Friday, March 1, 2024

Moral Injury Among First Responders

 


In the 1990s, the term Moral Injury was coined by psychiatrist Jonathan Shay and colleagues and defined it as “A betrayal of what is right by someone who holds legitimate authority in a high stakes situation.”

In 2009, the term “Moral Injury” was modified by Brett Litz and colleagues, adding,

“Perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”

In simple terms, it means acting in a way (witnessing, participating, or failing to prevent something) that goes against a person’s moral beliefs. These “transgressive acts” violate an individual’s acceptable boundaries of behavior.

Journalist Diane Silver describes Moral Injury as “A deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The pain of Moral Injury is a sign of a working conscience and the loss of deeply held beliefs and/or trust. It challenges our fundamental core values and eats away at us, undermining the trust we had in ourselves, in others, and the world we live in.

While Moral Injury research has mainly focused on military service members and veterans, it is gradually gaining recognition as a significant and widespread issue among first responders.

This isn’t surprising considering the constant exposure to traumatic events that come with their job. First responders have a multitude of responsibilities, including advocating for patients, providing social services, enforcing laws, and protecting the community. As professionals in bureaucratic systems, first responders must follow strict codes of conduct, adhere to standards of practice, and follow the law when making decisions.

The unpredictable and potentially traumatic nature of their work often requires first responders to make split-second decisions. These decisions are often made in high-stress situations where their own safety and that of others are on the line and may go against their personal morals. Even if a first responder's actions don’t violate their morals at the time, an unfavorable outcome such as the death of a victim or serious injury to a team member can reveal the injury in later feelings of deep remorse, guilt, and shame. As lifesavers and problem-solvers by nature, any deviation from this perception can have a damaging effect on a first responders' mental well-being.

 

Scenarios that could lead to moral injury:

  • A firefighter being unable to save a victim or having to choose between victims to save.
  • A law enforcement officer having to use physical or lethal force to resolve a criminal incident.
  • A paramedic having a patient die in route to the hospital or finding out that their patient died after arriving at the hospital.
  • Being forced to make difficult decisions about how to allocate resources during a crisis
  • making a mistake that led to the death of a colleague
  • A fellow first responder dying by suicide

 With Moral Injury, the trauma and its meaning need to be processed. We need to stare into the belly of the beast and process betrayal, anger, self-loathing, and the desire to self-harm. A 2018 meta-analysis found that exposure to potentially morally injurious events were significantly associated with Post-Traumatic Stress Disorder, depression, and suicidality.

Signs of Moral Injury

  • Feeling demoralized
  • Feeling guilt/shame
  • Feeling “haunted” by decisions, actions or inactions that have been made
  • Anger in particular following betrayal
  • Feelings of worthlessness, helplessness and powerlessness
  • Sense of loss of identify and role
  • Questioning our sense of self and a loss of trust in oneself and in others
  • Persistent self-blame or blaming others
  • Negative beliefs and self- condemnation
  • Self-isolation, avoidance and withdrawal from others
  • Reduced empathy or wanting to interact with others
  • Increase in substance use
  • Loss of spirituality or religious beliefs (if previously held).
  • Suicidal ideation

 It's important for first responders to recognize when their work has begun to take a toll and seek support and professional help. It’s time to drop the stigma. If you feel you are suffering from moral injury and from some of the symptoms above, please seek social support and professional help. Seeking help is not a sign of weakness, it's a necessary step towards healing and maintaining overall well-being.



*****

If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSDThe Soldier's Workbook

or Acknowledge & Heal, A Women's-Focused Guide to PTSD

Friday, February 23, 2024

Moral Distress in Healthcare and First Responders

 


Moral distress was first defined by Andrew Jameton in the 1980s. According to Jameton, “Moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”

Moral distress was first recognized among nurses, and the majority of studies have focused on this population. It is important to note that moral distress is not solely a nursing problem. This is particularly prevalent in disaster response situations, where responders are exposed to unsafe environments, overwhelming workloads, and where existing ethical guidelines are not equipped to handle the complexity and pressure of a disaster, and do not adequately address the needs of first responders.

Some examples of first responders' experience that may cause moral distress.

  • A Law Enforcement Officer (LEO) for reasons beyond their control, is not able to apprehend a dangerous criminal.
  • A fire crew on a hose line might be instructed to evacuate before the primary search team has confirmed whether there are victims in the structure.
  • A paramedic might be directed by a supervisor to provide treatment to a patient that goes against their belief on what is medically appropriate.
  • An EMS provider who feels a sense of duty to respond and struggles with their moral responsibility to provide care, when a patient denies treatment or transport regardless of medical advice.

The central element in moral distress is the individual’s feeling of powerlessness and their inability to carry out what they believe is ethically right.

External constraints that contribute to moral distress include:

  • Power imbalances between members of the healthcare or responder team
  • Poor communication between team members
  • Pressure to reduce costs
  • Fear of legal action
  • Lack of administrative support
  • Policies that conflict with patient care needs 

Moral distress is a significant threat to an individual’s core values, leading to a sense of inner turmoil and damaging their moral integrity. Over time, this distress can accumulate and result in feelings of helplessness, shame, compromised ethical standards, and emotional pain. It can occur in two stages: “initial distress” at the time of the issue and “reactive distress” later on. Even after the reactive stress subsides, it may leave behind a lasting impact known as “moral residue,” which can have a negative cumulative effect on mental well-being. This psychological suffering can also manifest into physical symptoms and contribute to chronic illnesses. 

One of the main challenges in addressing moral distress is identifying it in the first place.

  • New or worsening headaches, heart palpitations, & gastric upset
  • Lingering anger
  • Feelings of guilt or shame
  • Withdrawal and depression

If you suspect you may be experiencing moral distress, it is important to identify, assess, and address it. The presence of moral distress is a sign that ethical challenges are not being addressed adequately. It's important for first responders to recognize when their work has begun to take a toll and seek support and professional help. It’s time to drop the stigma. Seeking help is not a sign of weakness, it's a necessary step towards healing and maintaining overall well-being.


*****

If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSDThe Soldier's Workbook

or Acknowledge & Heal, A Women's-Focused Guide to PTSD

Friday, February 16, 2024

Cumulative Trauma and First Responders

 


Cumulative Trauma is a term used to describe the psychological, emotional, and physical strain that comes from repeated exposure to traumatic events. For first responders, this can manifest in various ways, depending on the nature of their work. Law enforcement officers (LEOs), firefighters, and emergency medical service (EMS) all regularly face high-stress situations that most people can't even imagine.

First responders need to maintain emotional control in order to effectively help victims. This means that they may not always have the opportunity to fully process their own reactions and emotions during these traumatic events. Over time, this unresolved trauma can take its toll on the responder's mental well-being.

Unfortunately, this means the signs of cumulative trauma are often not acknowledged or addressed.

Indicators of Cumulative Trauma:

  • Difficulty concentrating
  • Frequent headaches
  • Issues with sleep
  • Irritability or anger concerns
  • Social withdrawal
  • Frequent anxious or depressed
  • Relationship tension/problems reactions/thoughts
  • Thoughts of self-harm
  • Low motivation
  • Alcohol/drug use problems
  • Disciplinary problems at work

 Many first responders suffer in silence, believing that experiencing trauma is just part of the job. But as they progress through their careers, each traumatic event becomes like a heavy rock added to their mental load. And just like carrying a backpack full of rocks, eventually that heavy load becomes too much to bear.

How much can someone carry? The weight is different for each individual, as is how much each individual is capable of carrying.

This cumulative exposure to traumatic stress throughout the first responder’s career causes ongoing distress, often referred to as sub-threshold posttraumatic stress disorder (S-PTSD).

Sub-Threshold Posttraumatic Stress Disorder (S-PTSD) symptoms include irritability, sleep disruption, fatigue, anger, detachment, isolation, alcohol use increase, hypervigilance, startling, physical aches & pains, headaches and anxiety. Diminished quality of life can be ongoing and can contribute to a higher incidence of PTSD.

It's important for first responders to recognize when their work has begun to take a toll and seek support and professional help. It’s time to drop the stigma. Seeking help is not a sign of weakness, it's a necessary step towards healing and maintaining overall well-being. So please, take care of yourself, because you can’t save lives if yours is at risk. 


*****

If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSDThe Soldier's Workbook

or Acknowledge & Heal, A Women's-Focused Guide to PTSD