Moral Injury in Addiction Treatment
Moral injury is the psychological or spiritual pain of your morality being violated. Whether you have actively participated in, allowed, or only witnessed the acts in question, you are morally injured if you feel ongoing distress in conviction that the acts were (or are) wrong. It may bring guilt, despair, anger, or dehumanization, among other feelings. If this sounds like the air we breathe right now, yes—I believe moral injury provides helpful language for political resistance. But this post will focus specifically on the moral injury of substance use treatment.
Here are some components of the treatment system that violate my morality:
1. Under-resourcing: In community treatment—outpatient groups, typically the only services available unless you’re wealthy—what is and is not possible always comes down to the budget. Need a referral to different services? Those are under-resourced too, if they even exist. The wider context is the systemic under-resourcing of most of our clients’ lives, from birth: precarity in access to food, housing, fair wages, safe working conditions, health care, child care, education, and so on. Their lives are not valued, as conditions both in and outside the clinic make clear.
2. Treating without consent: Technically, everyone signs a consent form before receiving any health service. But in substance use treatment, clients often lack a meaningful choice in the matter. When the alternative is going to jail, losing custody of your children, or getting fired (just a few examples of the stakes), “consent” comes under obvious duress. What is often described as “resistance” among substance use clients is really their expression of non-consent—which should be no surprise.
3. Collaborating with carceral systems: The single largest source of referrals to substance use treatment is the criminal justice system. A client may be on bail, probation, parole, pre-trial conditions, or in a “diversion” program; in any case they face incarceration, and treatment staff are required to coordinate with legal authorities regarding their disposition. Fulfilling legal requirements, rather than the client’s wishes, is the goal. And treatment organizations often prioritize the demands of criminal justice authorities in order to keep these referrals coming.
I participated in all of this as a treatment industry employee. I even normalized it, to myself and others. “Just following orders” and internalizing inhumane practices feature frequently in moral injury. In fact, as a clinical concept it was first developed by Dr. Jonathan Shay, a VA psychiatrist, to describe soldiers’ “undoing of character” from combat in the Vietnam War. More recently, anticolonial clinical psychologists have shared similar concepts for intergenerational experiences of dispossession and genocide, as in Jennifer Mullan’s “sacred rage” or Eduardo Duran’s “soul wound.”
Whenever I tried to talk to supervisors, or more experienced peers, about discomfort with the way treatment worked, I always got the same response: Don’t take it on personally. Let things go. You get less sensitive over time. There’s only so much we can do. But I couldn’t let it go while I was working for treatment agencies, and I still can’t let it go even now that I work for myself. My clients with moral injury report exactly the same messaging in their workplaces. The only answer we are given for moral injury, in other words, is to numb ourselves to it.
What if we don’t? This is the basis of my writing and clinical work now, and it’s leading in much more promising directions.
Coming up: The opposite of "letting it go"!
NB: I have a 90-minute webinar on moral injury in “behavioral health” work here for an honest Maine $5. CE credit in ethics is available for clinicians, check website for details. I do not receive any payments for views/purchases.
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