Understanding Moral Injury in First Responders

by | February 9, 2024

What happens when a policy, procedure or your training keeps you from doing something you know is right, or directs you to do something you feel is wrong? What happens when you do the right thing, but the outcome isn’t perfect? First responders are faced with difficult decisions every day—sometimes, life and death decisions. When first responders act in a way that is contrary to their personal ethics, even when they’re doing the right thing and acting in accordance with their job, the psychological effects can be damaging. This is termed moral injury. Understanding what moral injury is and the impact it has on first responders is the first step in knowing how to address it.

In a recent webinar, “Moral Injury: What Is It and What Can We Do About It?” Dr. Jaime Brower, Nick Greco and Chief (Ret.) Steven Sund discuss what moral injury is, how it presents itself in first responders, its long-term impacts and how we can address it.

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Defining & Differentiating Moral Injury

The first step to understanding moral injury is defining it. We also need to clarify what moral injury is not. Moral injury is distinct from other psychological challenges that first responders may face over the course of their careers, including PTSD, burnout and compassion fatigue. While it’s possible for first responders to have moral injury AND one of these, moral injury is itself a unique question. Dr. Brower defines moral injury as:

The emotional and psychological injury that emerges from instances where we have personally engaged in behavior that betrays our moral compass and violates our ethical expectations for ourselves.

Another distinction to note: Moral distress is “one notch down from moral injury,” Dr. Brower explains. Moral distress is “knowing the right thing to do but being unable to do it due to institutional constraint.” This distress is marked by ongoing, regularly occurring situations that cause intense frustration and internal conflict. Moral injury goes much deeper, resulting in pervasive feelings of guilt (“I did something bad”) and shame (“I am bad”).

“In moral injury,” Dr. Brower clarifies, “Self-blame stems from the person’s actions. In PTSD, self-blame is often misplaced,” marked by a “would’ve, could’ve, should’ve” mindset. It’s important to understand that moral injury occurs in first responders despite the ability to place blame on supervisors or other authorities. Because the injury occurs in relation to an individual’s personal morals and sense of integrity, moral injury involves an inability to forgive yourself for your actions.

The first step to understanding moral injury is defining it.

Signs & Symptoms of Moral Injury

Moral injury “is something that has an all-encompassing effect,” says Greco. People who suffer from a moral injury experience significant changes in their worldview, their outlook, their core beliefs and values. Moral injury “presents as loss of meaning and purpose,” Dr. Brower explains. It results from the “deep ownership of the situation” first responders take. A few of the key signs and symptoms of moral injury include:

  • Feelings of shame and guilt
  • Self-doubt and self-loathing
  • Social isolation, withdrawal and alienation
  • Increase in irritability and aggression
  • Misconduct
  • Change in ethical attitude or moral and religious beliefs

It comes down to lack of trust, Greco explains. “ really has shaken them to the core—of who they trust. Not just others, but trust in themselves.” Moral injury is characterized by “a lot of hopelessness, helplessness, anger and betrayal,” Dr. Brower says. These feelings manifest themselves in social detachment and can lead to depression, anxiety and other mental health problems. As moral injury erodes a first responder’s sense of meaning, it impacts behavior: Be on the lookout for individuals who begin to have an increase in citizen complaints or disciplinary action.

Assessing & Addressing Moral Injury

“Moral injury requires a lot of processing,” Dr. Brower says. While professional psychological help may be needed, that certainly isn’t the only way to promote healing. “We have to understand that the heart of the issue requires boots on the ground,” she continues. “Call it out by name, pay attention to situations that may cause moral injury and proactively check in with people.” The way to heal from moral injury is to realign your life and actions with your core values, morals and beliefs. “Hearing an example of someone who made it through to the other side is impactful,” Greco explains. “Don’t turn away someone who wants to share their story.”

Peer support is at the center of these efforts. Whether through official peer support channels or through unofficial peer support, relationships are what help bring first responders back to their “why.” Remind each other of the purpose and meaning of the job and the impact you have on community members each day. But the first step in addressing moral injury is building awareness and understanding throughout the first responder community. Watch the on-demand webinar, “Moral Injury: What Is It and What Can We Do About It?” to learn more.

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