Creating a morally safe helping environment is probably more challenging today than it has ever been. The term “moral distress” describes situations where you know what the right thing to do is, but doing it is thwarted by constraints. Social service and mental health providers experience moral distress when they must act in a way that contradicts their personal beliefs and values. There is a sense of being morally responsible but unable to change what is happening . It has been shown that moral distress is a result of reactions originating in acting, or not acting, in ways that go against one’s conscience and moral beliefs.
Conversely, a morally safe environment is one where you are able to do your work with a sense of integrity because your sense of what is right is supported by the institution within which you work and the people who directly supervise you. Of course, what is right is likely to be perceived differently depending on who you are, your experience, and where you are in the hierarchy of the organization. So like the rest of what we describe as Sanctuary, discovering moral safety is a process that is constantly unfolding. It is an attempt to reduce the hypocrisy that is present, both explicitly and implicitly, in our social systems.
This is a fundamentally important quest for patients who are victims of abusive power because their internal systems of meaning are likely to have become confused and contradictory . Exposure to corruption can be contagious; exposure to abusive authority can create abusive behavior on the part of those who were once abused. Repetitive experience of injustice can make a person unable to act justly and more likely to seek revenge. So people who have been exposed to adversity, particularly at the hands of others, can only find a different kind of meaning and life purpose if they are exposed to environments that are different – not replicating – their earlier abuse. And people who have been exposed to adversity, injustice and trauma are likely to have a great deal of confusion about what is right and what is wrong, how people should be treated and should not be treated. As a result, their level of moral intelligence may be compromised and they require an environment within which other people are modeling a different way of relating to each other and the world around them.
A morally safe environment engages in an on-going struggle with the issues of honesty and integrity. Creating a morally safe environment means we must take a self-evaluative look at our therapeutic presumptions, our training, our rationalizations, and our fixed beliefs, as well as our practice. We must look at our own issues with authority and become willing to participate in, not just manage, the relational web that forms the structure of our workplaces. We are forced to ask ourselves, “What do we really believe in?” “What is it that we are actually doing, and what are we trying to achieve?” “Will the means get us to the desired ends?” “Do the means justify the ends?” “Do the activities we are prescribing lead to autonomy, connectedness, and empowerment or dependence, alienation and helplessness?”
These can be tough and embarrassing questions with answers that are, at times, noxious and difficult to swallow, particularly for managers who feel morally responsible for what happens in their organization. In an era of managed – some would say, mangled – care a morally safe environment demands that we be honest with our clients about our limitations, about our increasing inability to provide them with what we know they need, while continuing to offer them hope for the future and encouragement to keep on with the struggle towards recovery, even when they cannot get the support they deserve.
Similarly, our clients must confront the breaches in moral integrity that characterize the specific systems within which their normative behavior developed, be it their family, a religious organization, a cult, or an institution. This breach in moral integrity also relates to the fundamental reasons that people seek services in the first place, quite often because they are a clear and present danger to themselves or others. To be morally safe, we must honestly look at the ways in which our bureaucratic structures created for greater efficiency in handling large numbers of people, can inadvertently dehumanize the very people the organization is supposed to serve, because the greater the distance between actually living human contact, the easier it is to create policies and enforce procedures that cause people to suffer more not less. Additionally, we are all forced to look at the ways in which our culture reinforces the messages conveyed by the institutions within which we are socialized. This entails looking at the way our society – not just our organizations - is organized around unresolved traumatic experience and decide what we are going to do within this moral universe [1, 8-12].
- Bloom, S.L., Creating Sanctuary: Toward the Evolution of Sane Societies. 1997, New York: Routledge.
- Cox, S., B. Jones, and D. Collinson, Trust relations in high-reliability organizations. Risk Analysis, 2006. 26(5): p. 1123-1138.
- Haigh, R., The quintessence of a therapeutic environment: Five universal qualities, in Therapeutic Communities: Past, Present and Future, P. Campling and R. Haigh, Editors. 1999, Jessica Kingsley Publishers: London:. p. 246-257.
- Whitwell, J., Management issues in milieu therapy: Boundaries and parameters. herapeutic Communities: The International Journal for Therapeutic and Supportive Organizations, 1998. 19(2): p. 89-105.
- Campling, P. and R. Haigh, eds. Therapeutic Communities: Past, Present and Future. 1999, Jessica Kingsley: London.
- Austin, W., V. Bergum, and L. Goldberg, Unable to answer the call of our patients: mental health nurses' experience of moral distress. Nursing Inquiry (NURS INQUIRY), 2003 Sep; 10 (3): 177-83 (23 ref).
- Janoff-Bulman, R., Shattered assumptions: Towards a new psychology of trauma. 1992, New York: Free Press.
- Bloom, S.L., Neither liberty nor safety: The impact of trauma on individuals, institutions, and societies. Part III. Psychotherapy and Politics International, 2005. 3(2): p. 96-111.
- Bloom, S. and M. Reichert, Bearing Witness : Violence and Collective Responsibility. 1998, Binghamton NY: Haworth Press.
- Bloom, S.L., Neither liberty nor safety: The impact of trauma on individuals, institutions, and societies. Part IV. Psychotherapy and Politics International,2006 4(1): 4-23.
- Bloom, S.L., Neither Liberty Nor Safety: The Impact Of Fear On Individuals, Institutions, And Societies, Part I. Psychotherapy and Politics International, 2004. 2(2): p. 78-98.
- Bloom, S.L., Neither Liberty Nor Safety: The Impact Of Fear On Individuals, Institutions, And Societies, Part I I. Psychotherapy and Politics International, 2004. 2(3): p. 212-228.