MORAL INJURY

We don’t need another diagnosis

By: Chelsea Kavanaugh, MS, CHES ® and Christina Bott, MA

Chances are you’ve heard the term “moral injury” used in articles and discussions about firefighter wellness. What is moral injury?

Moral injury occurs when you face situations or respond to calls that violate your personal values and moral beliefs.

In talking with first responders including firefighters, certain themes have emerged as they express their thoughts about this topic. Similar to the cultural shift in acknowledging and talking more openly about the mental health and well-being of fire and EMS professionals, it seems that there are always new conditions and disorders to concern ourselves with.

Moral injury isn’t a new concept, and it’s not a mental health diagnosis. Even if you don’t consider yourself particularly spiritual or religious, you probably possess core beliefs about what’s right and wrong.

So if you do something or witness something that goes against what you believe to be right or ethical, your brain will try to process it logically and come to terms with what’s happened. You’ll feel a sense of moral distress until it’s resolved in your mind. And if you’re not able to resolve the distress caused by the conflict of what happened and what you feel should have happened, it can lead to moral injury.

Although moral injury and PTSD have similar features, PTSD is associated with your brain’s response to dangerous or life-threatening situations, while moral injury is linked to feelings that result from serious violations of your ethics, values, or moral beliefs. Moral injury gives a name to difficult experiences that may or may not include trauma and have a negative impact on your mental well-being.

Everyone has their own set of personal values and moral beliefs, so events that cause moral distress will naturally vary from person to person. Have you ever made a mistake that harmed someone else? Have you been upset about senseless calls you’ve had to respond to? What about non-emergency calls that can delay a response to actual emergencies? Have you ever let yourself down in your personal life?

These are all potential sources of moral distress and injury. Emergency services workers often refer to feelings of moral distress that aren’t a result of their own actions, but are caused by others. “Betrayal-based” moral injury is one example that can involve a serious failure of basic expectations of service and leadership.

Some things are unpleasant – you just need to suck it up. Other things are more problematic, and firefighters need to feel they can ask for support.

Maybe you were forced to comply with a policy that contradicted your personal beliefs, or you felt betrayed by someone in a leadership role in what might be called a “thrown under the bus” situation. Your sense of right and wrong is violated if you’re falsely accused of wrongdoing, or are criticized for a bad outcome, when you were simply following an order. Betrayal-based moral injury can leave you feeling disappointed and resentful, and it can make it hard for you to trust others.

Anyone in their right mind would think that’s not morally right.

A frequent source of moral injury for firefighters and EMS workers is repeated exposure to violent, immoral, or senseless behavior that leads to tragic outcomes. This often emerges as the focus of conversations with firefighters that begin around the topic of trauma. Discussions end up being less about what’s traditionally considered traumatic, and more about how emotionally exhausted they are from continuously responding to calls that expose the worst of humanity – violence, drugs, sexual assault, child abuse, and more. Ongoing, repetitive exposure to human suffering can create serious internal conflict. Moral injury can significantly alter the way people view themselves, the world and – for some – their relationship with God. A first responder might understandably begin to feel that it’s impossible to make a difference and that it’s no longer worth trying. After recognizing they’ve made a mistake, their personal moral code may begin to shift. What was once wrong or immoral becomes more acceptable, which generates a sense of hopelessness and despair. This flood of negative emotions can make someone more susceptible to substance abuse and isolation, factors that can increase the risk of suicide. Yet there is a positive aspect to using the term and talking about moral injury: it’s not a diagnosis or a label, but it is an explanation. It openly acknowledges that first responders routinely face very difficult things – things that didn’t happen by accident, are truly offensive, or the results of acts that violate basic human decency. These situations are an affront to your morals, values, soul, everything that guides you as a human being and a professional. How could they not have a negative impact?

You can experience symptoms of trauma that don’t rise to the level of a formal diagnosis of PTSD, but are still present and troublesome. Blows to our morals and values can also accumulate, and can lead to compassion fatigue, depression, anxiety, substance abuse, or suicide. Symptoms of trauma and moral distress or injury overlap in several ways, but there are things you can do to help relieve the burden.

How To Cope

Moral injury involves a sense of transgressions, and a conflict of right and wrong that can create spiritual turmoil. How to cope? Here are some ideas:

Choose To Forgive

Forgiveness can be a powerful step toward healing. It doesn’t excuse or dismiss what happened, but forgiveness allows you to accept it, release the pain or anger you feel, and move forward.

Practice Self-Compassion

There’s no need to punish yourself for what happened. Making a bad decision doesn’t mean you are forever unworthy of good things in your life. Recognize what can be learned, and remind yourself often that you deserve to be happy and have a fulfilling life.

Practice Self-Care

Mental and physical health are intricately connected, and every effort you make to take care of your body also improves your mind.

Reach Out For Support

Moral injury involves transgressions of right and wrong and often creates spiritual turmoil. A chaplain or clergyperson can help you navigate that turmoil and find meaning in what you’ve experienced. You could also talk to a peer, or call a mental health professional. Talking with someone who can help you regain perspective and parse out how you’re feeling can be a tremendous source of relief. Healing soul-deep wounds isn’t always easy, but just acknowledging the distress can kick-start the process. Whether you seek spiritual guidance, focus on self-care, opt for professional support, or use a combination of approaches, actively working through the details of events that caused moral injury will allow you to resolve your inner conflict and restore your moral compass.

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