Eye on Ethics

Moral Injury in Social Work
By Frederic G. Reamer, PhD
February 2014

During the past few years, I have had the opportunity to work with many social workers who provide services to military personnel and families throughout the world. I have been charged with providing these colleagues with training on challenging ethical issues on topics such as confidentiality, privileged communication, informed consent, boundaries and dual relationships, conflicts of interest, documentation, termination of services, risk management, and ethical decision making.

Many of the issues I cover during these meetings pertain to challenges one finds in civilian settings as well, such as mental health centers, family service agencies, addictions programs, correctional facilities, older adult centers, and schools.

However, social workers in the military face unique challenges. Clients may outrank military social workers on active duty, as opposed to those serving as civilians, posing complicated boundary and potential conflict-of-interest issues. Military social workers must be cognizant of complex confidentiality provisions in the Military Rules of Evidence and Uniform Code of Military Justice that may affect their management, protection, and disclosure of confidential information shared by clients.

Military social workers who are deployed to remote bases in distant lands tend to live and work in very small communities—relatively isolated military bases—which means they may encounter clients when working out in the gym, shopping at the base exchange, and dining. A social worker’s child may attend a Department of Defense (DOD) school and become best friends with the social worker’s client’s child who is a classmate. What I also have learned over time is that usually there are ways to manage these unique and sometimes intimidating ethical challenges.

What I have yet to discover, however, are easy ways to manage another daunting challenge military social workers encounter: moral injury.

The Nature of Moral Injury
Moral injury is a complex concept. It is ordinarily defined as the sort of harm that results when someone has perpetrated, failed to prevent, or witnessed acts that transgress deeply held moral beliefs (Litz et al., 2009). The most common instances occur when military personnel wound and kill innocent civilians during a raid. Ample empirical evidence documents the widespread suffering of soldiers and veterans who struggle with the aftermath and its special, often relentless torment.

Social workers who serve this population are well versed in the ravages, symptoms, and treatment of the complicated forms of posttraumatic stress that accompany moral injury. Writing in Newsweek, Tony Dokoupil noted:

Moral injury is as old as war. It is recognizable in The Iliad and The Odyssey, and in the oldest surviving play of Sophocles. It's hidden in the private thoughts of soldiers from every prior American war. It was perhaps first used in the journals of Mac Bica, a Vietnam vet turned philosophy professor. In the 1990s, two more PhDs popularized the idea, describing 'the psychological burden of killing' and the Homeric betrayal by leaders. The common thread is a violation of what is right, a tear in what some people freely call the soul.

It seems to me that moral injury, while especially graphic and compelling in the military, has important counterparts elsewhere in social work. Social workers in a wide variety of settings encounter clients who struggle with moral injury. In clinical social workers’ quiet, private offices, parents who have abused their children bare their souls and strong sense of guilt. So, too, police officers who, as social workers’ clients, talk about having mistakenly shot an innocent bystander or testified in court against a falsely accused defendant. So, too, spouses who tell their social workers about their extramarital affairs or the crimes they have committed.

Thus moral injury raises an ethical issue rarely addressed in traditional ethics education. It concerns the complex psychological dimensions of morality and ways of addressing them. This aspect of social work ethics is less about ethical decision making and management of ethical risks, topics typically addressed in ethics education. Rather, it strikes at the heart of what it means to be a moral person and how to help clients who are immersed in intense moral wrestling with the choices they have made in their lives and their conduct. This is the sort of social work that forces practitioners to take a deep look at their own values and their judgments about clients’ moral choices and judgments. Using psychodynamic language, this is social workers’ management of what we might call moral countertransference.

Social Workers’ Moral Injuries
Yet another layer involves social workers’ own sense of moral injury arising from instances when they feel they have perpetrated, failed to prevent, or witnessed acts that transgress their deeply held moral beliefs. Over the years, I have encountered many social workers who are distraught about their involvement in the removal of children from their homes, lies told to clients by colleagues or themselves, termination of services to vulnerable clients who begged for more assistance, and involuntary hospitalization of people with mental illness who preferred to live on the streets.

There is no simple remedy that heals moral injuries. No decision-making algorithm will resolve these dilemmas quickly and easily. Rather, moral injuries are the stuff of intense reflection and the kind of hard emotional work that social workers are trained to do when matters of life and death are involved. There may never be a right answer. Moral injury demands hard pursuit, even when there is no promise of resolution.

Many years ago, Donald Schoen wrote The Reflective Practitioner, which examines how the most skilled and talented practitioners in various professions do their work. Schoen’s principal point is that the most skillful practitioners have the inclination and ability to reflect on their work while they are in the midst of it. They can ask themselves why they are doing what they are doing as they do it. Reflective practitioners rely less on formulaic approaches to their work and more on the kind of skillful improvisation that comes with experience.

I suspect such reflective practice is what is required when social workers address issues of moral injury in their clients’ and their own lives. Moral injury does not lend itself to a fix; it requires deep reflection and awareness of the moral dimensions of the choices clients and social workers make throughout their lives and careers, especially when these choices cause harm.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work at Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, health care, criminal justice, and professional ethics.

Reference
Litz, B. T., Stein, N., Delany, E., et al. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706.