What is "Moral Injury" in Addiction Care?

A recovery expert tells us it’s a unique and debilitating type of anguish that professionals in the field suffer when too much is asked of them.

By William Stauffer



This post is reprinted with permission from one of TreatmentMagazine.com’s go-to blogs about addiction, treatment and recovery: Recovery Review.

I am not sure the first time I heard the term “moral injury.” I suspect it was probably in the context of military service members in combat situations in which they have to do things or witness things that wounded their souls. I have deep respect for persons who serve and understand that I have no frame of reference for the things they do to protect us.

Steve Martorano 
The Behavioral Corner is produced in partnership with Retreat Behavioral Health -- where healing happens

The Behavioral Corner 
Hi, and welcome. I'm Steve Martorano. And this is the Behavioral Corner; you're invited to hang with us, as we've discussed the ways we live today, the choices we make, the things we do, and how they affect our health and wellbeing. So you're on the corner, the Behavioral Corner, please hang around a while. 

Steve Martorano 
Hey, everybody, hi, and welcome again to The Behavioral Corner. To me hanging again, we hope you can spend some time with us. This is a podcast about everything because everything - one way or another affects our behavioral health. Our great partners and sponsors of the program, are Retreat Behavioral Health, you'll hear more about them a little bit later on. So we're back again, we see one able to escape the pandemic as a sort of broad area of concern, I don't have to go into the details of how this epidemic has impacted us on a worldwide basis in almost every, every aspect of our lives. Recently in boning up for our interview today, I came across a description that our guests sent to me of this phenomenon of the pandemic, in conjunction with other things going on in our lives. And again, you know, a war in Europe, political strife at home. What we are experiencing is mass trauma. We know what traumas are we think we do a mass trauma is it seems to be a whole different kettle of fish. And one of the aspects of this mass trauma - and it's the topic we'll be talking about today - is something called moral injury. And I came across it because of our guests. I'll introduce Bill, and then he can define terms for us. Bill Stauffer has been a friend of this program, before Bill's been on before, is the executive director of the Pennsylvania Recovery Organization Alliance that is a statewide organization here in the Keystone State. He himself is in long-term sobriety since the age of 21, which is probably three or four years ago. No, it's much longer than that. And he has been actively engaged in public policy in the recovery area for most of those years. Bill is also an adjunct professor of social work at Misericordia University in Dallas, Pennsylvania. And we welcome Bill Stauffer to The Behavioral Corner. Bill, thanks so much.

Bill Stauffer 
Thank you, it's great to be here again with you. And it is an important topic, and one, you know that we should be talking about so grateful to you for taking the time in the space on your program to talk about it.

Steve Martorano 
You know, some things just leap out at you as this is something we've got to talk about. Very often it's about areas that we're learning more about. That we knew something about before. But I'll be honest with you that the idea of moral injury didn't immediately occur to me. So tell us what we're talking about? What is moral injury?

Bill Stauffer 
So a moral injury...anyone can experience a moral injury, it's when one is placed in a situation where they're repeatedly expected to, to do things or provide services, beyond their capacity, or ones that they know will not be as effective as they could, given the resources at hand to do the work. These are the things we see medical personnel experiencing. We see combatants in war experience it, but in the pandemic we've seen, as you noted, other people starting to see this. So that you know, that's sort of a basic definition of it.

Steve Martorano 
Yeah. And it's fascinating because what it seems to depict is ordinary people -- and I mean that in a very broad sense -- ordinary people in extraordinary circumstances. It's never been easy, as you know, to treat substance abuse disorders, it's there's never enough money. There are never enough facilities. There are never enough people available to do it. All of which have been exacerbated by the pandemic. It's as simple as that. So, this might seem like well, a lot of people in the trenches complaining about their jobs, and some of the burnout. How's moral injury different from your garden variety burning out? 

Bill Stauffer 
Well, you know, it's deeper...it's a deeper wound and one that it's harder to carry on so I ran across this like you probably around 18 months ago, I had never seen the term before then. I'm a reader. I read History and I was as soon as I heard the term understood kind of what it meant. And right after I heard the term, I was actually in a panel discussion with some healthcare executives in Northeast Pennsylvania, and on the call was a nursing manager, talking about seasoned medical professionals just abandoning the work. And as she was talking about it. To me, it sounded like when Vietnam vets came back from war and did not feel welcomed in their community. And it was just like one straw, too many were into what she described as a medical care system that was really, really strained. And these are medical professionals who are accustomed to handling tremendous amounts of stress under less than ideal circumstances but added in the environment of sort of a hostile community, and that was their moral injury. And it reminded me of what a lot of combat and experienced coming back from Vietnam. It was around that time, I'd heard this term, and thought about the implications for our field. And you know, as you note, we have long been accustomed to doing more with less. But then when we add in all these other dynamics, for some, it's like the last straw, or just not being able to face it work based on how deeply it hurts to try to provide something to people. and knowing that we don't simply have the resources to provide what people are needing,

Steve Martorano 
Again, the deeper you look at it, the more fascinating it becomes because for me, what stood out was the difference between someone burning out on their job and someone suffering from a moral injury because of their job is that in the burnout situation, they probably just stopped doing the job. They can no longer do the job. That's what we're focusing on, I think what you're focusing on, are the people that are still doing the job. Suffering from this sense of no one appreciates, we don't have the resources, and they keep doing their job. They keep doing their job. But sometimes they have to cut a corner. Sometimes they can't give the kind of attention to the situation that it requires. Rather than quit, they keep plugging along and they pay a price for that. Is that pretty much the story?

Bill Stauffer 
I mean, I think I didn't take any put some of them end up leaving, but it does get to the point where they're just no longer able to carry on. And I think in the piece that I wrote about this, one of the examples that I gave is an administrative burden. And so, you know, I joke that it in the course of my 30-plus year career, there'd be like a 2% increase in administrative burden a month. That's not a lot month-to-month, but over the course of decades, it's many, many multiples. And so there are all these things in the way of doing the work. And when I was talking to people in the pandemic, they're short-staffed, they have all these barriers to jump to try to help people. And then as they're trying to help people, the individuals, they're experiencing colleagues that may be sick, or may not have had access to protective equipment, or they're worried about the implications of bringing home COVID to their families, something that they hadn't thought of before. And it's all of these things sort of compound into, we're not effectively able to do the things that we can. I think you know, there are things that we can do about this but one of the first things is to understand that it's a somewhat deeper type of wound.

Steve Martorano 
And the other thing that occurs to me that is of particular interest to those of us who are on the other side of the equation, we're not in the battle on a daily basis. But when we want access to this health care, it's not an optimum situation. So we have a stake in moral injury, whether we're suffering from it or not because we're not getting the kind of help we deserve and need.

Bill Stauffer 
That's a good example. And so in our field, for example, let's say you've gone through services multiple times, or you're on a continuum of care and you're being admitted to several places, you go to detox. You go to a residential step down to an outpatient, you know, every place that you go, they ask you all the same questions and you fill out all the same forms. And they're really difficult. You know, for someone outside of this field, like if you were a policymaker, I think one of the best things that you could do is go into all the questions and fill all the forms out and think about the impact of listing all of your failed jobs, difficulties that you may have had in your family. Arrests that you may have had. the thing what We ask people repeatedly all of these difficult and hard things about themselves. And oftentimes, we ask them over and over and over again. And if you're not in our field, just think about going into the hospital. And everybody that you run into asks the same questions, you may be asked them 30 times in a row. And the difference is with our issues. You know, sometimes these are highly stigmatizing things. So our patients are also mortally injured and you know it. Like as a clinician, and I'm asking people these things, and I can feel and see that they know the next question I'm going to ask because it was...it was all the questions that were asked on the prior treatment, and the one before that. As a result, you can feel and see that they're starting to shut down. And you, you still have to ask all these questions. 

Steve Martorano 
Yeah, you know what, it's interesting. We all suffer from a mild form of moral injury, no matter what we're doing. It's funny how this resonates with something I just had a conversation about. If you've ever been stuck in a phone prompt loop with your cable company or anything, I have a growing sense, I'm, you know, I'm not the Chicken Little guy here. But I have a growing sense that fewer and fewer things work well, in this country. Garden variety things -- trying to get someone on the phone that you can talk to. Trying to deal with your insurance company. It just takes an extraordinary amount of time. It's demoralizing. It defeats its purpose, which is to solve problems. In the case that you're talking about people's lives hang in the balance. We're not talking about a system that just burdens people with, you know, bureaucracy. We're talking about delaying a situation that results in people's lives being lost.

Bill Stauffer 

I think that as you were talking, I was thinking about struggling with a parking app that didn't work. And I can't go to my appointment because the parking app isn't working. And I used to put a quarter in there. You know. 

Steve Martorano Bill, Bill, I hate to say sound like this, nothing works. It's unbelievable. I think that's...we're getting off the track here. I think it's one of the reasons that Amazon is so over the top successful because whatever you may think of their practices everything, you click a button on the door. So maybe we should have Amazon doing something more important than delivering sweaters because everything else takes forever.

Bill Stauffer 
I don't think we're off-topic, though, in some ways, because, you know, we did a workforce survey of the substance use workforce of Pennsylvania, a number of years ago, and we asked a bunch of questions about the barriers and why people do the work. And, you know, most of us, if you've been around the field, you can anticipate the barriers: low pay high stress, not great working hours -- the kinds of things that we anticipate. But ultimately speaking, when we started asking people, what's going on, it ultimately gets to when all of those barriers get to the point where they're no longer able to do the work. It's pointless to continue on, because you get through those barriers, to pervert the work. And so, as those barriers get so high, sometimes that they're not surmountable, that then becomes part of that moral injury. And the analogy to what's going on in the larger society, I think is apt.

Steve Martorano 
Yeah, it's particularly sad, because the workforce you're talking about, is overwhelmingly speaking, dedicated, they're not in it for the money. They take hard jobs because they are wired to want to help people. And you take that positive and grind it down over a period of time, we're all worse off for that. And that's why this is a fascinating topic for us. You don't have to be an active member of substance abuse treatment in any way. Chances are, someday you'll need mental health advice, or substance abuse treatment. And you're going to run into this problem, whether you're aware that it's going on or not. One of the things that have gone on, again, driven by the pandemic, I suppose, is what's referred to as the great resignation, you have, you know, millions of people who just didn't go back to work or found other jobs. They just I'm not going to do that anymore. I think I'll do this. I saw numbers in some of the material you sent me on workforce attrition -- in the substance abuse field -- that are breathtaking. Just the one that leaped out at me estimated. There are over 4 million jobs that need to be filled in this area. Is that correct?

Bill Stauffer 

Yeah, those stats came actually from a federal workforce assessment and it was pre-pandemic. So the odds are it's worse than that. And I, you know, I could make that article available to your listeners,

Steve Martorano 

The one you sent me...the second piece that you sent me. 

Bill Stauffer 
Yeah, I can make that available as well. But those workforce numbers are estimated by the federal government. So...

Steve Martorano 
I wonder where the next generation of nurses is coming from? A young person that decides to go into the nursing field probably was influenced by an older person who had been a nurse. And that generation has paid a, as you say, a tremendous price to stay in the fight. And as they retire, or just quit I wonder how hard is going to be to get nurses?

Bill Stauffer 
You know, I think I don't want to be all hopeless because I think, you know, in any kind of trauma, you know, there is...we have trauma resiliency. And I think we have that just as we're undergoing mass trauma. There's resiliency occurring, and I think that a lot of people walking off their jobs in America may mean that they're searching for work that has more meaning. So if we think about it, we may want to consider how we engage people who would like to have those professional roles so that we can move them in and remove the barriers for them to do the work. We think that's important to do.

Steve Martorano 
Yeah, absolutely. Our guest is Bill Stauffer. He is the executive director of the Pennsylvania Recovery Organization Alliance. And we're talking about the unfortunate phenomenon of moral injury, the field of substance abuse has taken it on the chin, tough job made tougher, like everything else, because of COVID. We've talked about the big picture of what moral injury looks like? What are your personal characteristics? What do people suffer from, as individuals? I mean, there's stuff like depression and anxiety, what are we seeing?

Bill Stauffer 
People may feel anxiety, sleeplessness, disorientation, having difficulty concentrating, and having difficulty just getting up the motivation to go in to do that...that job, again. And also a conflict. You know, knowing that it's important to work, but struggling with the barriers to doing it. So those are the kinds of things that we hear people talk about.

Steve Martorano 
Yeah, so there's a personal price to pay, in addition to a system-wide price that's being paid by moral injury. You know, one of the things...the other things I found fascinating and reading the stuff that you've sent me in your article was that there is...there's thought that there is a perhaps unconscious, maybe conscious bias against people who have been in long term recovery going into this field, versus people who have not ever suffered from a substance abuse issue and they're working in the field is, is that a large portion of people who have successful long term recovery are drawn into this field, they feel they've been there and done that they have something to give back. So they would be a natural candidate for this kind of work. For many, many other people who have never had the problem they're just as effective, I suppose, as you know, recovering people. Is there a bias between those two groups?

Bill Stauffer 
You know, some of it's anecdotal, my own experience, as well as talking to other people. But if you look at our systems, if you lay the requirements for people who may be in recovery to do the work, we tend to make it harder. And we have to ask ourselves why that is? And you're right, you know that this field was actually started by recovering people, you know, that, even before there was funding.

Steve Martorano 
The medical establishment didn't look at the problem of substance abuse is their business. We take care of the heart, lungs, and livers. Well, we can't help it if you're drinking too much. So you're right. It was filled up with people who went Wait a minute, this is a disease.

Bill Stauffer 
Yeah, I mean, I hear it is sort of what when you're in policy circles, and people say things like, Well, are you sure that the recovering people are going to be capable of handling that? And the reality is, you know, recovering people are creative, intelligent people who are capable of a great deal. They're just like everybody else, but they've had substance use disorders. In fact, in some ways, they have a crash course, in the culture of addiction recovery, that other people do not have. I would argue that they're even better suited to it, that we have this underlying bias about what addiction is. And just looking at our field, and the regulatory processes between what we ask of our providers and others and some of the things that just, you know, there's a lot of extra hoops. And if you think broadly about it, that bias is the reason why those things exist...at least in my opinion.

Steve Martorano 
I think I certainly agree with that. The other I can't believe we're still talking about this. But like you, as you speak, I can see it rearing its ugly head. I've been doing, these interviews for over 10 years now. And we very often talk about the stigma attached to substance abuse. And I would have thought that, please, that went away. People no longer say this is a moral failure, there is still a lot of that. One of the things I suspect that really can cause a moral injury is if you're working in the field, and have a sense that the policymakers, the insurance companies, a lot of people may not be saying it, but they're certainly thinking these people did this to themselves. That still goes on, doesn't it?

Bill Stauffer 
So I've heard it outright said, you know, actually, it may be a medical condition, but the person decided to have it is a, you know, that's a direct quote, but, you know, example that we have a parity law, a National Mental Health Parity Law, that we passed it 108 And oh, nine, it took many years to get the regulations out for that. You know, and just, you know, to the credit of the current administration, we have a Secretary of Labor, US Secretary of Labor is a guy in recovery. And shortly after getting into office, this guy says, let's take a look at parity enforcement nationally. And if you read the report, on parity that was put out by our US Department of Labor in January, most of the insurance companies had not even considered if they were in compliance with the law, until the audit. You know, that's not how other things work. Like they didn't even consider whether or not they were falling along until somebody asked, you know, that says something.

Steve Martorano 
It says that, as we mentioned that attitude, that there's something about this situation, substance abuse, that is the responsibility of the person who has it, and no one or very rarely does anyone say that about a diabetic or someone who, unfortunately, gets cancer or some other disease, it's still there. It's still stigmatized, and certainly is in the mental health field. There is not much of regular folks can do about this except I guess, make noise with their representatives. What is the person looking for help do? You mentioned the process of getting out. Where you're asked the same questions over and over again, you're handed off to a number of different people becomes demoralizing. What can someone do to keep that process from grinding them down further, when they need help?

Bill Stauffer 
To people out there who are struggling, I would say, find someone who takes you seriously and allows you to feel comfortable. You know, when I'm working with people, I asked them what their dreams are? Or what's important to them? How well they've done something. I tried to take those questions and say, Well, you know, I got to cover all these things, you know, tell me, you know what your hobby is? So finding people who connect with you is important. That would be the number one thing if you go into somebody and feel like they're not treating you with respect or dignity or empathy, then that's a sign that that may not be the right person for you. But whatever you do, don't give up. Because recovery is a probable outcome. Like, I didn't think it would be for me. And a lot of people think that. And so I would say keep trying, with all these challenges. There are a lot of people who really want to help. That's the heart of that moral injury thing. Is it like you said that people want to in the service centers many of them are doing this wor because it's in their heart to do it.

Steve Martorano 
Yeah. You know, it's interesting, I read, this is a while very long while ago, as the world becomes more technical, and sophisticated and young people look for fields, they want to go into the STEM courses are emphasized. They are all the technical stuff, and the math and all that stuff. And somebody reading the article never forgotten this said, "You know, it's going to be in short supply for employers and in businesses? Empathy." So go get yourself a Bachelor of Arts in the humanities and become a better person and more empathetic and you'll get a job because we're going to need that. That's what we need, right?

Bill Stauffer 
Yeah, high emotional skills and emotional intelligence kind of stuff. 

Steve Martorano 
Get you a longer way than if you could write code.

Bill Stauffer 
I agree. One of the things I'd like to emphasize through all this isn't listening to all this. It really does sound grim. But, but if you're out there in a service system, if you're working, or you're running one, or you're out there in the policy world, you know, there's a lot we can do to stem this stuff. One of my go-to authors is Dr. Sandra Blum, who's done work on the sanctuary model, and creating therapeutic alliances and safe spaces. And, you know, we run in a parallel process to the people we work with. So we have to pay attention to our own systems. And so if you're an employer out there, and you're struggling with all of the challenges of higher costs, and a transient workforce, make sure that all the people you're working for you feel like they're part of your system, and that what they say has meaning it helps with the rest of it. And systems, we have all these intractable seeming problems. They may not be entirely solvable. But if we work together, we could. You know, and so, people want to feel like they matter. That's pretty basic.

Steve Martorano 
Yeah, yeah. It's sometimes it feels like the more basic ideas, the more easily forgotten and overlooked it is. People take it for granted. It's too bad. You know, what's not grim about this story -- and I mean, this sincerely -- is the fact that I found this article. And I know you and I know the work you do. And I know that you'll agree, I'm sure you're not alone in feeling passionate about this stuff. And raising attention to it. Almost everybody I've come in contact within the substance abuse treatment field is similarly motivated. And that's encouraging. No one has thrown their hands up and said, there's nothing more we can do about that. So is there anything we have missed, you'd like to highlight here before I let you go?

Bill Stauffer 
I want to thank you for your time on this subject. And I think, you know, as a society, we are going to need to focus a lot on human connection, hope, and purpose, wherever we are. And I suspect that our services are going to be much more needed over the next decade. So actually building out our workforce, solving these problems making programming that people want to work at, and getting some of these administrative barriers out of the way. It's time to do it. I suspect that in the next 10 years, the horrible COVID pandemic and the physical health losses will actually be less than the mental health and substance use losses that are still coming our way. And so we want to get on top of that and make sure that our infrastructure is in place to do it. The time to do that is now and there's a whole bunch of people who are actually eager to do the work. So let's get them into the workforce.

Steve Martorano 
You know that what you just described, focused as it was on the substance abuse field. If those values and techniques were applied, in a general sense. You wouldn't have trouble parking your car. I wouldn't have trouble getting my insurance guy on the phone. Lots of things might work themselves out.

Bill Stauffer 
It's exactly like you said, the simple things we seem to forget and have to be reminded of now. 

Steve Martorano 
Bill Stauffer thanks so much. People want more information about Pro A, we'll have a link to the website. You should read Bill's article on moral injury. I know it sounds esoteric and maybe it is, but it's not going to be for long because we're all touched by it. Treatment magazine?

Bill Stauffer 
Right. 

Steve Martorano 
We'll put a link on it. But that's where it's at.

Bill Stauffer 
Yeah.

Steve Martorano 
Bill, thanks for reading the article. And thanks for your work. And thanks for joining us on The Behavioral Corner. 

Bill Stauffer 
Thank you anytime. Take care. 

Steve Martorano 
Appreciate it. The rest of your thank you for your time. Don't forget to follow us on Facebook and like us if you like us and let us know what we're doing right or wrong. And we'll be back next time on The Behavioral Corner.

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