Depth-oriented group psychotherapy for moral injury with military veterans: relational psychoanalytic and psychodynamic theory, mechanisms of action, and clinical implications.

Some veterans are haunted by memories of action they have taken or betrayals they have experienced that violated deeply held moral beliefs; these experiences can lead to moral injury. We have developed a depth-oriented group psychotherapy for U.S. combat veterans, to address moral injury. Depth psychotherapy is an evidence-based form of psychoanalysis; the treatment we have developed is based on Relational psychoanalysis. The aim is for the group members to each develop an organized narrative about morally injurious events and their impact on their current lives to facilitate psychosocial recovery. The hypothesized change agents of this treatment are, in order of their use in the sessions: (1) warm-up team-building activities such as exercises from the improv and psychodrama/sociometry traditions; (2) reflective listening and speaking; (3) sharing moral injury event narratives with trusted others. The clinical model we have developed for treating moral injury emphasizes that veterans will be asked to describe, to the extent that they are able, the feelings, sensations, and fragmentary thoughts that are initially hard to articulate and sometimes difficult to recall. The goal of this article is to describe relevant depth psychology theory, its application to the moral injury context, the relevance of depth-oriented group psychotherapy for moral injury and, further, the depth-oriented group psychotherapy approach we have derived from these ideas.