Moral injury: The unspoken struggle

mental health

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Jeff Dill, founder of Firefighter Behavioral Health Alliance, sheds light on the growing concern of Moral Injury among firefighters and EMS workers

Let me clarify from the start. I know Post-Traumatic Stress Disorder (PTSD) is a real issue.

Within my thirty years in the fire service I have seen our brothers and sisters struggle with it for years.

The point of this article is to state my belief that Moral Injury might be just as prevalent or even greater than PTSD for first responders.

As founder of Firefighter Behavioral Health Alliance (FBHA) we have been keeping data on firefighter, EMS and dispatcher suicides.

The tracking and validating has currently given us a number of 1,920* losses of our brothers and sisters to suicide.

This number unfortunately, changes weekly as new reports our sent to us.

I am a retired fire captain, licensed counselor and currently the Behavioral Health Administrator for a large fire department in the West.

I have travelled over a million miles speaking on behavioral health and suicide but no by no way am I an expert – this subject matter is so difficult to understand.

When we started talking about PTSD in 2010 we took a hit from so many saying “PTSD is a military issue” or “You are making up the numbers of suicides”.

Now, in 2023, we know differently don’t we?

I am now stating and believing that Moral Injury is a term we need to know and train on.

Not only our people, but chaplains and clinicians as well.

So what is Moral Injury?

According to Dr. Jonathan Shay, who is credited as naming Moral Injury, describes it as “a betrayal of what’s right, by someone who holds legitimate authority, in a high stakes situation.” 

Dr. Brett Litz, of Boston University, and creator of the Moral Injury Outcome Scale (MIOS), defines moral injury as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”

In my words, it is the belief we are born to do good, to help others.

Then we are trained in the fire and EMS world to save lives.

Unfortunately, our percentages of saving lives is very low due to the nature of our victims injuries or medical emergency.

This begins to lead to emotional feelings of failure to do good, shame, guilt, lack of confidence and other emotional impacts upon our morals.

One large aspect of Moral Injury is betrayal.

Betrayal by management, others or even ourselves.

When Moral injury was brought to my attention by two firefighters I work with.

I advised them I had heard of Moral Injury but there was not an emphasis on it due too Moral Injury is not a diagnosis you will find in the Diagnostics and Statistical Manual of Mental Disorders-5 (DSM-IV).

After doing research on the subject I felt it was worthy of a White Paper.

With the help of two very good friends, Dr. Elizabeth Anderson Fletcher and Chaplain Mark Schimmelpfennig we produced Wounds of the Spirit: Moral Injury in Firefighters.

The main connection for me emerged when examining the aspect of betrayal within Moral Injury, and the number one reason identified in FBHA’s data for why people are taking their own lives.

When FBHA validates a suicide, it is done by me personally speaking to a Chief officer or a family member that contacts us.

Of the 1,920 documented suicides I have spoken to approximately 1,880 people to validate the data.

The number one reason is Unknown.

They just don’t know why they killed themselves.

The Number One Known reason is Relationships.

This can be either personal or work relationships.

PTSD is fear or trauma based whereas Moral Injury is an attack on our emotions.

The heart of makes us perform this difficult task in the first responder world.

One can struggle with both PTSD and Moral Injury.

The problem comes from the treatment aspect.

If a brother is sister is being treated for PTSD but not on Moral Injury then our member will struggle still especially to the point of suicide.

FBHA sees this in our data.

We have seen at least 40 of our brothers and sisters who went into in-patient treatment centers for PTSD, Addictions or Depression.

Yet, when they were released, they still took their lives.

Speculation only, but could they have been suffering from Moral Injury but it was not addressed?

We will never know. That is the point of this article: for treatment centres and clinicians to keep Moral Injury in their mind when working with their client.

Our second White Paper will address the treatment modalities of Moral Injury.

Moral injury reminds us that we are still humans first.

We suffer when we see others suffer.

Talking is our greatest gift to ourselves.

Do not bury what burdens you. The process of forgiveness for ourselves is a key factor for treating Moral Injury.

Remember, we are doing great work but we will never have the final decisions on who is to live and die.

All we can do is rely on our training and our compassion to help others. We need to always keep in mind the greatest life you can save is your own.

Seek help, listen to others when they have noticed changes.

Listen to your body when it tells you that you are hurting, you need sleep, work on reducing your stress and anxiety.

Coping skills

Internal Size-Up: Ask yourself two questions every day

  • Why am I feeling this way?
  • Why am I acting this way?

Listen to others, they see you better than you see yourself.

With Internal Size-up, begin working this with your support person.

Whether it is a spouse, partner, child, family member or friend.

At the end of the night build your communications by discussing “what emotions did I display?”, “how did it effect you?” and “what steps can I take to avoid these future behaviours?”

Opening up builds a bond with your loved ones.

It is has always been my belief at FBHA that I want you to have a great career but we want you to have a better retirement.

A retirement you can share with loved ones for many, many years.

This article was originally published in the September 2023 issue of International Fire & Safety Journal. To read your FREE digital copy, click here.

*Figure at time of article publication

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