We are still in it: A conceptual model for moral injury and burnout in alternative response programs to guide intervention

Miranda Worthen^1*Soma De Bourbon¹Omar Breedlove²Courtney Ewing²Joseph Graterol^3,4Amelia Harmon²Nakia Hines²Erik Lundgren²Michael Mason³Michael Marchiselli²Vania Mendoza²Khoa Nguyen²Britt Rubin²April Sloan³Shira Maguen^4,5

• ¹San Jose State University, San Jose, United States
• ²Richmond Area Multi-Services, Inc., San Francisco, United States
• ³San Francisco Fire Department, San Francisco, United States
• ⁴University of California San Francisco, San Francisco, United States
• ⁵San Francisco VA Health Care System, San Francisco, United States

Introduction: About 20% of police calls involve a person experiencing a behavioral health crisis. To better address these community member’s needs and reduce risk of harm, jurisdictions are developing programs that shift calls for crises related to homelessness, addiction, and mental health to non-law enforcement alternatives. In responding to these calls, first responders working in these alternative response programs are exposed to a different set of moral dilemmas and pressures, increasing their risk of developing moral injury. Methods: The Alternative Response Program Moral Injury and Burnout Model highlights causes of exposure to potentially morally injurious events and the interplay between moral distress, moral injury, and burnout among first responders working in alternative response programs. The conceptual model was developed through a multi-year participatory action research (PAR) study with members of a large urban alternative response program. The article draws on a highly diverse set of data sources that contributed to the development and refinement of the model, including focus group discussions, analysis of call logs, assessment of moral injury, and reflective conversations with members and leaders of the alternative response program. Through our collaboration, we identified contributory factors that can produce moral injury and opportunities for interventions to mitigate moral injury. We piloted several interventions collaboratively developed with team members and hypothesized to reduce moral distress and injury based on this model. Results: Our model explains sources of moral dilemmas and how these can lead to moral distress, moral injury, and burnout. The model also points to intervention pathways to reduce or prevent these outcomes. We provide illustrations of how moral injury arises, using data from the program members, describe six pathways, and share examples for how moral injury may be mitigated. Discussion: Despite scarce research in first responders, moral injury and burnout are growing concerns in alternative response programs. Our goal was to amplify participants’ voices to highlight both their struggles as well as proposed interventions fostering resilience. Through close collaboration, we developed a moral injury model that resonates for these first responders and can guide a better understanding of issues and pathways for interventions among high-risk occupational groups.