The Hidden Impact of Moral Injury in the Fire Service

Trauma, stress, and physical injury are constant sources of hardship for the men and women of the fire service. Firefighters and EMS personnel spend copious hours training to prepare for and prevent the worst of the effects from these inherent risks. But what do you do when the people and institutions you’re supposed to trust most are the source of conflict?

This frequently overlooked issue was the focus of a recent white paper titled, “Wounds of the Spirit: Moral Injury in Firefighters.” It was prepared by the Firefighter Behavioral Health Alliance (FBHA) in collaboration with Mark Schimmelpfennig, M. Div. and Elizabeth Anderson-Fletcher, Ph.D. In the white paper, Jeff Dill, founder of FBHA and Las Vegas Fire & Rescue Behavioral Health Administrator, and his colleagues shared the results of a study on moral injury in the fire service and the impacts it has on firefighters and EMS personnel across the country.

What is Moral Injury?

As defined in the white paper, moral injury 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.”

The source of moral injury could be peers, members of the public, superiors or agency leadership, the department or organization, or even the individual themselves. According to the white paper, moral injuries occur when an individual “perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical codes of conduct.”

Situations that could result in moral injury in the fire service include:

• Witnessing bullying or other negative interactions and failing to step in
• Personal or professional relationship troubles resulting from an individual’s own actions
• Being instructed to perform duties in a way that is inconsistent with training or policy
• Feeling overworked, unsupported, unprepared, or taken advantage of by leadership or peers
• Questioning recent or previous decisions made in the field

Moral Injury vs. PTSD

Guilt and feelings of betrayal are common threads in moral injuries, similar to post-traumatic stress disorder (PTSD). However, while there are many similarities, especially in terms of symptoms, Dill and colleagues also emphasized that PTSD and moral injury are not synonymous. Specifically, according to their research, PTSD is “grounded in fear-based events” and moral injury is “rooted in emotions and beliefs.”

What the Numbers Tell Us About Moral Injury in the Fire Service

As the founder of Firefighter Behavioral Health Alliance, Dill has been a longstanding champion of mental wellness within the fire service. He first founded Counseling Services for Fire Fighters (CSFF) in 2005, with the mission of offering behavioral health workshops to support firefighters, train officers, and educate clinicians regarding the fire service. He would go on to start FBHA after discovering the startling lack of data regarding firefighters lost to suicide.

“I didn’t know we had a problem,” Dill said during a presentation on behavioral wellness in the fire service. “I contacted organizations like the United States Fire Administration, National Fire Academy, and the National Fire Protection Agency…and no one kept any records or data on our lost brothers and sisters who died by suicide.”

He founded FBHA in 2010 to track and validate firefighter and EMS suicides. Several years later, they also began tracking dispatcher suicides. In 2023, the FBHA has validated 24 firefighter losses and six EMS personnel losses as of April 24th.

More recently, Dill came to learn about moral injury after being alerted to the term by two firefighters who reached out to him.

“Being a licensed counselor, I’d heard of it, but we were never really taught about it because it’s not in the Diagnostic and Statistical Manual of Mental Disorders used by counselors to diagnose and treat,” he said.

The more he learned about the concept of moral injury and previous research done on the subject, the more he came to realize how prevalent it could be in the fire service.

“Moral injury is based on emotion, whereas PTSD is trauma-based…and one of the biggest aspects of moral injury is betrayal, whether by management, or by others, or even by ourselves,” he said. “I started looking at our known reasons for fire and EMS suicides, and the number one known reason is relationship issues, whether personally or professionally…and I started putting two-and-two together.”

The term “moral injury,” was popularized in the 1990s by Dr. Jonathan Shay, a clinical psychiatrist and former staff psychiatrist at the Department of Veterans Affairs. According to Dill, moral injury and its impacts have been a subject of research by the military.

“Their data shows that there are more suicides related to moral injury than post-traumatic stress,” he said.

After thoroughly educating himself on the subject, Dill contacted Schimmelpfennig and Anderson-Fletcher to begin what he referred to as a “major team effort.”

In the first half of 2022, the three conducted a survey of nine fire departments across 5 states. They received 479 responses. Of those, 276 respondents (57.6%) indicated they perceived they had experienced a situation that would fit the definition of a moral injury. Additionally, a handful of respondents described incidents in write-in fields that could be defined as morally injurious despite not initially responding affirmatively to having experienced such a situation.

Of the 276 who believed they had experienced a morally injurious situation, 32% indicated they had been “constantly on guard, watchful, or easily startled” in the past month, and 49.82% said they had felt detached from people, activities, or their surroundings within the past month.

In examining the write-in responses to the survey, Dill and colleagues found several recurring themes in the descriptions of morally injurious events:

• Management/leadership failures
• Toxic organizational culture
• Lack of access to mental health resources
• Adverse working conditions caused by personnel shortages
• Perceived abuse of the 911 system for non-emergency medical calls
• Department policies

The inherent risks of the fire service can also increase the negative impacts of moral injuries when compared to the average person. Short staffing and the resulting overtime required of firefighters and EMS personnel is also taking a toll, Dill said.

“They’re exhausted and management is promising them to get more help and it’s hard to keep going when that doesn’t happen,” Dill said.

What Should Fire Service Leaders do About Moral Injury?

Unfortunately, based on the results of a survey conducted by Dill and colleagues, many firefighters may be unaware of what moral injury is, as well as its distinction from PTSD. This lack of understanding can be detrimental when individuals attempt to address and heal from either. On the other hand, education around moral injury and its impact can “help individuals normalize their own unique, personal reactions to morally injurious events.”

In addition to providing members with opportunities for education regarding moral injury in the fire service, it’s important for senior members of the department to attend workshops and training sessions with their team.

“I would say that for about 30% of all the workshops I’ve ever done, we never saw senior officers attend. What message does that send to your people about behavioral health?” he questioned.

Attending training alongside your members, championing programs that encourage behavioral wellness, and ensuring funding is available are all ways leaders can immediately support their members and be part of the solution instead of part of the problem.

“We have to be dedicated to making a change, not only for current members but for future members of our organizations,” Dill said.

When it comes to peers supporting each other, compassionate communication and being a good listener are key.

“The two things we always talk about are being direct and challenging with compassion,” he said. “One of the biggest things we need to learn is how to listen. And that’s a role reversal in our world…we’re used to solving problems. But it doesn’t work like that when it comes to behavioral health. It’s about listening to what someone is saying, picking up on key words, asking the right questions, and having the right resources.”

Most importantly, he said, members should feel comfortable reaching out for help when they need it.

“It’s okay to push pride to the side and say, ‘I’m struggling and I need some help,’” he said. “People will say, ‘do it for your kids, or your family,’ and I tell them, ‘do it for yourself,’ because I want you to have a fantastic career but I want you to have an even better retirement.”

Looking to create a behavioral health program at your department? Firefighter Behavioral Health Alliance (FBHA) founder Jeff Dill discusses 12 steps in this blog post.