Burnout Versus Moral Injury In the Mental Health Field
Burnout Versus Moral Injury
In the Mental Health Field
The Heart’s Way for Creative Clinicians
Burnout versus moral injury. Most mental health professionals are familiar with the term burnout, especially if they have worked in the field for a considerable length of time or if they work (worked) in a trauma-care type of environment. But what of moral injury? This is a less common term, but as some postulate, it may be more appropriate terminology for the mental health professional. This post is meant to compare the two in terms of definition, psychological impact and next steps.
Burnout, then…
The term burnout first came into use in the 1970s by Dr. Herbert Freudenberger, writes Sherrie Bourg Carter, Psy.D. The 1970s were fraught with social and personal stress, such as the Vietnam war, Watergate (government corruption), oil shortages, instability in the job market, and rising divorce rates. Workplace stress was on the rise, characterized by long work hours and difficulties in the work environment. Many people, usually those who were passionate to do well in their jobs, found themselves disenchanted with and unenthusiastic about their work.
Symptoms of burnout
Symptoms of burnout normally develop slowly, over a period of time. Mental health professionals have a great capacity to care for others and to place their focus on their clients’ needs. As a result, symptoms of burnout may build up over time, sometimes not even becoming noticeable to the clinician until the symptoms are quite significant. It may happen much like the story that we’ve heard about two frogs and two pots of water. Do you remember this story? One frog is caught and placed in a pot of boiling water. He is able to notice the danger immediately and jumps out of the pot. The other frog is caught and put in a pot of water that is room temperature. The water is heated slowly over the flames. This frog doesn’t notice the danger because the water heats up very slowly. In the end, he comes to his demise. Burnout is a little like that second frog. It’s important that we don’t let our water get so hot that we can’t do anything about it!
Here’s a short video about 10 Signs Work is Causing a “Burnout.”
Dr. Freudenberger originally identified symptoms of burnout to include:
- Exhaustion – usually the first distress signal noted with burnout
- Detachment – following disappointment by others and situations that leads to a feeling of “I don’t care”
- Boredom and cynicism – loss of enthusiasm and disillusionment
- Impatience and heightened irritability – resulting in increased difficulty to accomplish tasks
- Suspicion of being unappreciated – leading to anger and bitterness
- Paranoia – as a result of feeling mistreated by others
- Disorientation – feeling separate from your environment
- Psychosomatic complaints – frequent headaches, pains, etc. that are signs that something is wrong in one’s life
- Depression – unlike Major Depression, this is more temporary, specific, and usually dealing with a specific area of one’s life
- Denial of feelings – when we stop caring
Burnout, now…
In May 2019 the World Health Organization (WHO) included “Burn-out” in the 11th Revision of the International Classification of Diseases (ICD-11) as an occupational phenomenon. The ICD-11 has redefined burnout as follows:
“Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:
- feelings of energy depletion or exhaustion;
- increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and
- reduced professional efficacy.
Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.”
So, as this video explains, “Burnout is Now a Legitimate Diagnosis.”
Overcoming burnout
But, how does one “manage” chronic workplace stress, as the WHO states in their definition of burnout? Again, we return to Dr. Freudenberger’s work. He relates that there are “three basic ingredients for overcoming burnout:”
- Self-Awareness – asking yourself questions such as “Are you in charge of your life? Or has it taken charge of you?”
- Kindness – self-care, self-acceptance, and exploring our future goals and path
- Changing – being open to change, to new (or renewed) adventures and activities
Moral injury
The concept of moral injury has been with us for a very long time. It first arose out of soldiers’ experiences in war. Experiences where soldiers learned about, witnessed, perpetrated, or failed to prevent acts that seared into their deeply held moral beliefs and expectations about humanness.
In the healthcare and mental healthcare field, professionals can experience moral injury as well. Doctors, Simon G. Talbot MD and Wendy Dean MD have written very eloquently on this topic: “The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.” “Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These routine, incessant betrayals of patient care and trust are examples of ‘death by a thousand cuts.’ Any one of them, delivered alone, might heal. But repeated on a daily basis, they coalesce into the moral injury of health care.”
Drs. Talbot and Dean have identified many of the ways that healthcare professionals can experience moral injury. A business-oriented and profit-driven healthcare system makes it difficult for professionals to focus their attention on their client’s best interests for treatment. Multiple financial concerns abound, between hospitals, healthcare systems, insurers, and patients – which can lead to conflicts of interest. Electronic health records can distract healthcare professionals from their clients during visits.
Mental health professionals can experience moral injury in other ways as well. Frederic G. Reamer, PhD writes: “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.”
Symptoms of moral injury
Mental health professionals who are struggling with moral injury may exhibit some of the same symptoms of burnout, but overall the concept of burnout does not adequately describe how they are feeling. In a study of “Moral injury among Child Protection Professionals,” symptoms of moral injury included feelings of “anger and sadness, emotional numbing, and guilt and shame.” “Many also described troubling, existential issues including their ability to function in an ethical and moral manner within a system they viewed as deeply flawed, and in an unsupportive working environment steeped in human misery.” Although not related to CPS, here’s a video that deals with “How to Work with the Shame of Moral Injury” (this is a treatment related video of a first responder seeking mental health counseling).
Overcoming moral injury
The problem of overcoming moral injury is very different from that of overcoming burnout. Although burnout and moral injury are often spoken of together, or in tandem, they really do come from two distinctly different mindsets. When someone suffers from burnout, there sometimes is an assumption of a victim mentality. That the burnout results from not “successfully managing” chronic workplace stress. And the key to success here is making changes from within. On the contrary, moral injury in the mental health profession often arises when someone, with core professional values and ethics, passionately fights for what is right within a rigid system. In this instance, the key to success is making positive changes in the healthcare system itself. Another way to address this issue is to understand the “Importance of Language” when dealing with Burnout versus Moral Injury.
Personally, I can understand the basis for both burnout and moral injury. But, in my experience as a Clinical Social Worker, I believe that I have more often dealt with issues of moral injury as opposed to burnout. What are your thoughts on this topic?
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