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.

moral injury video pic 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 with 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.

The Sunday Scaries. Secondary Traumatic Stress in Public Defense.

It’s Sunday. So Monday is closing in on us.

When I first heard a public defender use the term Sunday Scaries, I didn’t need any further explanation. That feeling of bracing yourself for the next work week. That feeling of prep and motions I’d hoped to have finished already, but have not. That feeling of wishing I had better news to give clients about negotiations or investigations. The mountain of recordings that just came in and need reviewed.

When I have discussions with public defenders about what the Sunday Scaries actually feel like, we describe anxiety, sleeplessness, sadness, second guessing, emotional exhaustion, dreading work.

This work is just so very intrusive sometimes. It’s there all the time, imprinted on our minds and  bodies, reminders around every turn.

There’s a certain intersection I avoid, because driving through it, and past the flower memorial that has been continually refreshed there for a decade, causes my mind to revisit photos of a crash scene and child’s autopsy.

Every public defender I know has similar stories, but many of us fail to view these experiences through the lens of continually experiencing trauma at work.

Many of us learn about the impacts of trauma in an analytical way, through the preparation of our cases. We learn the importance of working with experts in PTSD or Adverse Childhood Experiences to understand and present the stories of the people we represent. We fail to turn this same insightful lens on ourselves, sometimes voicing the view that to do so would be unacceptably vulnerable, or even disloyal by taking our focus away from the traumatic experiences in the lives of the people we represent. Trauma impacts us, too, in ways we need to acknowledge and process if we are going to stay in this work.

There’s a case I think of often, and each time there is a dull ache in my hands and forearms. During the trial, as I questioned a child, I gripped the table behind me so tightly that eventually a weird, numb weight took over my hands and forearms. I loosened my grip and felt pins and needles in my hands. Jurors cried as the questions continued, about the night this child’s mother died on the other side of her bedroom wall. After a while, I felt the heavy, numb forearms again and realized that I was white knuckling the edge of the table again. The case had a good outcome, but every time I think of it my hands and forearms still ache.

Bessel van der Kolk, M.D, author of the beautiful book, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, explains that trauma results in a fundamental reorganization of the way the mind and body manage perceptions. Trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body. Apparently it even gets stuck in our forearms sometimes.

In addition to primary or direct experiences of traumatic events, we in public defense also experience secondary traumatic stress, which is the emotional duress that results when an individual hears about the firsthand trauma experiences of another person. This definition is from Figley’s Compassion Fatigue: Secondary Traumatic Stress Disorders from Treating the Traumatized. Everyone who works with and/or assists traumatized or distressed children, adults or families is at risk for secondary traumatic stress—including therapists, nurses, teachers, hospice workers, social workers, journalists, firefighters, physicians. STS is sometimes also called Compassion Fatigue, and we know from Linda Albert’s study of Wisconsin Public Defenders that public defenders are impacted (as described in this prior post).

A colleague had a case that we discussed constantly as he prepared for trial. At one point I listened to the recording of the wailing cries of the mother whose child had just drowned in the bathtub. Those sounds went into my mind and stayed there, where they still replay sometimes.

There are constant opportunities to experience primary and secondary trauma in public defense work, including: seeing a person you represent being taken into custody; seeing a person you represent being sentenced; seeing the pain and struggle of the family and community of the person you represent; watching your colleagues struggle and face abusive treatment by judges, prosecutors and others; viewing injury, autopsy and scene photos; scene visits; reviewing records of trauma; hearing stories of trauma; hearing testimony of violent events; dealing with prejudice and abuse within the criminal sentencing bureaucracy; seeing the reality of the jail conditions experienced by the people we represent.

The symptoms of secondary traumatic stress have a striking similarity to the Sunday Scaries: anxiety, hypervigilance, intrusive thoughts, chronic fatigue, sleeplessness, sadness, anger/irritability/impatience, poor concentration, second guessing, detachment, emotional exhaustion, fearfulness, shame, physical illness, lateness, absenteeism, difficulty sleeping, nightmares, stomachaches, headaches, strained relationships, disconnection from purpose, dreading work. Many of us experience some combination of these symptoms so frequently that we incorporate them into what we expect working in public defense to feel like.

Morning hike and meditation.

 Bessel Van der Kolk talks about recovery from trauma through mind-body connection and body focused practices like yoga and meditation. He emphasizes that human memory is a sensory experience, and movement practices can restore a sense of goodness and safety. In my own experience, yoga and meditation practices are particularly well suited for processing our constant intake of public defense trauma, and can help cultivate resilience in the face of feeling overwhelmed by these traumatic impacts. Dr. Van der Kolk also explores the benefits of writing and journaling.

Do you practice yoga or meditation? Do you write or keep a journal? Let us know in the comments how these practices help you sustain your public defense work, or other practices or approaches that you find helpful in response to the challenges of secondary traumatic stress.


Is Working in Public Defense Good for You?

Um, no. Obviously not.

I’m not trying to be a downer, but the research on this topic is not uplifting. In 2011, Linda Albert’s groundbreaking study of Wisconsin State Public Defenders examined “the effects of compassion fatigue—the cumulative physical, emotional, and psychological effects resulting from continual exposure to others’ traumatic experiences.” The study found significantly higher levels among public defenders than the general population of depression and post-traumatic stress disorder. 74.8% of attorneys described experiencing functional impairment, defined in the study as “the extent to which exposure to traumatic material interferes with functioning in work, social/leisure life and family/home life.” 34.7% of attorneys reported experiencing burnout, defined in the study as “job-induced physical, emotional or mental exhaustion combined with doubts about one’s competence and the value of one’s work.”

Those who conducted the Wisconsin study also saw what we see every day, that public defenders are dedicated and determined. They observed of public defenders: “It’s amazing what they do. They are handling the demands of the job, but not easily and not without it having an impact on their lives.”

The American Bar Association has issued a series of reports on lawyer well-being, including: Keeping Legal Minds Intact: Mitigating Compassion Fatigue Among Legal Professionals (2014), The Prevalence of Substance Use and Other Mental Health Concerns Among American Attorneys (2016 Ford Foundation Study for ABA), The Path to Lawyer Well-Being: Practical Recommendations for Positive Change. Report from the National Task Force on Lawyer Well-Being (ABA 2017), and Well-Being Toolkit For Lawyers and Legal Employers, (ABA 2018).

To put it bluntly, the legal profession is struggling with mental health concerns and substance use, especially alcohol. The statistics in the 2016 Ford Foundation Study are concerning:

2016 Ford Foundation Study of US Lawyers

21-36 % qualify as problem drinkers
28 % struggle with depression
23 % struggle with stress
19% struggle with anxiety

The ABA 2016 Ford Foundation Study describes a “parade of difficulties” that includes suicide, social alienation, work addiction, sleep deprivation, job dissatisfaction, a diversity crisis, and complaints of work-life conflict. Why do I think we need to have this conversation about well being early and often? According to this study, younger lawyers in the first ten years of practice experience the highest rates of problem drinking and depression.

This job takes a toll on us. By us I mean everyone who works in public defense— attorneys, investigators, social workers, paralegals, law office professionals, everyone.

One perpetually irritating aspect of this discussion is that, while the causes are often recognized as systemic, the proposed solutions are too quick to slide the responsibility for what to do about it over to the individual. For example, in its 2014 report Keeping Legal Minds Intact: Mitigating Compassion Fatigue Among Legal Professionals, the ABA lists these organizational contributions to compassion fatigue: heavy caseloads and long hours, inefficient administration, excessive paperwork, inadequate resources to meet the demands, and lack of supportive supervision. Even though these are organizational contributions, the majority of the suggestions for mitigating compassion fatigue focus on the individual: recognize the risks for yourself, find a way to debrief distressing material, work on self-awareness every day, take an inventory of how balanced your life is, evaluate your tension reducing behaviors, be intentional about protecting yourself. This will be the subject of future posts: the need to push for systemic organizational change and to find individual strategies to sustain ourselves in the meantime.

When I first became aware of these studies and statistics, I found them both daunting and reassuring. The daunting part is obvious. But right along with that was what a relief to know I’m not the only one. The fact that I think this job takes a toll on me isn’t just in my head.

Lizzy McLellan wrote a few months ago about Battling an Epidemic of Loneliness Among Lawyers (May 28, 2019). She described a sense of loneliness, isolation, and sadness that comes from feeling “I’m the only one who can’t handle it.” She wrote that loneliness and isolation are reasons “people are turning to all these coping mechanisms and ending their lives and having anxiety and depression.”

We suffer when our profession sees acknowledging this emotional toll as weakness. It’s my hope that this site and conversation might make this topic feel a little less isolating for some public defenders.

Also, at risk of revealing myself as an unreliable narrator, I believe it is possible to thrive in public defense. There are ways it can be good for you. Sitting here writing this at year 23, taking on new roles in training and handling capital cases as challenging and complex as I’ve ever seen, I feel as positive and energized as I ever have about public defense. This work can be incredibly difficult, and it can also be energizing and even transformative. We have opportunities to develop empathy and compassion that can transform our relationships with others, and with ourselves.

Please send or post your thoughts and comments to join this conversation. And take care of yourselves.

#besustained #publicdefensewellbeing #secondarytrauma #compassionfatigue

Why Launch Sustained? Why Write About Well-Being in Public Defense?

In 1991, I had a summer filled with aha, light-bulb, found-my-calling moments, when I worked as a student investigator at the Public Defender Service in Washington, DC. The first time I watched a young man being led into a courtroom in custody and a public defender fighting for his freedom, I connected with a sense of purpose. Even though I was deeply anxious about public speaking (still am), I had the crazy idea that maybe I was meant to do that thing.

I was filled with pride and anticipation when I joined the Alameda County Public Defender in Oakland, California, an office a few miles away from the Berkeley house I was born in.

eagle picThis photo, after one of my first misdemeanor trials, shows me holding the eagle art we posed with after an acquittal. The eagle is swooping down toward a mouse on the ground; the mouse is flipping off the eagle.  I couldn’t get enough. I missed weddings, family reunions and funerals for trials. I worked a lot. All. The. Time.

Seven years later, I slid into my cubicle desk, opened a document, and watched words appear on the screen that seemed typed by hands disconnected from the rest of me. I was surprised and confused to see my own resignation letter appearing in front of me.

I was 33 years old, seven years into a public defender career I thought I would stay in forever.  I had no job lined up, no idea how I’d pay the bills. It didn’t feel like a decision. It felt like I couldn’t stay there for five more minutes, like there was no oxygen left in the room. I fled the blur of motions, trials, midnight laundry, clients dying, vending machine lunches. Burnout.

I didn’t practice law for three years. I had this idea that doing moto pic.png“happy things” would make me happy, so I taught yoga and wrote for magazines and rode a motorcycle. When I wasn’t sufficiently brimming with happiness, I danced on rooftops in Cuba, ran a marathon and spent hours in my darkroom. The happiness quest made me somewhat happier until it didn’t. I felt separated from my own sense of purpose. After three years, I went back to being a public defender.

Since returning to public defense in 2007, I’ve explored how to do it differently. I think a lot about how to stay, how to develop strategies to re-charge my batteries and sustain this work.

At first, I kept this exploration to myself. Public defense is still a professions where tough it out, don’t complain, don’t show weakness culture prevails. When I occasionally whispered to colleagues, I actually burned out and left for several years, the response was not what I expected (awkward sidelong glances and people skittering away from me). It was an outpouring of similar stories. A comment became a conversation became a talk became a well-being workshop became a series of workshops that can’t begin to keep up with the demand. There seem to be many, many public defenders who are eager to have this discussion. How do we stay? We don’t want to leave but we are struggling. How do we sustain this work?

I have some ideas and so I created a site to continue the discussion. Please tell me what you think and send me your ideas if you’d like to contribute to this site.

And all you fierce freedom fighter public defenders out there, please take care of yourselves.

#besustained  #publicdefensewellbeing