Healing Moral Injury in our SUD Community & Care Service System

In late April, I wrote a piece on moral injury in our SUD care system. Moral injury, as identified in this Scientific American article is the psychic fallout of “morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress [one’s own] deeply held moral beliefs and expectations.” It would be difficult to be in the recovery community or serve people who need help with addiction and not be deeply harmed as so described.

It is also cumulative. The costs to oneself in trying to resolve a barrier that is killing your own community is much less on the first attempt than the ten thousandth attempt. Sisyphus was made immortal by the gods, we are not. Rolling the boulder up the hill repeatedly over the decades with minimal change leaves deep scars. While herculean efforts have resulted in some limited progress, it has not been commiserate with the level of sustained effort over the decades. Such decades long struggles with minimal to show for it is the norm in this work, not the exception.

One of the examples of moral injury that has stuck with me was one recounted to me by a non-recovering colleague who had been a high-level government official here in Pa. He was a passionate ally in trying to get more people into recovery. He would tell a story where he asked a medical professional what should be done with people with addictions that showed up at the hospital. The medical professional replied to him that if it were up to her, those drug addicts would be taken out into the hospital parking lot and shot to death. While this is a rare example of a person being open about how we are seen. It is not at all uncommon. For those of us who would be eliminated in this way, moral wounding is soul crushing in consideration of the sheer magnitude of bias against us. We are vermin to be killed even to some medical providers who take an oath to preserve life.

The injury occurs when every attempt to change these dynamics fail, and the person trying to change it is left with a sense of guilt and shame because they feel that they should have been able to accomplish more. One example of this dynamic is the emphasis of recovery stories as a means of resolving overwhelming stigma and discrimination that is present in our larger society. It is a set up for a moral injury. The sense that if only we told our stories better, society would understand, open its arms up to us and change. When society does not change, one can be left with a sense of betrayal. We touched on that in this paper on personal privacy and public recovery advocacy I had the honor to co-authored with Bill White and Danielle Tarino. Another example is providing care that is inadequate to the needs of the persons in care because the system provides less than what is needed for shorter durations of time that is required to heal. One becomes complicit in the wounding of others by working in such a care system even when the attempt is to help. These are the difficult internal dynamics of moral injury as they play out in respect to addiction and recovery.

What do we do to heal moral injury?

An important step in healing moral injury at the individual level is self-forgiveness, reclaiming a moral core and a sense of personal worth. Additionally, talking about and supporting those impacted by it as this recent article on moral injury in Nursing Ethics is critical. In essence, those of us in this community and doing this work must support each other. We must take care of ourselves and our own people, first and foremost.  

But what about systemic moral injury?

What do we do to heal moral injury that has occurred in a systematic way to our entire community?  It is a difficult question. I found this section of an article in the British Medical Journal examining the pandemic and wounds to medical professionals poignant:

“The process of moral repair, as Walker describes it, is not simply a dyadic process between wrongdoer and victim.  Wrongdoing takes place in a social context. It violates social norms. Thus, the community in which it occurs can be both partially responsible (for letting the violation take place) and partially victimized (insofar as its norms are being threatened). This theme first gets sounded in the introductory chapter when she claims, “Wrongdoers and victims — whether individuals or groups — are a natural focus for moral repair. It is less obvious but essential to see that moral repair is always at the same time a communal responsibility.”

Systemic discrimination against people in recovery is baked into our society. We have disparate care, a lack of service infrastructure and profound workforce shortages made worse by poor compensation and overwhelming administrative burden. Healing this damage would require a systemic approach in the very broadest of senses. The same article referenced above, Moral injury and the COVID-19 pandemic: reframing what it is, who it affects and how care leaders can manage it contains these steps which I have clipped below in full describing a framework for healing:  

1. Acknowledging an injured party as a moral equal. Moral repair will not succeed if one party is placed in an inferior moral position, seen as having less right to define the situation than those in authority. When people are told by authority ‘this is how we see it and how we see it is what counts’, they are not being treated as moral equals.
2. Acknowledging the authority of shared norms. Moral repair requires that we recognise the existence of shared norms, make clear that these norms remain important even though they may have been violated, and treat them as action guiding.
3. Acknowledging injury. A suitable context must be created in which the nature of (moral) injury can be spoken of, explained, heard and understood. Attending to the testimony of those affected by moral injury is critical.
4. Acknowledging responsibility. Moral repair requires that those who are truly responsible for something acknowledge that responsibility. This is not the same as laying blame. In acknowledging responsibility, the person or institution recognises that others have placed reliance on them and have been let down. Acknowledging responsibility reinforces the view that the norms are valid, and it is reasonable to rely on them.
5. Acknowledging that remedy is due, and that the injured party may define what is owed. The first part of this can be difficult, and the second part even more challenging. Failure to acknowledge that remedy is due is, to paraphrase Archbishop Desmond Tutu, equivalent to saying sorry for stealing your pen and then refusing to give it back. Moral repair obliges us to ask what we can do to rectify the wrong. In cases of medical harm we cannot change the past, and patients know this. What they ask us to do is take steps to prevent the same thing happening again. The remedy of future prevention has, unfortunately, been somewhat debased by organisations claiming to have ‘learnt’ from events while not implementing effective improvement.
6. Acknowledging righteous anger, or other negative feelings, in those who have been injured. While most will recognise the validity of resentment, anger, hurt and so on, it may need to be acknowledged for much longer than the commissioner of the injury feels comfortable with. It is common to complain that someone or some group now needs ‘to move on’. It is not for anyone who has (morally) injured another to determine the timescale for recovery or restoration.
7. Acknowledging that in injuring another, we should experience sorrow and regret. This is often viewed as a requirement for apologies. It is more than that. This is not about words but making it apparent that there is genuine sorrow and regret, perhaps remorse for moral injury one has inflicted.

The article I clipped it from is about the impact of the COVID-19 Pandemic with a focus largely on the medical community and hospital patients. Our medical care system has been devastated by the pandemic in no small part because of our fractured politics. We are seeing an increase in suicides and addiction in medical professionals. The same thing is happening in our space. There is little doubt that the lasting legacy of the pandemic will be an even greater loss of life and societal devastation as a result of increased addictive use of drugs and mental health issues. We will without doubt experience a loss of life from addiction related to the pandemic that will far exceed the direct loss of life from the pandemic. Addressing these moral injuries would help us change how we address addiction systemically.

The way that society has approached addiction has resulted in a moral injury to all those who have experienced addiction. It even acts as a positive feedback loop, increasing the devastation. Would some level of societal accounting improve these dynamics?  I think so. Such an accounting must start with the acknowledgement that “those people” who have experienced addiction are really “our people.” The injury to society is self-inflicted. 

The lives saved and restored if we account for an address these issues are likely to be our own brothers and sisters, friends, and neighbors.