Development of a Group Psychotherapy for Combat Veterans With Moral Injury: Protocol for a User-Centered Study

Approximately 25% of combat veterans with posttraumatic stress disorder (PTSD) seek treatment for traumas involving potentially morally injurious events (PMIEs), which involve acts of commission, omission, or betrayal that deeply transgress one's sense of right and wrong. The sequelae of exposure to PMIEs, called "moral injury," are associated with functional and psychiatric impairment and disrupt veterans' sense of identity and meaning, ability to connect with and trust others, and engender disturbing guilt, shame, rage, and disgust. Currently, no first-line treatments directly address moral injury, and evidence-based treatments for PTSD may be limited because they were derived from civilian contexts, poorly fit the war zone context, and do not allow veterans to discuss the details of the PMIEs with other veterans.

We propose a depth-oriented group psychotherapy for morally injured US combat veterans. Its development is guided by user-centered design principles.

This research plan will use user-centered design methods that continuously gather user experiences during treatment development, with the goal of increased effectiveness and usability. Aim 1 is to discover user needs and preferences as well as treatment-engagement barriers and facilitators from the perspectives of PMIE-impacted veterans and the US Department of Veterans Affairs (VA) trauma clinicians (ie, mental health providers and chaplains) using semistructured qualitative interviews. Aim 2 is to design a treatment manual and refine it using feedback from veterans, VA clinicians and chaplains, and an expert clinical advisory board. Aim 3 is to conduct 2 rapid prototyping open trials (ie, tangibly testing treatment approaches using a prototype manual) with PMIE-impacted veterans (N=12) and iteratively revise the manual based on veteran, provider, and clinical expert panel feedback. We hypothesize that the treatment manual will meet usability, feasibility, learnability, and acceptability criteria.

This study was funded with a start date of November 2021. Participant recruitment for Aim 3 pilot trials began in October 2023 and ended in January 2025. We anticipate study data collection and primary data analysis to be completed in January and April 2026, respectively.

This project aims to develop and pilot test a treatment manual for a depth-oriented group psychotherapy for moral injury. We anticipate that the manual will meet predetermined usability, feasibility, and acceptability criteria because we used user-centered design methods; if it does not, we are well-poised to revise the manual based on user feedback. Should primary outcomes be met, the next step will be to design and execute a parallel-group randomized controlled trial. We additionally plan to disseminate learnings about combat veteran and VA clinician needs, preferences, and barriers regarding moral injury group psychotherapy, which may inform treatment development efforts beyond this project and study team.