Should We Stop Saying Burnout and Start Saying Moral Injury?

I have called my experience of leaving public defense work after the first seven years burnout for many years. My experience followed the three classic symptoms of burnout:

1. Physical, emotional, and mental exhaustion. I went from energized by the work to barely dragging myself through each day. Some weekends I would sleep 14 hours straight and still feel exhausted, like I just could not recharge.
2. Feelings of self-doubt, loss of personal confidence. I started to wonder if I had what it took to actually be effective, not just in new and complex challenges (like learning about DNA), but in things I’d done many times (like writing and arguing search motions) that began to feel pointless.
3. Doubt for the value of one’s work. I felt like a cog in the machine of processing people through courtrooms to prison as efficiently as possible. At times it seemed like my presence even helped this machine run, by pretending the grossly unfair process complied with minimum constitutional requirements by having a lawyer present.

In May of 2019, the World Health Organization added burnout as an occupational phenomenon. My first reaction was to appreciate that more people might have access to leave from work or quality care for chronic workplace stress. My second reaction was irritation at the WHO’s definition of burnout: “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.” This definition places all the responsibility on the individual and frames the questions in terms of individual strength or weakness.
 
Last year, Dave showed me a YouTube video of Dr. Zubin Damania arguing that the term burnout and should be replaced with the term moral injury. I became convinced that the moral injury framework is a necessary shift to a more useful way of conceptualizing chronic workplace stress and trauma. This shift is important because it stops placing responsibility for solutions on the individual (do yoga! be more mindful!) and recognizes that systemic obstacles are the true causes of much of the chronic stress that we are experiencing. While we can mitigate some individual impacts with self-care, systemic solutions are needed to correct systemic causes.

Surgeon Simon Talbot and psychiatrist Wendy Dean wrote an article on the application of the term moral injury to physicians. They argued that “without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.” They assert that the concept of burnout “suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work.” They wrote that 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.”

The term moral injury was first used to describe soldiers’ responses to their actions in war. Doctor and clinical psychiatrist Jonathan Shay describes moral injury as perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations. Journalist Diane Silver describes moral injury as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

Dr. Shay’s version of moral injury is “derived from patients’ narratives and from Homer’s narrative of Achilles in the Illiad,” and is:

1. A betrayal of what’s right
2. by someone who holds legitimate authority (or by one’s self)
3. in a high stakes situation.

Public defense is filled betrayals of what is right by people with authority in high stakes situations. Deep soul wound is a perfect description of the impact of a criminal punishment bureaucracy that processes people—disproportionately people of color– into cages. Deep soul wounds result from a system in which: women are handcuffed to metal beds during childbirth in custody; money bail and mandatory minimums extort pleas for daylight; and fines, fees and forfeiture are used to line pockets and destroy communities.

If you substitute public defender wherever Talbot and Dean  reference physicians, it’s a perfect fit. The concept of burnout…suggests a failure of resourcefulness and resilience, traits that most [public defenders] have finely honed during decades of intense training and demanding work. The moral injury… is being unable to provide high-quality representation in the context of [public defense].

Talbot and Dean describe a career progression of physicians that suffer from moral injury: following a calling rather than a career path; desire to help people; almost religious zeal, enduring lost sleep, lost years of young adulthood, family strain, financial instability, disregard for personal health; each hurdle offers a lesson in endurance in the service of one’s goal; failing to consistently meet needs of clients has a profound impact on wellbeing. Many public defenders recognize ourselves in this same career progression.

Public defense leaders who have spoken publicly about impact of systemic obstacles like underfunding echo the language of moral injury. “I’ve had people come to my office and need immediate mental health leave, some considering self-harm. We come here with a goal to help people no one else is helping. When we can’t do it, it’s crushing.” (‘My Attorneys Are Ticking Time Bombs’ Kansas City Star May 31, 2019.) Public defense offices are filled with determined and dedicated people. Unfortunately, many offices are struggling to retain people. (Just a few of the many examples are Thin Ranks, High Risks (describing Kentucky), and One In Four Kansas Public Defenders Quit Last Year, Leaving Agency ‘In Crisis.’ Apr 8, 2019.)

The value of shifting from the framework of burnout to the framework of moral injury is in the discussion of causes and the solutions. Burnout focuses on individual inability to manage stress, and suggests individual responsibility to develop skills and strength to handle chronic stress—self-care practices like yoga, meditation, and therapy. Moral injury looks at systemic obstacles, abuses and transgressions, and suggests systemic solutions—such as reduced caseloads, supportive leadership, sufficient training, and mentorship support.

I speak and write frequently about things we can each do in our own lives to improve our well being—things like yoga, meditation, recreation, boundaries, and contemplative time away from work. I believe these practices are useful because (1) they aren’t dependent on a funder or office leader for support and can be started and maintained by each of us individually, which gives us ownership, control and autonomy in our own well-being, and (2) even with systemic solutions, secondary traumatic impacts will occur from working with people who have experienced profound trauma, and we will need personal practices to mitigate those impacts. This is not to suggest that self-care is the best or only needed response to moral injury.

Jonathan Shay outlined a definition of moral injury that comes with a solution. Moral injury deteriorates trust, ideals and ambitions; it creates an expectation of harm, exploitation and humiliation from others. He writes that the solution is within our control, and is “the need for leadership to be expert, ethical, and properly supported.”

In the context of public defense, self-care shouldn’t be used as a tool to shift responsibility to the individual where systemic solutions are needed. No amount of self-care can overcome the systemic obstacles and failings of the criminal legal system. Self-care can help us get through the day and keep fighting as public defenders, but it isn’t a replacement for the true systemic change that is needed.