A new paper has shed light on moral injury UK prison staff, and outlines practical steps that can be taken now to mitigate the effects of a potentially traumatic occupational environment.
Moral injury is the intense, persistent distress resulting from events that challenge one’s moral beliefs. It is characterised by feelings of shame, guilt, anger, worthlessness, or disgust and can contribute towards the development of serious mental disorders (Litz et al, 2009) . Studies have shown moral injury to be significantly associated with post-traumatic stress disorder, depression and suicidality (e.g. Bonson et al, 2023). Moral injury can follow exposure to potentially morally injurious events (PMIEs) which typically include acts of commission (e.g. something I did), omission (e.g. something I failed to do) or betrayal by trusted others.
Research has explored the adverse impact of moral injury in several occupational groups who often encounter ‘high stakes’ situations, including military personnel/veterans, healthcare workers, humanitarian aid workers and human trafficking survivors. In this context, prisons are uniquely challenging occupational environments which face widespread issues of overcrowding, understaffing and high workloads. Prison staff attempt to fulfil multiple and competing roles of security, care, and rehabilitation, all whilst incidents of traumatic or challenging events, including detainee violence, self-harm and suicide, are rising. Ministry of Justice figures show that rates of detainee self harm in prisons in England and Wales have reached their highest levels since records began in 2004. Nonetheless, there is little systematic research as to the potential for moral injury in prison settings.
“Reduced investment in the prison estate in the UK means… the net result is an overall more junior, more stressed workforce working in poorer conditions.”
– Williamson et al., 2024
The nature of working in prisons means that staff often face physically and psychologically challenging scenarios, and prison staff report high rates of mental ill-health and suicidal thoughts . Equally, detainees may be especially vulnerable to moral injury-related mental health difficulties having engaged in illicit actions and been found guilty by a jury of their peers as well as, in high profile cases, the court of public opinion. Despite this, there is an evidence gap about the extent of moral injury in both prison staff and detainee populations, and about how prison staff/detainees can be better supported.
Reduced investment in the prison estate in the UK means that there are widespread issues of overcrowding, understaffing, high workloads, and increased incidents of violence and self-harm. The impact of this is seen in studies showing high rates of work-related stress, burnout, mental health difficulties in prison staff (Bell et al., 2019). The increasing rates of prison staff turnover may also mean there are more junior, inexperienced prison staff. This results in a more junior, more stressed workforce working in poorer conditions and potentially exposed to a greater volume of PMIEs. For the detainees in the UK prison system, it is not known how moral injury may be related to wellbeing or recidivism outcomes.
Tackling the problem
Several barriers to care for moral injury exist. Trauma-focused therapies (e.g. prolonged exposure) may not address the distressed experienced by those struggling with moral injury-related mental health difficulties. Some studies have argued such approaches could even exacerbate distress (Steinmetz & Gray, 2015). Detainees may avoid seeking help because of stigma, mistrust of healthcare providers, or fear of incriminating themselves. While prison staff, already overstretched and burned out, often fail to access the help they need.
Researchers from King’s College London, University College London and Combat Stress have received funding from the NIHR Three Schools to explore the impact of moral injury amongst prison staff and co-design an intervention programme for staff. If future testing shows the programme is effective, this codesigned programme could not only improve prison staff wellbeing and reduce staff turnover, but it could also have positive effects on prisoners by reducing staff stress and improving staff-prisoner interactions. This study is the first step in ensuring a large population of prisoners with complex needs are better cared for by staff who are healthier and happier.
“The need to understand and address this problem in UK prisons is clear. By acting now, the end result extends beyond staff welfare and turnover and help ensure better health, conditions and cost-effectiveness for staff, prisoners and the system itself.”
In an article published in the European Journal of Psychotraumatology the team outlines practical steps that could be taken now to address moral injury in prisons:
- Tailored mental health programs. Develop treatment approaches that fit the limited resources available in prisons. Treatments that require months of 1-1 work may not be feasible in resource limited, prison settings.
- Prevention strategies for staff. Introduce co-produced workshops, psychoeducation, and peer support networks to help staff manage responses to PMIEs and stress.
- Provision of adequate resources. Ensuring stable staffing structures which allow adequate time and resources for staff to receive training, support and engage in reflective practice. Healthcare in prisons should be adequately resourced to ensure those requiring support for moral injury have timely access.
- Enhanced role for chaplains. Train chaplains to support both staff and prisoners in effectively dealing with moral injury.
- Creative therapies. Use group-based approaches like art or music therapy when one-on-one sessions aren’t possible.
It might ultimately be that, as in other healthcare domains, showing the cost-effectiveness of timely, evidence-based interventions, whether in terms of reoffending or staff turnover, is what galvanises change and leads to the design and delivery of the high-quality support that is needed in prison contexts.
