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Moral injury, defined as an experience of betrayal or transgression of moral values, has received increased attention in recent years and is associated with increased risk for psychiatric disorders, including posttraumatic stress disorder, depression, and suicidal ideation (Bryan et al., 2014; Currier, Holland, & Malott, 2015). Military servicemembers are at a heightened risk of experiencing a morally injurious event during combat. However, there are few effective interventions for those suffering from moral injury, and current treatments may not fully ameliorate common psychological symptoms associated with moral injury (Borges et al., 2020; Larsen et al., 2019). Importantly, moral injury can have an impact on an individual’s spirituality, but many treatments do not address moral injury through spiritual or religious frameworks (Koenig et al., 2017). Therefore, the U.S. Department of Veterans Affairs (VA) established a national initiative to enhance collaboration between VA/Department of Defense (DOD) chaplains and behavioral health clinicians to improve care for moral injury.

We aimed to examine feasibility and exploratory outcomes of a novel, psychologist-chaplain facilitated moral injury group psychotherapeutic intervention previously developed at the Corporal Michael J. Crescenz VA Medical Center (Antal et al., 2019). The group aimed to alleviate symptoms of moral injury by focusing on improving functioning and self-compassion. Furthermore, the group underscored the need for veterans to view their distress associated with their moral injury as normative, not pathological. One strategy to alleviate distress is to redistribute appropriate moral pain from the veteran to the civilian by engaging the larger public community. Therefore, the intervention culminates by having veteran members tell their stories of moral injury in a community healing ceremony which invites the community to take partial responsibility for the harmful consequences of war. 

Forty veterans, over seven cohorts, participated in the 12-week, 90-min moral injury group intervention. All Veterans had to report distress or functional impairment related to military-related morally injurious experience(s) and religious or spiritual struggles arising from military service. Because of the clinical nature of the sample, veterans were allowed to receive concurrent psychiatric or psychological treatment. Of the 40 included veterans, 23 (57.5%) received no concurrent treatment, and 17 (42.5%) received concurrent treatment.

Results of feasibility analyses suggested that veterans attended the group regularly, with a mean attendance of approximately nine and a half sessions out of 12, and with 80% attending nine or more sessions including the session 10 community healing ceremony. No significant differences in attendance were found between veterans who participated in concurrent treatment and those who did not. Furthermore, from pre- to post-intervention, there were medium effect size magnitude increases in psychological health and self-compassion, and decreases of a similar magnitude in depression symptoms. Changes in posttraumatic growth and religious and spiritual struggles were in the expected directions, though smaller. There were no notable effects of concurrent treatment status. 
Taken together, our results indicate that this novel, psychologist-chaplain facilitated moral injury group had favorable feasibility and was associated with improvement in certain psychological symptoms. It should be noted that the sample was small, and well-controlled clinical trials are needed to test the impact of this treatment more systematically. However, this proof-of-concept study contributes to the nascent body of moral injury intervention research and provides support for the potential success of a collaborative effort between a psychologist and chaplain to address moral injury. Results also suggest that future studies examining this intervention on a larger scale and with more control in research design are warranted. 

Reference Article

Cenkner, D. P., Yeomans, P. D., Antal, C. J., & Scott, J. C. (2020). A Pilot Study of a Moral Injury Group Intervention Using a Chaplain and Psychologist as Co-FacilitatorsJournal of Traumatic Stress. 

Discussion Questions

  • What are some of the barriers to collaboration between chaplains and mental health practitioners? How might these barriers be overcome in order to best address the challenge of moral injury?
  • In what ways might spiritual disciplines practiced in community, like lamentation and confession, better address the phenomenon of moral injury than evidenced based treatments applied in individual therapy? 
  • Why may a person’s spiritual or religious commitments play an important role in understanding and addressing their moral injury? 

About the Authors

David Cenkner, B.S., is a Clinical Research Coordinator at the Corporal Michael J. Crescenz VA Medical Center. David can be contacted at david.cenkner@va.gov.

Peter Yeomans, Ph.D., is a Clinical Psychologist at the Corporal Michael J. Crescenz VA Medical Center.

Chris Antal, D.Min, is a Staff Chaplain at the Corporal Michael J. Crescenz VA Medical Center.

J. Cobb Scott, Ph.D., is a Clinical Psychologist at the Corporal Michael J. Crescenz VA Medical Center, an Investigator in the VISN4 Mental Illness, Research, Education, and Clinical Center (MIRECC), and an Assistant Professor in the Department of Psychiatry at the University of Pennsylvania. 

References Cited

Antal, C. J., Yeomans, P. D., East, R., Hickey, D. W., Kalkstein, S., Brown, K. M., & Kaminstein, D. S. (2019). Transforming veteran identity through community engagement: A   chaplain–psychologist collaboration to address moral injury. Journal of Humanistic           Psychology. Advance online publication. https://doi.org/10.1177/0022167819844071

Borges, L. M., Bahraini, N. H., Holliman, B. D., Gissen, M. R., Lawson, W. C., & Barnes, S. M. (2020). Veterans’ perspectives on discussing moral injury in the context of evidence‐based psychotherapies for PTSD and other VA treatment. Journal of Clinical Psychology76(3), 377–391. https://doi.org/10.1002/jclp.22887

Bryan, A. O., Bryan, C. J., Morrow, C. E., Etienne, N., & Ray-Sannerud, B. (2014). Moral injury,  suicidal ideation, and suicide attempts in a military sample. Traumatology20(3), 154    160. https://doi.org/10.1037/h0099852

Currier, J. M., Holland, J. M., Drescher, K., & Foy, D. (2015). Initial psychometric evaluation of    the Moral Injury Questionnaire—Military Version. Clinical Psychology & Psychotherapy22(1), 54–63. https://doi.org/10.1002/cpp.1866

Koenig, H. G., Boucher, N. A., Oliver, Rev. J. P., Youssef, N., Mooney, S. R., Currier, J. M., & Pearce, M. (2017). Rationale for spiritually oriented cognitive processing therapy for moral injury in active duty military and veterans with posttraumatic stress disorder.  Journal of Nervous and Mental Disease205(2), 147–153. https://doi.org/10.1097/NMD.0000000000000554

Larsen, S. E., Fleming, C. J. E., & Resick, P. A. (2019). Residual symptoms following empirically supported treatment for PTSD. Psychological Trauma: Theory, Research, Practice, and Policy11(2), 207–215. https://doi.org/10.1037/tra0000384

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