Core Components of Moral Injury Groups Co-Facilitated by Mental Health Providers and Chaplains

Abstract

Despite increasing interest in moral injury, there is not yet consensus around what it is (and is not), who can have it and under what circumstances, or the degree and form of distress necessary to distinguish moral injury from other psychological and spiritual difficulties. The novelty of moral injury has created space for frontline Veterans Health Administration mental health and spiritual care providers to creatively apply their core professional skills and identities to moral injury. This paper presents findings of a core components analysis (CCA) derived from seven co-led chaplain-mental health moral injury group facilitation teams that were involved in a 16-month quality improvement endeavor of the Dynamic Diffusion Network (DDN). The DDN initiative engages providers in collaborative and iterative refinement of practices to promote rapid improvements in care for complex problems that lack a codified evidence base. Using CCA, we identified 10 core components of co-facilitated moral injury group care. Components include a clear conceptualization of moral injury, an inclusive approach to spirituality, and exploration of forgiveness, among others. This paper offers guidance that can be widely applied and readily adapted as our collective understanding of moral injury continues to expand and clarify. The core components are articulated here as principles for ongoing review and revision in response to future moral injury advances in the DDN and elsewhere.

Despite progressively increasing interest in the topic of moral injury (Nieuwsma et al., 2022), there is not yet conceptual or definitional clarity around what moral injury is (and is not), who can have it and under what circumstances, or the degree and form of distress necessary to distinguish moral injury from moral challenges, moral stress, or various forms of psychopathology (Litz & Kerig, 2019). At present, moral injury is not a psychiatric disorder and thus does not have diagnostic criteria or “symptoms.” Additionally, the term “moral injury” is variably used to refer to both events/experiences that are theorized to potentially lead to moral injury as well as sequelae (e.g., psychological, spiritual, social, etc.) that purportedly arise from the experience of moral injury. While working definitions of moral injury are numerous and varied, they share a common theme: a betrayal or violation of “what’s right.” Existing reviews summarize the rapidly evolving literature concerning what constitutes such a violation or betrayal, how to distinguish potentially morally injurious events from the experience of moral injury, associations between the experience of moral injury and various sequelae, limitations regarding the measurement of moral injury, and the intersections of mental and spiritual concerns in moral injury (e.g., Carey et al., 2016; Frankfurt & Frazier, 2016; Griffin et al., 2019; Yeterian et al., 2019).

Moral injury intervention efforts have employed various approaches to work through these murky waters (Currier et al., 2021). Some researchers have adapted interventions that were designed to target post-traumatic stress disorder (PTSD) (e.g., spiritually-oriented CPT; Pearce et al., 2018) or religious strain in the aftermath of trauma (Building Spiritual Strength; Harris et al., 2011). Others have developed interventions that target specific events (e.g., killing; Maguen et al., 2017) or sequelae (e.g., guilt; Norman et al., 2014) that are believed to be associated with moral injury. Still others have developed novel interventions that attempt to address the sequelae of specific working conceptualizations of moral injury (e.g., Gray et al., 2012). Finally, an existing transdiagnostic approach, Acceptance and Commitment Therapy, has been applied to the problem of moral injury by numerous individuals and groups (e.g., Borges, 2019). These varied interventions reflect only some of the diverse perspectives that should inform discussion of moral injury care. Notably, the interest in conceptualization, measurement, and intervention concerning moral injury is not limited to researchers; interest is also widespread among frontline mental health and spiritual care providers in the Veterans Health Administration (VHA; Drescher et al., 2011; Wortmann et al., 2021), as these are the providers who must find ways to respond effectively to the pressing needs their patients bring, using the best available evidence.

One persistent challenge in the realm of intervention development is the substantial time lag in translational research (Morris et al., 2011). Randomized controlled trials (RCTs) are one reliable, trusted way of generating clinical evidence; however, there are also field-based methods that address some of the limitations of RCTs by conducting inquiries in a more naturalistic manner (e.g., cohort studies, quality improvement initiatives). The quest to establish an evidence base for clinical interventions is further challenged by the lack of consensus regarding criteria for determining empirical support for psychotherapy generally, especially given that indicators of empirical support, such as statistical significance, may not be clinically relevant (Cook et al., 2017).

The American Psychological Association (APA) defines evidence-based practice in psychology (EBPP) as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (APA Presidential Task Force, 2005). Supporting evidence can derive from numerous methodologies (e.g., clinical observation, systematic case studies, studies of interventions delivered in naturalistic settings) as long as it is assessed and applied appropriately in clinical decision-making (APA Presidential Task Force, 2005). It is necessary for individual providers to have the appropriate knowledge, skills, and abilities to assess and apply evidence, and being part of a community of practice can help guide the collection, assessment, and application of evidence to clinical decision-making (Wenger et al., 2010). Notably, “the key to evidence-based psychotherapies is to use the best available evidence and differentiate between limitations and ‘fatal’ flaws” (Cook et al., 2017, p. 540). A fatal flaw risks irreparable harm to the person seeking care; a limitation can be grist for the therapeutic mill if approached carefully, cautiously, and with accountability to a community.

Furthermore, the evidence-building process should involve learning from what is already occurring on the frontlines of care (e.g., how patients present and how practitioners intervene with limited or no guidance from research). Too often research is limited by a narrow focus on rigorous methodology at the expense of external validity or on specific treatment ingredients that downplay contextual variables (Barkham, Stiles, et al., 2010). More effort should be devoted to building evidence through simultaneous integration of top-down and bottom-up approaches, making the best possible use of the triad of research, clinical expertise, and patient characteristics, culture, and preferences.

The novelty and readily apparent clinical relevance of moral injury has created a space for frontline VHA mental health and spiritual care providers to think creatively about how to apply their core professional skills and identities to moral injury - a form of distress that overlaps with and is also distinct from other concerns commonly addressed by frontline providers, such as PTSD and depression (Smigelsky et al., 2019). Some VHA providers have formed interdisciplinary collaborations that draw on the strengths of both mental health treatment paradigms and spiritual care traditions to intervene in the suffering of those with moral injury, and these providers comprised the moral injury arm of the inaugural Dynamic Diffusion Network (DDN; see Smigelsky et al., 2020 for a full program description). The DDN was formed in an effort to harness collective clinical knowledge and experience, with the hope of deepening understanding of moral injury and contributing to the development of evidence-based psychospiritual therapeutic practice. The multidisciplinary, network-based, measurement-focused, and reflective design of the DDN is consistent with the hallmarks of practice-based evidence, as described by Barkham, Hardy, and Mellor-Clark (2010). The purpose of the present project and analysis is to identify and describe the core components of co-facilitated moral injury group therapies based on findings from a 16-month DDN initiative.

Method

Participants and Procedure

Seven pairs of mental health providers and chaplains from sites across VHA were selected to participate in the DDN initiative based on approaches they developed to address moral injury (Smigelsky et al., 2020). These approaches were developed independently of one another at different times and in different locations. A request for moral injury group materials was made to all VHA chaplains in 2017 and yielded over a dozen submissions of protocols, curricula, and guides. Six different group curricula (with one curriculum being used at two sites) were selected for inclusion in this DDN process. Participating teams were based at VHA facilities in the following locations: Durham, NC; Madison, WI; Mountain Home, TN; Muskogee/Tulsa, OK; Philadelphia, PA; Portland, OR; and San Antonio, TX. The DDN was reviewed and approved by designated VHA Central Office authorities as a non-research quality improvement activity based on regulations summarized in VHA Handbook 1200.21.

Qualitative data were gathered from intensive consultation with DDN teams occurring between June 2019 and September 2020, which included but was not limited to: facilitated individual team calls (n = 8 per team); quarterly small group calls with all moral injury teams (n = 4); examination of moral injury group curricula and related documents (e.g., screening measures, recruitment materials); interviews with non-facilitating providers and facility leadership at the selected sites of care; review of written summary reports (n = 5 per team) and weekly survey responses submitted by teams; and participant observation by the first author (MS) in moral injury groups to the extent possible. The first author (MS) served as the facilitator of the DDN and thus was intimately involved in all of the activities described. Additional data was derived from personal and programmatic documentation as well as informal correspondence between the facilitator and DDN team members.

Core Components Analysis

Core components analysis (CCA) refers to a “systematic effort to identify the critical elements of a program,” or the elements that must be reproduced for successful implementation (Backer, 1999, p. 39). Non-critical programmatic elements may be included, excluded, or adapted based on contextual factors. CCA is a necessary step in the process of balancing fidelity with context-driven adaptation (U.S. Department of Health and Human Services, 2002). With regard to evidence-based psychotherapy specifically, core components refer to basic elements that are necessary for the intervention to be appropriate and valid (Cook et al., 2017). These elements are typically determined by the intervention developers and help describe “population characteristics, content of the psychotherapy, context or setting of the intervention, and sequence of treatment” (Cook et al., 2017, p. 541). Given that moral injury intervention research is limited, and in light of the real-world settings in which these groups are being employed, CCA was determined to be a developmentally appropriate methodology for analysis at this point on the trajectory of the work. In this CCA, the subject of analysis was moral injury group content and procedures. Various sources of qualitative data (described above) were reviewed in search of common components. Analysis involved determining whether a component met the following three criteria: 1) inclusion of the component across multiple moral injury groups at participating DDN facilities (as determined by the qualitative data collection methods noted above); 2) qualitative report of the importance of the component by DDN team members (e.g., via interviews, written reports, and/or group discussion); and 3) concordance with existing moral injury and/or psychotherapy literature. If all three criteria were met, then the component could be considered “core,” as defined and described above.

Results

Based on the evidence available at the time of this analysis, the CCA identified 10 core components of co-facilitated moral injury groups. Below we name each of these components, describe them and note existing research with which they are aligned, and provide illustrative examples from participating DDN teams as appropriate.

1. A Clear Conceptualization of Moral Injury That Is Reflected in the Intervention Components and Participant Selection

As was previously stated, there is not one agreed upon understanding of what moral injury is or what intervention should look like (Litz & Kerig, 2019). However, this need not be a barrier to providing care. Instead, any intervention that is said to target moral injury should, in the context of that intervention, provide a working conceptualization of moral injury that can be traced through the various intervention components. For example, the moral injury group offered at the VA medical center in Philadelphia (P-MIG) conceptualizes moral injury as stemming from the inequitable distribution of moral pain (Antal et al., 2019). This inequitable distribution is directly addressed through sharing of moral injury stories with the broader community as part of a healing ceremony. Such a ceremony would not be necessary for an intervention that is not based on a conceptualization of moral injury that involves shared culpability. Yet in the case of P-MIG, this intervention component clearly flows from the moral injury conceptualization. Furthermore, the conceptualization influences which veterans are appropriate for participation in the group. In the case of P-MIG, the group is specifically targeted to veterans with morally injurious experiences that occurred in combat. A group with an emphasis on shared culpability for war may not be appropriate for someone whose morally injurious experience involved a buddy being killed during a training exercise, or someone who was sexually assaulted by a fellow service member while awaiting deployment. In summary, there should be a clear connection between the conceptualization of moral injury that is communicated, the intervention components that address it, and the individuals who are recruited for participation.

2. Process Group Therapy Co-Facilitated by a Mental Health Provider and Chaplain

This core component is comprised of three parts, beginning with it being a process-oriented group. The key therapeutic principles of process group therapy articulated by Yalom and Leszcz (2008) all are important for optimizing group therapeutic processes; however, the principles of particular relevance for moral injury groups include: instillation of hope, universality, altruism, interpersonal learning, catharsis, group cohesiveness, and existential factors. A person suffering from moral injury is likely to feel some blend of hopeless, alone, worthless, powerless, misunderstood, purposeless, and stuck (Drescher et al., 2011; Koenig, Ames, et al., 2017). The key principles of process group therapy speak directly to these difficult experiences by the nature of the group, independent of targeted interventions that are also included. While some didactic and facilitator-led content is necessary, moral injury groups must contain sufficient space for the therapeutic group process to unfold, which in itself has the potential to help.

Part two of this core component is the expectation that group members will actively participate in the group process and share their moral injury story. This expectation is set upfront in the group, with considerable time in group devoted to preparing one’s story. Shay (1994) asserts that healing from the trauma of moral injury “depends upon communalization of the trauma – being able safely to tell the story to someone who is listening and who can be trusted to retell it truthfully to others in the community” (p. 4). It is important to note that the approach to sharing one’s story in the context of these groups differs from that of a trauma narrative in PTSD treatments like Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE). While the Socratic dialogue and emotional processing approaches utilized in those treatments rely on detailed accounts of what happened, the emphasis in moral injury groups is on the perceived meaning of what happened and the resulting impact on one’s perceived possibilities for the future (see core component 6). This is especially relevant when an individual struggles to identify a specific event that is the source of moral injury. For many, the sum total of a series of seemingly insignificant or unrelated offenses (perhaps summarized in an overarching statement such as, “Vietnam – the whole thing”) can be unpacked through a lens of meaning that draws from numerous events to articulate a broader narrative. While drawing from multiple experiences is not problematic, it is important that there is enough specificity in the story to identify and elicit that which brings about shame for the individual (see component 3).

Part three is co-facilitation by a licensed mental health provider and a board-certified chaplain. Moral injury is consistently theorized to contain both psychological and spiritual dimensions (Litz et al., 2009; Wortmann et al., 2017). Like moral injury, definitions of spirituality are diverse and varied. For the purposes of the present study, spirituality refers to “that which gives meaning, purpose, and hope in life” (Department of Veterans Affairs, 2019, p. 5). The opportunity to address these distinct yet intersecting dimensions concurrently in a co-facilitated group allows veterans to integrate their experience from multiple perspectives within a single care context. Furthermore, team-based healthcare is generally considered optimal for complex problems and problems with multiple etiologies. Thus, moral injury is a good candidate for team-based care consisting of mental health and spiritual care expertise in contexts where such care is feasible. Mental health providers should have training and experience with trauma processing and trauma-informed care. Chaplains should have training and/or board certification in mental health and experience working in pluralistic settings. Notably, the chaplains who were part of this DDN initiative had previously completed an intensive, year-long, sub-specialty training in mental health designed specifically for VA and military chaplains (Integrative Mental Health, 2021; Nieuwsma et al., 2015).

While the attributes and experiences of individual facilitators are important, the relationship between the facilitators is equally so. Research consistently demonstrates that the therapeutic relationship accounts for patient improvement (or lack thereof) at least as much as the treatment method (Norcross & Wampold, 2011), so deliberate attention to the therapeutic relationship, including between co-facilitators, is imperative. Furthermore, a solid working relationship between co-facilitators promotes peer supervision, which is appropriate for diverse professionals (Roller & Nelson, 1993).

3. Utilization of a Group Approach to Address Shame

Shame is commonly noted in discussions of moral injury. The impulsive response to shame is to hide out of a fear of losing connection (Brown, 2012). Shame is counteracted in moral injury groups through vulnerability leading to acceptance from one’s peers. Research examining the value of peer support services among veterans with PTSD found that peer support facilitates acceptance of one’s difficulties, relative to symptom resolution, and promotes improved functioning despite ongoing symptomatology (Kumar et al., 2019). While moral injury groups are facilitated by professionals, the peer support element of the group context should not be underappreciated. Furthermore, it is not uncommon for moral injury group participants to experience such powerful validation from the act of sharing in the group that they want to share their story with loved ones. Some groups facilitate this as part of a community ceremony (e.g., Philadelphia, Durham). However, it is important to note that sharing must be met with acceptance and validation, which is facilitated in a group therapy context but cannot be guaranteed with others. Thus, disclosure outside of the group context should be carefully considered and possibly facilitated. While the expectation of sharing in the group context is set early, and most individuals choose to engage, sharing is not an absolute requirement. Ultimately, the autonomy of the individual is respected.

4. Inclusive Approach to Spirituality and Religion, Especially as Related to Individual Meaning and Purpose

Co-facilitated moral injury groups are appropriate for individuals who are willing to explore existential/religious/spiritual aspects of their lived experience. Moral injury groups should be designed in a manner that is appropriate for persons of any religious faith or none to engage in the process together. Furthermore, groups should be able to accommodate a diverse range of spiritual perspectives simultaneously, from those that reflect the teachings of religious traditions to those that are more humanistic or philosophical in nature. This is made possible largely by the skilled co-facilitation of a chaplain. Chaplains are the designated spiritual care providers in VHA. Importantly, chaplain care is not about conforming to the chaplain’s faith but rather focuses on “respecting and supporting an individual’s religious/spiritual practice while providing emotional and pastoral care” (Nieuwsma et al., 2021). While some approaches to moral injury care explicitly adopt a specific religious lens (e.g., Ames et al., 2021; Pearce et al., 2018), co-facilitated moral injury groups do not focus on religious coping (Koenig, Boucher, et al., 2017) or even religious/spiritual struggles (Brémault-Phillips et al., 2019) per se, but rather create space for religion and/or spirituality in the process of meaning making. One way that facilitators seek to create this kind of space is through careful attention to inclusivity. For example, if a group member uses language from a particular religious tradition and is met with approving nods from several other group members (e.g., “I know I’m forgiven because Jesus died for my sins”), a facilitator may respond by saying, “It sounds like your faith teaches you that forgiveness is possible through Jesus. What do others’ faith traditions teach about forgiveness?” This type of response does not challenge the beliefs of the more outspoken group member while also validating and encouraging the expression of diverse religious perspectives.

Most psychotherapists receive little or no training in religious and spiritual issues (Magaldi & Trub, 2018; Vieten et al., 2013). Those that do are presumably better equipped to address such issues in the context of individual psychotherapy; however, the ability to simultaneously hold space for a Southern Baptist, an atheist, and a person who isn’t sure what they believe about God/a “Higher Power” is likely beyond the scope of competence for the typical mental health provider. Creating an environment that is safe and open to diverse religious and spiritual perspectives, as well as a space where those perspectives are invited and examined, is challenging. Mental health providers should rely heavily on well-trained chaplains to create that space, while mental health providers remain specially attuned to psychological difficulties that may arise, such as emotion dysregulation and difficulty tolerating distress.

5. Systematic Measurement

Measurement-based care is regarded as a core component of numerous evidence-based practices (Scott & Lewis, 2015). Given the novelty of moral injury as a clinical problem (and consequently the novelty of interventions to address it), it is reasonable that moral injury group facilitators should be especially diligent about measurement. This could include key constructs that are consistent with the conceptualization of moral injury guiding the group and that provide feedback to improve individual outcomes and/or the group experience. Such constructs include moral injury exposure and sequelae (e.g., Moral Injury Events Scale; Nash et al., 2013), mental health symptoms (e.g., PHQ-9; Kroenke et al., 2001; PCL-5; Weathers et al., 2013), religion/spirituality (e.g., Religious and Spiritual Struggles Scale; Exline et al., 2014), and other related constructs (e.g., psychological flexibility, posttraumatic growth, self-compassion, forgiveness, and meaning making, etc.).

Data can be quantitative or qualitative. Qualitative data may be captured from verbal (e.g., written narratives, as in the REAL group; see Smigelsky et al., 2022) or visual means, such as the cracked bowl drawings used by the San Antonio team (see Pernicano et al., 2022 for more information). Data can be captured once or at multiple time-points, depending on how it is to be used. Measurement may focus on symptom reduction, life promotion (e.g., post-traumatic growth), group processes, therapeutic alliance, and other relevant areas. In addition to the opportunity to use measurement-as-intervention (Sprott et al., 2006), measurement-based care in the context of moral injury groups helps to build an evidence-base for the effectiveness of these groups under real-world conditions.

6. Attention to All Three Phases of Herman’s (1992) Trauma Recovery Model in the Intervention Curriculum and Implementation Procedures

The three phases are stabilization, processing, and reintegration. Moral injury groups typically devote a few sessions to each phase. Early sessions focus on building rapport and establishing psychological safety. This may also occur prior to the start of group through individual sessions or, in the case of the San Antonio and Durham teams, through a separate, 4-week moral injury psychoeducation group. The common element involves familiarizing participants with moral injury and what participation will entail while helping them discern if the group is the right place at the right time for them. Processing sessions typically involve preparing for and telling one’s moral injury story, as well as witnessing the stories of others. Reintegration involves discovering or creating new ways to relate to one’s story as a result of the group experience and specific intervention components.

7. Cognitive Intervention Focused on Increasing Psychological Flexibility with Regard to Possibilities in the Aftermath of a Morally Injurious Event

Moral injury groups are not primarily concerned with the factual accuracy of the morally injurious event, including “accurate” attributions of blame (though this may be addressed in some cases; see Discussion below for adaptable components). Attributions of blame (which will be discussed in more detail as part of the core component of forgiveness) may be taken at face-value and accepted. Moral injury group intervention focuses on expanding cognitive flexibility about the possibilities in the aftermath of the event, which is typically where a person is stuck. Consider a soldier who has killed a child in combat. Socratic questioning about the event may help deconstruct responsibility such that the soldier recognizes that responsibility is shared by them, their commander, and the enemy fighter who used the child as a human shield. However, the crux of moral injury lies in the foreclosure of options the soldier can imagine in response to that event. Even though they are not fully responsible, they do not know how to release self-blame without minimizing or dishonoring the significance of the child’s life. Accepting the situation and its complexity and processing the related emotions is not enough, as shared responsibility can still lead to profound distress. Moral injury intervention builds on acceptance and enters realms of meaning and purpose through the event. For example, one group member who experienced this event chose to volunteer at a local elementary school. Being around children the age of the one he killed ensured that he would not forget. But it also gave him the opportunity to directly help children, which was his way of making amends.

8. Exploration of Forgiveness and Attributions of Blame

“Failure to forgive” was part of Litz and colleagues’ (2009) working conceptualization of moral injury, though the overwhelming emphasis was on self-forgiveness. Building on this theoretical foundation, multiple moral injury group interventions relied on the work of psychologist Everett Worthington (e.g., Worthington et al., 2013, 2014; Worthington & Langberg, 2012) to directly inform interventions around forgiveness. The topic of forgiveness may constitute a substantial or relatively minor part of a moral injury group intervention. Moral injury groups should explore forgiveness in a manner that helps participants identify who they blame for the event, regardless of whether they struggle with forgiveness. It is commonly accepted that perpetration-based morally injurious events are more likely to involve difficulties with self-forgiveness, often accompanied by explanations such as, “If I forgive myself it’s like letting myself off the hook or saying her life didn’t matter. I don’t ever want to forget what happened.” Betrayal-based morally injurious events are typically associated with difficulty forgiving others, such as “I want to let go of what happened, but he doesn’t deserve forgiveness. He needs to pay for what he did!” What is less commonly explored but equally important is morally injurious events that result from moral paradox, when no one is to blame (Fleming, 2021), or moral ambiguity, when what is right or wrong is unclear. A person may be “stuck” with regard to forgiveness because they cannot identify who is to blame and therefore cannot work through a process of forgiveness. This may sound like, “I was screwed either way. There was no right answer. War is supposed to be this noble thing, fighting for what’s right, but I can’t even tell what’s worth fighting for. Maybe nothing.” The absurdity of moral paradox can lead to despair or, ideally, transcendence (Fleming, 2021). While it is likely that most people suffering from moral injury are experiencing difficulty with forgiveness in some fashion, identifying and understanding that struggle is more likely to begin in a moral injury group than to be resolved. For many, explorations of blame attributions and forgiveness difficulties directly inform future directions the person takes (e.g., making amends, participating in humanitarian efforts, advocating for others).

9. Incorporation of Ritual

Rituals are an important part of human life, particularly during times of transition or crisis; they “empower healing and help restore experiences of belonging” (Ramsay, 2019). Rituals are performed outwardly and often involve invoking or connecting to something sacred that transcends the individual. Moral injury causes people to feel that they do not belong and that the world does not make sense; ritual provides an opportunity to respond to those needs through symbolism and communal expression (Ramsay, 2019). While ritual can take different forms across moral injury groups, it is always present. It may be as simple as group members reciting a quote together to conclude each session or as complex as the ceremonies that occur in the Philadelphia and Mountain Home groups, wherein veterans tell their stories to an audience of community members who are invited to assume partial responsibility for veterans’ actions in war (Cenkner et al., 2021).

10. Person-Centered Orientation with Emphasis on Both Insight and Action

Co-facilitated moral injury groups do not pledge allegiance to a single theoretical orientation. However, a person-centered orientation is intentionally manifested in the facilitators’ attitudes. Unconditional positive regard (UPR) is sometimes misunderstood as accepting or condoning whatever the patient says. More accurately, UPR is about conveying to the patient that they are fundamentally valuable and worthwhile. This is especially important when addressing moral injury. According to Rogers (1961):

As [the individual] expresses more and more of the hidden and awful aspects of himself, he finds the therapist showing a consistent and unconditional positive regard for him and his feelings. Slowly he moves toward taking the same attitude toward himself, accepting himself as he is.

(p.63)

Additionally, the attitudes of the facilitators should reflect the belief that patients are agents of change in their own lives and that they have the capacity for self-healing (Cook et al., 2017), and while the facilitators bring expertise, they are first and foremost companions on a journey (Wolfelt, 2005). In the words of Jonathan Shay (1994), “healing [from moral injury] is done by survivors, not to survivors” (p. 187). Thus, group facilitators adopt a posture of journeying alongside, utilizing their professional skills to help group members discover valuable insights and to encourage change as group members wrestle with their own experiences and pursue meaning from them.

Discussion

The purpose of this paper was to identify and describe core components of co-facilitated moral injury group therapies based on findings from a 16-month quality improvement initiative consisting of six distinct collaborative moral injury group interventions that were developed without knowledge of one another. The consistencies across these approaches suggest a common understanding of the clinical presentation of moral injury in veterans. The first core component – a clear conceptualization of moral injury that is reflected in the intervention components – reflects both the diversity of perspectives that have shaped early conceptions of moral injury as well as the “essence” of those diverse perspectives, namely a violation of what is “right.” The fact that each group therapy has slightly different emphases and interventions is indicative of two things: 1) a perceived need by frontline providers to develop novel care practices and adaptations to evidence-based modalities to optimally address moral injury, rather than relying upon preexisting interventions for other mental health problems (Burkman et al., 2019; Finlay, 2015); and 2) a responsiveness to clinical needs as presented in the local context, which is a key aspect of implementation science that can be overlooked in broad-based dissemination efforts (Bauer et al., 2015).

Our findings support existing literature suggesting that shame is commonly experienced in the context of moral injury (Bryan et al., 2018; Lloyd et al., 2021) and this appears to be the case regardless of the type of precipitating event. Shame – especially when it is the result of a combat-related morally injurious event – may be more meaningfully addressed in the company of fellow veterans than solely one-on-one with a care provider. This bodes well for VA care, where group approaches can help increase access and reduce wait times. However, shame is also a known barrier to engaging in care (Clement et al., 2015). To help veterans overcome this barrier, facilitators may wish to communicate to potential group members that those who listen to the stories must be “trustworthy,” meaning that listeners possess the ability to hear another’s story without being injured themselves, the capacity to hear the story without denying its reality or blaming the teller, and the readiness to experience some of the teller’s raw emotion (Shay, 1994, p. 188).

Additionally, for veterans whose experience of shame is connected to religious beliefs or expectations, the co-facilitation of a chaplain may be especially relevant (Hodgson & Carey, 2017). Many individuals’ sense of “right” and “wrong” is influenced, if not directly shaped, by religious or spiritual teachings. Some veterans fear rejection by their religious/ spiritual community, leaders, and/or Higher Power for what they have done or experienced, and others have experienced that rejection outright. Willingness to participate in a group co-facilitated by a spiritual care provider, especially in the presence of such fear and/or rejection, provides a unique opportunity to process those beliefs and experiences, whether in one’s own mind or verbally with a chaplain. Furthermore, it can be beneficial to hear how others reconcile their experiences with their religious or spiritual identities and convictions.

Utilizing approaches that offer an inclusive approach to spirituality and religion may help address both logistical and therapeutic considerations in VA settings. The religious breakdown of veterans is overwhelmingly Christian, specifically Protestant (U.S. Veterans Eligibility Trends and Statistics, 2015). Thus, it may be relatively easy to convene a group of veterans who identify as Protestant Christian in a singular location, but incredibly difficult to assemble a group of veterans who identify with other religious, spiritual, or sociocultural groups. For this reason, group-based approaches from a particular religious perspective may present a barrier to care, especially for those who do not identify with the majority.

Therapeutically, it is imperative to remember that, particularly for highly religious or very spiritual veterans, their way of identifying what is “right” – and thus what was violated by the morally injurious event – is likely to be connected to their religious or spiritual faith and may be interpreted as a “moral struggle” (Exline et al., 2014; Wilt et al., 2019). If a person believes they have violated a core tenet of their faith (e.g., desecration of the sacred; see Pargament et al., 2005) , they may not be appeased by sacred texts or behaviors (e.g., prayer) that are thought to bring comfort. By contrast, they may feel that those very resources are unavailable to them, or they may be disillusioned by them. In the midst of this kind of complexity, an inclusive approach to spirituality and religion not only creates an environment where all are welcome but also encourages meaning-making from the individuals’ lens, rather than relying on a religious framework that may have been fractured by the morally injurious experience. This is not to say that religious frameworks should be dismissed entirely; theological questions are valid in the face of moral injury and facilitators may choose to encourage veterans to seek out the perspectives of community clergy/faith leaders to help them understand and apply the teachings of a given faith to the experience of moral injury (Pyne et al., 2019). However, given the potential risk of rejection and ostracization, facilitators should proceed with caution in making such recommendations.

Moral injury should be regarded as traumatic in that it shatters core assumptions individuals hold about themselves, others, and the world (Janoff-Bulman, 1992). Individuals suffering from moral injury may or may not meet diagnostic criteria for mental health problems, particularly trauma-related disorders. However, it is imperative to recognize that the traumatic nature of moral injury arises from senselessness and/or meaninglessness, which erode one’s ability to comprehend what happened and/or lead to existential disorientation, or a lack of “footing” in the world (Holland et al., 2010). The psychological and spiritual fragility engendered by this type of trauma requires an approach to care that prioritizes psychological safety, autonomy, curiosity, and creativity.

Given the traumatic nature of moral injury, it is worth noting that many of the veterans who participated in co-facilitated moral injury groups had been diagnosed with PTSD and had received gold-standard treatments for PTSD from VA providers, specifically CPT. While CPT may help the individual cognitively restructure their interpretations of the event (particularly the “facts” around how and why the event happened), it seems to stop short of addressing the shame, guilt, and other core aspects of moral injury that elicit existential questions about how and why such a thing could happen in the first place. According to providers, CPT may do a good job of helping a veteran recognize that they were not solely responsible for the morally injurious event, but the treatment has been perceived to offer little to help the veteran contend with the grief, regret, sadness, anger, etc. that they felt over their portion of responsibility. As a result, the veteran may remain stuck in a particular belief about what they must do or how they must live in order to atone for their share of responsibility. The behavioral manifestation of this may appear adaptive, such as volunteering at a local school, and be conceptualized as prosocial behavior arising from appropriate guilt. Indeed, in cases of PTSD without moral injury, this conceptualization and interpretation may be accurate. However, if the underlying distress stems from morally injurious beliefs (e.g., I am a monster; No one could forgive me for what I’ve done; I must continue to suffer as penance for the suffering I caused) that have not been addressed, then the suffering and pain may remain unabated but hidden from view by adaptive behaviors. Co-facilitated moral injury groups can pick up where traditional cognitive restructuring leaves off by focusing on that enduring pain and seeking to transform it from something that should be “treated” to something that gives the individual a unique perspective and capacity to contribute knowledge and wisdom to the world. In this way, co-facilitated moral injury groups strive to transform “unbearable pain into livable disappointment” (K. Meador, personal communication, May 7, 2021).

The relevance of forgiveness and attributions of blame (core component 8) is reflective of the relational nature of moral injury. Moral injury seems to be fundamentally about disconnection – from oneself, others, a Higher Power, community, etc. Assigning blame (or responsibility) allows the person suffering from moral injury to inch closer to that from which they have been disconnected. However, given that many experiences of moral injury involve a perceived sense of personal responsibility, each person reaches a point when attributions of blame have closed the gap as much as possible and forgiveness is the remaining means available to make up the difference. While forgiveness is never forced on an individual (which is particularly important in the context of betrayal-based moral injuries), exploration of the possibility of forgiveness can help a person unpack the ways unforgiveness is negatively affecting their life. This exploration can lead to increased empathy for self and others, as group members realize aspects of their shared humanity – that all people are flawed, make mistakes, and have the capacity for evil. With this recognition, group members are often more willing to consider extending or receiving forgiveness, which can be a necessary step toward reconnection and personal restoration (Griffin et al., 2017).

The importance of ritual in moral injury care (core component 9), particularly among those whose moral injury stems from combat-related events, may be a direct result of the lack of ritual associated with returning from war in the present day. Modern aviation has made possible in a matter of hours geographic transitions that historically would have taken days if not weeks or months to complete. Units are quickly disbanded, without opportunities to meaningfully debrief what has occurred. Research on healing from moral injury among combatants in Zimbabwe suggested that soldiers need to be debriefed after war as a means of cleansing their “intrinsic moral fibre [sic], to enable them to live a life free of the disturbing, lively, and traumatic experiences of war” (Moyo, 2015, p. 7). Similarly, Shay’s work with Vietnam veterans led him to conclude that “combat veterans and American citizenry should meet together face to face in daylight, and listen, and watch, and weep” (Shay, 1994, p. 194), acts which have the potential to assist those who have been disconnected from their communities to re-enter as people who are known and seen. Furthermore, ritual can help promote shared responsibility for acts committed by individuals on behalf of the group (i.e., American service members on behalf of the American public), breaking down invisible barriers between “us” and “them.”

This analysis provides a roadmap for frontline providers interested in offering care for moral injury based on a comprehensive understanding of commonalities among existing research-informed moral injury practices. The elucidation of core components contributes meaningfully to care provision for the majority of veterans, rather than only those who fit narrow criteria (e.g., those whose moral injury is the result of having killed), and fidelity to core components maximizes the likelihood of good outcomes (Cook et al., 2017). Furthermore, core components help facilitate “flexibility within fidelity,” by which providers can follow basic treatment guidelines of an evidence-based psychotherapy without rigid adherence to specific techniques (Kendall et al., 2008).

Beyond the core components lie an extensive array of potentially adaptable components, though one in particular warrants special acknowledgement. The sixth core component states that cognitive intervention should focus on flexibility regarding possibilities in the aftermath of a morally injurious event – not the event itself. However, some co-facilitated moral injury groups may incorporate additional cognitive skill-building work (e.g., ABC model; cognitive distortions) or event-specific exercises (e.g., responsibility pie). This content is not considered a core component for two primary reasons: 1) these skills are typically addressed in cognitive-behavioral groups offered widely in VHA and are not unique to moral injury; and 2) studies suggest that the approach to cognitions used in PTSD treatments like Cognitive Processing Therapy and Prolonged Exposure avoids or does not adequately address moral injury and associated distress (Borges et al., 2020; Finlay, 2015) and thus may be problematic in moral injury care. Moral injury groups that do include this type of cognitive work, particularly any that focus specifically on the morally injurious event, should be attuned to the potential challenges of conflicting messages concerning the “accuracy” of cognitions.

What is particularly exciting about core components of co-facilitated moral injury groups is that there is room for flexibility within the core components themselves: ritual can take many forms; forgiveness can be discussed in multiple ways; measurement tools and approaches can vary. This flexibility addresses the diversity of patients’ characteristics, values, and contexts and empowers providers to make the most of their clinical expertise. It is also reflective of the variety of clinical settings in which care is provided. Among VHA mental health clinicians providing evidence-based PTSD care, a perceived lack of control over one’s work has been shown to contribute to burnout (Garcia et al., 2014), so increased flexibility may be especially welcome and beneficial for these providers and the healthcare system more broadly. In the words of one DDN participant, “I might have retired, honesty. This keeps me going. We feel a responsibility, not just to our VA, but to this greater purpose, to this greater cause.” Others expressed that developing expertise in moral injury helped them become “leaders” and recognize the value of their professional contributions.

It is worth underscoring that these findings are the result of an intensive, 16-month experience through which a community of practice was formed and fostered. Collectively, these providers have the knowledge, skills, and abilities necessary to collect, assess, and apply evidence to their clinical decision-making. Providers interested in offering moral injury care are encouraged to seek training and consultation like that offered through the DDN, the accountability of which provided a means of ethical engagement in a new area of intervention. In the words of another participant, the DDN:

has really helped me to be a reflective practitioner. Having to stop and answer questions like this, in terms of motivation and accountability… I’m feeling kind of emotional right now in a gratitude kind of way because we are so busy… But to have these times protected to reflect about our work and find it meaningful is just deeply, deeply precious.

Limitations of the present paper include the following: first, a convenience sample of co-facilitated moral injury groups was included. While these diverse groups share the core components that have been articulated, they may not be representative of all moral injury collaborative care efforts across the VHA. Second, the sample was limited to chaplains who have been part of an intensive specialty mental health training that teaches incorporation of evidence-based psychotherapeutic practices with spiritual care (Meador et al., 2017). Thus, the results may not be generalizable to all VHA chaplains. However, the fact that the core components described in this paper were derived from work by chaplains working to integrate evidence-based practices into their moral injury care is promising for future dissemination and implementation across VHA. Third, while DDN teams have anecdotally shared clinical outcomes collected as part of measurement-based care, we did not obtain IRB approval to consolidate or report on those outcomes here. However, individual teams have published group-specific findings (e.g., Cenkner et al., 2021; Pernicano et al., 2022; Smigelsky et al., 2022), which contribute to the evidence base for this work. Finally, while CCA is a developmentally appropriate methodology at this stage of moral injury intervention research, future efforts should employ a diverse range of approaches to contribute to the evidence-base for group-based moral injury interventions. The core components presented here are based on currently available evidence. As exploration of the moral injury construct continues, these core components should be reevaluated in light of new evidence, with adaptations to care considered accordingly. For the present time, we submit that these findings provide a roadmap for VHA implementation of co-facilitated moral injury groups that can be utilized at sites of care with appropriate training and support. Furthermore, these findings form a basis for potential clinical trials and/or comparative effectiveness studies examining the impact of these core components on outcomes.

Conclusion

This paper presents 10 core components of co-facilitated moral injury groups. Articulation of these components contributes to the field’s efforts to conceptualize and define moral injury and inform intervention. As interest in moral injury grows and the suffering associated with it becomes more apparent, it will be important to balance restraint with responsivity. This paper offers guidance that can be widely applied and readily adapted as our understanding of moral injury continues to expand and clarify. The core components are articulated here as principles for ongoing review and revision in response to future moral injury advances in the DDN and elsewhere. Future research should build on these components by focusing specifically on those related to facilitators, since what makes a practitioner effective is as important as the intervention itself in the realm of practice-based evidence (Barkham, Stiles, et al., 2010). While not exhaustive, these components provide a clear roadmap of testable hypotheses for future research and actionable guidance for frontline mental health and spiritual care providers interested in caring for moral injury.