges, we would be well served to consider indicators of workforce wellness that systemically align with occupational moral integrity or moral resilience in which people see their efforts to help people heal from substance use conditions routinely affirmed in ways that are consistent across the whole system.  

Let’s together build a care system and a workforce built on resiliency!

Sources

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Darcy Clay Siebert. (2008, October 9). Personal and Occupational Factors in Burnout Among Practicing Social Workers. ResearchGate; Taylor & Francis (Routledge). https://www.researchgate.net/profile/Darcy-Siebert/publication

Legislative Analysis and Public Policy Association. (2024, December 3). Model Building the Substance Use Disorder Workforce of the Future Act | LAPPA. LAPPA. https://legislativeanalysis.org/model-building-the-substance-use-disorder-workforce-of-the-future-act/

Shale, S. (2020). Moral injury and the COVID-19 pandemic: reframing what it is, who it affects and how care leaders can manage it. BMJ Leader, 4(4), leader-2020-000295. https://doi.org/10.1136/leader-2020-000295

Stauffer, W. (2021, May 11). What Is “Moral Injury” in Addiction Care? – Treatment Magazine. Treatment Magazine. https://treatmentmagazine.com/what-is-moral-injury-in-addiction-care/

Stauffer, W. (2022, May 24). We’re at a Tipping Point in the Treatment Workforce Crisis. Treatment Magazine. https://treatmentmagazine.com/were-at-a-tipping-point-in-the-treatment-workforce-crisis/

Stauffer, W. (2023, October 28). Cerebral Hypoxia & the “Opioid Epidemic” – An Elephant in the Room. Recoveryreview.blog; https://recoveryreview.blog/2023/10/28/cerebral-hypoxia-the-opioid-epidemic-an-elephant-in-the-room/

Steven Ross Johnson. (2024). Study Shows a Black-White Shift in “Deaths of Despair.” US News & World Report; U.S. News & World Report. https://www.usnews.com/news/health-news/articles/2024-04-15/study-deaths-of-despair-move-higher-among-blacks-than-whites

Thomas, V., Bizumić, B., & Quinn, S. (2023). The Occupational Moral Injury Scale (OMIS) – Development and Validation in Frontline Health and First Responder Workers. https://doi.org/10.31219/osf.io/ht7ne