Preventing Psychological and Moral Injury in Child Welfare
(Originally published August 2012)
Casework in child welfare is a dangerous occupation, obviously not as dangerous as military service in a combat zone or police work, but nevertheless an occupation with definite risks. Most experienced caseworkers and supervisors (and occasionally their families) have been threatened by angry parents. When I was a regional administrator in Washington State (1997-2004), I conducted a survey of staff in the region regarding personal safety issues. Approximately, three quarters of line staff and supervisors reported having been on the receiving
end of physical threats, and about 5% of respondents indicated that they had been assaulted (mostly minor assaults) during their careers. Several years ago, a caseworker in eastern Washington was attacked and severely injured by an angry father with a machete before a sheriff’s deputy shot and killed the man. It only takes a single incident of this type to convince child welfare practitioners and managers that they may be occasionally risking their lives, and that some (but not all) of these risks are preventable.
Caseworkers, supervisors and managers are also aware of other risks that occur in organizational settings with greater frequency than serious physical assaults. High profile child deaths sometimes result in furious public outcry and intense pressures to fire whomever was involved in making case decisions and sometimes agency leaders as well. There have been cases in Washington and other states which have led to public vilification of caseworkers and managers in the media, as well as demands by legislators that someone be held accountable, i.e., fired or demoted. During recent years, there have been a number of high profile cases in other states that have led to criminal prosecutions of caseworkers and supervisors, sometimes for fraudulent case recording but (occasionally) also for failure to comply with policy requirements such as visiting children and families within specific time frames. It is a reality that top managers in these
situations sometimes sacrifice practitioners and middle managers to save themselves and quiet a media firestorm. Again, it only takes a few incidents of this type to make a lasting impression on employees at all levels in public child welfare agencies.
In addition to these risks, there are also moral dangers associated with the exercise of power over the lives of relatively powerless children and parents. Incompetence and abuse of power occur to some degree in all organizations, but when agency actions or inaction can place children in mortal danger, or lead to unnecessary and unjustified disruption of families these risks are magnified.
I would be surprised if there is anyone with a decade or more experience as a caseworker or supervisor in child welfare who does not regret some past case decisions. While there are other risks to the overall health and mental health of veteran practitioners, the main points I want to make are the following: (a) public child welfare is a dangerous occupation and (b) policymakers and managers have an ethical obligation to organize the work and support staff in a way that prevents or reduces the physical, psychological and moral injury of employees.
The most insightful and eloquent book I’ve read about the ethical duties of organizations whose work puts employees in danger is Odysseus in America: Combat Trauma And The Trials of Homecoming (2002) by Jonathan Shay, a psychiatrist who previously wrote the classic, Achilles in Vietnam. Shay has taken themes from Homer’s The Iliad and The Odyssey to illuminate the effects of war, especially the Vietnam War, on soldiers in combat and during their return to civilian life. What Shay has to say about preventing psychological and moral injury in combat applies equally to child welfare. Every policymaker and child welfare manager whose actions affect the lives of hundreds or thousands of employees should read Odysseus in America.
According to Shay, the main factors that prevent psychological and moral injury of soldiers in combat are the social cohesion of units, tough and realistic training and leadership that engenders trust. Shay refers to these factors as “strength multipliers”, that is, small numbers of cohesive well trained military units led by trusted leaders are far more effective than 2-3 times as many units weakened by practices such as individual deployments (and replacement) and inadequate training and leadership.
Shay writes that “During the 1980s the U.S. Army instituted a program called COHORT, an acronym for “Cohesion, Operational Readiness, Training” that kept soldiers together in their squads, platoons, companies, from the beginning of recruit training, right through to the end of their first term of enlistment. … Before COHORT, recruits would go through Basic Training with one group of recruits, then – shuffle the deck – with another group through Advanced Infantry Training – then shuffle again – assigned as an individual to an operational unit. In a three- year first term of enlistment, the average peacetime U.S. Army soldier made and broke the small-unit face-to-face social bonds five times! In peacetime this leads to low-skill units, enormous waste, rampant dissatisfaction, and the creation of the bored, resistant, negativistic enlisted man stereotype. In war, it means that a soldier arrives in a battle zone with strangers. In Vietnam, this was the overwhelmingly predominant experience …”
In child welfare agencies, newly hired caseworkers from many units and offices are typically given basic training in centralized locations, advanced training with different peers locally or regionally, and then assigned to units that may replace all or most of their members every two to three years. In addition, some large offices are given to frequent restructuring of units and responsibilities that leads to a further shuffling of unit membership. These practices are rarely discussed, much less questioned, within agencies because they seem inevitable given turnover rates and the needs of states’ training programs to operate efficiently. Nevertheless, child welfare units vary greatly in stability of membership, degree of social cohesion, for example the extent to which unit members interact socially and develop shared ideas about practice and, most importantly, in expertise. In child welfare, as in the military, units and offices with high turnover rates (one third to one half per year) have difficulty transmitting basic skills to new caseworkers, and the achievement of an advanced level of practice is virtually impossible in units with turnover rates of this magnitude.
Furthermore, Shay asserts that “The human brain codes social recognition, support, and attachment as physical safety.” Cohesion, he maintains, “increases the ability to overcome fear (we call that courage) and reduces fear.” One of the reasons that unit supervisors in child welfare agencies are so important is that their day in - day out actions have a powerful effect on unit cohesion. When supervisors act consciously to increase their units’ cohesion, caseworkers and the supervisor interact frequently regarding both the collective responsibilities of the unit and ideas for improving practice. Supervisors can prevent factions developing or ensure that they occur. Supervisors can prevent scapegoating of unit members or encourage it through their verbal and non-verbal behavior. Supervisors, like managers at all levels, can encourage initiative or discourage it.
I worked in public child welfare agencies for over 30 years in two states, and the best experience I had during my career was working in and then supervising a high performing veteran unit in which all unit members exercised leadership and felt socially accepted and valued. There is no substitute for this experience in maintaining morale in difficult conditions, and agency managers who undermine its possibility are doing their staff a disservice.
Shay comments that in the wake of the Vietnam War, the U.S. military reformed its training programs. He writes, “The most visible legacy of these reforms is the combat training centers with resident opposing forces (OPFOR) units … The visiting units are typically thoroughly whipped by the highly skilled – but low tech equipped – opposing forces (OPFORS).” How and why does this occur? Shay quotes military experts who assert that OPFORS units prevail because of the training they have received.
In an exceptional article on military training, Ralph Chatham asserts that “In the late 1970s, the United States Army fostered a revolution in warfare training by institutionalizing group experiential learning with feedback.” In these exercises brigade sized units (3500 soldiers) are brought together on huge training battlefields. Chatham asserts that “The process is superbly effective, delivering in just weeks a measured order- of- magnitude increase in warfare proficiency…”
He goes on to say that “A certain kind of training (i.e., engagement simulation) can increase combat effectiveness … by factors of 5 to 30 in periods as short, in some cases, as a few weeks.” Chatham describes “a training revolution” in the military, a revolution “based on the discovery of the power of engagement simulation to change military performance.”
Chatham describes the modest or negligible effects of military training programs prior to the implementation of engagement simulation, a theme which recurs frequently in reviews of child welfare training programs. Developers of child welfare training programs continue to discuss how to ensure that participants in training acquire any measurable skills, one reason that adding follow up coaching to training programs has become common in some agencies during recent years.
Shay comments that “Excellent training engages the whole person: mind, body, emotions, character and spirit. It prepares for the demands and stresses of war and other situations with mortal stakes. [ my emphasis ]” Furthermore, it is worth repeating that military training that involves units, even very large units, has proven to be far more effective in preparing for combat than training individuals.
Chatham describes the U.S. Army’s use of After- Action-Reviews (AAR) following simulated combat as a major cultural shift. He writes “ The result of this institutionalization of the AAR process is a force that constantly challenges itself to improve …” The extent to which engagement simulation and AAR can be used in child welfare training programs is an open question that deserves careful consideration in agencies that need to become dramatically better at training new and experienced staff. Shay asserts that “competence is an ethical imperative in military service;” ditto in child welfare.
Shay summarizes a U.S. Army leadership program developed by a former Army Chief of Staff, Edward “Shy” Meyer during the period of military reform discussed above. Meyer referred to the following principles as “positive leadership”:
Make it safe to tell the truth.
Support subordinate leaders’ professional growth.
Trust them and work hard to assure their success.
Assign missions without prescribing the means to accomplish them.
Build their competence to assess situations and take initiative to develop adaptive solutions.
Mentor, rather than intimidate, subordinate leaders.
Refrain from meddling in their spheres of responsibility.
Require subordinate leaders to study their profession.
Take responsibility for setting mission and priorities, not assigning every task as “highest priority, to be done immediately.”
Listen to subordinate leaders’ feedback on budget and resources, supporting realistic time management.
Support self–maintenance, rather than defeating it.
Shay asserts that:
“The leadership culture that both protects the troops from psychological injury and makes them militarily effective is well understood: It is the constellation of leadership culture described above.” Shay goes on to say, “In combat, trust goes to the leaders who give critical obedience, not blind obedience, to their own bosses” because blind obedience to an irrational or illegal order gets the troops killed without purpose…”
Shay is at his most compelling in his discussion of the importance of the culture of truth telling. He states that “Consistent, reliable truth telling is only possible when power is deployed in such a way that it is safe to tell the truth. Only then do subordinates air their doubts and problems, tell bad news, own up to failures.” And in a comment that should reverberate in child welfare agencies which have a single minded focus on performance measures, he writes “Leadership truthfulness at all levels means eliminating perverse incentives to look good at the expense of being good.”
Shay emphasizes the importance of ethical leadership: “Nothing destroys trust in the chain of command so quickly as the leader’s exploitation of institutional power to coerce a private gain from subordinates, be it sexual, financial, or careerist,” with careerist motives being by far the most common reason for exploitation of subordinates, according to Shay. He comments that “everyone that learns of the violation of “what’s right” also suffers injury to the capacity for social trust.” He adds, “Everyone watches the trustworthiness of those who wield power above them; and this fishbowl factor is far reaching.”
Organizational cultures designed to protect employees in dangerous occupations from psychological and moral injury must operate in ways that produce trust, according to Shay. He writes, “Trust is the master concept that links cohesion, leadership, and training. In fact, they are the things that build trust, forming and strengthening character throughout a military career.” Shay proposes that “we make creation and preservation of trust across all ranks … as the “vision statement … with cohesion, leadership and training as its embodiment.”
No organization is likely to make such a commitment unless leaders understand that line staff, i.e., direct service providers, are not interchangeable parts who can be easily discarded or replaced; and that the health and wellbeing of these staff are crucial to the achievement of organizational mission.
Chatham, Ralph E., The 20th- Century Revolution in Military Training, Chapter 2 in Development of Professional Expertise: Toward Measurement of Expert Performance and Design of Optimal Learning Environments, edited by K. Anders Ericsson, Cambridge University Press, 2009.
Shay, Jonathan, Odysseus in America: Combat Trauma and the Trials of Homecoming, Scribner, 2002.