Introduction

Chaplains serve as a primary resource for care when it comes to treating moral injury as they are uniquely qualified in guilt, shame, grief, loss, theodicy, and facilitating sacred space for the healing of the deep wounds of the soul that result from moral injury. Spiritual injury and soul loss are being recognized as some of the core wounds within moral injury. The field of professional chaplaincy has been developing several evidence-based models of care to address moral injury, but they are seemingly limited to clinical or church settings in their applications. These modalities are ground-breaking thus far and much needed. Many of the modalities do seek to create a sense of sacred space, simulate learning to trust self and others through pre-planned exercises, and address betrayal and perpetration through cognitive and theological practices and they are effective. But how much more effective and deeper could the healing be if moral injury groups were facilitated with experiences that do not just mimic or talk about trust, but embody trust through experiences of healthy relationship and boundaries in safe real-life situations, and wholistic immersion in nature as a sense of sacred space?

This article seeks to explore the potential efficacy of combining chaplain care and equine-facilitated learning as a therapeutic intervention in veterans with moral injury. While there is extensive research on suicidality in veterans and service members, and a solid foundation of evolving researching on moral injury, there is little to date that addresses the links between moral injury and suicide, let alone how treating moral injury can lower suicidality rates. There is also scant research done on the efficacy of equine-assisted interactions as a treatment modality within the veteran population. There is anecdotal evidence from equine programs across the country that are being run for veterans, but no research has been done in the area of equine-facilitated learning and moral injury. This article will evaluate the equine-facilitated learning model and preliminary findings of Horses and Heroes of Southeast Florida as a potential model of innovative chaplain care for moral injury. By implementing a specific type of equine-facilitated learning based on relationship, safety, trust, and mindfulness, veterans may experience healing of moral injury.

Moral injury

While moral injury is relatively new within psychological literature, it is not new to the human experience and has been around as long as humans have had a sense of morals and values. In its current understanding, there are a plethora of definitions with no clear consensus, although there are some standing classic definitions that serve as a backbone such as those from Litz et al. and Shay [1, 2]. There are agreements and disagreements on whether it lives within the mental health discipline or within the chaplaincy/spirituality. But what is an absolute about moral injury is that it effects the whole person: mind, body, and soul. For this reason, it will never land all in one discipline. The treatments for moral injury must contain the elements of mental health, chaplaincy/spirituality, and physical/social health for a person to return to wholeness. Moral injury can be experienced within the moment of violation or be preceded by a potentially morally injurious event (PMIE) in which an individual has an experience that does not register as an acute violation but is identified later as an injury [3]. These entail acts of commission such as cruelty or assault, acts of omission such as being unable to prevent an event, bearing witness to an event without the ability to affect the outcome, or being a victim of grave betrayal [3]. Studies have found that PMIEs are found amongst 36.3–41.8% of combat veterans [4]. The causes of moral injury in veterans are complex and multifactorial. Some of the widely accepted and classic definitions of moral injury include:

  1. 1.

    “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” [1].

  2. 2.

    “Disruption in an individual’s confidence and expectations about one’s own or others’ motivation or capacity to behave in a just and ethical manner, brought about by bearing witness to perceived immoral acts, failure to stop such actions, or perpetration of immoral acts, in particular acts that are inhumane, cruel, depraved, or violent, bringing about pain, suffering, or death of others” [5].

  3. 3.

    Betrayal by leadership or peers in a high-stakes situation. This may include incidents of sexual harassment, bullying, or other forms of mistreatment by those in positions of authority [2].

  4. 4.

    “A particular trauma syndrome including psychological, existential, behavioral, and interpersonal issues that emerge following perceived violations of deep moral beliefs by oneself or trusted individuals (i.e., morally injurious experiences). These experiences cause significant moral dissonance, which if unresolved, leads to the development of its core symptoms” [6].

Moral injury is an injury to a person’s trust in self, others, community, or God which leads to symptomatic features such as guilt, shame, spiritual/existential conflict, depression, and a hypervigilance to reoccurring betrayal [1, 5, 6]. Studies have found that veterans who experience moral injury are at an increased risk of developing a range of mental health problems, including post-traumatic stress disorder (PTSD), depression, and suicidal ideation [6, 7•, 8•]. The ability to trust others, feel a sense of moral and psychological safety, and to act with moral congruence are basic core human needs and at the heart of moral injury [9].

According to Frank Libutti, LtGen USMC (Ret.) and CEO of Horses and Heroes of Southeast Florida, moral injury starts at the leadership level and permeates down through the ranks. Horses and Heroes of Southeast Florida is a non-profit that seeks to offer veterans healing through equine-assisted learning which will be discussed later in this review. During his 30 plus years of service, one of the key elements of “betrayal of trust in the ranks” was a lack of communication from leadership which led to a lack in morally aligned decision-making that went against the military ethos and values therefore leading to moral injury [10]. He saw from experience that moral injury happened not just in combat, but in the daily operations of military life. It is both the large and small breaches of trust that can fracture a person according to Libutti [10]. The smaller betrayals of morals and values can pile up leading to an overwhelming sense of feeling dislocated in one’s sense of self. This dislocation is further compounded when a service member discharges from the military. If trust and moral congruence can be restored through meaningful activities, then a “troop” has a chance at recovery from moral injury [10].

In addition to its impact on guilt, shame, trust, and self-worth, moral injury can also lead to feelings of isolation and a loss of purpose [6, 9]. Moral Injury can dislocate a person from their sense of “true north”; it misaligns their inner moral compass, and even sends it into an uncontrolled spiral. A veteran who suffers from moral injury may lose their ability to trust in self and others leading to the inability to hold healthy boundaries in relationships, feeling dislocated from God and a sense of divine, a loss of meaning and purpose, and being trapped in the past which prevents them from being fully in the present moment.

In the early days of the rise of moral injury, researchers theorized that treatments for PTSD could also be applied to moral injury. It has come to pass that treatments such prolonged exposure (PE) and cognitive processing therapy (CPT) are less effective in the treatment of moral injury [11, 12]. There are now newer treatments such as acceptance and commitment therapy for moral injury [13], impact of killing [14], adaptive disclosure [15], building spiritual strengths [11], and reclaiming experiences and losses (REAL) [16•] that have a measurable effect on addressing the specific elements of moral injury. Of these widely used and accepted evidence supported treatments, some of which include interdisciplinary teams with chaplains, none include equine-assisted interventions.

Integrative equine-assisted intervention as a model of care for moral injury

Equine-assisted interactions (EAI) is a category of equine therapeutic interventions that utilize horses and equine-based activities to help facilitate healing in humans physically, mentally, emotionally, and spiritually. EAI for veterans includes hippotherapy [17], therapeutic horseback riding (THR) [17,18,19], equine-assisted psychotherapy (EAP) [20, 21], and equine-assisted learning (EAL) [22, 23]. Equine-assisted learning (EAL) is part of the overall discipline of equine-assisted interventions (EAI) used to help humans heal from issues such as physical, emotional, moral trauma, and PTSD that is not identified as psychotherapy and focuses more on the relational and psychosocial aspects of healing. EAL will be the focus of this article as a method of interacting with horses that is experiential and focuses on the relationship between horses and humans. It is a gentle and effective way for humans to learn about themselves through the reflective experience of the horse. It involves working with horses in a non-threatening, non-judgmental environment to help build self-confidence, develop problem solving skills, and cultivate healthy communication. The benefits of EAL range from social, emotional, cognitive, physical, relational, and self-esteem [23]. EAL can bring a participant into their heart space and “out of their head” in a sense. Equine activities within EAL generally range in activities from approach and retreat, haltering, lead walking, undemanding time in shared space, grooming, and ground-based obstacle courses. There are three main organizations that certify equine-assisted learning, equine therapeutic riding, and equine-facilitated therapy practitioners which are PATH International, EAGALA, and Equine Connection. Each organization has slightly different standards for certification, but the overall goal is the safety of horses and humans, and a quality and transformational experience with horses. EAI is gaining momentum as a viable and effective treatment modality for veterans with PTSD [17,18,19, 24]. In one systematic review of nine EAI studies effectiveness in treating PTSD in veterans, the inconsistencies in equine educational methodology, facilitator certifications/experience, group duration, and curriculum yielded mixed findings [21]. To date though, no evidence-based research has been done on the efficacy of EAI in the treatment of moral injury in veterans.

Chaplain Rachel Mikaelsen of the West Palm Beach VA Health Care System has partnered with Karen Woodbury of Horses and Heroes of Southeast Florida (HHSEF) to provide innovative care that combines mindfulness practices, chaplain care, and EAL to veterans. HHSEF’s goal is to “Connect the spirit of a horse with the soul of a Veteran.” Karen Woodbury is an equine professional with 30 years of experience, a licensed 3* Parelli Instructor, and a PATH certified Mental Health Equine professional. Chaplain Rachel Mikaelsen is an Army Chaplain Veteran, and dual board-certified VA chaplain with a specialization in moral injury and VA Calm Mindfulness, 10 years of EAL experience, and in PATH certification process. Karen and Chaplain Rachel’s approach to EAL is one that focuses on mutual relationships, connection, trust, whole body communication, and safety. They teach that horses are able to bring us into the present moment where a person can connect to their true sense of self apart from trauma and injury. HHSEF’s approach is to provide a safe environment where veterans can gather to feel a sense of belonging with both the horses and humans in community and friendship. This is achieved through herd observation, undemanding time spent with the horses, and basic equine skills that are focused not on completing the task, but the relationship and connection found in the task. Veterans also learn basic life skills such as non-verbal communication, trust, how to set boundaries, and safe space for self and others through activities such as approach and retreat, haltering, leading, moving massage, and calling the herd. Veterans are also able to experience diffusion from emotional and moral trauma through present moment awareness experienced with mindfulness practices conducted at the beginning of every group. Chaplain Mikaelsen has integrated mindfulness practices with the equine activity themes to create complimentary and supportive mindfulness experiences that reflect the learning goals for each session. VA Calm Mindfulness practices teach the veterans to be intentional with their attention, self-regulation, loving kindness, gratitude, self-awareness of intention and energy, and how to enter into a state of ease and calm [25]. By starting each session with evidence supported mindfulness programming, the veterans are able to start the sessions with a sense of calm, relaxation, and self-awareness. The veterans are also encouraged that there is never a “wrong” answer or way of doing something, but rather an opportunity to build curiosity, confidence, and self-worth.

The class outline and approach of HHSEF is not yet evidence based, nor an experimental intervention, as there are no randomized clinical trials yet. These are forthcoming with future research. The model presented here is based on the combined experience of Mikaelsen and Woodbury and should be treated as an example of developing innovation in care. To ethically and safely implement an EAL program, significant safety and training protocols must be in place to ensure the welfare of both horses and humans. EAL protocols should not be implemented without an equine or other professionals specifically trained in EAL from organizations such as PATH or EAGALA, natural horsemanship, trauma informed care, military culture, mental health, and moral injury [26, 27].

Groups are 8 weeks long, 90 min per session. Veterans are required to obtain a release form from a mental health provider so that it is known that support is available. Session summery is as follows:

  1. 1.

    Orientation to group and ranch rules, group introduction, chaplain led mindfulness practice, horse introductions, end with processing.

  2. 2.

    Weekly check-in, chaplain led mindfulness practice, approaching horses, herd observations, end with processing.

  3. 3.

    Weekly check-in, chaplain led mindfulness practice, discussion about use of energy and communication with the horses, recognizing inner state such as fear, anxiety, calm, relaxation through approaching horse, and mutual space and touch, end with processing.

  4. 4.

    Weekly check-in, chaplain led mindfulness practice, setting boundaries, and creating safe space during the haltering process and practicing posture/position/partnership and invitation to connection. Veterans learn the difference between acceptance and tolerance from the horse. End with processing.

  5. 5.

    Weekly check-in, chaplain led mindfulness practice, leading the horse on halter to learn compassionate, self-aware leadership, trust of self and others, how to be a leader through following, earning trust, developing a better sense and feel for use of body energy and intention.

  6. 6.

    Weekly check-in, chaplain led mindfulness practice, undemanding time with the horse to focus on being in the present moment and becoming an invitation to connection. End with processing.

  7. 7.

    Weekly check-in, chaplain led mindfulness practice, a combination of previously learned activities based on group needs and development. End with processing.

  8. 8.

    Weekly check-in, chaplain led mindfulness practice, review of all skills and concepts within the program. End with graduation and certificate ceremony.

You will notice that there is no grooming, obstacle courses, or other traditional equine handling activities built into the program as you might find at other EAI programs. This is because in order to be able to complete such tasks, a true and deep understanding of the relationship fundamentals much exist in order for the veteran to experience a bond of substance and authenticity vs one that is based on mere tolerance of an activity and perceived obedience from the horse. Just as with human relationships, equine relationship bonds take time and trust to become established. Traditional EAP activities serve a purpose at the appropriate time after relationship, trust, safety, and communication have been established between horse and human. Trust and safety are core needs for a horse. Trust and safety are also core needs for humans and components of morals and values that become fractured, and even destroyed during a morally injurious event. To begin to heal moral injury in a trauma informed way, taking a slow and intentional approach that focuses on these core needs lays the foundation for deep and meaningful healing experiences. In the HHSEF program, it is emphasized that you do not need to be touching or engaging in a goal-orientated task to experience connection and relationship. The veterans are coached through what it means to approach the horse with the intention of meeting individual needs vs mutual connection where the needs of all beings involved are respected, acknowledged, and met. Through this approach, a foundation of trust, respect, and compassion is set so that all future activities come from the intention of respectful relationship and shared space between horse and human. This approach also allows for the inherent organic flow of each group based on the changing nature of horses, humans, and the outdoor elements. The learning is not based on the activity, but relationship. The specific daily activities can change to reflect the needs of all elements involved while still communicating the learning topic for that particular session all activities start and end with relationship and connection.

Table 1 highlights the relationships between moral injury and the corresponding mindfulness and equine-assisted learning concepts that could help address each injury area. While this list is not exhaustive to the areas addressed in the overall program, it is a general view of what is covered.

Table 1 Aspects of moral injury and corresponding VA Calm Mindfulness and EAL activities
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Each veteran is given a pre- and post-wellness assessment. Without a formal research study having been conducted yet, the pre- and post-assessments serve as preliminary evidence of the potential efficacy of the specific method of EAL offered at HHSEF. While the current wellness assessment does not explicitly screen for specific moral injury markers such as guilt, shame, betrayal, or perpetration at this time, it is noted that a more comprehensive category of assessments will need to be given in future work. The wellness scale asks veteran to provide their best perceived reaction to each response on a scale from 1 to 5 where 1 is least favorable and 5 represents their best experience. In the assessments given from 3 groups held over January 2023 to April 2023, the results show an average increase of 2 points per category of improved wellness (Fig. 1).

Fig. 1
figure 1

Wellness assessment.

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Veterans have also self-reported statements such as “I finally have some confidence which I have not had in years,” or “So this is what real trust can feel like,” and “I have not felt this peaceful in a very long time.” They also report that their ability to handle stress has strengthened, they feel more resilient, their desire to engage into community has increased, and they have less suicidal thoughts.

Conclusion

The preliminary results of the Horses and Heroes Programming are exciting and hopeful for continued effectiveness and implementation. The gap lies in formal research studies being done to quantify the qualitative experiences that we see each veteran having and to be able to articulate the effects of our specific style of EAL. Our hope is to be able to capture both the numbers and heart of the work we are doing. Ways that we can capture the data will be developing more comprehensive pre- and post-assessments that capture moral injury through the moral injury event scale [28], suicidal ideations via a Columbia Suicide Prevention Screening, and our current wellness assessment. Finding creative and innovative ways to capture the essence of the veteran’s experience will be crucial as the program and its results are truly experiential. One of the largest hurdles in furthering the use of EAI in treating moral injury is that each EAI team will have their own “recipe” for doing the work. While the formatting could be controlled by the curriculum, set activities, tools used, and certification standards of practitioners, what cannot be controlled are the horses and humans. Each horse is as unique as each individual person. Each day you show up to the facility for a group will be unique and dynamic due to the environment. There are a multitude of factors that naturally cannot be controlled. But this is also a similar dynamic when a person experiences moral injury: multiple factors, values, needs, and intentions coalescing into a moment in time. What can be known is that horses’ and humans’ basic needs for trust, safety, communication, and relationship will never change. It is how we are made. The integrated EAL program at Horses and Heroes of Southeast Florida seeks to heal the core wounds of moral injury through the combination of chaplain-led mindfulness practices and equine-assisted learning that focuses first and foremost on mending broken trust, teaching how to create a safe and mutual space, whole body communication and connection, and balanced relationship. Through connecting the spirit of a horse with the soul of a human, we seek to heal moral injury and reduce the risk of suicide through innovative and interdisciplinary care based on trust, relationship, communication, safety, and love.