Abstract
Throughout social work’s history, some practitioners and their employing organizations have caused harm. This article explores the concept of moral injury and its relevance to the social work profession. The author explores essential components of a meaningful response to moral injury in social work that simultaneously acknowledges the impact of moral injury on individual victims and addresses the need for structural reform. The author discusses the nature and causes of moral injury, prevention strategies (including the need for practitioner self-care and organizational and community advocacy), the role of apology, restorative justice, and moral courage.
Keywords
Throughout the profession’s history, some social workers have caused moral injury by harming vulnerable clients. Examples include social workers who became sexually involved with clients, violated clients’ confidentiality rights, mistreated clients in residential treatment facilities, violated the rights of social work research participants, and discriminated against clients (Reamer, 2015). In addition to harming clients directly, some social workers have witnessed moral injury, learned about moral injury from third parties, or failed to prevent moral injury. Moral injury includes “the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009). Drescher et al. (2011) define moral injury as “disruption in an individual’s confidence and expectations about one’s own or others’ motivation or capacity to behave in a just and ethical manner” (p. 9). Moral injury can lead to what Corley et al. (2005) refer to as “moral residue.” Moral residue is the product of the cumulative effect of unresolved moral distress.
This discussion explores the concept of moral injury and essential components of a meaningful response to moral injury in social work that simultaneously acknowledges its impact on victims and addresses the need for relevant structural reform. Key topics include the nature and causes of moral injury; meaningful responses to moral injury, including moral repair, apology, and restorative justice, and moral courage.
The Nature of Moral Injury
Among the most challenging ethical dilemmas in social work involve moral injury (Campbell et al., 2016; Griffin et al., 2019; Shay, 2014). What these phenomena have in common are instances when social workers must decide how to handle circumstances that are deeply troubling because they have caused, or have the potential to cause, harm (Jaskela et al., 2018).
The term “moral injury” was first coined by psychiatrist Johnathan Shay (2014) when describing the “undoing of character” and difficulty coping with moral pain he observed among Vietnam veterans. Initially, discussions of moral injury concerned active-duty military personnel’s moral distress and emotional pain (including feelings of shame, guilt, anger, betrayal, and distrust, among others) when they witnessed or perpetrated an act in combat that was morally repugnant (Brock & Lettini, 2012; Dombo et al., 2013; Farnsworth et al., 2017; Meagher, 2014).
Over time, discussions of moral injury have expanded to include other professions, especially in health care (Austin et al., 2005; Reamer, 2021). The moral challenges faced by social work professionals are reminiscent of those encountered by military personnel and health care professionals. However, there is significantly less scholarly discussion and research on moral injury in social work than in the military and health care professions (Briggs & Fronek, 2019; Fantus et al., 2017; Fine & Teram, 2013; Fronek et al., 2017; Haight et al., 2016; Kopacz et al., 2015; Lev & Ayalon, 2018; Lynch & Forde, 2016; Oliver, 2013; Weinberg, 2009). Haight et al. (2016) conducted a comprehensive review of relevant literature and found evidence that there is a paucity of literature in social work journals, compared with psychology and psychiatry journals.
Research suggests that social workers and other professionals encounter morally troubling dilemmas in three principal domains: clinical, administrative, and interpersonal (Pauly et al., 2012). For example, clinical challenges arise when social workers are troubled by morally suspect clinical orders given by supervisors, such as when a social worker’s clinical supervisor orders her to implement a poorly designed treatment plan that may harm a client or discharge a vulnerable client prematurely due to funding constraints (Corley et al., 2005; Keinemans & Kanne, 2013). Haight, Sugrue, & Calhoun (2017) and Haight, Sugrue, Calhoun, & Black (2017) documented evidence of moral injury specifically among child protection professionals and parents involved with child protection services.
Administrative challenges occur when social workers are expected to comply with organizational policies and practices that they consider to be immoral, for example, compromised staff-to-client ratios, inadequate informed consent protocols, unsafe practices during a pandemic, and refusal of services to uninsured or undocumented clients (Griffin et al., 2019; Shay, 2014). Finally, interpersonal challenges occur when practitioners believe that a colleague is impaired or has behaved unethically, for example, when a social worker believes that a workplace colleague is a perpetrator of sexual harassment or has engaged in fraudulent documentation.
The Causes of Moral Injury
Moral injury in social work can result from four unique, albeit related, phenomena (Litz et al., 2009): (a) perpetrating acts, (b) witnessing acts, (c) failing to prevent acts, and (d) learning about acts that transgress deeply held moral beliefs.
Perpetrating Acts that Transgress Moral Beliefs
The social work profession typically attracts practitioners who care deeply about addressing human suffering and social injustice (Martin et al., 2012; G. Wilson & McCrystal, 2007). The vast majority of social workers have altruistic instincts and would not knowingly harm the people and communities they serve.
Sadly, some social workers and the organizations they represent harm others. Their actions have a negative impact not only on their victims but also on their colleagues, who may experience secondary trauma or moral distress as a result. Examples include social workers who knowingly lie to undocumented immigrants about their eligibility for welfare benefits, engage in sexual misconduct with clients, falsify client records to camouflage wrongdoing, or fail to confront colleagues who abuse youths placed in detention facilities (Reamer, 2015; Strom-Gottfried, 1999).
In some instances, social workers admit their guilt and take responsibility for the harm they have caused. In other instances, practitioners deny their guilt and are held accountable when they have been the subject of media reports, found guilty in criminal court, found liable in malpractice lawsuits filed against them, and sanctioned by licensing boards.
Witnessing Acts that Transgress Moral Beliefs
Some harmful acts, such as the blatant mistreatment of psychiatric patients, prison inmates, and people who struggle with homelessness, are witnessed by social workers. These practitioners may be tormented by what they have witnessed and struggle with secondary trauma. Practitioners sometimes grapple with ethical decisions about whether to disclose or blow the whistle on colleagues’ alleged wrongdoing (Reamer, 2018, 2019).
Failing to Prevent Acts that Transgress Moral Beliefs
Sometimes social workers learn about immoral and unethical conduct in their workplace and experience moral distress because they did not take steps to address it. According to Wilkinson (1987), moral distress is “the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the behavior indicated by that decision” (p. 16). An example includes social workers who are aware that colleagues in a psychiatric facility are abusing residents but fail to challenge or expose the misconduct.
Learning About Acts that Transgress Moral Beliefs
In some instances, social workers learn about allegedly unethical conduct that they do not witness directly. Typically, these practitioners hear about transgressions indirectly from workplace colleagues, clients, or outside parties. Examples include social workers who learn through the grapevine from reliable sources that the CEO of their organization has sexually abused employees or committed financial fraud, intake personnel have mistreated potential clients, or that the organization has discriminated against people of color in its hiring and promotion practices.
The Role of Moral Repair and Apology
In some instances, social workers seek to address their feelings of remorse or guilt when they believe they have caused, witnessed, learned about, or failed to address moral injury (Dekel et al., 2016). Practitioners who wrestle with these complex issues may yearn for what has become known as moral repair. Moral repair is the process of moving from a situation of loss and damage to a situation in which some degree of stability in moral relations is regained. The process of moral repair involves efforts to restore or create trust and hope in a shared sense of value and responsibility (Cohen, 2017; Walker, 2006).
For some social workers, apologizing for their association with moral injury is a central element of moral repair. Apologies can help individuals who feel remorse about their actions or failure to act and, perhaps, provide solace to victims.
Apologies that follow instances of moral injury in social work settings can serve several functions. Some apologies are public, in which transgressors acknowledge their wrongdoing and seek to make amends. Other apologies are more private. Apologies may also provide an opportunity for victims to forgive those who harmed them, if circumstances warrant, and they may provide an opportunity for those who have caused moral injury to establish or regain trust.
In some instances, people who feel responsible for causing moral injury apologize to victims directly. In one case, a social worker who had sexual contact with a client was prosecuted in criminal court. The practitioner was convicted and, at the time of sentencing, turned to the victim, who was in the courtroom, and apologized for his egregious misconduct.
In other instances, social workers and others apologize through third parties. This is known as “vicarious apology” (Cohen, 2017). In one case, a social worker employed by an agency was disciplined by his regulatory board after a client filed a complaint alleging that the practitioner had violated professional boundaries and engaged in an inappropriate online relationship with her. The social worker was fired by the agency, and his professional license was suspended. The executive director of the agency reached out to the victim to arrange a meeting. During the meeting, the executive director apologized to the former client for the social worker’s misconduct. This is a classic example of vicarious apology.
In a notorious case of collective apology, Australia’s prime minister apologized publicly for the government’s failure to protect children from sexual abuse. A 5-year government investigation produced evidence that many children in the care of schools, churches, sporting clubs, and foster homes had been abused and that many institutions had gone to great lengths to shield abusers (Rojas, 2018). This followed an earlier apology issued by Australia’s prime minister to that nation’s Indigenous population for policies that removed Aboriginal children from their families and compelled them to reject their cultures in favor of assimilation, creating what is known as the “Stolen Generation” (Wahlquist, 2018).
The social work profession itself has offered a profound moral apology. In 2021, the National Association of Social Workers (NASW, 2021b) issued a formal public statement apologizing for the profession’s “racist practices in American social work.” According to the statement, “as the nation looks at its long, cruel history of systemic racism, the NASW acknowledges that our profession and this association have not always lived up to our mission of pursuing social justice for all. NASW apologizes for supporting policies and activities that have harmed people of color.” NASW’s widely publicized apology acknowledged the role the social work profession has played in supporting discriminatory systems and programs for decades, including, for example, instances when Progressive Era social workers built and ran segregated settlement houses; social worker suffragists blocked African Americans from gaining the right to vote; social workers helped recruit Black men into the infamous Tuskegee Syphilis Study; social workers participated in the removal of Native American children from their families and placement in boarding schools; and social workers took part in intake teams at Japanese internment camps during World War II.
There is empirical evidence that health care professionals’ apologies for harm they have caused can have a significant salutary effect on clients (Berlinger, 2005; Mazor et al., 2006; Robbennolt, 2009). More specifically, there is some empirical evidence that social workers and other behavioral health professionals can promote moral repair and help clients cope meaningfully with their moral distress. For example, Barth et al. (2020) report on the effectiveness of the Resilience Strength Training intervention, which incorporates a military squad model of group trust and bonding to address moral injury. Nieuwsma, et al. (2015) assess the effectiveness of acceptance and commitment therapy to address moral injury. Litz et al. (2016) summarize the impact of “adaptive disclosure” therapy to treat moral injury, which uses cognitive behavioral therapy and other therapeutic strategies to target life-threatening trauma, traumatic loss, and inner conflict produced by moral injury.
Restorative Justice
In social work, the restorative justice movement has emerged as a prominent way to facilitate meaningful apologetic gestures when moral injury occurs. Restorative justice is a theory of justice that emphasizes repairing the harm caused by unethical conduct. Restorative justice is based on a belief that an important goal should be to restore victims of wrongdoing—both individual victims and the broader community—who have been harmed or injured by perpetrators (Reamer, 2017; Umbreit & Armour, 2011). Another goal of restorative justice is the rehabilitation of perpetrators through reconciliation with individual victims and the community at large. More specifically, restorative justice stresses the importance of supporting and assisting victims; holding wrongdoers directly accountable to the people and communities they have violated; restoring the emotional and material losses of victims, to the degree possible; providing a range of opportunities for dialogue among interested victims, wrongdoers, families, and other supportive people; offering perpetrators opportunities for competency development and reintegration into productive community life; and strengthening public safety through community building (Umbreit & Armour, 2011).
Restorative justice models broadly define victims as including individual victims (as in cases where social workers have been involved in racial discrimination or abuse of clients); organizational victims (as in cases where social work administrators have been involved in financial fraud or embezzlement of agency funds); and the broader community (as in cases when low-income neighborhoods are razed and vulnerable residents are displaced by organizations that employ social workers to make way for profitable commercial development).
Restorative justice programs involving social workers take various forms, the most common of which include victim–perpetrator mediation, conferencing (a process that brings together the victim, perpetrator, and family and friends of both to discuss the impact of the wrongdoing), and circles (a long-standing Aboriginal, Native American, and First Nations practice in which community members meet with the perpetrator to discuss the harmful conduct and offer opportunities for reparation, restitution, and community service) (van Wormer & Walker, 2013). Multiple formal studies indicate that restorative justice efforts can help both perpetrators and victims cope with moral injury (Latimer et al., 2005; D. Wilson et al., 2017).
Implications for Practice
Social workers can take a number of steps to help prevent and respond meaningfully to moral injury caused by individual practitioners and human service organizations. In some instances, this requires social workers to address their own ethical judgment, burnout, or impairment. In others, social work organizations’ policies and protocols cause moral injury and must be addressed. Overwhelming workloads, limited resources, poor employee compensation, poor working conditions, and performance demands can lead professionals to engage in practices that harm clients. Ideally, social work professionals would take steps to advocate for organizational change to address these phenomena and, ultimately, minimize moral injury.
Social Worker, Heal Thyself
Social workers who cause or are at risk of causing moral injury should take steps to enhance their own well-being and prevent the kind of impairment and burnout that can lead to moral injury (Smullens, 2015). Social workers’ self-care includes various elements: physical, psychological, spiritual, support, and workplace changes. When appropriate, social workers who struggle with the sequelae of moral injury and distress may find it useful to seek their own psychotherapy. In 2021, the National Association of Social Workers added language to the profession’s code of ethics referring explicitly to practitioners’ self-care: Professional self-care is paramount for competent and ethical social work practice. Professional demands, challenging workplace climates, and exposure to trauma warrant that social workers maintain personal and professional health, safety, and integrity. Social work organizations, agencies, and educational institutions are encouraged to promote organizational policies, practices, and materials to support social workers’ self-care.
Organizational Change
Planned change in social work organizations to prevent moral injury can incorporate a series of steps, including setting a change goal, assessing organizational conditions, choosing a strategy, implementing the change process using change tactics and specific change technologies, and assessing outcomes of the change process (Packard, 2013). In this context, the change goal may be to hire more staffers to reduce workloads, make performance demands more reasonable, improve working conditions, and enhance employee compensation. These changes may enhance employee morale and help them avoid actions that cause moral injury.
Pursuing these goals requires systematic assessment of the organizational factors that increase the likelihood of moral injury. This assessment entails examining the organization’s readiness for and commitment to change, possible sources of resistance, capacity for change, and leadership options. Effective organizational change typically involves a series of steps (Packard, 2013):
Assess the present: At the outset, it is important to identify which agency staffers are in a position to assume leadership responsibility. Ideally, these individuals are passionate about the need for constructive change to prevent moral injury and have demonstrated leadership skills.
Create a sense of urgency: A principal goal when seeking to prevent moral injury is to convince workplace colleagues that time is of the essence. Social workers who are committed to preventing moral injury must be vigilant in their efforts to keep colleagues on track. Educating colleagues about the costs associated with not addressing the causes of moral injury—including potential harm to clients, staff burnout and turnover, loss of funding, and harm to the organization’s reputation and credibility—is essential.
Communicate the change vision: Clear communication about change efforts is key. Practitioners who take the helm must provide a clear and specific plan for how the change process will be implemented, what the core goals will be, who will be involved, what planned activities and resources will be included, what the time frame will be, and which persons will be responsible for the activities.
Develop and maintain support: Skilled leaders recognize how important it is to sustain staffers’ commitment to organizational change efforts designed to prevent moral injury. Periodic updates from influential administrators and, when appropriate, board of directors members and reputable community leaders can be very effective.
Develop an action system: Broadly speaking, an action system in a typical social work organization that seeks meaningful change to prevent moral injury can include line staffers, supervisors, middle management personnel, senior administrators, outside consultants, and representatives from the board of directors.
Implement the plan for change: Organizational change requires a series of discrete, manageable tasks. A detailed timetable can help organize participants’ efforts.
Institutionalize the change: Substantive and meaningful organizational changes designed to prevent moral injury often include new or revised agency policies, workload assignment protocols, quality control mechanisms for service delivery, performance measures, staff recruitment and development protocols, staff wellness and burnout prevention efforts, and resource allocation procedures.
Evaluate the change: To enhance the likelihood that planned and implemented changes are sustained, it is important to build in an evaluative component. This component can include “formative” evaluation during the process of organizational change and “summative” evaluation once key changes are implemented.
Community Advocacy
Social work practitioners often need to address causes of moral injury that occur at the community level. Social workers have long recognized that skilled community organizing can be an effective way to address injustices that cause moral injury. For example, beginning in the Progressive Era in the United States, settlement house practitioners, such as Jane Addams, Lillian Wald, and Stanton Coit, used a community-based social action approach to respond to the needs of immigrants arriving from Eastern Europe (Mondros & Staples, 2013). Especially during the 1960s, community organizing was a key element of the antiwar, civil rights, welfare rights, and women’s movements that were engaged in large-scale social change efforts. A variety of organizing initiatives, such as National People’s Action, the Midwest Academy, the Pacific Organizing Institute, Association of Community Organizations for Reform Now, and Cesar Chavez’s United Farmworkers used community organizers to reform housing policies, challenge lending practices, lower utility rates, institute tax reform, improve city services, and raise wages for migrant laborers (Mondros & Staples, 2013).
Effective community organizing to address injustices that cause moral injury involves multiple stages (Eichler, 2007). Initially, the process involves locating a specific issue to address. Organizers must then identify a way to create a network of like-minded people to address the issue. Organizers must motivate and empower these people to engage in organizing efforts, which may include educating key informants and the public, building coalitions to promote policy changes, lobbying, and, when warranted, protesting. Also, organizers should monitor the implementation of changes.
Policy Advocacy
Another major tool to address social injustices that cause moral injury is policy advocacy. Policy advocacy, a form of policy practice, entails efforts to create or reform policies in the public and private sectors that address social justice issues. The process involves several key stages, including analysis of the policies that need to be addressed, implementation of policy creation or reform, and feedback to ensure adequate implementation (Iatridis, 2013). The analysis stage begins with identification of the problems to be addressed and, when appropriate, analyses of socioeconomic conditions surrounding them. Depending on the social conditions and social justice issues to be addressed, relevant socioeconomic conditions might include local poverty rates, unemployment rates, crime rates, school graduation and dropout rates, housing affordability, health risks, and citizens’ access to health care resources, among others.
It is then important to identify key players (individuals, groups, organizations, communities, and institutions) who shape policies, including elected and appointed officials, organized groups, consumers, and community leaders. Key players may also include prominent social work leaders in governmental and private agencies, community residents, current and former clients, influential politicians, local coalitions and neighborhood organizations, and religious leaders.
Identification of key players is followed by recognition of the nature of the problem and its socioeconomic environment, factors contributing to the problem, key policy issues and their implications, effectiveness of current policies, past efforts to resolve the problem, decision-making bodies, policy alternatives and their implications (comparisons, costs, and benefits), and recommendations (Iatridis, 2013).
Moral Courage
Social work professionals’ decisions to engage in advocacy and social action efforts to address causes of moral injury require a deep commitment to social justice. In many instances, engaging in social change and reform comes with risks. These efforts can become adversarial and exact an emotional toll when professionals find themselves in the midst of confrontation. Also, highly publicized social action activities can jeopardize practitioners’ safety and careers.
In this respect, addressing moral injury often requires moral courage (Groessl, 2017). The term “moral courage” was first coined in the 19th century and is defined as the willingness of people to face “the pain and dangers of social disapproval in the performance of what they believe to be duty” (Sidgwick, 1913, p. 333). According to Press (2018, p. 181), moral courage as a form of social action has four essential components: (a) It is animated by a strong set of personal convictions, (b) it transgresses established customs or attitudes, (c) it is carried out in the face of high social risks or costs, and (d) it is normatively driven conduct in which certain norms are accepted as binding, even as other norms are flouted and ignored.
Moral courage, a concept rooted in the German concept of Zivilcourage, entails a willingness to challenge authority and, when necessary, take on unpopular causes in the name of justice (Comer & Vega, 2011; Kidder, 2006; Strom-Gottfried, 2016). In their efforts to define moral courage, Kidder and Bracy (2001) asked a question whose answer has profound implications for social work professionals: What, then, is moral courage? It can be defined as the quality of mind and spirit that enables one to face up to ethical dilemmas and moral wrongdoings firmly and confidently, without flinching or retreating. . . It enables us to “face up” to problems—not necessarily to resolve them, and certainly not to promise that we will master them, but to address them squarely, frontally, and with determination. . . It requires action that is both firm in its persistence and confident that its tools—the moral, mental, and emotional elements of argumentation and persuasion—are sound enough to weather serious resistance. (pp. 2, 3, 6)
The social work profession includes noteworthy examples of moral courage designed to prevent moral injury. Social worker and former U.S. Senator Barbara Mikulski began her political career by using her social work skills to organize neighbors to stop construction of a highway through a historic section of Baltimore, Maryland. In 1966, the Baltimore City Council proposed building an east–west highway through the heart of the city. The highway was favored by the city’s business elite as a way to funnel cars downtown from the fast-expanding suburbs (Grier, 2015).
At the time, Mikulski was a social worker in Highlandtown, an ethnic community east of downtown. She knew that large numbers of Polish Americans, African Americans, and generally lower-income residents would be forced out of their homes by the highway. Many historic neighborhoods would be permanently altered. Mikulski formed a community group called Southeast Committee Against the Road and organized the opposition. The citizen uprising blocked the road. Litten (2015) cites road opponent Gloria Aull, who told the Baltimore Sun in 1987 that “Barbara would say, ‘The British couldn’t get us, the bedbugs couldn’t get us and the road planners can’t get us.’”
Another influential social worker in the United States who was involved in activism was Whitney Young, Jr., who worked with the Urban League in Minnesota after receiving his graduate social work degree. Eventually, he became executive director of the National Urban League in 1961. Young earned a reputation as a national black activist who helped bridge the gap between white political and business leaders and poor blacks and militants. During the turbulent civil rights era, diverse elements of the activist community worked together to form a sustained and identifiable movement just as Whitney Young assumed his duties as executive director. Young was credited with almost singlehandedly persuading corporate America and major foundations to support the civil rights movement through financial contributions in support of programs for jobs, housing, education, and family rehabilitation (Weiss, 2016).
Conclusion
Moral injury in social work arenas is a complex phenomenon. Moral injury can cause significant harm to victims and, as well, secondary and vicarious trauma, compromising professionals’ well-being and the quality of their work. Fortunately, over the years professionals have learned a great deal about ways to prevent moral injury, address the impact on those affected by it, and engage in efforts to prevent injustices.
Social workers who believe they have caused harm, witnessed harm, learned about harm, or failed to prevent harm caused by others can take assertive steps to heal those who have been injured and minimize the likelihood of recurrence. In some instances, these measures require practitioners to address challenges in their own lives that may have contributed to moral injury; in other instances, what is required are purposeful and sustained efforts to address dysfunctional and destructive organizational policies and protocols and cultural injustices that lead to moral injury and demoralization. Social workers who are concerned about moral harm, moral distress, and demoralization in the profession must focus simultaneously on relevant private troubles and the public issues that surround them. This simultaneous focus on individual well-being and key environmental forces is the hallmark of social work’s unique mission.
Addressing moral injury in social work is an essential element of professionals’ obligation. At its foundation, responding to moral injury involves moral choices and ethical judgment about matters of right and wrong.
Being a social worker requires a remarkably unique combination of principled commitment, integrity, and skill. Over the course of a career, social workers are likely to encounter instances of moral injury. Ideally, these professionals have the wherewithal to recognize moral injury when it occurs, identify contributing factors, and engage in meaningful efforts to prevent harm (in their own lives, in their organizations, and in the broader culture).
Footnotes
Disposition editor: Sondra J. Fogel
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
