For Whom the Bell Tolls: Moral Injury in the Fire Service

By Kristopher Blume

Firefighters are trained to protect life and property from fire hazards and other emergencies. However, our profession involves exposing ourselves to many traumatic incidents that can have long-lasting effects on our physical and mental well-being. One of the most significant challenges that we face is moral injury. This term is not new; however, as an ever-changing profession we must engage in understanding it. Moral injury is a term that refers to the psychological distress that occurs when an individual is exposed to an event that violates their moral or ethical beliefs (Litz et al., 2009). It is not the same as post-traumatic stress disorder (PTSD), although it can coexist with PTSD. PTSD is a reaction to a traumatic event that involves intense fear or helplessness, while moral injury is a response to an event that challenges an individual’s values and beliefs.

At the headwaters of moral injury is the understanding that we as a profession are, in fact, the quintessence of Carl Jung’s Wounded Healer theory. Wounded healers are driven by the desire to relieve the suffering of others after experiencing or witnessing suffering in their own lives (Christie & Jones, 2014). Jung (1961) believed adverse experiences afforded wounded healers’ great empathy and transformative power in their interventions. Firefighters embody the concept of wounded healers as we face physical and emotional wounds resulting from our demanding profession. Nevertheless, we continue to heal and help others, demonstrating remarkable resilience and compassion. It is for this reason that the fire service will always be a noble calling.

Defining Moral Injury

Moral injury is a concept that was first used to describe the psychological impact of war on military veterans. The term has since been expanded to include individuals in other professions who have experienced exposure to morally challenging situations. Moral injury is “the psychological and spiritual impact of participating in, witnessing, or failing to prevent actions that transgress deeply held moral beliefs and expectations” (Litz et al., 2009, p. 700). Moral injury can result from commission (doing something that violates one’s moral beliefs) and omission (failing to do something morally required). In the fire service, moral injury can result from various situations, including responding to calls involving child abuse, domestic violence, suicide, and fatal accidents.

Causes of Moral Injury in the Fire Service

It does not take long to realize that we often encounter traumatic situations such as loss of life, property destruction, and injuries to ourselves and others. These experiences can lead to moral injury if our values and ethical principles have been compromised. While moral injury is a relatively new concept to the fire service and there is still much research to be done on the topic, some studies have suggested that it can have severe consequences for individuals who experience it. It is essential to recognize the many fracture points that can cause injury. Individuals who experience moral injury may have difficulty adjusting to civilian life, struggle with depression and anxiety, and have an increased risk of suicide (Bryan et al., 2016). To list several examples of moral injury in the fire service we can begin with witnessing unethical behavior or actions by fellow firefighters or superiors. Firefighters are expected to act with integrity and uphold ethical standards. When they observe colleagues or superiors behaving unethically or engaging in immoral actions, they may experience feelings of betrayal, disillusionment, and anger, leading to moral injury. Additionally, firefighters may experience moral injury when they face conflicts between their ethical principles and organizational policies or decisions. For instance, if an organization requires firefighters to engage in activities that they perceive as unethical or go against their values, they may experience moral injury. This type of injury can also occur when firefighters witness discrimination or harassment within the organization or towards members of the public we serve.

Further, and in a classic example, firefighters may be exposed to situations where they cannot save someone’s life despite their best efforts. They may be forced to make difficult decisions about how to allocate resources during a crisis, which can lead to feelings of guilt or shame. They may also be exposed to situations where they witness or participate in behavior that violates their sense of ethics or morality, such as hazing or harassment. Going a step further and examining our organizational fabric, firefighters may also experience moral injury as a result of the culture of the fire service. For example, firefighters are often expected to be stoic and unemotional in the face of danger, leading to reluctance to seek help when experiencing psychological distress. Firefighters may also feel pressure to conform to a certain image of being a “good” firefighter, which can lead to feelings of inadequacy or shame if they do not live up to these expectations.

Impacts of Moral Injury on Firefighters’ Mental Health

Moral injury can significantly impact firefighters’ mental health and overall well-being. Firefighters who experience moral injury may develop symptoms of anxiety, depression, PTSD, and other mental health conditions. They may also experience a loss of motivation, decreased job satisfaction, and lower performance. Moral injury can also affect firefighters’ relationships with their families and friends. Firefighters who experience moral injury may withdraw from their loved ones and experience difficulties in maintaining healthy relationships. They may also experience a sense of isolation and detachment, which can lead to further mental health issues. Firefighters who experience moral injury may also have difficulty adjusting to civilian life. They may struggle to find meaning and purpose in their lives outside of the fire service and may have difficulty transitioning to a less structured environment. They may also need help finding employment outside of the fire service, as they may feel they are not qualified for other professions beyond fighting fire.

Prevention and Management of Moral Injury in the Fire Service

Several strategies can be implemented to prevent and manage moral injury in the fire service. One of the most effective strategies is to provide training and education on moral injury and its effects. Firefighters should be educated on the causes and impacts of moral injury and strategies to manage and cope with these experiences. This training should also include education on ethical decision-making and conflict resolution. Another strategy is to create a supportive and inclusive organizational culture. For example, firefighters should feel comfortable reporting unethical behavior or actions by colleagues or superiors without fear of retaliation. The organization should also have clear policies and procedures for addressing these incidents.

Organizations should also prioritize mental health and well-being by providing access to mental health services and support resources. For example, firefighters should have access to confidential counseling and support services such as employee assistance programs (EAPs). These resources should be easily accessible and tailored to the unique needs of firefighters.

Finally, organizations should prioritize using evidence-based practices in treating and managing mental health conditions.

Interventions for Moral Injury

Several interventions have been proposed to mitigate the effects of moral injury on firefighters. One such intervention is peer support. Peer support involves connecting firefighters with others who have experienced similar events and can offer support and guidance. Peer support can help firefighters feel less alone and can provide them with a sense of community. Another intervention is cognitive-behavioral therapy (CBT). CBT is a type of therapy that focuses on changing negative thought patterns and behaviors. Empirical evidence supports using CBT as an effective treatment for PTSD. Intervention begin with prevention and requires a comprehensive approach that addresses the emotional and psychological impact of the job. Here are some steps that can be taken to intervene in moral injury:

Awareness and Education: Increase awareness about moral injury within the fire service. Provide education and training to firefighters and leadership about moral injury, its causes, and its potential consequences. This can help individuals understand and recognize the signs and symptoms of moral injury.
Supportive Culture: Foster a culture that encourages open communication, empathy, and support within the fire service. Create an environment where firefighters feel safe discussing their experiences, challenges, and emotions without fear of judgment or repercussions.
Peer Support Programs: Establish peer support programs that allow firefighters to connect with their colleagues who have had similar experiences. Peer support can help individuals feel understood, validated, and supported. Training peers on active listening skills, empathy, and confidentiality is important.
Mental Health Resources: Ensure that firefighters have access to mental health resources, such as counseling services, therapy, and support groups. Make these resources easily accessible, confidential, and stigma-free. Collaborate with mental health professionals who have experience working with first responders.
Regular Debriefings: Conduct regular debriefings following critical incidents, such as traumatic events or moral dilemmas. Debriefings provide an opportunity for firefighters to share their experiences, express their emotions, and process the event. Trained facilitators can help guide the debriefing process and ensure that individuals feel heard and supported.
Wellness Programs: Implement wellness programs focusing on physical, mental, and emotional well-being. These programs can include exercise, mindfulness training, stress reduction techniques, and resilience-building workshops.
Leadership Support: Encourage supportive leadership that promotes ethical decision-making, values the well-being of firefighters, and addresses issues related to moral injury. Leaders should lead by example, prioritize self-care, and actively support their team members.
Resiliency Training: Provide resilience training that equips firefighters with coping strategies and skills to navigate moral challenges and stress. Resilience training can include techniques for emotional regulation, mindfulness, and building a sense of purpose and meaning in their work.
Work-Life Balance: Promote work-life balance to prevent burnout and reduce the risk of moral injury. Encourage firefighters to prioritize self-care, maintain hobbies and interests outside of work, and spend quality time with loved ones.
Ongoing Support: Recognize that managing moral injury is an ongoing process.

Continuously evaluate and refine support systems, programs, and policies based on feedback and evolving needs. Regularly check in with firefighters to assess their well-being and provide support when needed.

As our understanding of the profession evolves, moral injury is a somber reminder of the sacrifice many have made for our communities and profession as we all become wounded healers at some point. This time, however, I cannot help but think of the timeless question—maybe a Hemingway novel or a Metallica song title left the impression—asking for whom the bell tolls. It tolls for you, me, and the profession. If we focus intensely on this inquiry an assumption can be drawn from John Donne’s “For Whom the Bell Tolls,” which explicitly highlights the loss of a piece of oneself with each casualty while at the same time highlighting the importance of discovering new ways to reduce risk and save firefighters in the line of duty. Moral injury is a just and rightly reminder of the perils of this profession.

References

Bryan, C. J., Bryan, A. O., & Anestis, M. D. (2016). An empirical review of moral injury in combat veterans. Clinical Psychology Review, 45, 33-42. doi: 10.1016/j.cpr.2016.03.002

Bryan, C. J., Bryan, A. O., Anestis, M. D., Anestis, J. C., Green, B. A., Etienne, N., Morrow, C. E., & Ray-Sannerud, B. (2016). Measuring Moral Injury: Psychometric Properties of the Moral Injury Events Scale in Two Military Samples. Assessment, 23(5), 557–570. https://doi.org/10.1177/1073191115590855

Christie, Wanda & Jones, Sara. (2013). Lateral Violence in Nursing and the Theory of the Nurse as Wounded Healer. Online journal of issues in nursing. 19.

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. doi: 10.1016/j.cpr.2009.07.003

Kristopher T. Blume is the fire chief of the Meridian (ID) Fire Department and has more than two decades of fire service experience. He is an author, lecturer, and independent consultant. Blume is a graduate of the Executive Fire Officer (EFO) program and an instructor at the National Fire Academy. As a student of the fire service, he is focused on values-driven, mission-focused leadership for the profession.