Collaborative Groups Offer Healing for Veterans Suffering from Moral Injury

Veterans’ Perspectives highlights research conducted by HSR and/or QUERI investigators, showcasing the importance of research for Veterans – and the importance of Veterans for research.

In the May - June 2025 Issue:

• Introduction: Moral injury is a clinically significant condition for many Veterans, but there aren’t yet widespread best practices or protocols in the VA healthcare system to guide moral injury care.
• The Dynamic Diffusion Network (DDN QUERI) and Practice-Based Evidence: The DDN was founded in part to generate practice-based evidence that could achieve rapid advancements in the development of VA’s moral injury care.
• The Core Components of Moral Injury Groups: A team from the Durham VA Health Care System evaluated seven moral injury groups participating in the DDN, and identified ten core components among the groups’ approaches to moral injury care.
• Next Steps: The core components provide a roadmap for future research and actionable guidance for mental health and spiritual care providers interested in moral injury care.  
• Information Resources: Links to further information about moral injury care in general, and about group-specific implementations.

Introduction

In traumatic or highly stressful circumstances, people may experience, witness, fail to prevent, or participate in events that contradict their deeply held values and beliefs. When these circumstances create an unresolved dilemma or moral conflict, this can lead to moral injury. While not a diagnosis, moral injury is clinically significant, often overlapping or accompanying mental health diagnoses such as depression, anxiety, or PTSD. Moral injury also often carries existential or spiritual weight that does not fit inside a diagnostic box.

Moral injury is a subject of increasing interest among VA clinicians, who continue to work toward consensus about what it is (and isn’t); about who can have it, and under what circumstances; about how to distinguish moral injury from other afflictions of the mind and spirit; and about how to relieve the suffering it causes. Veterans who experience moral injury have both mental health and spiritual needs, and a major challenge in implementing moral injury care across VA is that best practices, guidelines, and protocols are still developing.

The Dynamic Diffusion Network (DDN QUERI) and Practice-Based

VA’s Integrative Mental Health program (IMH; formerly Mental Health and Chaplaincy) was established specifically to build more collaborative systems of biopsychosocial-spiritual care in VA by equipping chaplains to work effectively with mental health colleagues and to respond appropriately to mental health needs. In 2017, building on years of training and quality improvement efforts with chaplains and mental health providers, IMH partnered with the Durham VA Health Care System’s Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) on a VHA systemwide survey and request for moral injury group materials such as protocols, curricula, and handbooks. Numerous innovative moral injury groups being co-led by chaplains and mental health providers were identified, and these innovators were then brought together with initial support from VHA’s Innovation Ecosystem Office and later from HSR’s Quality Enhancement Research Initiative (QUERI) to form a Dynamic Diffusion Network (DDN). The DDN aims to help innovators share insights, refine their practices, and expand promising clinical practices beyond early adopters of innovations. These activities occur under real-world conditions, within a structured network that promotes evaluation and sharing ideas—and ultimately promotes relatively rapid improvements in care.

Groups participating in the DDN generate practice-based evidence that can be applied to the adoption, sustainment, and refinement of collaborative moral injury care for Veterans.

The Core Components of Moral Injury Groups

One goal of the DDN was to compare diverse approaches to moral injury care and identify “core components,” or elements that were present in most approaches despite their different origins and influences. Through conversations with practice developers, review of practice-related materials, and consultation of existing empirical literature, the team of evaluators at the Durham VA Health Care System and ADAPT studied seven collaborative moral injury groups involved in a 16-month program. While there was considerable variability in the structure and content of the groups, ten core components of these groups were identified and explained.

For example, one core component is that the groups are co-facilitated by a mental health provider and a chaplain. The developers of these practices felt strongly that both disciplines were necessary to address both the psychological and the spiritual dimensions of moral injury, and this opinion was validated by the experience of later adopters who integrated interdisciplinary co-facilitation.

Another core component is the use of a peer group to help address the shame associated with moral injury. The impulsive response to shame—to hide, out of fear of losing connection—is counteracted in moral injury groups by means of sharing vulnerabilities, which leads to mutual acceptance:

• “These people are sharing things that are so intimate and so from the heart, it tears me apart. Sometimes, when I got to the group and listened to them reveal things that they wouldn't discuss with other people – that pulls it out of me as well.”
• “I was determined to become a human being who isn’t ruled by shame or self-hatred.”
• “Something opened up inside me demanding healing and attention.”
• “I first got there, I didn't say anything. I just listened. But the more I listened, the more I was hearing about me.”

Since moral injury involves a violation of deeply held beliefs and values, it is important for care to incorporate open, non-judgmental discussion of the influences that have shaped a person’s beliefs and values. For many, one such influence is religion, regardless of whether the person continues to identify with a particular faith. Though some group participants have troubling memories or associations with religion or spirituality, others find them to be sources of meaning, purpose, and connection. Because of their inherent meaning and purpose, one of the goals of moral injury care is to help group members connect to the values that were violated by the morally injurious experience.

To invite exploration of such values most effectively in a group therapy context, it is important that the group adopts an inclusive approach to spirituality and religion, which is another core component. Even among a group of people who endorse the same religion or faith tradition (e.g., Christianity), there will be individual differences that render generalizations moot at best, and harmful at worst. This core component asserts that co-facilitated moral injury groups should be designed for people of any religious faith, or none, to engage in the process together.

These are just some examples of core components, and they are subject to ongoing consideration and evaluation. In fact, a commitment to continuous, systematic measurement of outcomes is itself one of the core components of moral injury group care. Rather than limit the focus of evaluations on symptom reduction, which is a typical outcome measure of mental health care, assessments of moral injury groups should include a variety of measurements, including qualitative and narrative reports of impact. Sometimes Veterans in moral injury groups express these changes with language that is unique to them and their experience, and thus is much richer than what could be captured by a generalized indicator (e.g., I feel disgusted). Here are some examples:

• “I went from thinking I needed to learn to be strong to realizing I was strong all along.”
• “Yesterday I was able to speak directly to my husband and share something very emotional with him. In the past I would have avoided this conversation. But I was able to have this hard conversation with him.”
• “I have taken steps with my personal demons.”
• “My husband and I are being more authentic with each other – this is helping our marriage. I can communicate more honestly and authentically. I see myself differently.”

The suffering of moral injury is often hidden or disguised. Yet loved ones and Veterans themselves may notice that something is different, even if the Veteran has limited language to articulate the distress they feel. Veterans typically engaged with their groups because either they, or their loved ones, recognized a problem:

• “It was very hard when I came home. My family told me, what's going on? I said to them: ‘I'm not the same. You can't go through this and be the same.’ I said: ‘I don't know what that means exactly, but I know that I don't see the world like I used to at all.’”
• “I’ve done horrible things in the name of goodness.”
• “Everybody said that I was different, but I didn't feel different. I didn't notice being different. I definitely had anger issues that I never had before, but I didn't recognize them. It took somebody else to tell me, because I thought I was normal.”
• “I had lost a big part of me that day and I didn’t know how I was going to get it back.”

Some Veterans, despite this awareness, were hesitant to participate in moral injury groups because they feared the vulnerability required of participants. But many felt better—and some felt transformed—afterward. Some experienced not only personal relief, but improved relationships with family and friends:

• “This was the most meaningful journey I’ve taken. It was not easy but I realize I’m not alone.”
• “I did four months in PTSD residential, and this program helped me more than those four months.”
• “Please keep this awesome program going, it’s not only helping the student [veteran] but everyone’s family and all who walk into his life.”
• “I can actually feel joy – in the past couple of weeks I have felt joy. I have not felt that in a long time. I am hopeful that joy can become more a part of my life. I think it is possible to become unstuck. We give each other courage.”
• “I'm telling you, if you're thinking about it, do it. You'll be amazed and you'll be surprised at the relief you will get. But don't take my words. Sit in the chair. You don't have to say a word. Just come to a meeting. Sit in the chair. You'll see for yourself how far it can take you.”

Next Steps

To date, over 30 VA care facilities are equipped to offer collaborative moral injury groups.  The core components, though not exhaustive and subject to ongoing consideration, provide a clear roadmap for future research and actionable guidance for providers with an interest in providing moral injury care. IMH encourages interested providers to seek consultation and training like that offered through the DDN and the Mental Health Integration for Chaplain Services (MHICS)rogram.

Jason Nieuwsma, PhD is a clinical psychologist who serves as the Associate Director for VA Integrative Mental Health and who holds faculty positions in the Department of Psychiatry at the University of North Carolina and in the Divinity School at Vanderbilt University. His work focuses on increasing the availability and relevance of evidence-based psychosocial approaches across various contexts, with expertise in the areas of health psychology, dissemination and implementation science, and spirituality and health. Dr. Nieuwsma has helped to lead multiple nationwide projects aimed at more effectively integrating chaplaincy and mental health care services. He has authored numerous journal articles and book chapters, serves as Senior Associate Editor for the Journal of Health Care Chaplaincy, and has co-authored the books: ACT for Clergy and Pastoral Counselors, and Addressing Moral Injury in Clinical Practice.

Melissa Smigelsky, PhD, is a licensed psychologist with VA Integrative Mental Health and Assistant Professor in the Department of Psychiatry at the University of North Carolina. Dr. Smigelsky’s work focuses on equipping VA chaplains and mental health clinicians to provide moral injury care that integrates evidence-based psychosocial principles with spiritual care. She facilitates an expanding network of chaplain-mental health teams and individual providers that focuses on the development, refinement, implementation, and dissemination of promising practices for moral injury. She has published more than 30 articles on topics such as moral injury, grief and bereavement, suicidality, and intervention and process development and evaluation. Dr. Smigelsky is the primary author of the Reclaiming Experiences And Loss therapeutic moral injury curriculum and the Understanding Moral Injury education group, both of which were developed in collaboration with VA chaplains and mental health clinicians. Dr. Smigelsky provides moral injury care to Veterans within the Durham VA Health Care System.

George L. Jackson, PhD, MHA is a healthcare epidemiologist and implementation scientist with a background in health administration. He is the Co-Director of the Implementation and Improvement Science Lab/Core at the Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) and the corresponding principal investigator of the VA Dynamic Diffusion Network QUERI Program.  Dr. Jackson is also a member of the faculty at the University of Texas Southwestern Medical Center as a Professor and Director of the Advancing Implementation & Improvement Science Program in the Peter O'Donnell Jr. School of Public Health. For over a decade, Dr. Jackson has collaborated with the VA Integrative Mental Health Program on efforts to enhance collaboration between mental health and healthcare chaplaincy.

Evaluation Publication

Smigelsky MA, Trimm V, Meador K, Jackson GL, Wortmann JH, and Nieuwsma JA. Core Components of Moral Injury Groups Co-Facilitated by Mental Health Providers and Chaplains. Spirituality in Clinical Practice. 2022;9(3):159-174.

Information Resources

Moral Injury and Moral Injury Care:

• Moral Injury - MIRECC / CoE
• Collaborative Moral Injury Groups (Mental Health & Chaplaincy)

Moral Injury Group-specific Resources/Studies:

• A Pilot Study of a Moral Injury Group Intervention Co-Facilitated by a Chaplain and Psychologist
• Acceptance and Forgiveness Therapy for Veterans with Moral Injury: Spiritual and Psychological collaboration in group treatment
• Let’s Get “REAL”: A Collaborative Group Therapy for Moral Injury
• Collaborative Moral Injury Groups in VA (Video)
• https://news.va.gov/92169/moral-injury-group-place-of-healing-place-of-peace/
• Dynamic Diffusion Network (2020)

*The quotes used here were not featured in the Durham team’s published evaluation of core moral injury group components, but were expressed by Veteran participants in follow-up surveys.

The views expressed in this publication are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

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