Coping and Adaptation for Recovery From Moral Injury: A Group Intervention for Clinical Psychology Residents

Clinical psychology residents may encounter situations in which clinical responsibilities, patient needs, institutional constraints, supervisory decisions, or limitations in available resources conflict with deeply held professional values. These experiences can generate moral distress and may be accompanied by guilt, shame, anger, helplessness, self-criticism, reduced professional confidence, or loss of meaning in clinical work. Residents may be particularly vulnerable because they combine direct clinical responsibility with a professional role that is still developing and with dependence on supervision and organizational structures.

Coping and Adaptation for Recovery from Moral Injury (CARE-MI) is a manualized, group-based intervention designed to prevent and address the psychological impact of morally difficult professional experiences. The intervention has been adapted for clinical psychology residents, taking into account their previous psychological knowledge, their role as therapists in training, and challenges related to supervision, therapeutic responsibility, professional identity, and institutional limitations.

The program consists of four 90-minute group sessions. The first session, Moral Awareness, helps participants identify morally difficult situations and recognize the professional values involved. The second session, Emotional Flexibility, focuses on recognizing and responding flexibly to difficult thoughts, emotions, and patterns of experiential avoidance. The third session, Moral Repair, addresses guilt, shame, self-criticism, and attribution of responsibility, and explores possibilities for repair, learning, acceptance, support, and contextual action. The fourth session, Professional Flourishing, focuses on professional identity, strengths, values, sources of meaning, and the development of a realistic plan for professional care and protection.

The intervention uses psychoeducation, guided reflection, experiential exercises, hypothetical clinical situations, and individual worksheets. Participants are not required to disclose detailed personal or clinical experiences to the group. The emphasis is on personal application of the material while maintaining privacy and psychological safety.

This is a prospective, single-group pilot study using a pre-post design. Participants will complete assessments before the first session and after completion of the intervention. The study will examine the feasibility and acceptability of CARE-MI and explore preliminary changes in the psychological variables specified in the outcome measures section. The findings will be used to refine the intervention and inform the design of a subsequent controlled evaluation.

• CARE-MI Group Intervention (Behavioral): CARE-MI is a manualized group intervention consisting of four 90-minute sessions. The four components are Moral Awareness, Emotional Flexibility, Moral Repair, and Professional Flourishing. The intervention includes psychoeducation, guided reflection, experiential exercises, hypothetical clinical situations, and individual worksheets adapted for clinical psychology residents. Participants are not required to disclose detailed personal or clinical experiences to the group.

Primary outcomes

• Change in Moral Injury Assessed With the Health Care Moral Injury Scale [Baseline and Week 4 (immediately after completion of the four-session intervention).]: Moral injury will be assessed using the 10-item Health Care Moral Injury Scale (HMIS). Each item is rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Item scores are summed to produce a total score ranging from 10 to 50, with higher scores indicating greater moral injury. The outcome will be the change in total HMIS score from baseline to post-intervention.

Secondary outcomes

• Change in Mental Well-Being Assessed With the Warwick-Edinburgh Mental Well-Being Scale [Baseline and Week 4 (immediately after completion of the four-session intervention).]: Mental well-being will be assessed using the 14-item Warwick-Edinburgh Mental Well-Being Scale (WEMWBS). Each item is rated from 1 to 5. Item scores are summed to produce a total score ranging from 14 to 70, with higher scores indicating greater mental well-being. The outcome will be the change in total WEMWBS score from baseline to post-intervention.
• Change in Depressive Symptoms Assessed With the Patient Health Questionnaire-9 [Baseline and Week 4 (immediately after completion of the four-session intervention).]: Depressive symptoms will be assessed using the 9-item Patient Health Questionnaire (PHQ-9). Each item is rated from 0 to 3. Item scores are summed to produce a total score ranging from 0 to 27, with higher scores indicating greater severity of depressive symptoms. The outcome will be the change in total PHQ-9 score from baseline to post-intervention.
• Change in Anxiety Symptoms Assessed With the Generalized Anxiety Disorder-7 [Baseline and Week 4 (immediately after completion of the four-session intervention).]: Anxiety symptoms will be assessed using the 7-item Generalized Anxiety Disorder scale (GAD-7). Each item is rated from 0 to 3. Item scores are summed to produce a total score ranging from 0 to 21, with higher scores indicating greater severity of anxiety symptoms. The outcome will be the change in total GAD-7 score from baseline to post-intervention.
• Intervention Completion Rate [From the first intervention session through Week 4.]: The intervention completion rate will be calculated as the percentage of enrolled participants who attend at least three of the four CARE-MI group sessions.
• Participant Satisfaction With the CARE-MI Intervention [Week 4 (immediately after completion of the four-session intervention).]: Acceptability will be assessed after the intervention using a participant satisfaction questionnaire. The questionnaire will evaluate participants' perceived usefulness, relevance, comprehensibility, and overall satisfaction with the CARE-MI intervention. Higher scores will indicate greater acceptability.

Sex: All, ages: 18 Years to any, accepts healthy volunteers

Inclusion Criteria:

* Aged 18 years or older.
* Currently undertaking specialized postgraduate training as a clinical psychology resident in Spain.
* Able to understand written and spoken Spanish.
* Willing and able to attend the CARE-MI group sessions and complete the study assessments.
* Able to provide informed consent.

Exclusion Criteria:

* Not currently undertaking specialized postgraduate training as a clinical psychology resident.
* Inability to understand the study information or provide informed consent.
* Insufficient command of Spanish to participate in the group intervention or complete the assessments.
* Any acute psychological or psychiatric condition that, in the judgment of the research team, requires immediate or more intensive clinical care and would make participation in the group intervention inappropriate.

• Regina Espinosa López, PhD, Principal investigator, Camilo Jose Cela University