Cover Story: Moral injury

As a physician who has worked in many settings ranging from large city teaching hospitals to rural and remote emergency departments over the last few decades, I have nothing but respect for our first responders. I can speak for my medical colleagues when I say that we regard our police officers, paramedics and firefighters, whose paths we cross in the emergency department, as colleagues and comrades.

I have had many firefighters as patients, and it is a privilege to have had them share with me some of the salient issues that challenge their working lives and minds. In our work with Project Trauma Support, our medical team has gained insight into the types of situations that can cause significant psychological and moral distress for firefighters working in various settings.

Years ago, working in a rural setting where many of our community members had stepped up to work on our volunteer fire fighting service, I started sensing that many of these brave and selfless men and women were feeling the impact of some of the calls that they had attended. They had performed impeccably, following the protocols they had so carefully learned, yet they were left with sadness and stress. They often felt grief from tragic, untimely loss of life. In a small, close knit community, those lives lost often belonged to their neighbors or friends, or the loved ones of people known to them. Sometimes, tragically, it was the loss of a colleague. Often a difficult call would leave them second guessing their performance and questioning whether they could have done more. They might have done or said things they wished they hadn’t, or maybe did not do things they wish they had. Or, maybe, they hadn’t done them soon enough. Or, maybe, in following the prescribed protocols or orders given at a scene, they felt that they contributed to sealing an unfortunate fate of one or more individuals. It is always worse if they had to bear witness to this fate.

After we had a few tragic occurrences in our community, I could see that there was a significant heaviness in the hearts of our firefighters. I offered to go to speak at one of their training meetings one night. We reviewed airway management, but my real agenda was to see how they were doing emotionally and psychologically following these calls. We got on the topic of post traumatic stress and moral injury. We created a forum where the team felt it was safe to speak about their experiences and the true impact it was having on them. I felt like I was bringing water to people who were parched in the desert. The meeting was only supposed to last for an hour. We were still at the station three hours later.

Working in the emergency services challenges one to do some deep soul searching and to develop a personal resilience philosophy. The nature of emergency work is that the extra-ordinary will become the ordinary. Firefighters are the ones who must run into a fire when everyone else is running away. There is no doubt that learning protocols and best practices in fire fighting and in managing medical calls is crucial. When the chaos of a critical incident threatens to challenge the wits of those in attendance, training becomes the authority. However, it is rare to find emergency services where as much emphasis is placed on readying their members to withstand the human challenges of working in life and death situations.

The average citizen will face one or two critical incidents in a lifetime. The average emergency service worker will have hundreds over the course of a career. Each critical incident has the potential to cost some peace of mind, cause some loss of faith, or take a piece of the heart and soul of each person who attends the call. Unless the first responders are supported to effectively process each critical event, they run the risk of accumulating negative effects that could threaten the course of their career and affect many aspects of their life.

Unfortunately, there continues to be a significant amount of stigma that prevents a first responder from putting their hand up stating they need some help dealing with the fallout of difficult calls. There seems to be the belief that if someone is not coping well with the physical, emotional and psychological demands of the job, they must somehow be weak or inadequate. The truth is, with the critical nature of the demands of emergency service, there would be something wrong with a person if they did not feel the impact of salient calls. This work challenges the very humanity of a person.

There is increasing awareness of moral injury as a significant contributor to operational stress injuries in addition to the better-known post traumatic stress disorder (PTSD). Moral injury is just now coming on the radar of mainstream psychiatry. Our work with Project Trauma Support focuses on moral injury, and we have learned much about the nature of this injury, its symptomatology and impact, and it has also allowed us to formulate and research an approach to addressing it.

Moral injury is an injury to the heart and soul of a person. It can be caused by witnessing things that feel just plain wrong, for example when bad things happen to good, unsuspecting people. These situations are a reminder that these things can happen to us or to our loved ones and there may be little we can do to prevent them. They challenge the notion that we can control our lives and keep our loved ones safe.

Moral injury can occur when a person is involved in a situation where they later question their performance. As previously mentioned, maybe they didn’t do something they wish they had, or they didn’t do it fast enough and there were dire consequences. Or maybe they did something they wish they hadn’t, and this then weighs heavily on their conscience. The symptoms of moral injury are very different from those of PTSD. They include guilt and shame, and overwhelming sadness.

Many individuals who attend our program also suffer from what is known as sanctuary trauma. Sanctuary trauma occurs when the people or institutions that one would expect would provide support in times of difficulty seem to instead tromp on a person and make everything worse. This can happen when colleagues stigmatize a person who requests help for psychological strain, when leaders seem to scapegoat an individual or unfairly target them, or when insurance companies deny assistance or cause grief. The symptoms of sanctuary trauma are anger, a sense of disillusionment, and a sense of injustice or betrayal. We regard sanctuary trauma as another type of moral injury.

Because moral injury is an injury to the very humanity of a person, it requires a novel treatment approach. We have found that group therapy with an experiential component works well. We have also found that medication does not help with moral injury. Many people have come to our program on multiple psychiatric medications, and they do not touch the site of the injury.

Throughout human history, tribes, civilizations and communities have come together to share the burdens, trials and tribulations of the human experience. Ceremonies, rituals, traditions, celebrations and storytelling have been used to try to make sense of unexpected and sometimes terrifying happenings that sometimes make no sense. It is our inheritance as human beings coming into the world that there will be hardship and struggle. What helps to mitigate this is the fact that we are hardwired for connection.

It has become apparent to me that there are three levels of connection, and if these are hampered, each can lead to its own unique stigma.

The first level of connection is connection to oneself and one’s own story. How much self compassion do you possess? How do you tell yourself the story of the difficulties you’ve had? Are you stigmatizing yourself by beating yourself up when you are feeling the natural consequences of a difficult, traumatic call? Are you telling yourself that you should have known better, done better, or been braver or more resilient? Are you questioning whether you are really cut out for this work? Are you feeling inadequate and do you worry that it is just a matter of time before others see your shortfalls? Or are you able to realize that you are human after all? In fact, it does not matter how brave, well intentioned, well trained or experienced a person is, they can be just one call away from a significant moral or psychological injury. Help is available, and you owe it to yourself, your family and your career to reach out for help when the going gets rough.

The second level of connection is with others. How are you as colleagues, leaders and management responding to the psychological needs of your members? Are you addressing those facing difficulties with compassion and understanding and providing the help they need and deserve? Or are you punishing them by making them feel like they are weak, not pulling their weight, or causing inconvenience to their colleagues and their service? In spite of the recent attempts to lessen stigma of those facing mental health challenges, there is still much room for improvement. This type of stigma coming from the individuals and institutions who should be providing necessary support is a very real deterrent to asking for help. Effective help is possible, and the sooner it can be accessed, the better the outcome and greater chance that a member will be able to successfully remain at work and be able to enjoy a long and rewarding career and life.

The third level of connection that is apparent to me, is a connection to some greater calling. How do you come to find meaning and purpose in serving your community and your fellow firefighters? When you think of your last bad call, why was it that it was you who was there? What did you uniquely bring to the situation? Was there something that you could offer that no one else could? Or was there something you needed to learn? Was this call bringing you face to face with the fact that you could benefit from doing some soul searching to find some more perspectives that could allow you to make peace with this challenging occurrence?

The stigma that comes from lack of connection to a higher purpose is demoralization, loss of faith in humanity, feelings of futility, and lack of motivation. Pushing forward with these feelings causes exhaustion, joylessness, burnout and even depression.

How do we address moral injury? By the true time-tested power of connection. By being in the presence of others that can validate our experience and acknowledge the difficulties inherent in our careers, hear our confessions and commiserate with our pain. That is why the group experience is so important. Ironically, when it comes to guilt and shame, which provide some of the greatest burdens of moral injury, there is one undeniable difference between the two. One can feel guilty quite easily sitting all alone, but to feel shame, you need the presence of other people whose judgment you feel reflected onto you. We cannot heal from moral injury alone.

Sadly, unrealistic expectations that emergency service workers must act as superhuman heroes in society has led to harsh judgement, sometimes unnecessarily harsh punitive measures and much destructive stigma. These are myths that need to be dispelled. The truth is that our heroes are human, they can get injured in human ways, and they can heal with attention to their humanity. We have seen many instances where the proper support can allow a person to bounce back higher and stronger than ever. 

Manuela Joannou, MD, is the medical director for Project Trauma Support, a novel program she developed that addresses PTSD in military members, veterans and first responders. Dr. Joannou is a family and emergency physician practicing in Perth, Ont.