Producer:
This episode of Social Work Talks is brought to you by the University of Central Florida. Built for those who don't wait for permission to change the world.
Josh Klapperick:
From the national association of Social Workers, this is Social Work Talks. I'm your host, Josh Klapperick. Joining us today is Pari Thibodeau. Pari is a licensed clinical social worker providing therapeutic interventions for adults coping with trauma at the Stress Trauma Adversity Research and Treatment center at the University of Colorado School of Medicine. Pari is also a doctorate level social work researcher in the space of workforce well-being with a special focus on well-being and mental health of behavioral health providers. Pari examines the concept of moral injury as a metric of well-being and I am very excited for this conversation because moral injury is something near and dear to my heart and feels applicable in the world at large. So thank you for joining me today, Pari.
Pari Thibodeau:
Thanks for having me, Josh.
Josh Klapperick:
We start every podcast by asking what drew you to social work and how has your career evolved?
Pari Thibodeau:
Yeah, that's a great question and it's actually really nice to be able to reflect on now. I got my master's in social work almost 10 years ago at this point and so I have to sometimes draw back a little bit and be like, oh yeah, why did I do this? And I think it's a good reminder at times. I think what really drew me honestly to the mental health field overall, and then I'll get into social work was the human connection aspect of the work. I knew just personality wise and the life I've had that I really wanted to be in a space where I was connecting with others. And mental health was an area in which you can actually talk to other people about their lives for your job. Right. And so that really drew me to the profession of mental health as a whole. And then when I narrowed into whether it was social work or psychology, I really liked social work values. They felt really personable to me. They felt how approachable I felt like as a student and a learner in my undergrad classes when I first was getting into mental health, they were more accessible as a learner to me in some of my psychology classes. And so I thought found that they were really relatable. So, I chose actually for undergrad at human service studies degree at Elon University because we didn't have a BSW program at that time. And then after that pursued my master's in social work at WashU and St. Louis. And it was really like the hands on internship experiences that helped me like hone specifically into My niche area of trauma at this point, but even broader healthcare, social work specifically. And I had originally thought I wanted to do more juvenile justice work and work with like the legal system and social work. And I did a few internships and I realized that for me, working with adults felt like a better fit, particularly because of the helplessness that comes with working with children that I felt like I wasn't able to create personal boundaries on that I carried home more with me. And so I pivoted a bit into healthcare social work and really found that like an intriguing learning opportunity that was fast paced, that kept me on my toes. Um, and that's where I landed.
Josh Klapperick:
What a fascinating trajectory. Uh, why the pivot away from justice?
Pari Thibodeau:
After choosing to work with adults from the justice system and my training in social work at that time, which is interesting cause it's changed, I think that I didn't feel equipped, I didn't have enough legal knowledge. And especially as an intern, there's always a learning curve when you're a learner. Right. And so it was almost too intimidating for me at the time. And so I was like, I don't think I have the information, maybe it's not for me. And I pivoted. Ironically, anyone who's a social worker actually is engaged with the justice system in some which way. And so we actually work with the justice system pretty closely in the clinic at start right now. Especially when you're working with families who are coping with trauma, there's a lot of different things that come up, like abuse and divorce and different situations that lead to an entanglement with the justice system. So now as I'm like more in my career, I've learned that there's not really like a way to escape one domain of a policy or institution when you're in social work, because it will. It all like folds together. But I think I learned a lot along the way and I think the intimidation factor got reduced, as I've learned along the way too. And then I've always had an interest in healthcare, so I was just like, let me explore that a little bit to see if it's a better fit. And I felt like I was able to grasp onto some of the learning curve of the medical system faster, which made me feel more competent at doing my job.
Josh Klapperick:
That makes sense. I don't remember my MSW program explaining the ins and outs of the legal system. So as an intern, that had to be being thrown into the deep end.
Pari Thibodeau:
Yes, absolutely.
Josh Klapperick:
So with this pivot, what does your practice look like during the week.
Pari Thibodeau:
Yeah, absolutely. So thinking about how I got from like working in a healthcare system till now where I work in a trauma clinic at an academic medical center, there's a bit of extra chapters that I think would be helpful for context. So after I got my MSW, I completed my clinical training at a long term care facility. And so working in long term care is a unique healthcare experience because your place of employment is actually where someone lives 24 7. Right. And but it's a healthcare setting, so it's kind of deceiving as it being more institutional healthcare setting, but it's actually someone's home. Right. And so you are commuting to someone's home, which is a unique experience. I really saw so much adverse workforce well-being in specifically the nursing staff, but not only the nursing staff, but the mental health staff. There was only two of us, social workers for a facility with 20 or 250 residents. So thinking about actually your caseload of someone who needs 247 care, it's a lot. And so not ever feeling like you can meet the need was really defeating. That motivated me to get my PhD and do research on like what can we do about this? Why are the policies the way they can? They are. Right. And so then I went over to University of Denver where I pursued my PhD in Social Work and started the study of workforce well-being amongst healthcare workers and then honed in there on what we're going to talk about today, moral injury. And then from there a bit of a pivot. They're in social work training. Often when you get your master's level degree and you decide to go into direct practice, you get clinically licensed, as I'm sure everyone listening knows. But when you get PhD trained in social work, that's an emphasis on research. And often while we know that macro and micro social work practice should not be siloed, that still sometimes happens based on the systems that have been created. When I was graduating with my PhD, most of the job opportunities are research focused, which makes sense because that's where you're spending your research training in your PhD program. I wanted to maintain both the clinical and the research side of things and not many organizations or institutions support that. So where I saw a good fit for me was the School of Medicine, where physicians are doing research all the time. Right. And so that is the norm. And so that's where I got this opportunity at the University of Colorado in the Stark Clinic doing trauma centered work and focusing on adults with trauma. So when you ask about my week I like to describe it as a sprint in a marathon in which sometimes my clinical practice is the sprint and the research is the marathon, but sometimes it's the opposite. So I usually spend about three days a week in the clinic seeing patients or doing clinical consultation or mentorship. Um, I do have a social work trainee, which is one of the best parts of my job is actually teaching future generations about doing ethical and meaningful trauma therapy. So the first half of the week I really spend in the clinic doing the patient care work. Second half of the week I do research at that more macro level.
Josh Klapperick:
What a wild trajectory. I'm still stuck on a caseload of averaging 125 per social worker. And I guess that kind of ties in because you said adverse workforce experience. And that brings us to our topic of moral injury. So how would you define moral injury versus an adverse workforce environment experience?
Pari Thibodeau:
Totally. Yeah. How I like to paint the picture is there's an umbrella of adverse workforce well-being or well-being at work. Right? That's the umbrella. And we can describe that in several different ways. It can be mental health, it can be burnout, it can be imposter syndrome, it can be self compassion. There's several different, you know, ways. When I actually started my research, I was looking into burnout because that's what I was seeing, right? And that's what I was hearing. That was the buzzword. Oh, I'm so burned out. Another day I worked another 12 hour shift up, right? Like it was very burnout centric. And I actually had a colleague in my PhD cohort say, have you seen this new term that's going around about healthcare workers about moral injury? And I was like, no. And I did a little digging with some information she shared with me and it felt way more relevant to the actual cause of the experience, not just the experience. And so moral injury, kind of in my definition that I've combined from some research scholars like Dr. Brett Litz and Dr. Jonathan Shea, is defined as the moral transgression or boundary breaking of values. Right. Or of morals by either yourself or by someone in a position of power and the negative outcomes that are related to that experience. And so in describing that, that can be a little like philosophical. So I can break it down a little bit. Moral injury is when something you morally find correct cannot be upheld or is actually violated by something you have to do because it's in your job description or you're told to by your supervisor or by like an insurance policy. Right? Like for example, like an insurance policy saying, hey, that person doesn't need physical therapy. So you as a social worker in the hospital have to go tell them, hey, your insurance is not covering your physical therapy for your hip replacement surgery. How do you tell someone that? It makes no sense morally. It doesn't feel right. Clinical practice, it doesn't feel right. And you're the messenger in that situation. And so then you're off in the face of like receiving the reaction to the patients. And it's something that violates your morals and has negative outcomes. So then you feel maybe helpless, powerless. You're maybe then discharging that patient into the community without adequate resources, knowing that they're maybe not as safe as they could be, not as supported, not as engaged in healing. And so that's just one example of like how moral injury can. It's kind of this pronged thing. It's a violation of morals, there's a power factor and then the negative outcomes, which often generates like a sense of powerlessness, hopelessness, loss of sense of purpose. Right. Like feeling like is my job actually doing anything.
Josh Klapperick:
Yeah, that's a very unique situation that social workers end up finding themselves in. And it brings me to something that you wrote about in your articles, which is the concept of street level bureaucrats. Can you kind of go into that concept?
Pari Thibodeau:
Yeah, absolutely. And I can offer more examples that kind of paint the picture of moral injury when I talk about street level bureaucracy. So street level bureaucracy is a theory created by Dr. Michael Lipsky, who really painted the picture of public service workers being these bureaucrats or enforcers of public policy. Right. And so when a policy is created on a macro level, there is information that is shared about, let's say, how Medicaid works. Medicaid is a pretty rigorous policy. And so there's not a lot of bending of the rules with Medicaid because they have gone down to a lot of the details. Right. But maybe who can get coverage or the income requirements don't actually fit the actual needs of the individual. So let's say someone owns a house and they're going into long term care. Their long term care setting actually becomes their permanent resident. And you can't have two permanent residences. So you do have to then get rid of your home, which is an asset, and you lose income or assets. Right. So it kind of puts people in these like choice positions. How it ties back to street level bureaucracy is like maybe Medicaid isn't the best example, but in other situations where we as social workers are enforcing some of these policies. So let's say like the Social Security office, let's say they're open from 8 to 5. Right. And you're going in and you're going in to get something recertified for your disability benefits. And let's say it's 505. Technically I don't have to see the person waiting in line even though they've been waiting for three hours. But do I bend the rule and do I see that person to make sure that they get benefits recertified so they don't have a gap in income? Right. Like some of those things. And so we can be the enforcer on different policies, whether it's from the government down or even from the institution. Hey, typically we don't as a clinic, let's say this is hypothetical. We typically don't schedule something in the evening, 7:00pm Right. Like, but because of your unique case, I'm going to make sure you get services today because of your unique job. Because. Right. Like, and so it actually because we're humans caring for humans, there's always discretion and that's what street level bureaucracy says. Right. A policy is not a person, it's a creative policy that often isn't in human form or best like applied. Right. Like, because all people are different, all needs are different. And so there's not a one size fit all policy that usually is effective. And there are bends that need to happen usually in order to best fit the policy to the person or situation you're serving. But then we as people have, you know, subconscious biases that come up. So who do we decide to flex that for? And that's a part of it.
Josh Klapperick:
That is all of that internal mental math that we don't think about until we're kind of confronted with this outside perspective. And like you said, it's like we have our policies that we can bend, but then when it comes to things like Medicaid and working in healthcare systems, there's these hard and fast rules of cutoffs. You mentioned assets for people receiving Medicaid. Well, that comes into Social Security and all of those other like rolling things. So how would you differentiate between something like moral injury and something like burnout, which you brought up and I know is a buzzword in the social work community because people say burnout and then self care and it feels like we're talking about two actually very different concepts.
Pari Thibodeau:
Yes. I have so much to say about this. I think burnout is a real experience. Right. And I think it's something that people can relate to. You know, I hear new parents all the Time talking about, I feel so burnt out. Right. It's burnout is, you know, divided into three main constructs. Right. So it's divided into emotional exhaustion, which is kind of the main domain. When people think about burnout, like, I am so emotionally exhausted. Then there's depersonalization, where you kind of become a little numb and disconnected from what you're experiencing. And then there's low personal accomplishment of when you feel burned out. You actually don't feel the sense of fulfillment or accomplishment in the work you're doing. You feel like there's high workload, usually low resourcing, not enough time in the day to get the work done. You're repeatedly doing something, you become kind of numb to it, and then you also don't feel fulfilled. So that's the sense of burnout. It's a real, real experience. I think there are precursors to getting burnt out. And I think that's where the research is actually not as well versed or helpful in knowing what the causes are. And I know in research it's really hard to identify a cause. Right. And so that's where I am really positioning more of moral injury because I think moral injury is a real experience in itself. But I think that moral injury, my hypothesis is more so leads to burnout. I've done a systematic review on the different outcomes of workforce well-being and looking at their associations, and there are a lot of correlations and associations with moral injury and burnout. So, we know they're related. We don't know in what direction or what causes what. But I think that the experience of moral injury, where you experience like a fracture or a moral wound, that kind of like ouch feeling or that didn't feel so good, if you experience that repeatedly and then it turns into more of a continuous experience of distress or moral distress at work, I think that can then perpetuate burnout. Right. Like, I think that when you're repeatedly injured by your workplace or by the work that you're doing, then you can feel emotionally exhausted, lose that sense of purpose, feel, become disconnected. And moral injury is really like this internal turmoil experience of like, what am I doing? Because it's not aligning with what I believe in. Right. And burnout is more of an overall exhaustion, not that deeper moral questioning that happens. Does that feel helpful?
Josh Klapperick:
Yeah, it seems like moral injury is something that can lead to burnout, but they are not one in the same. You also mentioned moral distress. What is the difference between that and moral injury?
Pari Thibodeau:
Absolutely. So moral distress has been a concept that's been around for a long time and it really is rooted from the nursing workforce and research. And it's an experience in sure, that's really described by knowing the ethical thing to that you could do, but not being able to do it because of internal or external constraints for some reason. So moral distress, and there's a lot of debate in the literature actually of is what healthcare workers experience actually moral distress. Right. Not moral injury. Because moral injury, on the other hand, is rooted in the military population. And the definition of moral injury really stems from a very severe, high stakes situation. And so they're talking life and death. Right. And so all of this when I started doing my research and questioning of like, can healthcare workers or specifically social workers experience moral injury? I did get a lot of pushback of like, well, they're not necessarily dealing with life and death, but as you and I know, we actually are. Mental health is something that people die by. And so while there might not be direct combat, and I don't want to discredit military moral injury, that is a real unique experience that's not the same as healthcare moral injury. But our patients do die, right? Mental health does kill people. And so we are talking about high stakes situations, especially when we're talking beyond mental health, but as health, holistically people die and we are talking about that life and death and access to care. Right. And so there are these social determinants of health factors that impact people's health and lives. And so I think that's where I kind of root myself in actually, like we are talking about life here. And so moral injury is a real experience. Now, moral injury, the way I see it, again debate in the literature and by researchers is that it's an experience in which there's a violation that actually occurred. Distress can be the pressure that continually builds over time. And sometimes there's an injury that occurs, but it's more of a prolonged experience. So I imagine like moral distress as a, like timeline and injury as like different time points on the timeline that can happen time and time and time again. But moral injury, you're able to say that's what happened in that specific experience. Again, some people will talk about it in the other direction and I think it's just about framing and language that we're using. But I think they are two different but very closely related experiences that are entangled.
Josh Klapperick:
Yeah. And the comparison of, well, I guess the focus on military versus everybody else reminds me a lot of the way that people have viewed trauma throughout the years where it's like military PTSD was the introduction and that was like, if you don't have that, then you don't have trauma. And the definition has slowly moved across and it seems like you've seen a similar start to understand you with moral injury where it was that and then it's like, well there are versions of this, like you said, people still there's life and death. So that comparison is, I feel, a lot more apt.
Producer:
This episode of Social Work Talks is brought to you by the University of Central Florida. Built for those who don't wait for permission to change the world, the fully online Master of Social Work at UCF is a powerful next step to advance your career and make a greater impact. Offering hands on field experience and internship connections. The degree is accredited by the Council on Social Work Education and available as a 3 year track for 16 months if you earned a BSW in the last 6 years. So, join UCF in daring to invent what's next for your career, your field and beyond. Visit ucf (dot) edu (forward slash) online
Josh Klapperick:
You've mentioned healthcare workers. Are there other social workers or people you found in your research that are likely to experience moral injury whether it's official or not or arguable or...
Pari Thibodeau:
Yeah, so I actually get -- my research itself is centered on healthcare social workers. So it's the intersection of both social work and healthcare. But I think that actually in my next studies I wanna focus on behavioral health clinicians, right? Altogether, not just social workers, but the umbrella of all of us. And especially because we experience a lot of, I would say secondary trauma. And I think that the like you mentioned the relation and the thread of trauma starting in the military population and then actually becoming more of a general experience that a lot of people relate to and seeing clinical symptoms for. I think moral injury is following that in a lot of ways. And so I even wonder, not even just like social workers, but anyone. That's my next question is like can anyone feel moral injury? Does it have to be a work related experience? Right. Because right now we're examining it in the workplace and right now while I there's a focus on, you know, healthcare population and especially because of COVID right? Like when I started this research, my research on it in 2019 and then Covid happened three months later or so and so there was this huge impetus for focusing on the healthcare workforce, right? And then there's this like secondary pandemic of mental health crisis right after and so then there's the focus on the behavioral health clinicians. But there are other People I think about, I think about the invisible healthcare workforce, I think about housekeeping, I think about the people who work in the kitchen, I think about people who work in the lab, you know, the pharmacists who maybe don't get the frontline recognition. I think about the occupational physical therapists, there are several other people who keep a healthcare system operating. And then outside of healthcare, I think about teachers, I think about education and child welfare workers and thinking about the people who are in this, like their unique sandwiched predicament of policy and people and how do they make it work. And we talk all about, right, curriculum and values and beliefs and what are we teaching our future generations. And I think that puts teachers in that street level bureaucracy position to often be at risk of experiencing moral injury. So I think that there are plenty of people in the workforce. And then I think actually on a personal level this might be a bit off topic, but it's related, I think is, is experiencing like global distress actually a type of moral injury? And specifically I'm thinking about like when there's oppression, when there's racism, when there's sexism. And I never think that moral injury should replace those terms, think oppression is oppression and we should call it what it is. But I think that is a moral injury, actually an experience that happens as a byproduct or result. Right. Or similarly, is moral injury in our general lives more like secondary traumatic experiences or secondary traumatic stress? Right. Like maybe something's not directly happening to us right now, but we're witnessing something so unjust that's bringing up the sense of powerlessness, helplessness and questioning of purpose. What am I doing? Right. And I see that with political administration, with the ice rates, with overturn of Roe v. Wade, I see that with war and violence and a lot of, maybe it's not impacting our general day to day bubble, but it does impact us and obviously it does impact different people with different identities in different ways more directly versus the secondary lens on it. So I have a lot of questions there of like, do we all experience some type of moral transgression or hurt in our personal lives when things seem unjust? And is that a way that we need to pay attention to our well-being as people?
Josh Klapperick:
Yeah, it immediately made me think of the concept of vicarious trauma. And we focus on once again the healthcare workers and behavioral health workers who are staring at that every day. But in our modern age where you have all the trauma directly onto your phone, where does the line get drawn because you're staring at it either way, just because it's not in a workforce setting does not mean that there's not like a societal push to be aware of these atrocities that are occurring. And once again, if you're staring at that trauma, what does that look like?
Pari Thibodeau:
Absolutely. I think the technology aspect is huge, right? Like, I mean, I love advancement in science in general and technology faults under that umbrella. So on one hand there's like a moral alignment, but then there's also so much moral questioning and values questioning of like, what am I looking at? Or I'm doom scrolling. Right. We all know what that is. And actually I feel worse, I feel a little depressed, I feel actually a little more anxious right when I'm getting off my phone, getting off Instagram or other things. Right. And so I think with advances in technology, we need to have advances in mental health. And I think that we can't leave one without the other. And that's why I think social workers are even more important as we advance right into this like, technological future that's like involves AI and all of these things. I think our mental health treatment needs to advance with it too.
Josh Klapperick:
I couldn't agree more. Speaking of which, I guess treatment for moral injury, what does that look like presently? Where do you see it going?
Pari Thibodeau:
Yeah. So moral injury, I'll place the emphasis on while it's a deeply personal experience because we all have different moral compasses, right. That are uniquely catered to ourselves. It's actually an experience that results from systems fractures and gaps that then we're not able to bridge or band aid. Right. So I think moral injury is personally impactful. But the biggest, most important intervention I think is actually a macro level change or even a mezzo level change. Right? Like, hey, my patient keeps coming and saying that our building is really hard to access. Like, are we attaching a map every time we're sending them information about an appointment? Are we telling them where they can park? And you know, things like that. Like, are we, are there actually like institutional level changes that are not that big that we can actually bridge some of the harm of accessibility obstacles? So I think there's some of those things that exist. So I think it's actually like when there's a bad policy, can we create a better one? Right. So that's like I think the most foundational thing to prevent moral injury moving forward when someone has already experienced moral injury. I think there are several levels of things that we need to think about. So there is current, not, I would say well researched, but current practice of using trauma based treatment for moral injury. Because moral injury is a concept that is rooted in the trauma experience as well. Because you see something that's violating or harmful or right, like leads to a negative outcome. And so that experience I think does make sense to have some individual therapy, right? Like do, let's do some trauma treatment. There's also evidence for acceptance and commitment therapy being helpful in kind of like accepting what's within our control and what's out of our control and processing the experience as well. So both of those individual level therapeutic experiences have started to be trialed and some people have found it helpful. There's not a ton of evidence there. And so I think there needs to be more research on that. And so I'm not saying either way it's the best practice or not. But what I think with the nature of moral injury is this like questioning of your purpose and your role and feeling helpless. It can be really isolating and lonely to experience that. And so I think there's actually a nature of moral injury treatment that needs to be rooted in more group based intervention. And a lot of like in the healthcare settings, a lot of departments do like what we've called like moral rounds where you have like a debriefing session and different institutions call it different things where you debrief like what went well, what was hard, is there any unresolved grief or you know, questions that need to be discussed as a team? The research shows that like that is helpful. What I hear narratively from people is that sometimes that turns into a complaint session which makes them feel even more helpless because everyone's, it's collective helplessness. And so I think that there needs to be a pillar of that that is solutions focused even on the smallest level to restore power, to be like, this is what went wrong. What can we do next time? What is needed in the future? Even if it's case by case in the future or if it's a policy, right. That can be changed. And so I think having time to process. But then there needs to be a so what? There needs to be an actionable so what? And so I think that's part of an intervention. And then I've kind of like circling back to what you had mentioned about self care earlier and how self care burnout have become these buzzwords, especially in social work. Right. Something that stands out to me is that actually in 2021 with the new code of ethics from NASW, there's an explicit call for self care. And so how it's actually like an ethical thing. To care for your professional well-being and to take care of yourself so you can be a good social worker. I do firmly believe in that. But my reaction over the years of processing and teaching my students, whenever I bring up the self care class, I get a wave of virals of like, here we go again. Another professor telling me that I should take care of myself. But how can I take care of myself when I feel like the. It's so out of my control. Right. And so I think I really believe that social work is a profession rooted on relationships and on community and on being together. And then you throw the word self care in there, which actually feels like a moral opposition to the community and collectivism of social work. And so I wonder what collective care actually looks like and how do we teach that Right. For interventions like how do we actually process together and create solutions together? I do believe we as individuals do need to take care of ourselves, but I don't know if that's the curriculum that needs to be pushed. Right. I think we need to brainstorm together how can we do this together? Right. I feel like that feels more aligned for the profession of social work is collective care. And so thinking about, does that look like group therapy for moral injury? Does that look like advocacy work? I'm not really sure what, but I hope in my research agenda to actually in my next step do some like interviews with social workers and behavioral health clinicians to imagine what a solution could look like and then test an intervention on it. Um, that was long winded, but I think that it's all relevant.
Josh Klapperick:
No, it's a really good insight because I mean, my question inherently had a flaw because I was asking how do you individually address something that we have discussed as being a societal, systemic, mezzo, macro level breakdown? You can't micro affect a macro issue. And I think it kind of relates back to what you said about that self care eye roll. It's like, it doesn't stop me from watching people not being able to eat because I started doing yoga. It kind of comes with that same thing of like, you're depressed. Have you tried taking a walk where it's just like neat, wow, groundbreaking kind of a thing. So you can't kind of like feel better about something that you're seeing as a systemic failing of the world. So you need that bigger picture intervention. And oddly enough, it seems like you have found yourself in a wonderful role where you can kind of take that micro thing and be like, that's a yikes, breakdown of the system. What can I look at for that mezzo, macro level intervention that might. To address this micro issue that I'm seeing.
Pari Thibodeau:
Yes, absolutely. Yeah. I think that my role is, you know, a really privileged position to be able to do both. Right. Like, because when I see something in my patients that feels extremely helpless, I can resource, I can consult, I can brainstorm solutions. I can actually lean on peers within social work or outside of social work and say, hey, how can we make this better? Right. And advancing mental health is part of that is like doing it together. Right. Not alone. And I think that social work has always fundamentally been that way. But I think that we do need to update the language around self care and especially academically. Like, what are we teaching to our students about caring for themselves? Because I think that they probably get enough about self care from TikTok, you know. So I think like, actually what do we talk about instead? Right. Like, I think that we can talk about a lot more and have a lot more impact. And I find, at least in the students I've taught is when I acknowledge a name that some of this is out of their control. It is actually more liberating than saying you need to go take a bubble bath or take a walk or. Right. Like any of those things. And it doesn't mean it frees them from responsibility, but it frees them from the pressure of when the world is on fire. I can do something about it when I take care of myself. And that will change how I feel because that won't change that larger feeling of helplessness. Does it make you at a better place to then do something about it? Sure. But I think there needs to be more acknowledgement and conversation about the different driving factors that are impacting our wellbeing and not just the one thread of are we taking care of ourselves?
Josh Klapperick:
Yeah. And I think that is the interesting difference between like moral injury versus burnout. Is burnout always felt like a like victim blaming where it's like you as a provider are not emotionally strong enough or whatever to be managing these. So go take care of yourself so that you can continue to do this when you are seeing these systemic breakdowns. And I'm not going to like, you can't teach somebody to budget when they don't have enough money. And that is kind of like you can't yoga your way out of having to tell somebody that sucks. Sorry, you can't eat every day.
Pari Thibodeau:
Yes, exactly. Do it. It's just like, it's actually just not related. Right. Like, and I think sometimes we stretch the relation. I do believe in taking care of ourselves in that like mind, body, connection. All of that is great. Like I do believe in it, but I think we're at a place where we need to advance further and that our values are clear, that it is collective. It's not an individual effort. And so what are we dreaming up of as a better solution to make people feel better in doing the work? Because now more than ever we need social workers and the career has high turnover, high bad outcomes related to the work because of how distressing it is. But I think if we talked about what the actual distress was and how to actually acknowledge those pain points and create change and care for each other in that, I think people will stay longer and we need them. And we need them too.
Josh Klapperick:
Completely agree. I think there's just a certain validity that comes to experience when there's something like moral injury or moral distress being discussed versus burnout. Because one is like, okay, no, you're seeing the cracks in our society that leave people falling through versus you just can't handle this. You can't tough it out. And that is, I guess, where do you see the research and information about moral injury going as it progresses? Since it seems like it's pretty new to start expanding it to outside of the military in general?
Pari Thibodeau:
Yeah, I have several dreams of where I want it to go and I know I can't do it all. So I'm always looking for collaborators and ideas to, you know, I think all of us who are interested in it should move the agenda forward. Right. It's not. Again, not a one person job here, but I think that I'm really curious about treatment at this point. I think we have a clear, clear enough definition of what it feels like to be morally injured. But the. So what, what do we do about it? How do we like treat people who are morally injured? Right. I think that I would love to see clear evidence on that of what works. Right, like what works in making people heal from moral injury. And of course they want the prevention side of it as well. But I do think treatment is real because people are actually experiencing high, pretty high levels of moral injury. So I think treatment, intervention is really where I hope to go next. And then I would love to kind of study the experience of moral injury in parallel to that secondary traumatic stress experience. And I've done a little bit of studying on this. I did a secondary data analysis of some survey data that I collected a few years ago. And I compared trauma and moral injury symptomology. And what we really found is that there's an overlap between secondary traumatic stress. And so I would love to like replicate or do more intentional research because again that was the secondary data analysis. And so I would love to do more intentional primary data collection on what are the overlaps like in these experiences? Again, they're not one in the same experience. But if someone is experiencing moral injury by witnessing something happening, not that it directly happened to them or it's something that they had to do, but maybe you saw a supervisor do something that violated your morals or a colleague or maybe a trainee, right? Like do something differently than you would do, it still impacts you. And what we've learned about secondary traumatic stress is it doesn't really matter if it's PTSD or secondary traumatic stress. You still have the symptoms of PTSD and you still, the treatment is still PTSD treatment. Right? Like it's still trauma treatment. And so it doesn't matter what the source is for the treatment to be effective, but it's helpful to differentiate it what happened into who and what the power rules are. And so I think it would be helpful to understand similarly in the general population outside of the workforce, are people experiencing a semblance of moral injury maybe specifically related to the political infrastructure and global situation right now too? So there would have to be some more balance on my research because I know it's not pie in the sky, but I'd be curious what people describe moral injury as outside of the workplace as well.
Josh Klapperick:
It going to be fascinating to watch it because like you said, there's the vicarious trauma part of it and it is something that as we've talked about, it's happening in civilian populations all of the time. So where do we start drawing that line of like no, this is a workplace moral injury versus the, this is impacted by the societal workplace injury that we are all witnessing essentially being forced into by the world in which we live. So it, it feels like that line is a little bit blurrier. Whether it's something that can just occur in the workplace versus outside of it. But finding the way to navigate that along with like systems of oppression without throwing the baby out with the bathwater seems like, like you said, pie in the sky. And it starts to get really complicated as we dig into something new.
Pari Thibodeau:
Yeah, absolutely. And I think that the experience of moral injury or a lot of like adverse well-being or mental health are best told by people. Right. And so that data collection is a unique and long process. Right. This is where I say my research is a marathon. Right. Because if you're going to do good research. Like when you want to study a phenomenon or experience, you engage in that qualitative storytelling and data collection. And that takes time because it's, it's so valuable. So you can't throw a scale or an instrument at the situation and be like, hey, what are we measuring? That storytelling piece is crucial to the data in the representation of what's actually happening. And so I think it takes time and has to, you know, there's so many bounds and important variables to consider in research as well. So that's my hope one day to get to even like a drop in the bucket of exploring moral injury as a concept outside of the workplace. And before we do that, I think we have to have some trial interventions so we know when we're finding something, how we can offer direction to people.
Josh Klapperick:
Yeah. Because being able to recognize it is awesome. But essentially we need something to give people other than a thumbs up after we've confirmed that they are experiencing that.
Pari Thibodeau:
Absolutely. Yeah. I give them a sense of hope.
Josh Klapperick:
Yeah. And a direction for, hey, I know it's challenging and all of this, but ta da. Rather than once again finding another version of go do yoga or self care for folks.
Pari Thibodeau:
Yeah, exactly.
Josh Klapperick:
Awesome. Well, any final thoughts, things we've skipped over that you wanted to make sure we touched on?
Pari Thibodeau:
I don't think so. I think it's a really interesting topic. Obviously, I'm biased because it's my area of research, but. But you know, I actually see it in my research world, obviously with my research participants, but I hear my patients talk about it a lot and some of them work in healthcare and some of them don't. And whether they're using explicit words of moral injury or just describing some of these powerless, helpless feelings, I think it's relevant. And centering what we believe in is really important to us as humanity. Right. And it's a guide of everything we do. And so I think having these metrics to name when we're feeling injured on those fronts is important. But yeah, I'm excited. I hope the research continues to move forward and hopefully we can have some evidence based treatments on it.
Josh Klapperick:
Well, I can say as a former direct practice person, reading your qualitative studies and just hearing quotes that could have been directly out of my mouth of the struggle of doing that dance is, you're right. That that has a lot more impact than seeing like, oh, 7.8 on this scale that we measured found it was rough. It's a lot more healing to be like, hey, somebody's seen something that I'M seeing, even if there's not a ta da wave, a magic wand resolution.
Pari Thibodeau:
Yes, absolutely. Yeah, that. And again, that collective experience of I'm not the only one experiencing this is validating.
Josh Klapperick:
And especially in, like we said, if we're going to expand it to the world at large, we're all staring at it. So just having that collective communication which once again, technology, it's, it allows us to have these wonderful conversations states apart, but it also means that we can have conversations and not have that connection. So finding that middle ground seems like a worthy cause.
Pari Thibodeau:
Absolutely.
Josh Klapperick:
Well, thank you for joining me, Pari, and it was wonderful chatting with you. Is there anything you want to shout out or point folks to that we can add to the show Notes?
Pari Thibodeau:
I'm happy to share a link to that article. Right. The qualitative article. If people wanted to read that narrative experience or any additional studies, we're happy to share some of those data points so people can start reading the literature qualitatively and quantitatively. I think that's a great thing to include.
Josh Klapperick:
Sounds perfect. We'll get that added and otherwise, thank you for joining us.
Pari Thibodeau:
Of course. Thanks, Josh.
Quotes:
1. "Moral injury is a violation of morals by yourself or someone in power, leading to negative outcomes. It challenges your sense of purpose."
2. "Healthcare workers often face moral injury when policies force them to act against their values. It's a systemic issue, not a personal failure."
3. "Moral distress occurs when you know the right thing to do but can't act due to constraints. It's a prolonged internal struggle."
4. "Burnout is emotional exhaustion, depersonalization, and low personal accomplishment. It's a symptom, not the root cause."
5. "Street-level bureaucrats are enforcers of public policy, often caught between policy and people, leading to moral injury."
6. "Self-care alone can't fix systemic issues. We need collective care to address moral injury and burnout effectively."
7. "Technology advances mental health challenges. We must advance mental health treatment alongside technological progress."
8. "Moral injury treatment needs a macro-level change. Better policies can prevent moral injury, not just individual therapy."
9. "Collective care aligns with social work values. We should focus on community solutions, not just individual self-care."
10. "Moral injury research should explore treatment and prevention. Understanding overlaps with trauma can guide effective interventions."