Moral Injury in Police Work
By Konstantinos Papazoglou, Ph.D., George Bonanno, Ph.D., Daniel Blumberg, Ph.D., and Tracie Keesee, Ph.D.
The study of moral injury began with research and clinical work involving active U.S. Army personnel and veterans. Moral injury results from extraordinary, critical life events during which a person perpetrates, fails to prevent, or witnesses actions that “transgress deeply held moral beliefs and expectations.”1 Consequently, exposure to morally injurious experiences can lead individuals to alter what they believe. For instance, such an event may cause persons to abandon their view of the world as a safe and benevolent place or of human beings as trustworthy.
This concept has existed in human knowledge and literature for a long time. In the Greco-Roman tradition, warrior narratives reference the experience of moral injury (called miasma, or moral pollution and purification), describing it as the effect of a critical situation wherein a person with legitimate and recognized authority betrays what is right.2
Today, the U.S. Marine Corps employs terms such as inner conflict when referring to morally injurious experiences during tactical training.3 On the battlefield, a soldier might face moral injury because of the inner conflict caused by obeying an order to leave a severely wounded comrade behind. When following the command, this Marine may experience psychological consequences for doing so. Other examples of situations that can lead to moral injury include death-related incidents, such as witnessing killings, handling human remains, or tending to gravely injured people without being able to help.
Research found that greater exposure to morally injurious events correlated significantly with guilt, frustration, depression, self-harm, shame, loss of spirituality/religiosity, or a sense of rejection.4 Studies also identified a moderate to strong association between moral injury and negative psychological outcomes.5
However, this relationship does not always exist. After exposure to adversity, many individuals continue to function without developing mental difficulties. Similarly, among those who do experience some negative outcomes, many recover quickly from morally injurious events without any long-term ramifications.
While research aimed at assessing the epidemiology of moral injury remains in its infancy, various studies focusing on active military service members and veterans indicated that 15 to 45 percent of those exposed to traumatic events appeared to suffer from moral injury.6
The aforementioned conclusions correlate with the theory and research findings of one of the authors regarding resilience among human beings exposed to trauma. Adult populations who experienced potentially distressing incidents showed relatively stable patterns of healthy functioning in the aftermath of the exposure.7 The author’s research was antithetical to prior studies that assumed—or overestimated—that most people faced negative health outcomes after exposure to potentially traumatizing incidents.
To this end, it appears that a plethora of factors (e.g., personality, self-efficacy, family, and community support) interact to influence an individual’s ability to adapt flexibly after encountering aversive events.8 Analogously, at least some persons exposed to morally injurious events will suffer enduring consequences, while many—likely a majority—will have stable health functioning afterward.
Against this backdrop, the authors aim to shed light on the phenomenon of moral injury among police personnel and provide practical recommendations for officers who experience it during their careers.
Presence in Law Enforcement
Police officers must perform their tasks and make decisions in accordance with agency values. Namely, they have a mandate to do what is right, as well as to serve and protect with integrity and judiciousness.
However, officers commonly encounter gruesome crimes, atrocities, and death-related situations. In addition, they often respond first to a critical incident scene and support those severely wounded or traumatized by a perpetrator or catastrophic event.
If officers cannot save a gravely injured victim at the scene of a crisis, they may feel like failures. As a result, they may blame themselves and experience feelings of guilt, frustration, and shame.9 The variability of reactions among officers involved in the same traumatic event may result from differences in how firmly these personnel hold to their values. Therefore, moral injury may reflect what happens to the individual faced with cognitive dissonance during a critical event.10
Dr. Papazoglou, a postdoctoral scholar at Yale University School of Medicine in New Haven, Connecticut, has collaborated as an expert with law enforcement agencies in the United States, Canada, and Europe.
Dr. Bonanno is a professor; director of the Loss, Trauma, and Emotion Lab; and director of the Resilience Center for Veterans and Families at Columbia University, Teachers College, in New York, New York.
Dr. Blumberg has been a police psychologist for 33 years and is an associate professor at the California School of Professional Psychology in San Diego.
Dr. Keesee, former deputy commissioner for the New York, New York, Police Department, is vice president of Law Enforcement and Social Justice Initiatives for the Center for Policing Equity.
Additionally, moral injury can occur in situations that, although not traumatic per se, may cause first responders to question their tactical decision-making or their ability to prevent what happened in the line of duty. For instance, inner conflict may arise when police officers must enforce a law that conflicts with their personal moral standards, such as when they arrest someone protesting for a cause they strongly favor or protect a person whom they consider morally repugnant.
Of course, officers can become traumatized in many ways by their on-duty actions. Research has shown that the most stressful scenarios associated with their duties occur when they seriously injure or kill someone.11 In two other studies, officers reported that the most traumatizing experience they could imagine would involve making a mistake that led to the death of a colleague.12
Further, regarding cases where the traumatic event included the experience of a moral injury, research has found increased incidences of mental health issues, such as post-traumatic stress disorder (PTSD), substance abuse, and depression.13 For example, this may occur following a justifiable on-duty shooting of someone who the officer thought did not have evil intent, but, nonetheless, was confused, disoriented, and threatening.
Moral injury can compromise an officer’s performance in the line of duty. It leaves the individual struggling with feelings of rejection, guilt, shame, and emotional paralysis—all detrimental to mental functioning and job performance.14
One police veteran who served in a metropolitan city described an incident in which an officer pursued a suspect. During the chase, a train struck and killed the individual. The officer, considered one of the best in the department, experienced moral conflict to the point of considering himself responsible for the suspect’s death. Eventually, he committed suicide.15
Similar incidents of self-destructive behaviors due to exposure to morally injurious events have been recorded in the military literature.16
The impact also can extend outside of work. One Canadian police veteran described how his personal life became deeply affected by the moral injury that resulted from a situation in which he fatally shot someone.
It is this moral injury that sometimes feeds our anger the most. Everyone around you is treating you like a hero for having the courage to do what you had to do. Outwardly, you show appreciation for their supportive comments, but, inwardly, you feel emotionally broken.17
Possible Cues of Moral Injury
1) Social and behavioral problems
- Social withdrawal and alienation
- Sociopathy (behaviorally expressed as an inability to get along with others or abide by societal rules)
2) Trust issues
- Lack of trust in self or others
3) Spiritual and existential issues
- Loss of religious faith
- Loss of trust in morality
- Loss of meaning
- Fatalism (behaviorally expressed as powerlessness or an attitude of resignation)
- Negative changes in ethical attitudes and behavior
4) Psychological symptoms
- Impulse to seek revenge
5) Self-deprecating emotions and cognitions
- Self-loathing (behaviorally expressed as self-blame, self-attack, and self-destructive behaviors)
- Feeling of being damaged
6) Unwanted reexperience of morally injurious events
- Intrusive recollections
Sources: Kent D. Drescher, David W. Foy, and Caroline Kelly, “An Exploration of the Viability and Usefulness of the Construct of Moral Injury in War Veterans,” Traumatology 17, no. 1 (March 2011): 8-13; William P. Nash and Brett T. Litz, “Moral Injury: A Mechanism for War-Related Psychological Trauma in Military Family Members,” Clinical Child and Family Psychology Review 16, no. 4 (December 2013): 365-75; and B.T. Litz et al., “Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy,” Clinical Psychology Review 29, no. 8 (December 2009): 695-706.
“Moral injury can compromise an officer’s performance in the line of duty.”
Based on available research and theory, the authors recommend several actions for preventing or combating moral injury’s impact on the health, well-being, and occupational performance of police officers.
Officers who identify any moral injury cues should seek assistance from peer support groups, as well as health professionals, familiar with the challenges of police work. Doing so will help them mitigate any cumulative effects of moral injury and associated future health complications.18
Police mental health professionals (e.g., psychologists, psychiatrists, and counselors) should partner with trainers and supervisors to educate officers about moral dilemmas that may arise during critical incidents and how the resultant moral injury can impact their health and well-being.
They also should train officers to identify moral injury cues exhibited by themselves or their colleagues. Also, these specialists can conduct assessments and screenings to identify personnel who have a higher risk of experiencing moral injury and monitor these officers in a caring, nonjudgmental, and nonstigmatizing way.
Such an approach would allow police departments to mentally equip their personnel to deal with these dilemmas, and it also would enable mental health professionals to further explore how morally injurious incidents occurring in the line of duty negatively impact officers’ health and well-being.
This method has aided survivors of terrorist attacks. For instance, crisis response teams have identified and assessed high-risk survivors and provided evidence-based interventions. Alternatively, crisis counseling and psychoeducation both have proven limited in effectiveness.19
In the medical field, some hospitals require employees to record any moral dilemmas they experience when working with patients to create a system wherein staff can receive recommendations and support from their peers. A similar system could be incorporated into police briefing and debriefing meetings.20
Research focusing on military personnel and veterans has indicated that certain self-care actions appear to facilitate moral repair.
1) Make or seek amends. Some veterans prefer to become involved in service activities as volunteers or even write forgiveness letters tailored to their moral repair goals and needs.21
2) Engage in pleasant activities. Physical exercise, yoga, traveling, and other pleasurable pursuits can help divert officers’ minds. Studies have found activities such as exercises and hobbies effective in minimizing the negative impact of moral injury.22
3) Communicate with spiritual healers or religious leaders. This can help officers suffering from moral injury to examine the importance of self-forgiveness and gratitude, restore a sense of purpose in life, and reestablish a relationship with a higher power or God.23
Researchers should collaborate with law enforcement organizations and conduct rigorous studies to improve the body of knowledge related to police moral injury, including its cues, symptoms, and association with potential physical and mental health issues among police officers. Consequently, this line of research may lead to the development of evidence-based interventions that can help protect officers against morally injurious experiences and support impacted personnel during their journey to moral repair.
Although the study of moral injury began within the context of active duty and veteran military personnel, many scholars have emphasized that police officers also likely experience its impact due to the high occurrence of morally injurious experiences in police work.
Law enforcement officials, clinicians, and policy makers should incorporate interventions designed to prevent and repair moral injury to support officers in maintaining their health, well-being, and high level of job performance. To this end, personnel should be encouraged to seek help from police health professionals if they identify any moral injury cues.
Thus, future research should focus extensively on how moral injury affects police officers’ health and job performance, as well as support the development of interventions for preventing and repairing moral injury.
Finally, when expanding the theory of moral injury from the military to civilian law enforcement, police administrators should conceptualize moral injury more broadly. It can result not only from exposure to severe forms of trauma but also from officers’ fairly routine encounters in which they experience inner conflicts with their strongly held values.
“…future research should focus extensively on how moral injury affects police officers’ health and job performance, as well as support the development of interventions for preventing and repairing moral injury.”
Dr. Papazoglou can be reached at email@example.com, Dr. Bonanno at firstname.lastname@example.org, Dr. Blumberg at email@example.com, and Dr. Keesee at firstname.lastname@example.org.
1 B.T. Litz et al., “Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy,” abstract, Clinical Psychology Review 29, no. 8 (December 2009): 695-706, accessed May 17, 2019, http://dx.doi.org/10.1016/j.cpr.2009.07.003.
2 Jonathan Shay, “Moral Injury,” abstract, Psychoanalytic Psychology 31, no. 2 (April 2014): 182-91, accessed May 17, 2019, http://dx.doi.org/10.1037/a0036090.
3 William P. Nash and Brett T. Litz, “Moral Injury: A Mechanism for War-Related Psychological Trauma in Military Family Members,” abstract, Clinical Child and Family Psychology Review 16, no. 4 (December 2013): 365-75, accessed May 17, 2019, http://dx.doi.org/10.1007/s10567-013-0146-y.
4 Joseph M. Currier, Jason M. Holland, and Jesse Malott, “Moral Injury, Meaning Making, and Mental Health in Returning Veterans,” abstract, Journal of Clinical Psychology 71, no. 3 (March 2015): 229-40, accessed May 17, 2019, http://dx.doi.org/10.1002/jclp.22134; Marek S. Kopacz et al., “Moral Injury: A New Challenge for Complementary and Alternative Medicine,” abstract, Complementary Therapies in Medicine 24 (February 2016): 29-33, accessed May 17, 2019, http://dx.doi.org/10.1016/j.ctim.2015.11.003; and Shay, 182-91.
6 Nash and Litz.
7 George A. Bonanno, “Loss, Trauma, and Human Resilience: Have We Underestimated the Human Capacity to Thrive After Extremely Aversive Events?” abstract, American Psychologist 59, no. 1 (February 2004): 20–28, accessed May 17, 2019, http://dx.doi.org/10.1037/0003-066X.59.1.20; George A. Bonanno et al., “Weighing the Costs of Disaster: Consequences, Risks, and Resilience in Individuals, Families, and Communities,” abstract, Psychological Science in the Public Interest 11, no. 1 (2010): 1-49, accessed May 17, 2019, http://dx.doi.org/10.1177/1529100610387086; and George A. Bonanno, Maren Westphal, and Anthony D. Mancini, “Resilience to Loss and Potential Trauma,” abstract, Annual Review of Clinical Psychology 7 (April 2011): 511-35, accessed May 17, 2019, http://doi.org/10.1146/annurev-clinpsy-032210-104526.
8 George A. Bonanno, “Resilience in the Face of Potential Trauma,” abstract, Current Directions In Psychological Science 14, no. 3 (2005): 135-38, accessed May 17, 2019, https://doi.org/10.1111/j.0963-7214.2005.00347.x.
9 Jeff Morley, “Moral Distress, Compassion Fatigue, and Bureaucratic Cruelty,” abstract, Gazette 65, no. 3 (2003): 34-5, accessed May 17, 2019, https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=205312; and Konstantinos Papazoglou and Brian Chopko, “The Role of Moral Suffering (Moral Distress and Moral Injury) in Police Compassion Fatigue and PTSD: An Unexplored Topic,” abstract, Frontiers in Psychology 8, no. 8 (November 2017): 1999, accessed May 17, 2019, http://doi.org/10.3389/fpsyg.2017.01999.
10 Kent D. Drescher, David W. Foy, and Caroline Kelly, “An Exploration of the Viability and Usefulness of the Construct of Moral Injury in War Veterans,” abstract, Traumatology 17, no. 1 (March 2011): 8-13, accessed May 20, 2019, http://doi.org/10.1177/1534765610395615; and Jeremy D. Jinkerson, “Defining and Assessing Moral Injury: A Syndrome Perspective,” Traumatology 22, no. 2 (June 2016): 122-30, accessed May 20, 2019, http://doi.org/10.1037/trm0000069.
11 John M. Violanti and Fred Aron, “Police Stressors: Variations in Perception Among Police Personnel,” abstract, Journal of Criminal Justice 23, no. 3 (1995): 287-94, accessed May 20, 2019, http://dx.doi.org/10.1016/0047-2352(95)00012-F.
12 Brian A. Chopko, Patrick A. Palmieri, and Richard E. Adams, “Critical Incident History Questionnaire Replication: Frequency and Severity of Trauma Exposure Among Officers from Small and Mid-Size Police Agencies,” abstract, Journal of Traumatic Stress 28, no. 2 (April 2015): 157-61, accessed May 20, 2019, http://doi.org/10.1002/jts.21996; and Daniel S. Weiss et al., “Frequency and Severity Approaches to Indexing Exposure to Trauma: The Critical Incident History Questionnaire for Police Officers,” abstract, Journal of Traumatic Stress 23, no. 6 (2010): 734-743, accessed May 20, 2019, http://doi.org/10.1002/jts.20576.
13 Morley; and Papazoglou and Chopko.
14 Jeanie M. Leggett et al., “A Pilot Study Examining Moral Distress in Nurses Working in One United States Burn Center,” abstract, Journal of Burn Care and Research 34, no. 5 (September-October 2013): 521-28, accessed May 20, 2019, http://doi.org/10.1097/BCR.0b013e31828c7397; and Papazoglou and Chopko.
15 Interview by Konstantinos Papazoglou.
16 Gadi Zerach and Yossi Levi-Belz, “Intolerance of Uncertainty Moderates the Association Between Potentially Morally Injurious Events and Suicide Ideation and Behavior Among Combat Veterans,” abstract, Journal of Traumatic Stress 32, no. 3 (June 2019): 424-436, accessed June 21, 2019, https://doi.org/10.1002/jts.22366.
17 Sylvio A. Gravel, 56 Seconds (Ottawa, ON: Syd Gravel/Budd Publishing, 2012); and Sylvio A. Gravel and Brad A. McKay, Walk the Talk: First Responder Peer Support (Ottawa, ON: Syd Gravel/Budd Publishing, 2016).
18 Drescher, Foy, and Kelly; Nash and Litz; and Liz et al.
19 Chris R. Brewin et al., “Promoting Mental Health Following the London Bombings: A Screen and Treat Approach,” abstract, Journal of Traumatic Stress 21, no. 1 (February 2008): 3-8, accessed May 20, 2019, http://doi.org/10.1002/jts.20310; and Chris R. Brewin et al., “Outreach and Screening Following the 2005 London Bombings: Usage and Outcomes,” abstract, Psychological Medicine 40, no. 12 (February 2010): 2049-57, accessed May 20, 2019, http://doi.org/10.1017/S0033291710000206.
20 For additional information, see Patricia S. Pendry, “Moral Distress: Recognizing it to Retain Nurses,” abstract, Nursing Economics 25, no. 4 (November 2006): 217-21, accessed May 20, 2019, https://www.researchgate.net/publication/5992186_Moral_distress_Recognizing_it_to_retain_nurses.
21 Kent D. Drescher and David W. Foy, “When They Come Home: Posttraumatic Stress, Moral Injury, and Spiritual Consequences for Veterans,” Reflective Practice: Formation and Supervision in Ministry 28 (2008): 85-102, accessed May 20, 2019, http://journals.sfu.ca/rpfs/index.php/rpfs/article/view/158/157; and U.S. Department of Veterans Affairs, National Center for PTSD, Moral Injury in the Context of War, Shira Maguen and Brett T. Litz, accessed May 20, 2019, https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp.
22 Drescher and Foy.
23 Marek S. Kopacz et al., “Moral Injury: A New Challenge for Complementary and Alternative Medicine,” abstract, Complementary Therapies in Medicine 24 (February 2016): 29-33, accessed May 20, 2019, http://doi.org/10.1016/j.ctim.2015.11.003.