A Contextual Model of Moral Injury: Redefining Trauma in Frontline Professions through Ethics and Context

Abstract

To date, the interrelations between mental health and ethical challenges in frontline professions, such as the military, police and health care, have remained underexamined. This article addresses this gap by developing a contextual model of moral injury: psychosocial trauma resulting from morally significant experiences. This model is the result of grounded theory research with 50 expert interviews, 250 hours of participant observation and 170 interviews with former military and police personnel, iteratively analysed through an emerging multidisciplinary framework, including the concepts of moral injury, dirty work and recognition. The framework encompasses personal, situational, occupational, organisational, socio-political and technical dimensions. This study both contributes to a paradigm shift in understanding trauma and advances sociological research on the experience of frontline work. It expands the focus beyond individual pathology to include ethical and contextual dimensions of moral injury, providing comprehensive insight into the omnipresent and complex moral-psychological dimensions of frontline work.

Introduction

In discussions of mental health in frontline workers, such as military and police personnel, the most dominant concept remains post-traumatic stress disorder (PTSD), characterised by symptoms including intrusive memories, hypervigilance and avoidance (American Psychiatric Association [APA], 2022). However, recent years have seen growing attention in ‘moral injury’: guilt, shame and anger arising from situations where their actions, or those of others, conflict with their moral beliefs and expectations (Litz et al., 2009; Shay, 1994). This concept sheds light not only on the psychological aspects of trauma but also on its ethical and contextual dimensions, contrasting with prevailing trauma frameworks that focus primarily on internal psychological processes (Griffin et al., 2019; Litz et al., 2009; Shay, 1994). For instance, police confrontations with violence and military killing have evoked feelings of both guilt and anger among involved personnel, directed towards themselves, their organisation and the political and media portrayal of events. These moral responses demonstrate the significant role of organisational, political and societal actors and factors in moral injury – and trauma more generally. Yet, to date, the role of context in (moral) trauma has largely been neglected in both research and practice (De Rond and Lok, 2016; Hodgson and Carey, 2017; Hollis et al., 2023).

Thus, although the concept of moral injury has been commended for its ability to capture the ethical and social dimensions of stress and trauma, much current research and practice remains individual- and pathology-focused (Hollis et al., 2023; Molendijk et al., 2022). Studies concentrate on specific events, such as experiences of violence and acts of killing, the role of individual characteristics, such as disconstraint and neuroticism, and psychological symptoms (Frankfurt and Frazier, 2016; Koenig et al., 2019). Accordingly, research is largely aimed at developing diagnostic and therapeutic models (Frankfurt and Frazier, 2016; Koenig et al., 2019).

In contrast, sociological and anthropological research on work does typically situate mental health and ethics within broader contexts. Take studies on frontline work, for instance, which by definition focus on how this work involves direct engagement with the public, examining military, policing and health care, as well as occupations such as social work, emergency services, education, public transport and retail (Eikenaar, 2023). However, much of this scholarship has considered moral issues and mental health in broader discussions on job demands and identity rather than as primary focal points (Garavan et al., 2024; Granter et al., 2015). One reason may be that only some frontline roles involve significant high-stakes and potentially traumatic situations, which can render the moral-psychological impact of such work less visible.

That said, moral issues and mental health also remain far from central in studies on ‘extreme work’ (Garavan et al., 2024; Granter et al., 2015; Hällgren et al., 2018) and ‘dirty work’ (Ashforth and Kreiner, 2014; Deery et al., 2019; Hughes et al., 2017). Extreme work studies have often focused on either macro-level extreme environments (Garavan et al., 2024; Hällgren et al., 2018), or on specific, micro-level phenomena deviating from traditional understandings of ‘extreme’ or ‘dirty’ work, for instance long-hours cultures (Granter et al., 2015; Hewlett and Luce, 2006). Research on dirty work has examined how workers manage the stigma associated with their jobs but has left underexplored how morally challenging tasks really affect them, and may even traumatise them (Eikenaar, 2024). As a result, this field has yet to fully explore how moral and psychological impacts take shape in frontline work and how these are embedded within their micro, meso and macro contexts.

This article develops an interdisciplinary model of contextual dimensions of moral injury among frontline workers. It draws on the Moral Injury in Context project, a six-year inter- and transdisciplinary research initiative examining moral injury among well-known high-stakes frontline occupations, namely the military and police, sectors where moral and psychological issues clearly come to the surface. Specifically, the project explored organisational, technical and socio-political dimensions of moral injury in collaboration with practitioners and stakeholders of said occupations. As an interdisciplinary endeavour, this article brings together moral philosophy and ethics through its focus on the ‘moral’ in moral injury, psychology through its attention to the ‘injury’ and sociology and anthropology through its analysis of occupational, organisational, socio-political and technical factors. In doing so, it advances psychological research on trauma, where these contextual factors have often been underexplored and undertheorised. At the same time, by focusing on moral issues and mental health, it contributes to sociological scholarship on frontline work, extreme work and dirty work, providing a systematic account of how contextual factors shape the moral and psychological experiences of frontline workers.

Following a discussion of the theoretical framework and research methods, the subsequent sections present key findings, examine the contextual dimensions of moral injury and conclude with the proposed model and its broader implications.

Moral injury and its (underexplored) ethical and contextual dimensions

The concept of moral injury refers to the psychological, spiritual and social problems that people may develop when their own actions or those of others conflict with their moral beliefs and expectations. Psychiatrist Shay (1994) coined the term ‘moral injury’; psychologist Litz and his colleagues (Litz et al., 2009) played an important role in systematically conceptualising the notion. They did not intend the concept of moral injury as a new diagnosis, but to shed light on the potential ethical and social dimensions of psychological suffering, which had been given minimal consideration in prevailing trauma research (Griffin et al., 2019; Hollis et al., 2023; Litz et al., 2009; Shay, 1994). Despite this, the bulk of subsequent research has been psychological in nature.

Morally injurious situations and types of moral injury

Moral injury arises in high-stakes situations where lives and values are on the line (Richardson et al., 2020; Shay, 1994). At the same time, it exists on a spectrum (similar to other psychological and social issues). Moral challenges can engender moral frustration, critical situations with painful outcomes can induce moral distress, and severe, traumatising situations can lead to moral injury (Litz and Kerig, 2019).

Two main types of moral injury can be distinguished: commission-based moral injury, which involves actions that individuals come to regret, such as acts of violence and killing; and omission-based moral injury, arising from failure to prevent suffering or provide assistance to those in need (Frankfurt and Frazier, 2016; Koenig et al., 2019). In line with this, moral injury can emerge in various settings. Research on soldiers shows that commission-based injury appears more common in roles requiring force, while omission-based injury seems more prevalent in settings like peacekeeping (Frankfurt and Frazier, 2016).

Moral injury can be self-directed and other-directed. Guilt and shame often arise from actions taken against others, sometimes under orders from leadership, while feelings of anger and betrayal stem from actions taken against oneself or others (Hodgson and Carey, 2017; Hollis et al., 2023; Shay, 1994). Specifically, when trusted authorities betray a person’s trust, whether through denial of wrongdoing or failure to uphold moral values, they perpetrate what Shay (1994) famously termed a ‘betrayal of what’s right’.

Moral injury as relational and context-shaped

So far, these insights are well established in moral injury research, which, as mentioned, has been predominantly psychological. While our interdisciplinary research confirms these insights, it also challenges several other aspects, aligning instead with emerging views from philosophy and social sciences.

Rather than clear, unequivocal moral transgressions, of which most current research speaks, our research shows that individuals typically experience confusing moral conflict. This makes sense from the perspective of moral philosophy. As is well understood in this discipline, people do not typically experience unequivocal moral violations but rather moral dilemmas, where they must compromise one value to uphold another (Hodgson and Carey, 2017; Molendijk, 2018). Further, typically, there are multiple morally critical events in play, each shaping the meaning of the others. Sometimes, moral injury results from an accumulation of such events, leading to moral-psychological ‘attrition’ (Eikenaar, 2024). This can involve profound moral disorientation (Molendijk, 2018).

As elaborated below, the broader context always plays a role in both the emergence of specific situations and the meaning they take on for the person. This has a clear logic, making it all the more striking that context has so often been bracketed: moral emotions are inherently relational – they always concern one’s relationship with others (Molendijk et al., 2022; Tangney et al., 2007). Guilt and shame are about the harm done to others or the harm one could not prevent, while anger arises from perceived betrayal by others. More fundamentally, moral emotions emerge from violations of moral beliefs and expectations, which do not develop in isolation, but in relation to the communities we belong to – for example, the family we grew up in, the society in which we are socialised and the organisation in which we are trained. For this reason, a moral violation can cause profound disorientation both within a person and in relation to their social environment (Molendijk, 2018).

Further, as such, moral injury is connected to experiences of misrecognition. This connection was first articulated by philosopher Honneth (1997) in his influential conceptualisation of recognition, though it is often left implicit in sociological applications of the concept (Groutsis et al., 2020; Hancock and Tyler, 2024). Honneth (1997) explicitly defines recognition in terms of a moral relationship with others, a relationship that can be either respected or violated. When another person’s experiences are not acknowledged as valid, he argues, misrecognition occurs, which can inflict moral harm.

While psychological research has expanded understanding of moral injury, it struggles to capture the ethical and contextual forces that shape it. At the same time, sociological scholarship on extreme and dirty work has provided valuable insights into the conditions of frontline work but has rarely treated moral issues and mental health as central concerns. As mentioned earlier, drawing on empirical research, this study brings these fields together, integrating research on dirty work, recognition and other relevant themes, to advance moral injury research and the sociology of work.

Methods

Our research project adopted grounded theory principles, which are well-suited for studying underexplored social processes (Charmaz, 2006; Glaser, 2014). Unlike approaches that test predetermined hypotheses, or completely inductive research, grounded theory research is iterative, with data and theory continuously informing each other (Charmaz, 2006; Glaser, 2014; Richardson and Kramer, 2006). Existing theories serve as ‘sensitising concepts’ that may be revisited during the research (Bowen, 2006; Charmaz, 2006). Thus, rather than either deduction or induction, this process involves abduction, which refers to the process where analytical findings are the result of regularities and associations found in the empirical material for which theoretically sound explanations can be given (Reichertz, 2007; Richardson and Kramer, 2006). As a result, the theoretical framework that emerged in this research project was not predetermined but evolved through the research process. Likewise, the findings and contributions are grounded in its empirical findings while also being shaped by continuous engagement with existing scholarship.

For data collection, we conducted extensive fieldwork between 2015 and 2024 involving both interviews and participant observation in the Netherlands, in Dutch. The studied populations spanned various military and police units, ranging from conventional infantry units to military police units tasked with escorting immigrants declared illegal on their forced return, to units specialised in autonomous systems and artificial intelligence (AI), including robotics and drones. Also, fieldwork was conducted among various veteran groups, exploring their unique socio-political activities, such as organising theatre productions by veterans and survivors from deployment areas, engaging in return trips to deployment zones and pursuing legal proceedings against their own organisation or the state.

In total, more than 250 hours of participant observation were conducted during activities such as police shifts, military exercises and veteran return trips. Also, over 50 expert interviews were conducted with researchers, professionals and stakeholders, including chaplains, psychologists, health care programme leaders, policy officers and commanders. Over 170 semi-structured life story interviews were conducted with military and police personnel, most ranging between two and three hours. The interviewees ranged in age from 19 to 60, with most between 20 and 40. All military branches and ranks were represented, from private to general, with a majority between private and major, reflecting the overall rank distribution in the armed forces. About three-fifths were men, again mirroring general military demographics. Respondents were selected to include a substantial group with moral distress. One-third reported no issues, one-third minor short-term problems and one-third serious, lasting difficulties.

The analysis of the integrated empirical material followed grounded theory principles, including the abductive reasoning outlined above (Charmaz, 2006; Reichertz, 2007; Richardson and Kramer, 2006). It employed an open approach yet guided by sensitising concepts such as ‘moral injury’ (which evolved during the research), and by other theoretical concepts – pre-existing, adjusted or newly developed – that emerged as necessary for understanding the data. For instance, one such concept is ‘recognition management’. The empirical data revealed that moral injury among frontline workers often involves a sense of misrecognition, experienced as an injustice and thereby further morally injurious. We also found that this experience prompted responses ranging from seeking acknowledgement and justice to distancing themselves from society. These patterns led to further literature review, focusing on the concept of recognition, as well as delving into studies of dirty work and the associated concept of taint management. Synthesising these theoretical insights led to the emergence of the term ‘recognition management’.

Table 1 provides an overview of the research process and findings, around which the next sections are structured.

Table 1.

Overview of the methodological process and analytical results.

Contextual dimensions of moral injury

I have a trauma, because of what happened with my buddy [who was killed during deployment]. But it’s far more than that . . . feeling helpless, feeling guilty about not being able to do anything, being abandoned by the United Nations and the government, and being accused in the media.

These are the words a Dutch veteran uttered in an interview with us. He witnessed the fall of Srebrenica, Bosnia, unable to prevent the ensuing genocide, clearly expressing the significance of ethical issues and the wider social context in his suffering.

Personal and situational: Complexity and high stakes

As discussed above, personal and situational aspects of moral injury involve distinct yet interrelated dimensions (see Table 1). On a personal level, a person’s moral compass is never an ordered, harmonious system but a complex and sometimes conflicting constellation of beliefs and expectations, which can clash with reality or each other. Situationally, for a situation to be morally injurious it must be a high-stakes situation, where lives are at risk and, thus, values are on the line.

Next, the important role of context is discussed.

Occupational: Doing violence as an honourable dirty job

An honourable dirty job

Our study focused on ‘frontline work’, a sociological term referring to roles at the literal or metaphorical frontline (Eikenaar, 2023). We specifically examined the military and police as contexts where workers often confront human suffering and make decisions with high impact. This overlaps with other sociological and organisational concepts, such as ‘high-risk occupations’ and ‘extreme work’, which refer to physical risks, emergencies or disruptions, both in the task itself and in the work context (Garavan et al., 2024; Hällgren et al., 2018), as well as ‘dirty work’, which denotes labour that is physically, morally or emotionally tainted (Hughes et al., 2017). Building on these frameworks, the term ‘high-impact profession’ emerged as an overarching category to capture the significant, yet complex, effects these professions can have on workers.

One might expect the ‘high impact’ of soldiering and policing to arise from a fundamental tension between the necessity of violence and the notion of doing good. However, this is not necessarily the case. Despite common slogans like ‘serving the country’, police officers and soldiers are often not focused on abstract ideology. Their primary motivations include an affinity for sports, camaraderie and a stable salary (Eikenaar, 2023; Gibson and Abell, 2004). Also, they are generally not troubled by the use of force, although they do need it to occur in a framework that offers justification. Police officers stress ‘wanting to do something for society’, while soldiers emphasise that ‘I do stand behind what I do’ whereas society has ‘the luxury of judging war from a safe distance because we take up that nasty job for them’ (Eikenaar, 2023; Molendijk, 2024; White et al., 2010).

So, the moral complexity of frontline work does not necessarily lie in the exposure to violence as such, but rather in workers’ complex relation to violence and human suffering. First, unlike any other profession, their position towards violence is complex: they are potential witnesses, victims and perpetrators of violence and suffering, all at the same time (Hannah and Sowden, 2013). Second, they face violence in dual roles: as obedient instruments, executing state-mandated directives and policies, and willing agents, consciously serving as conduits of state authority (Molendijk, 2024). Third, their use of violence carries a morally ambivalent status: soldiers and police members are not mere lawless aggressors but wield force as agents of an organisation that is granted the monopoly on violence by the state, in the name of society, yet in the name of freedom, peace and safety.

Taint management

Owing to the moral complexity of their roles, soldiers and police officers are particularly vulnerable to experiencing moral conflict, while the stigma surrounding violence can further compound moral turmoil. Clearly, they work in high-impact professions. Some cope by stressing that their work is actually morally virtuous, while others strengthen an us/them divide between themselves and society. Recall, for instance, the soldiers judging civilians for judging them ‘from a safe distance’. They bond with peers while condemning those who criticise their actions. At the organisational and political leadership levels, similar defence mechanisms are used. Organisations often maintain a low profile or rebrand their actions as humanitarian, while in both cases maintaining a culture of silence regarding incidents towards ‘the outside world’ (see also Ashforth and Kreiner, 2014). Simultaneously, within the organisation, a strict division of tasks may be imposed, limiting professionals’ direct encounters with the source of their ‘dirty work’, such as human suffering, thereby allowing them to maintain emotional distance (see also Eikenaar, 2024).

These coping mechanisms can be considered forms of ‘taint management’. Take this officer’s remark: ‘The rules give you a lot of grip. They protect you. And they are binding.’ Another insightful statement: ‘I wanted to keep a distance, I didn’t want to bond too much with the people [because] that makes you weaker’. In our research, we were told many such statements, showing that these coping strategies are partly inevitable for moral-psychological protection.

That said, such coping can also lead to problematic emotional detachment, and it may perpetuate a cycle of silence and misunderstanding. As one veteran phrased it: ‘I wanted to help people, and then you find out the world is rotten. . . . I was maybe naïve [and then] I became numb. . . . But nobody understands – or well, nobody gives a shit.’ Another related: ‘Going forward strewing teddy bears, long live the rainbow, the bees, the butterflies, you know . . . That’s how people here would like to see it. But that’s not how it is.’ As a result, while frontline workers’ coping strategies may offer short-term relief, they can have counterproductive long-term effects, increasing the risk of creating more morally injurious situations and fostering disillusionment and isolation.

Organisational and political leadership and decision-making: Double binds

This section turns to the role of organisational and political leadership and decision-making in moral injury. Imagine a frontline worker who makes a difficult decision, such as taking an aimed shot at a person in a dangerous situation, only to then lack backing and support from their superior; for example, when an investigation is launched against them following a complaint. Such experiences are often felt as a profound betrayal.

Betrayal, double binds and ambiguity

Shay (1994), who coined the term moral injury, has always emphasised the important aspect of betrayal. In line with Shay’s work, our research led us to consider leadership and decision-making – and thus moral betrayal by leaders and decision-makers – not only as an indirect, circumstantial factor in moral injury but also as a direct cause of moral injury, namely in high-stakes situations.

To reiterate, frontline professions like policing and soldiering are essentially high-stakes occupations, and thus high-impact professions. Members of these professions operate as instruments of the state in dangerous contexts, putting them in a state of great vulnerability and requiring them to relinquish a great deal of control over their safety to the leadership (Shay, 1994). Moreover, doing such ‘dirty work’ means being socialised into a specific occupational culture with an associated moral constellation, where values such as service, loyalty and a willingness to sacrifice are central (Eikenaar, 2024; Gilhuis et al., 2024; Shay, 1994). Consequently, members are in a position of great dependence and necessary trust in their organisation and government, embodied by organisational and political leadership. Dependence is the reliance on a person or institution for one’s well-being, safety and integrity (Smith and Freyd, 2014). Trust is the expectation that this other will be benevolent, or at least do no harm, while, by definition, it also entails uncertainty regarding the other’s ability and willingness to do so. Dependence and trust therefore occur in a relationship of inequality and reinforce one’s state of vulnerability. Betrayal, then, is the willing violation of this relationship and, moreover, the violation of deeply held moral values: it is a betrayal of ‘what’s right’ (Shay, 1994).

A leader is the representative and guardian of their members’ well-being, safety and integrity, and as such is entrusted with a critical responsibility. Therefore, experiences of betrayal by leaders can be not just painful but profoundly morally injurious (Molendijk, 2019; Shay, 1994). For instance, the Afghanistan veterans we interviewed recounted feeling that their leaders prioritised the mission’s political and societal image at home over soldiers’ safety, delaying critical support decisions like providing fire support to soldiers in dangerous situations. This perceived lack of support in life-or-death situations prompted some soldiers to say: ‘Our biggest enemies are not outside the gate, but above us – that’s who our biggest enemies are’. In turn, these veterans’ superiors were often frustrated by pressure from their own higher-ups. For instance, as one former colonel recounted, when he initiated a particularly risky operation, a general was sent out from the Netherlands to tell him: ‘If things go wrong, you’re accountable [. . .] so that they could say, we sent someone’.

Importantly, experiences of betrayal can result not only from evidently unethical leadership, but also from more nuanced leadership transgressions that may not be immediately apparent. The complex relationship between frontline work and violence – marked by a complex position, dual roles and a morally ambivalent status – can place not just frontline workers themselves but also their leaders in tragic dilemmas. Leaders may find themselves trapped between competing interests and values, for example, in a complex web of ambitious political goals (e.g. a peace mission in a war zone), while simultaneously facing significant constraints on their abilities due to societal sensitivities (e.g. restricted rules of engagement, limited troops and lightly armed troops) and budgetary cuts (leading to staff shortages and inadequate training) (Molendijk, 2019). Thus, leaders may become caught in dual pressures and double-bind messages.

Ambiguity management

Unable to resolve tensions, leaders often resort to compromises. This can involve ‘strategic ambiguity’ in their decision-making and communication: the deliberate use of vague or ambiguous language to achieve a sense of agreement among stakeholders while allowing for multiple interpretations (Kalkman and Molendijk, 2021). While such compromises and ambiguity may smooth over disagreements between actors, they often do not truly solve the problems. That is, compromises may not mean that actual synthesis is achieved – that conflicting views and interests are truly reconciled – but rather, that conflicting views and interests are handed down or left to the lower levels to deal with (Molendijk, 2019).

The Srebrenica genocide in Bosnia is a tragic example of leadership feeling caught and thus unwillingly inflicting moral injuries on others. In 1995, the United Nations troops were deployed to protect the Safe Area of Srebrenica, but their mandate was intentionally (strategically) vague. They were mandated ‘to deter attacks’ against the Safe Area of Srebrenica, but no explicit authorisation was given to ‘defend’ Srebrenica (Rapporteur Report, 2015). At the Dutch political level, the decision was made to deploy only a few hundred peacekeepers armed with light weaponry – which Dutchbat soldiers dubbed ‘water pistols’. Consequently, the declaration of Srebrenica as a demilitarised Safe Area was not just violated during Srebrenica’s attack in July 1995, but daily from the outset. Military commanders in Srebrenica found themselves forced to keep their troops motivated while prohibiting them from intervening in violent incidents to avoid escalation, effectively trapping both themselves and their soldiers. For instance, one soldier recalled witnessing a Bosnian soldier being killed from an observation post and wanting to act, only to be told by his commander, ‘no, we’re not allowed to do that’. He felt powerless and humiliated, as the perpetrator ‘just waved at us with his gun’. The UN officials who had been responsible for the diplomatic drafting of Safe Areas later referred to it as ‘a fake solution’ primarily intended ‘pour la galerie’, and ‘not linked to operational realities on the ground’ (Rapporteur Report, 2015: 13–14).

So, while members of frontline professions clearly face moral challenges when their personal values unequivocally conflict with organisational or political directives, ambiguity can likewise lead to moral injury. Such ambiguity breeds disorientation and internal conflict among members, especially in high-stakes situations where these challenges acquire particular moral significance. In response to this moral disorientation and conflict, they may resort to different coping strategies. On the one hand, they may redefine their duty in clear-cut terms, while on the other hand, they may latch on to personally felt moral beliefs (Kalkman and Molendijk, 2021). Yet, in conditions of ambiguity, no response can completely protect them from the risk of developing moral injury. In the first case, they must actively distance themselves from moral challenges beyond their duty, which in retrospect may cause stress; in the second case, they will embrace these challenges and follow felt moral obligations, but they will face competing values while doing so.

Institutional: Lost in the bureaucratic family

A bureaucratic family

The police, and especially the military, exemplify what sociologist Goffman termed ‘total institutions’ (Goffman, 1961). They demand complete commitment from their members, blurring the lines between work, home and personal time, while also deindividualising members to create a uniform collective. While research has extensively (and justifiably) criticised these processes (e.g. Bikos, 2024), an exclusive focus on their negative potential risks overlooking their benefits. Terms like ‘brothers in arms’ (military) and ‘blue family’ (police), often used by members themselves, should not be hastily dismissed as mere indoctrination. Rather, they reflect a genuine and necessary sense of belonging, camaraderie and shared purpose. For many, these institutions provide identity and meaningful connections, which provide stability and vital support in high-impact conditions (Wakefield et al., 2024).

Then again, precisely because of these dynamics, these institutions also earn the label of ‘total’ or even ‘greedy institutions’ (Coser, 1974). Furthermore, they are not just families but also bureaucracies, whose bureaucratic nature imposes strict regulations, hierarchy and procedures on soldiers and police members, who are ‘assets’ and ‘resources’ rather than brothers and sisters (Chappell and Lanza-Kaduce, 2010; Eikenaar, 2023; Gilhuis et al., 2024). While this family–bureaucracy duality inevitably arises from the nature of military and police work, our research revealed it as particularly morally risky. Quite literally implying an institutional ‘two-facedness’, it can create morally damaging situations and, more significantly, contribute directly to moral injury by causing profound experiences of betrayal. As outlined in the previous section, the complex relationship between frontline work and violence – a complex position, with dual roles and a morally ambivalent status – makes professionals inherently reliant on and trusting of their leaders and institution. The family-like dynamics in such institutions deepens this trust, but also amplifies the risk of perceived betrayal when the bureaucratic nature of the system manifests itself, as discussed below.

Hot ‘n cold management

Members thus must manoeuvre through an institution that is ‘hot and cold’. As with most things, this is a matter of degree. Minor grievances are typically laughed off, providing fodder for running gags. For instance, a common joke among soldiers (and a recurring meme on military social media channels) is that, while they are trained as ‘brothers in arms’ handling highly dangerous weapons systems, they are prohibited from having a sandwich toaster in their rooms due to fire safety regulations – meaning they cannot make a toastie after a long day of dangerous work. While soldiers generally understand and accept that such paradoxes are inherent in their profession, grievances become more serious when higher stakes are involved, and the two faces of their institution truly begin to feel like two-facedness.

The following example illustrates the complexity of this. Nowadays, when scandals involving moral transgressions appear in the media, organisational and political leadership often responds with measures such as stricter protocols, zero tolerance for mistakes, ethics training, codes of conduct and integrity committees. While these adjustments appear highly morally responsible and indeed tweak some aspects of the work, they typically leave the overall nature of the job and its tasks unchanged (cf. Dekker, 2013). What this means is that, as one respondent put it:

So, you go through all the ethics training, and the codes of conduct and so on, . . . and then you’re still in the same situations, like dealing with aggressive, confused people, . . . but now you feel extra responsible [and] then they turn around and have integrity committees judging whether you did it right.

Thus, these interventions aimed at preventing future moral transgressions produce a paradoxical outcome: the moral burden of high-impact professions is shifted entirely onto the frontline workers, whose jobs become increasingly complicated, thereby increasing the risk of both self-directed moral injury (feeling guilt or shame due to a heightened sense of responsibility) and other-directed moral injury (feeling betrayed by the organisation and/or government that put them in these situations).

The most damaging scenarios are often Kafkaesque, especially following distressing incidents. No matter how well intentioned leaders may be, personnel are essentially viewed as assets in bureaucratic systems – either useful or expendable. For example, bureaucratic logic often leads to treating members who seek recognition for work-related illness as suspects, requiring them to prove their condition while fostering a tendency to remove sick individuals deemed ‘useless’ (Gilhuis et al., 2024). Meanwhile, colleagues may express concern, only to be told, ‘we’re not supposed to ask how you’re doing’ because bureaucratic rules dictate that giving the person rest means prohibiting all contact with the affected individual. As the institution increasingly manifests as a bureaucracy, members may realise that when sick, ‘all of a sudden, you don’t exist anymore’, and that ‘this “beautiful family” drops you like a hot potato’ (Gilhuis et al., 2024).

In response to such experiences, professionals may react in different ways: they may accept the harsh reality of being reduced to an obsolete asset and isolate themselves in disillusionment, or they may acquiesce and seek a new purpose and identity. Alternatively, they may fight back, demanding recognition and reparations for their service and the trauma-related problems caused by an incident and its aftermath. In bureaucratic systems, seeking recognition often requires filing formal claims or even pursuing lawsuits. A Srebrenica veteran explained his motive for filing a claim as follows: ‘Doesn’t somebody have to pay for the mistakes back then? The only way you have is to demand compensation.’ Consequently, many police and military members involved in incidents find themselves embroiled in legal battles against their organisation or government while primarily seeking recognition and justice (Gilhuis et al., 2024). This creates a frustrating ongoing cycle where they fight harder and harder for recognition and justice, only to encounter more bureaucratic red tape, which reinforces their sense of misrecognition and leaves them stuck in a ‘solidified fighting mode’ (Gilhuis et al., 2024).

The following section will explore the meaning of recognition and misrecognition in greater detail as it expands its focus to society at large.

Societal: Discomfort and misrecognition

Discomfort and misrecognition

As stated, frontline workers are not a rabble of bandits, but use force on behalf of an organisation, acting as instruments of the state, which has granted them the monopoly on violence. Their work occurs in the name of society, with soldiers and police members themselves being members of that same society. Accordingly, they engage in activities that are outsourced by society, as such endorsed and even admired, yet simultaneously laden with stigma (Hughes, 1962).

This ambivalence is integral to the sociological concept of ‘dirty work’ (Hughes et al., 2017), a term already referenced several times. While workers themselves may not always view their job as such, society often regards it as a necessary evil. ‘Dirty work’ includes professions stigmatised in different ways: physically (e.g. bin men), socially (e.g. maids) or morally (e.g. paparazzi). Physically and socially, ‘dirty work’ is typically seen as more necessary than evil, whereas morally ‘dirty work’ is often perceived as more evil than necessary (Ashforth and Kreiner, 2014). Military and police work carries physical, social and moral taints, while also being physically, socially and morally respected at the same time (Eikenaar, 2024).

Members of high-impact professions frequently express feelings of misrecognition, particularly those who have been injured in their work. While the concepts of recognition and misrecognition may appear straightforward – where misrecognition is associated with negative perceptions and recognition with praise – far more nuanced meanings emerged in our research. When professionals expressed feelings of misrecognition, they were not simply seeking sympathy. Nor did they mean that they lacked praise – many, in fact, vehemently dismissed ‘hoorays and cheers’ as ‘bullshit’. Rather, they contend that the public often fails to understand or acknowledge that ‘I’m a human being too’. These accounts resonate with Honneth’s (1997) concept of recognition as revolving around a moral relationship with others, which may be respected or damaged.

Recognition management

Many of the military and police personnel we spoke to noted they are ‘cautious about sharing experiences with people who don’t really understand’. On the one hand, they fear judgement. On the other, they find it equally problematic to reject all responsibility for their actions. As one respondent reflected on their inability to prevent a fatality: ‘You can tell me a thousand times, “there was nothing you could do”, but I was there. We couldn’t do anything – we didn’t do anything.’

While many factors contribute to this discomfort, a common thread is that caricatures such as hero, victim or perpetrator distort the complex experiences of professionals and, in doing so, commit an injustice to these experiences. In fact, recalling respondents’ laments about society’s failure to recognise that ‘I’m a human being’, these caricatures contribute to dehumanisation. Heroic narratives romanticise complex, morally fraught decisions as noble sacrifices, focusing on honour while concealing the grim realities of human suffering. Similarly, victim narratives reduce professionals to passive figures, stripping them of agency and rendering them as helpless patients suffering from illness. Whether through condemnation, glorification or pity, the complexities, tragedies and contradictions of frontline work are erased. This reduces the many-sided realities of this high-impact labour into simplistic, black-and-white stories, forcing professionals into one-dimensional roles, which obscure difficult questions of morality, responsibility and justice.

As discussed in the previous section, those who have experienced betrayal, neglect or misunderstanding may acquiesce to this reality, isolate themselves and/or become entangled in legal battles with their organisations and government. What they typically seek is recognition and justice, but instead, they often encounter the opposite, deepening their distrust and anger towards not only their employers but also the broader political system, and society as a whole.

Thus, our findings show that misrecognition can deepen moral injuries, and inflict new ones, while recognition can facilitate moral healing. Moreover, they indicate the importance of distinguishing between different types of recognition. In particular, a distinction between affirmative recognition and transformative recognition proves helpful (Gilhuis, 2025). ‘Affirmative recognition’ occurs when individuals feel acknowledged but remain trapped in guilt, shame or anger. ‘Transformative recognition’, on the other hand, enables individuals to move beyond binary roles of perpetrator or victim, helping them heal their relationship with themselves and society (Gilhuis, 2025).

Technical dimensions of moral injury

Frontline organisations are increasingly integrating new technologies into their operations. While technological innovation does not fit neatly into a specific level, such as the organisational or societal level, its prevalence makes it worth briefly discussing our findings on its impact and its relationship to moral injury.

Operators working with AI, autonomous weapons and other emerging technologies face moral-psychological risks stemming from several dynamics. A first significant challenge concerns the paradox of intimacy and estrangement (Van der Maarel, 2025). On the one hand, engaging with new technologies can feel like playing a video game, creating a sense of detachment. On the other hand, the experience is often more intimate than traditional methods of warfare (Enemark, 2019; Van der Maarel, 2025). For instance, during a conventional military firefight, soldiers typically only see the muzzle flash from their opponents’ firearms, whereas drone operators closely monitor their targets and directly witness their deaths as a result of their actions.

Second, new technologies can alter experiences of control and trust. For example, operators may feel a reduced sense of control because AI systems process vast amounts of data and may generate targeting information without operators fully understanding the underlying processes. As a result, they struggle to understand what happens within the black box of these systems. Operators must rely on systems that are never entirely reliable, that may ‘betray’ their trust. Consequently, they may experience feelings of uncertainty and distrust towards the technologies they are using (Hauer, 2021; Molendijk et al., 2025).

Finally, new technologies reshape experiences of legitimacy and responsibility, as the ‘frontline’ is no longer as literal as in traditional frontline work. Unlike conventional altercations, where professionals can invoke moral permission by framing their actions as self-defence – reasoning ‘It was him or me’ or ‘I was in danger’ – the same cannot be easily applied to modern technologies. Drone operators, for instance, may struggle to find similar moral justifications, which can lead them to feel more like perpetrators than protectors. As such, this shift in perceived legitimacy also reshapes professionals’ expectations, sense of purpose and professional identity. Being a ‘keyboard warrior’ is generally not viewed as honourable in the informal hierarchy of military identities (Van der Maarel et al., 2023). Also, as responsibility becomes shared between humans and machines, accountability often becomes ambiguous. When something goes wrong, it is often unclear who should be held responsible. This uncertainty can foster feelings of guilt and shame, as well as betrayal as operators feel left in the dark by their leaders and organisations.

Discussion

Table 1 offers an overview of the personal, situational and contextual dimensions of moral injury that emerged from the research. It also outlines the methodological process that led to these analytical insights, including the sensitising concepts identified as relevant either at the outset or during the course of the research. Figure 1 presents a conceptual model illustrating the dynamics of the identified personal, situational and contextual dimensions. The following sections describe these dimensions as presented in the table and figure, and discuss their theoretical implications.

Figure 1.

Conceptual model of personal, situational and contextual dimensions of moral injury.

A contextual model of moral injury

At a personal level, we found, individuals embody not an unequivocal moral code, but a complex constellation of moral beliefs developed through socialisation in different contexts, making this constellation inherently relational. To cope with this complexity, they may engage in value management through strategies such as compartmentalisation or flexibility in their moral reasoning. In terms of situations, what is potentially morally injurious involves scenarios where lives and values are at stake. In such high-stakes situations, individuals often try to manage these stakes through either disengagement or commitment to their responsibilities. The right course of action is rarely obvious, as morally challenging situations often present tragic dilemmas involving competing commitments to multiple communities: personal, organisational and beyond. Accordingly, despite employing coping strategies, long-term symptoms of moral injury, such as guilt, shame, betrayal, disillusionment and disorientation, may still develop.

Turning to the role of context, at the occupational level, many professionals view their work as ‘honourable dirty jobs’. This may lead them to taint management strategies, where they either sanitise their work, for instance by reframing their work as humanitarian, or condemn those who criticise it, for example by blaming them for ‘the luxury of judging war from a safe distance because we take up that nasty job for them’. Leadership and decision-making processes present additional challenges. Frontline workers often view their leaders as representatives and even guardians of the occupational moral ‘code’, which explains why they may feel not just disappointed but deeply betrayed when leaders prioritise bureaucratic procedures over ethical considerations or engage in moral transgressions. Yet, most failing leadership is not so straightforward; it is often characterised by double-bind (contradictory) messages and unclear directives. In response, workers may engage in ambiguity management, where they redefine their duty in clear-cut terms, disregarding everything outside these boundaries, or instead latch onto felt moral obligations, regardless of the consequences.

At the institutional level, structures and cultures create a ‘bureaucratic family’ that is ‘hot ‘n cold’: the brother- and sister-in-arms dynamic in high-impact professions creates strong bonds of dependency and trust between workers and the institution but also heightens the risk of experiences of betrayal when the bureaucratic nature of the institution asserts itself. In response, workers must engage in hot ‘n cold management. They may acquiesce, withdraw in disillusionment, or instead fight back, demanding recognition and reparations. However, resistance often only deepens moral injuries, trapping workers in a futile bureaucratic struggle and a solidified fighting mode: even when the organisation eventually extends a conciliatory hand, they often perceive it as too little, too late. At the societal level, finally, simplistic public perceptions, shaped by societal discomfort, can be problematic. Superficial accolades can be just as dehumanising as vilification, as neither does justice to the person’s lived experience. As a result, both fascination and condemnation can contribute to moral injury by fostering a profound sense of misrecognition. This may compel individuals to adopt recognition management strategies, seeking alternative sources of recognition, alienating from society, or, conversely, pursuing acknowledgement and justice. As with institutional struggles, these efforts may occasionally yield recognition, but more often they trap the individual further into a solidified fighting mode.

In sum, navigating varied contexts in high-impact professions prompts varied coping strategies, which, to summarise, all revolve around relationship management, involving different kinds of (dis)engagement with the experiences of moral conflict. These strategies may be effective unless, or until, the conflict becomes so great that they break down, leading to moral injury.

Implications for the psychology of trauma and the sociology of work

Offering insight into the omnipresent and complex moral-psychological dimensions of frontline work, this study and the resulting model contribute to both psychological trauma studies and sociological scholarship on frontline work.

As discussed, research on mental health in frontline professions is largely shaped by a psychological perspective, with a dominant focus on PTSD. Yet, PTSD research tends to overlook the ethical and contextual dimensions of trauma-related suffering (Griffin et al., 2019; Litz et al., 2009; Shay, 1994). In contrast, the concept of moral injury has the potential to go beyond the level of intra-individual psychological processes to consider the role of broader factors and actors. Despite this, even in the growing body of work on moral injury, the wider context and its ethical complexities remain insufficiently addressed (Hodgson and Carey, 2017; Hollis et al., 2023). This study addresses this gap. Our findings lead us to propose not a rejection of the dominant focus on individual psychology but an expansion to include more comprehensive, ethics- and context-informed approaches.

For example, the existing research on moral injury speaks of people having a coherent moral code or belief system, unequivocal moral transgressions and isolated morally injurious events (Frankfurt and Frazier, 2016; Griffin et al., 2019; Koenig et al., 2019; Litz et al., 2009; Shay, 1994). Our findings, however, show that both our moral beliefs and the situations in which these beliefs may be violated are never straightforward, but complicated, partly due to their relational and context-shaped nature. As morally injurious experiences undermine the very concepts of good and evil, they cannot be reduced to transgressive events violating one’s moral belief system. Instead, a more apt conceptualisation includes a moral belief constellation, moral dilemmas and value conflicts, and morally injurious situations. Also, the focus of current research on both moral injury and trauma in general as individual, intra-psychic processes is insufficient. Stress and trauma must be understood as always relational and context-shaped, involving ruptures in significant relationships: a rupture in one’s relationship with oneself, with specific others and with the wider community.

In addition to advancing the primarily psychological field of trauma studies, this study contributes to sociological research on ‘frontline work’, ‘extreme work’ and ‘dirty work’. As noted, in studies in this field, the actual impact on workers often remains peripherally examined (Eikenaar, 2024). While it may seem self-evident that frontline work is burdensome, our study reveals why this is so. It demonstrates that the greatest risk of (moral) trauma does not arise from specific violent or life-threatening events, as is often assumed in much current research – both psychological (Frankfurt and Frazier, 2016; Grossman, 1995) and sociological (De Rond and Lok, 2016; Garavan et al., 2024). Instead, the more profound threat emerges from the context in which the work takes place, and from the moral tensions that context generates. Specifically, this study sheds light on morally critical paradoxes and complexities at the heart of frontline labour, such as its manifestation as ‘honourable dirty jobs’ within ‘bureaucratic families’, factors that previous research has struggled to fully capture (e.g. Ashforth and Kreiner, 2014; Garavan et al., 2024; Hällgren et al., 2018).

These insights also have implications for our understanding of recognition. Our study expands Honneth’s (1997) conception of recognition as being about a moral relationship, making visible the moral-psychological stakes often left more implicit in sociological research on workplace recognition (Groutsis et al., 2020; Hancock and Tyler, 2024). It explains why misrecognition can even inflict moral injuries. To recognise someone is to do justice to their person and their experiences; misrecognition, by contrast, constitutes an injustice against them. Recognition, thus, lies not only in rewards or accolades – which may even be perceived as misrecognition if judged inappropriate – but in acknowledging the difficulty of frontline work.

Relatedly, building on research highlighting the potential satisfaction of ‘dirty work’ (Deery et al., 2019), our findings show that its ‘dirt-dimensions’ can cause harm yet also provide meaning and purpose. Paradoxically, the societal stigma attached to such work can even generate pride, reinforcing workers’ sense of honour in their willingness to roll up their sleeves and get their hands dirty, confronting what others reject. This reveals that organisations are open rather than closed systems, influenced by societal perceptions that shape and complicate the moral significance of work and the meaning of recognition.

Conclusion

Frontline work in high-stakes situations is high-impact work. Workers face human suffering while bearing significant responsibilities, exposing them to situations in which they must make complex decisions with far-reaching consequences, embodying a morally charged professional identity in morally complex contexts. Accordingly, what makes frontline work morally injurious – or morally enriching – is not just specific extreme events, but the context. This article introduced a contextual model of moral injury, thus contributing to both psychological trauma research and sociological studies of frontline work, while also pointing towards new directions for inquiry.

Mainly, additional studies across different occupational and national settings would be needed. Indeed, the central argument of this article is that context matters. Also, while the model presented here is empirically and conceptually grounded, it invites further testing. Future research could operationalise its components to explore how the different dimensions interact in shaping experiences of moral injury, using both qualitative and quantitative methods.

Understanding the context of mental health at work is both academically and practically relevant. Our findings indicate that relying exclusively on a psychological approach to trauma, focusing on intra-individual pathology, is not only incomplete but may also exacerbate moral injuries, since it places a disproportionate burden on workers while neglecting broader contextual factors. Undeniably, doing so is challenging. Even in our project, we found ourselves repeatedly drawn back into mainstream individual, pathology-focused interventions rather than systemic change. It is easier to implement isolated interventions that fit into existing infrastructures than to reshape the wider context. Yet, to effectively address stress and trauma at work, such a broader approach is needed – one that recognises the shared responsibility of individuals, organisations and society.