I recently came across an article titled, "Reframing Clinician Distress: Moral Injury Not Burnout." Moral injury is a concept that refers to the psychological, social, and spiritual impact of challenging events on individuals who uphold strong values, such as providing quality care for patients, especially in high-pressure situations where they may have to compromise these values. Common symptoms of moral injury include feelings of guilt, shame, anger, and contempt towards a system that may prevent individuals from delivering proper care.

The concept of moral injury sheds light on many of the difficulties we currently face in our profession. As clinical social workers, an understanding of moral injury can help us to identify the root cause of our distress and burnout within a flawed system, rather than attributing it solely to individual shortcomings. This perspective allows us to recognize and address larger systemic issues at play. By acknowledging our role within the system, we can work towards implementing meaningful changes.

Whether we work in private practice, academia, or healthcare settings, it is important for all of us to understand the factors that contribute to moral injury and how the existing system perpetuates it. This understanding can guide us in advocating for systemic improvements that promote well-being for both clinicians and the individuals they serve.

Many types of mental health treatment include some form of exploring feelings.  In Neurodynamic Couples Therapy, exploring feelings is the pathway to metabolizing and integrating them into a cohesive sense of self and relationships and creating a bond of empathy and understanding between partners.

The term “woke” means to be aware. It is the opposite of slumber and suggests a person is consciously aware of their role, its influence on others, and the associated societal climate. It is an act of submission which recognizes the importance of the patient’s agency.  The term “woke” was first introduced in the 1940’s to emphasize the importance of being aware of social injustices (Ng, 2021). At the height of the racial tensions within the last ten years, the term was used in a pejorative nature to undermine another person’s stance on issues that he or she identified as worthy cause(s) to elevate. To be deliberate in addressing systemic issues that impact the underrepresented members of our communities as well as granting them the authority to narrate their stories clinicians must practice “staying woke.” Wokeness suggests an active pursuit of knowledge and consciousness. Wokeness is a deliberate practice of taking action to better inform a clinician’s practice. It requires introspective engagement, minimizing judgment to promote social change.

Couples have a nonconscious, intersubjective system between the two partners that has been existent and developing in complexity since they first met each other.  It has been well-established in recent years that this type of system gestates during childhood and becomes the template that dictates who we will be attracted to and commit to as a life partner.

I have written many times about the radical intersubjective stance that Neurodynamic Couples Therapy takes regarding the treatment of couple relationships.  In essence, we are treating what happens between the partners–not individual psychologies.  The theory holds that it takes two brains in each other’s presence to access the affective material that has been generating the couple’s conflicts in order to heal historical wounds.  The individual psychologies heal and change through the couple work.

Most of the time most of us therapists work as hard as we can to keep a treatment going, knowing that attempts to derail therapy have many meanings that can be explored and understood.  I know that I have always been extremely reluctant to “give up.”

Most therapists have had the experience of feeling that a treatment is being derailed and perhaps headed for failure.  Even when we are able to see it coming and try to redirect the treatment, it can be like attempting to turn a battleship around (as the saying goes).

September is Suicide Prevention month.  Suicide continues to be among the leading causes of death in the U.S.  This public health challenge affects various population groups ranging from youth to White men and Native Americans to Veterans.  According to the American Foundation for Suicide Prevention, 94% of adults believe that suicide can be prevented. When considering this and protective factors such as social support, relationships are an area to further explore.  A question is “how can we be more intentional to support meaningful social connectedness?” Social connectedness is recognized among the pillars of lifestyle health.  Being connected well has been researched through the quality of interactions, belonginess and longevity.  Social connection was recently discussed in relation to near-term suicidal ideation (Ammerman & Jacobucci, 2023).  Preliminary evidence suggested the need to assess for current social contact in conjunction with the risk for suicidal ideations.  This could facilitate timely interventions.

In previous blog posts, I have written about the importance of understanding a couple’s persistence in seeing one partner as the identified patient.  Quite often, couples will enter treatment with both partners having decided that there is something wrong with the other, and that they themselves are in fact “normal” or “innocent.”

A major goal of Neurodynamic Couples Therapy is to help partners complete the metabolizing of troublesome emotions, which they have already been nonconsciously attempting to accomplish through their conflicts.  Some forms of therapy purport that this metabolizing can be done nonverbally, but we believe that it takes the translation of right-brain experiences into words in order to adequately and fully create the understanding of self and the other that is necessary for genuine empathy.

As I was growing up, I remember one of the mantras that I heard from some of the adults in my world.  They would say one of the best approaches to difficult situations is encapsulated in the acronym KISS–Keep It Simple, (warning! pejorative word coming up) Stupid.  I found this to be quite helpful as I grew and developed.

The New Oxford American Dictionary defines resistance as “the refusal to accept or comply with something”; and “the ability not to be affected by something, especially adversely.”  Our training histories as therapists have unfortunately tended to focus more on the first definition.  I would like to challenge us to think more about the second one.

Brenda was a beautiful woman with long black hair who came for therapy and recounted her story: “Two months ago I had a double mastectomy. At that time, my husband left me for another woman. My daughter, who saw me through all this, is leaving next month for school in California. Now I have no one. Both my parents died in a car crash when I was 12. I went to live with my grandmother who died when I was 17. That’s when I got married. And now I have no one.” She stared straight ahead, lost in reverie. The image of her parents’ violent death, her mastectomies, and all her other losses were overwhelming.

As a private clinician, and Manager of the Social Work Department at the Valley Hospital, collectively we view our purpose as making a difference, making connections, making meaning and making a life- all of which entails breaking barriers on a daily basis. As social Workers, we are trained to help people address personal and systemic barriers to optimal living.  Social workers are tasked uniquely to assist patients in the most difficult psycho-social circumstances and guide patients families and medical providers with navigating medical care coordination and social service challenges in the midst of an unprecedented pandemic.  We must adapt to change manage stress and innovate.  We are employed to effect positive change with individuals, families, groups and entire communities. Social workers use their collective skills to establish policies that give more people to access community services.

In the previous blog post, I addressed the importance of using the present-day conflicts that couples bring to therapy to access historical wounds, traumas and losses.  But often couples don’t want to talk about their pasts.  They have usually come to deal with current conflicts–not their family histories.

Intersectionality refers to the interconnectedness of social categories such as race, gender and socioeconomic status.  It can enhance understanding an individual and the interplay among their identities.  For example, a person may identify as non-binary and self-report in an ethnic minority category.  In addition to these primary identities, there could be less salient ones such as religious or spiritual preferences and generational group.  Intersectionality was first coined in 1989 by Kimberlé Crenshaw, Columbia University law professor, to describe factors contributing to the social being of African American women.  In particular, the intersection of their race and gender was purported as a significant factor.  Intersectionality became widely applied over the years and has relevance when understanding systems and structures that impact vulnerable populations such as children and persons who are wrongfully criminalized.  Consider a child who experienced adverse events such as family violence and is also subjected to impoverished conditions.  Knowing them from these circumstances will offer insights for clearer visibility.

Couples come to see us to help them resolve their conflicts — not to create growth.  But if we stop at attempting to help them resolve their present-day conflicts without moving on to creating growth, we have cheated our clients out of at least half of the potential of couple treatment.

Just like public speaking or any other skill, I am realizing that conflict resolution is a skill worth mastering. As an Army officer, you are expected to lead, but in order to lead, you have to know how to manage conflict to accomplish the mission. The “mission” does not always mean going into battle or winning a war. Depending on your specialty, your unit, or work environment, the mission may be proving good health care, gathering intelligence information, maintaining and supplying units, etc. Whatever the mission is, conflict in the workspace can feel like you are going into a battlefield. Your heart starts to race, your temperature may increase, you become nervous. It is a similar physiological reaction to when a soldier is facing a threat. The big difference is that work conflict, for the most part, does not present a danger to us. However, our physiological reaction makes us feel like we are, thereby guiding our thoughts and behaviors, potentially leading to increased conflict. This is why it is so important to consult, use humor, and not personalize the situation to be in the best possible stance to manage workspace conflict.

In 2009, the South Carolina governor reportedly “disappeared” for a few days.  It was later discovered that he had been with his mistress in Argentina.  In one of his former wife’s interviews on a news talk show, she described their therapy together after his return.  She said that she could recall the moment in their treatment when she knew their marriage was over, as she began to realize that he was not going to take any responsibility for his part of the problems in their marriage.

Positive Psychology is the study of conditions and processes that contribute to the optimal functioning of people, groups, and institutions (Gabe & Haidt, 2005). Therapy builds on the client's positive experiences to improve their well being and to ascertain the role of their positive experiences. Clients begin to recognize they have the solutions to their problems; each moment and each situation is a moment of growth and learning. Our clients need to have hope in their situation and in the challenges they face.