How can we protect the SUD workforce from moral, social & psychological hazards?

This was originally published in a 2018 National Association of Social Workers’ Alcohol, Tobacco and other Drug specialty section newsletter. Bill’s recent post on moral injury got me thinking about Sandra Bloom’s concept of moral safety, which got me thinking about this article.

Before the pandemic began, we frequently talked about the workforce moral, social, psychological, and physical safety hazards being universal and serious enough to warrant workplaces thinking about their safety obligations in the same way they are obliged to provide PPE (personal protective equipment) in hazardous situations.

It may not be as timely as it was a few years back, but it’s adjacent to Bill’s post. So… I decided to share it here.

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“The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet. This sort of denial is no small matter. The way we deal with loss shapes our capacity to be present to life more than anything else. . . . .  We burn out not because we don’t care but because we don’t grieve. We burn out because we’ve allowed our hearts to become so filled with loss that we have no room left to care.” (p. 52)

Rachel Naomi Remen (1996)

By now, readers of this publication may have become numb to the near daily stories about the opioid crisis. The scale and persistence of the crisis is staggering. From 1999 to 2016, the death toll climbed to 351,612 (Felter, 2018) and is continuing to accelerate rapidly. The publication STAT asked 10 public health experts to forecast the death toll for the coming decade—the average of their predictions was 500,000 deaths (Blau, 2017).

The crisis is eclipsing every other issue in addiction services. Many angles have been covered, including the scale of the overdose crisis, the role of race in the public policy response, the impact on child welfare, the suffering of bereaved mothers and their advocacy activities, the role of harm reduction, and on and on.

An important, but neglected aspect of the crisis has been its effect on the addiction workforce. What kind of toll do these deaths take on social workers and other addiction professionals? How can workers protect themselves from burnout and vicarious trauma? How can agencies protect and support their workforce?

With so little written on the subject, workers and agencies are left to find their own way to maintain professional wellness while serving people with Opioid Use Disorders (OUD), their families and their communities.

As the clinical director of a community-based addiction treatment and recovery support program, these questions became important. While we had some knowledge of burnout, vicarious trauma, and self-care, these matters became salient in new ways. This article shares some of our experiences in the face of the crisis.

Our program primarily serves people with high severity SUDs and services are organized around long-term engagement and facilitating involvement in the recovering community. It is common for us to stay engaged with clients for 18 months and many of them provide support to current clients for years and decades. We also have dozens of members of the recovering community visiting facilities every day. Historically, this had been a powerful protective factor against burnout—every day, staff see living proof every day that their work is important and effective.

As the crisis escalated, we found ourselves convening increasingly frequent sentinel event meetings (A meeting to identify the root causes of an unanticipated event involving serious injury or death.) for overdoses. Of course, we spent considerable time seeking better ways to meet the needs of our clients and prevent overdoses. At the same time, we found ourselves increasingly concerned about the effect these losses were having on our staff. We reached out to other programs to hear about what they were seeing and how they were supporting their staff. To our surprise, they were aware and concerned about overdoses as a national issue, but they were not directly affected to the degree that we have been. This led to a surprising realization—that our long-term engagement with clients, their families and our connections in the recovering community (our historical protective factors) are risk factors for burnout and vicarious trauma in this crisis. It seems we hear about every overdose, while other programs often don’t learn about overdoses that occur once patients leave their programs. Further, our deep involvement in the community means that we become a source of support for people throughout the recovering community, many of whom have never been clients. (e.g. volunteers, family members, attendees of education events, community members that support and sponsor clients, etc.)

It took some reflection to notice this and consider how to respond, and it was not always a planned, purposeful process. We eventually gravitated toward framing it as a safety issue for staff, as described by Bloom (2013). Bloom is an expert on trauma-informed care and describes a “safety culture” as an essential element of any trauma-informed system. A safety culture addresses four interacting safety domains: physical, psychological, social and moral (2010) Attention of parallel process is also critical, as systems in sustained close contact tend to develop similar patterns of thoughts, feelings and behaviors (2012). This means it is not possible to maintain a safety culture for clients without also maintaining a safety culture for staff.

Moral safety is probably the least concrete of these domains but it was one of the first domains on our radar. We were concerned about the moral distress that staff might be experiencing, including:

• a gnawing sense that they’ve failed their clients, client’s families, colleagues, community and organization;
• a vague sense that they could have and should have done more;
• wondering if we were living up to our organizational and personal values;
• ideas about what could be done to prevent overdose, but a sense that their supervisor or organization won’t seriously consider it; or
• a sense (real or imagined) that interrogation of our practices would not be accepted.

We sought to ensure moral safety by making a concerted effort to ensure open dialogue in sentinel event meetings. We developed a preamble to the meetings, stating and restating that the purpose of the meeting was to learn and improve, not to assign blame. We also tried to convey a desire to discuss anything that seemed relevant to anyone at the table—that nothing is taboo. Administration took the lead by asking challenging questions about agency policy and whether the problems we face demand new practices and an evolution in organizational philosophy.

It didn’t take long for social and psychological safety issues to emerge. Many of these questions were unspoken, but just beneath the surface:

• I’m a professional, should I be feeling this grief?
• What if I cry? How will others respond? What will they think of me?
• I want to reach out to the family. Is that about my needs, or theirs? If I share that thought, will others see that as a boundary problem?
• I’m angry at the client. If I share that feeling, will others judge me?
• I’m noticing some things I think I failed to do. What will others think? Will they blame me?
• I don’t know if I can keep doing this work. Will others think I’m weak or not committed?
• Do I know what I’m doing? Do we know what we’re doing?

We addressed these safety issues by expanding the sentinel event preamble to create an expectation of grief and inviting everyone to share their thoughts and feelings as addiction professionals and as human beings who have experienced a loss. It also reminds us that this experience of loss is not a problem to be solved. As such, our response will be to listen generously and care for each other, rather than attempt to fix it.

Again, it was important that organizational leaders modeled sharing their thoughts and feelings, even if it made them feel vulnerable. This made it possible for others to do the same. Many of us imagined that this might open floodgates and consume considerable time and resources. This has not been the case. It appears the most important element is creating space for staff to share their reactions and support each other. The result is actually the opposite of what we feared. Staff spend less time ruminating, they are less anxious, and are more connected to each other in ways that support each other’s wellness and growth.

This has not just been about protecting the wellbeing of our staff. As a result, we’ve been able to work together to adapt policies, develop new practices and improve existing practices to prevent overdoses, improve recovery monitoring and follow-up, improve collaboration with other providers, improve informed-consent, and identify and provide support for others affected by the overdose.

We don’t profess to have all the answers and are very interested in hearing how other agencies are weathering this crisis. Please consider sharing your experience below, if we get enough responses, we’ll publish a follow-up.

References

Blau M. (2017). STAT forecast: Opioids could kill nearly 500,000 in U.S. in next decade. STAT. Retrieved 11 June 2018, from https://www.statnews.com/2017/06/27/opioid-deaths-forecast/

Bloom, S. L. (2010). Organizational Stress as a Barrier to Trauma‐Informed Service Delivery. In Becker, M. and Levin, B. A Public Health Perspective of Women’s Mental Health, New York: Springer (pp.295‐311).

Bloom, S. L. (2012) Building Resilient Workers and Organization: The Sanctuary Model of Organisational Change. In N. Tehrani (Ed.), Workplace Bullying: Symptoms and Solutions (pp. 260-277). London: Routledge.

Bloom, S. L., & Farragher, B. J. (2013). Restoring sanctuary: A new operating system for trauma-informed systems of care. Oxford: Oxford University Press.

Felter C. (2018). The U.S. Opioid Epidemic. Council on Foreign Relations. Retrieved 11 June 2018, from https://www.cfr.org/backgrounder/us-opioid-epidemic

Remen, R. N. (1996). Kitchen table wisdom: Stories that heal. New York: Riverhead Books.