Rita Nakashima Brock and Ann Kansfield

Opinion contributor

The beeping still haunts them. Personal alarms that firefighters wear sounded from the rubble as 343 New York City firefighters died on Sept. 11, 2001. Amid the smoldering ruins, the living searched while the sirens of their dead colleagues continued to call out.

First responders face disaster regularly, and their loyalty to each other drives them to work tirelessly to rescue those in trouble. But when rescue fails, they are never at peace with leaving anyone behind. Recently, DNA results identified the remains of firefighter Michael Haub, nearly two decades after he ran toward danger on 9/11. Such discoveries are bittersweet, a relief to the families and a sad reminder of the lost who might never be found.

Rarely do we stop to consider the traumatic impact on the human spirit of such high-stakes work.

Moral injury is a war inside

A 2018 Ruderman Family Foundation report noted that first responders are more likely to die by suicide than in the line of duty.

The statistics on active duty military and veteran suicides are also telling. The largest number of active duty military suicides since the Department of Defense began collecting the data occurred last year, with 325 deaths. Veteran suicide rates are well above those in the general population and is rising for young veterans.

Nationally, the suicide rate in the United States has increased 30% from 2000 to 2016.

What more can be done to save lives? We believe a significant factor in suicides remains invisible and largely unaddressed. That factor is moral injury.

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Identified in veterans by Jonathan Shay in his 1994 book, "Achilles in Vietnam," it has also been researched by Veterans Affairs clinicians. Moral injury is the result of violating core moral foundations by causing or witnessing serious harm or failing to save others. It can also occur by being exposed to a great evil, like a terrorist attack, that shakes our foundation. Losing moral grounding challenges people’s identity and meaning systems when they condemn themselves for doing the wrong or inadequate thing, even if there was nothing they could have done.

Moral injury can feel like a war inside because people’s consciences cannot make sense of experiences that derailed their identities. Among the most challenging of moral injuries is being betrayed by people we trust and who violate what we believe is right. Such betrayals can lead to outrage, humiliation and distrust.

Anyone can have moral injury. It is not a mental health disorder, yet the suffering is intense. Those afflicted can be crushed by guilt; tortured by anxiety; trapped by emotional solitary confinement; immobilized by meaninglessness; haunted by the dead; frayed by overwork; seduced by drugs, gambling, or sex; consumed by outrage. Often, they can experience all of the above.

How to process the pain

Increased mental health services can help, but without understanding it, a counselor might not address it. We run a week-long peer-facilitated moral injury program at Volunteers of America (VOA) called Resilience Strength Training (RST). Many of the veterans who have gone through our program note that what they shared with their peers is something they would never have told their therapists.

James Wong is one of those veterans. An Air Force computer programmer in the Vietnam War, James also served as a security officer. In that role, he spent hours, uncertain of his fate, in machine gun towers and fox holes. He recalls the sinking feeling each time an aircraft took off, knowing people were going to die. “I never saw enemy faces and they never shot back at me, but I knew I helped kill people,” he tells us. What’s worse, he remembers, there was nothing he could do about it.

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When James came home, he felt hopeless, unworthy and depressed. Only recently, after being in RST, was he able to identify moral injury as the catalyst for his suffering and begin the work to heal. James has become an RST facilitator, helping fellow veterans cope with their moral injury.

What is required to calm the war inside? For many, like James, the first step is sharing moral injury experiences with peers who understand and will not pass judgment. Moral injury must be disclosed through writing, speaking or art so the traumatizing memory can be processed. The inner pain cannot be avoided, suppressed or forgotten; it must be struggled with and embraced until it is exhausted. Only then can the experience become a source of wisdom that informs the future rather than defines a life.

When religion is involved, faith in a judgmental, punitive higher power can make recovery harder — but telling people what to believe can also derail the recovery process. Sufferers must rediscover their heart and conscience and find compassion for themselves in order to reconstruct what they believe.

Miracles can happen when people have a chance to share what they are carrying and to discover that they are still worthy of love, and that their willingness to talk about their moral injury can encourage others to find peace. We know that calming the war inside saves lives.

Rita Nakashima Brock is senior vice president and director of the Shay Moral Injury Center at Volunteers of America. Ann Kansfield is pastor of the Greenpoint Church and a chaplain serving in the Fire Department of New York City.