Speaker A: Welcome to the therapist burnout podcast, episode 44. Hey therapist, welcome back. I am just talking to you today. So I am going to do a recap of the month and then talk a little bit about moral injury. Today I had a guest on in episode 43 where I talked with Dr. Jenny Byrne about her book on moral injury. And so I just want to have the application also to therapists. So that stuff purpose of this episode today. But first I just want to dive into a little bit of LinkedIn action. So this is how much I know about current events. I usually just get them from my husband, I think because I hate watching anything related to politics during these election cycles. So I was talking with him and he was saying how, oh, you should cover this strike they’re having. So Kaiser is having a strike in Southern California over staffing and workloads for mental health workers. It includes therapists and other mental health workers, like nurse practitioners, for example. So I posted about it, I found an article on the Associated Press and posted about it. And I think it’s just resonating a lot with what therapists are feeling who are likely working in settings where they’re asked to take on caseloads that are astronomical. There’s not enough people at their facility or at their clinic to meet the demands of what they’re asked to do. And so a lot of you guys, you know, post a lot about that. The therapists are saying they really wish there was a union or alliance for therapists in private practice because reimbursement rates are what they are. And we’re fighting a multi billion dollar industry who is making record profits, by the way. Just, just so you know, that’s happening. So I think the average therapist feels like we have no say in our reimbursement rates and there is no hope of being able to get more. Right. Also, one person was saying that therapists are being pushed to work these high case loads by organizations appealing to helpful tendencies of the therapist community by creating an unnecessary urgency like we’re solving the mental health crisis. We need to open up our slots, we need to be available because people might be really needy, right? So we need to meet that demand because people need our services and we know this. And I think because most therapists want to help, they don’t want to see suffering. We do that extra session, we open up our schedule because there is such a great need when doing so is at our own detriment. And one person said it’s such a powerful reminder that therapists are humans too. No job supersedes your humanity and your basic human needs. Yet for so many, particularly those of us in healthcare, the reality of our own humanity is overlooked. And this was from someone who stopped direct practice years ago, but struggled with how exploitive the mental health industry was and is, by the way. So I think the segue into talking about today about moral injury. So I had Dr. Jenny Byrne talk about moral injury. She is a psychiatrist and part of her story, which you can listen to that episode is not my story to tell, it’s her story. But go back to episode 43. So her story was of receiving a board complaint and the process of going through that and being treated really inappropriately by her colleagues in the process of that. But just an introduction into moral injury. So just some statistics because I feel like it’s helpful because we often feel like we’re so alone. Right. And if we feel like we’re alone, then we’re not really aware of what’s going on. Right. I don’t think many therapists are reading these statistics. So I always put some of these in for you guys so you know you’re not alone. A lot of people are feeling what you’re feeling. So this review I’m reading the association association of Moral Injury and health care clinicians well being a systematic review and I’m reading this on healthcare professionals with regard to moral injury because there are not really great many articles for therapists. So in my research I haven’t found too many articles just talking about therapists. So I’m looking broadly at healthcare providers with regard to this specific topic. So in a report of clinicians of the future, only 57% of healthcare workers believed they had a good work life balance. They said the reason for achieving a good work life balance in healthcare is challenging due to the high strain in the healthcare system in the United States and what it places on healthcare workers. Another statistic, about 47% of US based clinicians of nearly 3,000 people surveyed in a recent study stated they intended to leave their job within the next two to three years. And that is similar for therapists. So I’ve also quoted similar research. It has been in the past hovering around that 50% mark of people that want to leave the field. So I think those numbers are very similar for therapists. So just to define moral injury, it’s a term that comes from the military populations and it states three things. It’s a betrayal of what’s right. And second, either by a person or a legitimate authority or by oneself. And three, it’s A high stakes situation. Okay, so that is kind of that military definition. There’s other people that define it differently. And I was talking about terms and definitions. I feel like there’s a lot of overlap with vicarious trauma too, with some of this stuff, because that inherently talks a little bit about depersonalization. So another definition by Litz and Craig, their definition is more flexible and is applicable to a variety of settings and describes moral injury as transgressive harms and outcomes of those experiences. They talk about moral injury as defined by moral transgression or a boundary breaking of oneself or one’s position of power in a high stakes situation. And the outcomes of those experiences. They talk about more of a range of moral outcomes that can be experienced from a potentially morally, morally injurious event or a PMIE situation that can cause ethical dilemmas and can lead to moral transgression. So for therapists, I think there can be multiple part. I’m going. Let me look at the acronym again. Multiple potentially morally injurious events or PMIEs. So if we’ve had multiple of those in our career. And when I thought about this when I was talking with Dr. Byrne last week, I thought of my own experiences of potentially morally injurious events. And a lot of those were working with youth. So when I first came into the field, I worked in residential, and that was in the process. I was interning before I got my bachelor’s degree. So I was interning as a. At a residential treatment treatment center with the highest acuity I probably had seen in my entire career. So these were children who had been placed out of state many times into this residential facility and needed a higher level of care than was able to be provided wherever they were in their state. And we did have some kiddos that were. Were in state actually after that I was a caseworker in foster care. And I think a lot of my situations that were potentially morally injurious were with working with children. So I worked as a caseworker and a casework supervis in New York. And some of those situations where I had to remove children from placements still stick with me to this day. And I remember the things that some of those children told me, which I had to reckon with. You know, I’m like, how can I live in a world where kids who are in a foster care placement show up with trash bags full of their items for removing a placement like that just feels really, really awful. And so witnessing some of that and being part of that. Right. And one of the agencies I worked for, she demanded that the foster parents, if they didn’t have one, they. That they would purchase a piece of luggage for that child. So that was part of our agency policy that we would never have a child show up with garbage bags full of items, which I saw a number of times as a caseworker. But me at, see, how old was I in those situations, like 23, 24, 25. It didn’t, it didn’t dawn on me to think of those things. Right. It didn’t dawn on me like, oh, this is just the way it is, but it doesn’t have to be the way it is. And also sitting in the situations where, you know, a judge can decide what they’re going to decide no matter what I say. So as a caseworker, I can say, well, I really don’t think going back to home is an appropriate placement for this child because of X, Y and Z. We haven’t, We’ve, you know, whatever it was based on the case. I can’t even remember, you know, some of the details of the situation, nor can I put exact details right, but that me as the caseworker is saying, I don’t think this is appropriate. And these are these reasons it’s not healthy for the child. They are thriving in their placement and, you know, maybe the parent had not done what they needed to do and vice versa. Maybe the foster care placement wasn’t the placement for the child and I was advocating for them to leave that placement and then the placement was retained and I felt maybe there were some questionable things the foster parent was doing, such as not observing birthdays, not caring for the emotional needs of the child, which, you know, it gets sticky. So those are just some examples, I think, from my career and then more recently from my practice closure. More recently from my practice closure. I think some of the potentially morally injurious events, and if I’m thinking from like an outside perspective, was interfacing with insurance. So during 2021, I. My biggest payer was. I mean, can I just say it? I don’t know, like, I’m. I’m not paneling with them. So. Yeah. Anyway, I’m not going to say the payer. I don’t know why I still feel like I shouldn’t say it, but maybe I should just do some consulting on that. We’ll see. Anyway, I had the. I had a biggest payer. Many of the people I’ve talked to, it is the same payer that has been denying claims. And it’s a very Large payer. So a majority of my caseload was that insurance panel. And they stopped paying me for months. And I was seeing as many clients as I could see at that time, with also having young children at home, working as hard as I ever had as a therapist, taking on as much stress as I ever had as a therapist, seeing clients who were highly acute and I was doing EMDR with many of them. And I had to make a decision, right? I had to make a decision that felt incongruent with what I felt like I should do it as a psychologist. So I never felt the need before that time to go off of insurance panels. I kind of was okay with the amount of money at that point in time that I was making from insurance. And they had me kind of question, okay, can I practice as a private pay therapist? And I’m not putting that on any therapist. If that’s their decision and they don’t have moral stuff about it, then that’s fine. But I think I saw posts, a lot of posts from other therapists who were trying to make referrals and you know, would make these comments of like, you know, we should not be, we should not be full fee therapists. We should take insurance. It should be our ethical imperative to provide access to clients. And I know we all want that. I know we all want access for clients. At the same time, we are not able to fulfill our role as therapists and be well cared for and have a solid wellbeing if we’re taking on as many clients as we need to take on like 30 plus clients in order to make the income that we need to support our families. So right there we are, we have to kind of reckon morally with what we believe about providing therapy. Do we think we need to work the 30 plus hours to do that? So we’re providing access at the detriment of ourselves. So I think having this kind of moral reckoning with what we even think about therapy and us as providers is potentially morally injurious. And I’m talking speaking more to the private practice clinician versus someone who is in an agency or is in a clinic or working for one of these tech companies who also have the layer of you need to make, you need to see each week bill 25 sessions, right? So when I worked in agency, I had to bill, I had to actually bill 30 hours in order to take vacation. If I didn’t want to take vacation, it was just 25. So at that time it was a pretty high expectation that I needed to meet in order to basically have the basics rate take two to three weeks off a year. So I think those are some of the things we are being asked to work from some companies, hours in which totally drain our energy. And we don’t have anything left for families that is potentially morally injurious because then work is getting the best parts of me and is getting all of my emotional resources that I have. And I don’t have these emotional resources left for my family members. And I think we don’t consider as well how the work changes us. I keep hearing this time and time again on consult calls with therapists is they feel like I am just different. I see the world differently from this work. And part of that is compassion fatigue. But part of that is also, I think, feeling morally injured from the greater system of the health healthcare system, from insurance or from agencies that are dictating that we must work this much in order to quote unquote, be a good therapist to fulfill the role. And if we don’t do that, what does that mean about us? And I think that question that we don’t ask ourselves, but we are internally struggling with is part of moral injury for therapists. So just to. I love the way this is differentiated on this Commonwealth Fund. It’s probably, you know, funding their intervention. But anyway, I like the way this was stated by Cinda Cinda Rushton on this website. So differentiating between burnout, moral distress and moral injury. So Rushton sees burnout as a mismatch between the demands placed on people and the resources they have to meet their workplace. So they’ve been tracking burnout among clinician clinicians for decades. And using the Maslach Burnout Inventory. Maslock is like the huge researcher in the burnout space which measures clinicians level of emotional exhaustion, depersonalization and personal accomplishment. And we know the levels of burnout are high, 40% for nurses, 38% for physicians. This is on healthcare. And that’s it’s pretty high also for around that 50% mark for therapists as well. So she’s contrasting moral distress is experienced when a clinician struggles to do what they believe is ethically correct and for whatever reason they’re unable to enact it. So I think that would fall underneath working less. And I think going back to these strikes that are happening in California, they are asking for more support and I think similar benefits than other healthcare workers. So they aren’t given similar benefits at other healthcare workers. I read one research study that said that Doctors spend about 50% of their face time with patients and 50% of their other work time documenting or making collateral contacts, for example. And so our expectations as workers within this healthcare system is different compared to our other colleagues. Right. And our pay is dramatically less. So I think asking the healthcare system to increase our pay to see the what the value of what we’re bringing to the space and to have similar expectations for our time, they were given more time for documentation, for collateral contact and things of those natures. And I think ultimately that means raising our reimbursement rates across the board. I think also moral distress. So I am consulting in a school and I can’t really talk about any of the issues particularly, but I do see a role of the system having to ask workers to do things that they may believe is ethically incorrect. And certainly I come in sometimes in these situations and can speak to, hey, actually clinically, I think we should be listening to that clinician or we should be doing X, Y and Z. And, you know, that is my role kind of to look from the outside coming in on these situations, because a lot of times I think the system is just trying to meet the demand of whatever is placed upon it and is trying to do that in the easiest way possible. I sat with a number of clinicians in kind of a burnout talk. And they were talking about how they felt like the administration was trying to increase the capacity of the staff and not think about what do the staff need to be supported. And so I think it’s just an interesting concept that a lot of times as humans, we’re seen as like, okay, we need to increase their capacity or their output like we are a machine. And I think when I talk with Dr. Byrne, she talked a lot about this concept that clinicians are saying they felt like a cog and a machine, that I’m just one part and that I have to do this part so I can keep the machine going. I can keep. Keep the greater healthcare system running so it makes the money it needs to make, and we know that they’re profiting. So I think all of that causes moral distress. Right. Because we don’t think our system is there for the health of our clients or our patients over time. She’s saying that repeated feelings of moral distress can lead to moral injury. A profound sense that you’ve betrayed your own ethical code or you were unable to follow it because of external factors or people you trusted have betrayed some fundamental obligation. And I think that last piece that people you trusted have betrayed some fundamental obligation is kind of important. And again, moral injury among Healthcare workers has been linked to feelings of guilt, shame and anger, leading to depressive episodes, post traumatic stress disorder and suicidality. And I think Rushton also explains it. It’s more of a corrosive form of moral suffering because all of these things stack throughout our careers, right? That we experiencing these little, not little. We experience multiple incidents of moral distress and then those tend to stack. And I think that’s what I’m feeling when I sit with therapists on these consult calls. It’s just like I don’t know who I am. That depersonalization is coming up a lot in the calls. I don’t know what I can offer anymore to people. I feel like I’m doing all of this wrong. I feel like I failed comes up for a lot of people around these issues. And I feel like the concept of moral injury can be helpful in seeing that a lot of this is systemic and it’s no result of your personal failing. And that’s the thing I keep telling people on these podcasts, is that we need to really zoom out and look at a system. And that’s why I’m grateful that these mental health professionals at Kaiser in California are striking. I think it’s starting to give us a little more of a voice. I. I know a lot of therapists talk about these unions, like do we need to unionize? I don’t know. I don’t even know what that looks like. But I think we’re starting to have these questions and that’s a good thing. So at any rate, I am wrapping up today. My episodes might be shorter as we go through the year because I’m getting busier and I still am committed to this podcast. So I have a couple interviews coming up for you in November and also I want to talk a little bit about handling highly stressful times. So I know that we are in the midst of election cycle. I know your ears are burning, bleeding. I’ll go back. So I, I sent this email out and the title was your ears are bleeding. Because I remember sitting in the room in the election cycle of 2020 and just wanting to do anything but be in the chair. Oh, it is so tough. And I talked often about like these moral dilemmas that I would have when clients would tell me things that were racist or scrofulously inappropriate that I didn’t want to hear. And yet I felt trapped in many ways on the couch sitting there listening to these things and struggled to feel like I need to find my way in pushing back in session or raising concern in session. Or referring this client out, because there were times where I just could not do it anymore with some clients. So I think talking through some of that messiness is something I’d like to do. I know that it’s, you know, reaching a fever pitch as we’re about to approach that in the next week. So next week I might have a little bit of a episode on how we handle the distress of other people based on external events from our world, political otherwise. And how we can take more breaks next week because next week is probably going to be heavy for. For you therapists. And then after that, just talking a little bit about, you know, managing the stress of the hol holiday season. So a lot of times we are more stressed, our clients are more stressed. And so I just wanted to provide some episodes on resources for you, how you can have resources to handle your own family stuff. Because we have families, too, who need us and have drama and demand things of us at the holiday season. And I think a lot of us just have nothing left. And so we’re just kind of coasting and thinking like, well, let’s just get through this because it’s. It’s a lot. Right. So I. I remember kind of in the height of my burnout, when the holiday season came, I was just waiting and writing it out until it was over. And it felt like a relief when it was over. And I was grateful to get to January, honestly. And often January for therapists brings our hardest season. So we know that our clients are going to be unpacking the holiday season. They’re going to be dealing with seasonal stuff. So it doesn’t mean our work gets lighter coming into January. So anyway, that’s the focus in November, kind of managing stress, managing the holiday season, and giving you guys some resources and tools. I think talking more about how we handle these external events I think is always helpful. And then some of that is also talking about our mental health. And in December, I usually like to talk about grief and loss and joy. So the holidays are heavy for a lot of reasons. We often think about people we’ve lost, and we often, you know, struggle to access those joyful or renewing emotions. So I also want to give attention to that. Like, how can we access more of that? Because a lot of people I sit with are like, I have not felt a sense of joy in a long time. So even, like those mini little experiments we can have with joy are great. Okay, well, if you’d love to get on a consult call with me, I. I love talking with therapists. I really see it as a service to you guys so I’ll include that in the show notes. But I also just have a pen pal list so I have a email. It’s a me email list right? But I reply and I talk to you guys and it really is no obligation and you get these little tidbits from me about things I’m reflecting on, things I’m hearing from other therapists and it’s more of the stuff that I don’t talk about on social that I don’t feel comfortable sharing on social media. So you get all the juicy bits if you’re on that list so certainly sign up below. It’s my pee and pal list. I don’t know I have to say it like that but it’s my pen pal list and I hope you’ll sign up and send me an email because I’d love to hear from you. So the link will also be in the show notes. Have a good one.
