Wounds of the Spirit: Moral Injury and Mental Wellness in Firefighters
Elizabeth Fletcher, Ph.D.
Captain/Chaplain/Safety Officer
Cypress Creek Fire Department (TX)
Moral Injury (MI) refers to experiences/situations that go against an individual’s internal moral compass such as lack of fairness or the inability to do what is right and just. It is the damage done to the conscience (or wounds to the spirit) when a person perpetrates, witnesses, or fails to prevent acts that violate his or her moral beliefs, values, or ethical codes of conduct. Firefighters may experience Moral Injury in many different ways: disagreeing with an order given by incident command on the fireground, providing treatment to a patient that goes against belief of what is medically appropriate, witnessing bullying and not stepping up to say something, or being overworked through excessive overtime due to staffing shortages. These experiences are piled on top of repeated exposures to traumatic stress on the job, as well as the ordinary stress of just being alive in this world. MI can affect a firefighter’s mental and spiritual health; it can impact lives both on and off the job (i.e., co-workers, supervisors, spouses, children).
Moral Injury is different from PTSD, although there are similarities in symptoms (i.e., re-experiencing and avoidance). PTSD has been viewed as more fear-based than MI since PTSD is more likely to involve life-threatening danger and/or victimization. Furthermore, PTSD is thought to be more related to self and shame, whereas MI is more related to others and betrayal of trust. Regardless of whether the “label” is MI or PTSD, manifestations can include anxiety, depression, substance abuse, marital/relationship problems, and suicidal ideation/behavior. The impact on relationships is particularly noteworthy since the Firefighter Behavioral Health Alliance (FBHA), in discussions with family members and/or colleagues of firefighters who have died by suicide, has found that relationship issues, whether personal, family, or work-related, are one of the leading reasons for suicide.
Is Moral Injury a better term for what firefighters and other first responders experience? Maybe. Moral Injury may be less threatening since it does not appear in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and thus, may not carry the same stigma as a recognized clinical disorder such as PTSD.
FBHA recently released its inaugural white paper on Moral Injury, which I co-authored with Jeff Dill (Retired Captain, Founder, and CEO of FBHA) and Mark Schimmelpfennig (Chaplain at the Rush Center of Excellence for Veterans and their Families). Our white paper reports some of the results of a study conducted by FBHA using the Moral Injury Outcomes Scale (MIOS). Of our 479 responses across nine fire/EMS departments, 57.6% reported having experienced a morally-injurious event such as mass shootings, motor vehicle accidents, injured children, evidence of abuse, or their own failure to call out colleagues making mistakes on the job. Furthermore, a third of our sample responded affirmatively to items from The Primary Care PTSD Screen for DSM-5 regarding nightmares, intrusive thoughts, avoidance, hypervigilance, and guilt. Finally, almost half of our sample responded affirmatively to the question about detachment/isolation, which is one of the key indicators of suicidal ideation/behavior. To say these results are alarming is a serious understatement; from 2014 through 2020, firefighter suicides outnumbered LODDs.
Mental wellness is finally being talked about in the fire service; awareness is improving and many departments are developing programs to address this critical need. However, more work needs to be done. In January at the TEEX Leadership Development Symposium, I will share more results from the study behind the white paper, including significant findings on stigma, access to mental health resources, organizational culture, and implications for management at the company officer and command staff levels.
