Liz Frings

What Is Moral Injury? Guilt, Betrayal and Counselling for Emergency Services Staff

Not every wound from the job comes from fear. Some come from what you did, what you couldn't do, or what you saw others do, when it went against your sense of right and wrong. A patient left waiting because no ambulance was free. A decision made in seconds that you have gone over ever since. A colleague who crossed a line while you said nothing. Feeling let down by the service at the moment you needed it most. The lasting distress this can leave behind has a name, moral injury, and knowing the name can be a relief in itself.

Where the term comes from

The idea grew out of work with military veterans. Researchers describe it as the harm that can follow doing, failing to prevent, witnessing or learning about acts that go against your deeply held moral beliefs. It is not a diagnosis, and you won't find it in the diagnostic manuals. It often sits alongside guilt, shame and anger rather than the fear and flashbacks that mark PTSD, and it can also affect mental health more widely, through depression, heavy drinking or burnout.

The research in emergency services is newer but growing. A 2021 scoping review of studies with firefighters, paramedics and police officers found 32 studies, most of them with police (Lentz and colleagues, 2021). The common sources it identified were betrayal, being unable to prevent death or harm, and ethical dilemmas. In EMDR with First Responders (Luber, ed., 2015), Robbie Adler-Tapia uses the term "betrayal trauma" for the experience of not feeling supported by the department, command, the media, the public or family.

How it differs from PTSD

PTSD is driven by threat. The memory carries danger, and the body reacts as if it is still happening. This kind of wound is driven by conscience instead. The memory carries a judgement, about yourself, about other people or about the organisation. The two often overlap, and the same incident can cause both. In these jobs it can follow:

  • a split-second decision you keep going over
  • not being able to save someone, or having to choose who to help first
  • following an order or a policy you disagreed with
  • seeing a colleague behave badly and not stepping in
  • arriving too late because there was no one else to send
  • being blamed, investigated or left unsupported after doing your best

What it can feel like

  • guilt that doesn't ease with time or reassurance
  • shame, and a sense of being a bad person rather than someone who did a bad thing
  • anger at yourself, colleagues, managers or the system
  • losing trust in people and institutions
  • pulling away from others, or feeling you don't deserve support
  • questioning your values, your faith or why you do the job at all

Researchers who looked at frontline staff during the COVID-19 pandemic noted that people struggling in this way are often reluctant to talk about guilt and shame, and may focus instead on the more obviously traumatic parts of what happened (Williamson, Murphy and Greenberg, 2020). That fits my experience. The shame often surfaces only once someone feels safe enough to say it out loud, sometimes many sessions in.

How counselling can help

At heart, this is about your relationship with yourself, with other people and with what you believe. That is why I think person centred counselling suits it well. It offers a space where you can say the thing you have never said, without being judged, rushed or told how you ought to feel. Being met with acceptance by another person can begin to loosen shame in a way that reassurance from friends rarely does. Over time, many people find they can hold what happened in a way that no longer defines them.

Specialist approaches are being developed too. In the UK, Combat Stress and King's College London piloted Restore and Rebuild, a 20-session therapy designed specifically for moral injury, with 20 veterans. Participants showed significant reductions in PTSD, depression, alcohol misuse and moral distress (King's College London, 2023). A randomised trial has since been funded, and the researchers have suggested it may one day help other groups, including the police (Pathfinder International).

Where one memory keeps replaying, especially when fear and guilt are tangled together, EMDR can help. EMDR for emergency services staff explains how it works with these roles. Where the hurt is more about betrayal by the organisation, in my view, counselling that leaves room for anger and grief often matters more than working through any single incident. Many people need some of both.

Steps that can help now

Recovery from this kind of hurt is rarely quick, but there are things that tend to help along the way.

  • Name it. Simply knowing there is a word for what you feel, and that others in the job feel it too, can ease the sense of being uniquely bad or broken.
  • Separate what you did from who you are. Guilt about an action can be looked at and worked through. Shame about who you are tends to keep you stuck.
  • Notice hindsight. Looking back, it's easy to see things that weren't clear in the moment. Recognising that can change how a memory feels.
  • Reconnect with your values. Many people find it helps to act on the values that were hurt, through how they treat colleagues, family or the public, rather than only thinking about the moment that stays with them.
  • Talk to someone you trust. That might be a peer supporter, a chaplain, a friend who has been there, or a therapist. Saying it out loud to someone who doesn't recoil is often the first real step.

Families can be affected too. Partners may notice withdrawal, irritability or a loss of faith in things that used to matter, without knowing the cause. Helping someone with PTSD is written for them, and much of it applies here as well.

Frequently asked questions

Is it the same as burnout?

No, although the two can go together. Burnout is exhaustion from long-term workload and pressure. Moral distress is about what the work asks you to do, or stops you doing, and how that sits with your values. If you work in healthcare, burnout in the NHS looks at how the two overlap there.

Can you have it alongside PTSD?

Yes, and in these jobs that is common. An incident can be both frightening and morally troubling, and good treatment pays attention to each.

Will I have to talk about what I did?

Not before you are ready. You stay in charge of what you share and when. Some approaches need very little detail at all, which EMDR without talking about the trauma explains.

Who else can help?

Your GP is a good starting point. Police Care UK, The Ambulance Staff Charity (TASC) and The Fire Fighters Charity all offer independent support. If worries about your career are holding you back, is counselling confidential? sets out what stays private.

Talking to someone

I'm a BACP registered counsellor offering person centred counselling and EMDR therapy in Nottingham and online. If something here has struck a chord, you can get in touch to talk it through, without committing to anything.

Sources

More about person centred counselling