moral injury

What Is Moral Injury?

Published on November 27, 2019 by First Responder Wellness

Firefighters, police officers, paramedics, and other first responders make many sacrifices to serve their communities, sometimes to the detriment of their own mental health. Mental health disorders such as depression, anxiety, and post-traumatic stress disorder occur at higher rates among first responders. These issues can lead to dangerous and unhealthy coping strategies, such as substance abuse. Post-traumatic stress disorder, or PTSD, was a term initially used to describe the lasting trauma experienced by combat veterans. Within the spectrum of PTSD, some concepts pertain to certain circumstances, one of which is the experience of moral injury. Like PTSD, moral injury is a term that was once used exclusively for combat veterans. However, this term is now applied to first responders that may experience damage to their core values after trauma at work. Moral injury can create a lasting emotional and psychological impact. This impact increases the risk of mental health disorders such as anxiety and depression, as well as the risk of substance use disorders and suicide.

Beyond PTSD

While PTSD explains the brain’s reaction to near-death experiences and its lingering effects on mental health, some experts believe this term isn’t sufficiently specific. Moral injury is the term for experiencing a fundamental betrayal of “what is right.” Clinical psychiatrist Jonathan Shay introduced the concept after working with combat veterans who witnessed an event that violated their moral code. Military members participate in an institution that normalizes violence. It is common for those who engage in violence to struggle with the ethical and spiritual implications of those actions. Shay argues that moral injury occurs when there is “a betrayal of what is morally right by someone who holds legitimate authority in a high-stakes situation.”

Since the coining of the term “moral injury,” other experts have built on Shay’s observations. They have found that moral injury can exist among first responders and physicians as well as combat veterans. Although law enforcement officers, for example, are not prompted towards violence in the same way as soldiers, they do operate within a similar culture. First responders may experience a moral injury after witnessing injury or death due to the ethical betrayal of peers or leaders within their organization. The emotions most often associated with moral injury are a deep sense of shame and despair. These feelings go beyond the typical symptoms of PTSD. It has been theorized that moral injury may be the leading cause of suicide among those who suffer from PTSD.


Only an expert can assess if an individual is suffering from moral injury, but people with this specific kind of mental anguish experience similar symptoms. Symptoms may include anxiety, inappropriate fear, demoralization, and intrusive thoughts or memories. Additionally, moral injury may cause an individual to lose their sense of self, have difficulty trusting themselves and others, and feel powerless to change their circumstances. People suffering from a moral injury might always blame themselves or others, believe that they are weak or morally corrupt, and feel perpetually haunted by their past. These feelings can lead to significant issues in relationships and at work, as well as unhealthy coping strategies such as substance abuse. The most severe cases of moral injury may result in suicidal ideation. In these cases, the individual or their loved ones should seek emergency medical care.

Prevention and Treatment

Jonathan Shay proposes the implementation of three principles to prevent moral injury. He advocates for “positive qualities of community of the face-to-face unit that create ‘cohesion'”, “expert, ethical, and properly supported leadership”, and “prolonged cumulative, realistic training for what they have to do and face.” While these concepts were constructed for implementation in a military environment, similar strategies could be used among first responders. Unfortunately, the idea of moral injury currently lacks adequate research and treatment is still in the early stages of development. To simplify the matter, may experts focus on the treatment of shame as a significant factor affecting symptoms of PTSD. One way that shame is remedied is by fostering emotions and values that have been shown to decrease guilt and improve self-esteem. These values include humility, gratitude, and compassion. For those who believe they or a loved one may be suffering from moral injury, PTSD, or any other mental health disorder caused by the extreme conditions of their profession, it is important to seek professional care as soon as possible.  

The First Responders Treatment Program at Simple Recovery uses trauma-informed strategies to cater to the unique needs of law enforcement, firefighters, paramedics, and other first responders with substance use disorders and co-occurring mental illnesses. We recognize that first responders encounter job-specific barriers and obstacles that come with the culture of their careers. Existing stigmas may make seeking help for addiction and mental health issues especially tricky. Addiction does not have to mean the end of your career. Nor do you have to resign yourself to a lifetime of struggling with your health and relationships.

At Simple Recovery, we take a holistic approach to treatment and addressing the underlying causes of addiction. This approach makes it possible for first responders to regain control of every aspect of their wellbeing. First responders dedicate their lives to protecting their community. At Simple Recovery’s First Responder Treatment Program, we dedicate our time to helping these compassionate individuals find a path to lasting sobriety and mental wellness. If you or someone you love is struggling with addiction, call us now at 888-743-0490