Religion-Adapted Cognitive Behavioral Therapy: A Review and Description of Techniques

Systematic reviews have shown the efficacy of religion-adapted cognitive behavioral therapy (R-CBT); however, many clinicians lack practical knowledge of these protocols. We describe here the techniques of religious adaptation to CBT that have proved effective. We selected randomized clinical trials comparing R-CBT with control conditions in clients with a diagnosis of a psychiatric disorder and extracted the information from their adapted manuals. The most frequent religious adaptations were the integration of religious content to perform cognitive restructuring, psychoeducation and motivation; engagement in religious activities such as behavioral activation, meditation, or prayer to help cognitive restructuring, using religious values and coping strategies. A description of these techniques is presented here, as well as some practical examples.

Companions in the Abyss: A Feasibility and Acceptability Study of an Online Therapy Group for Healthcare Providers Working During the COVID-19 Pandemic

INTRODUCTION

In the context of the global pandemic of the SARS-CoV-2 coronavirus (COVID-19), healthcare providers (HCPs) have experienced difficult moral and ethical dilemmas. Research is highlighting the importance of moral injury (MI)-a trauma syndrome related to transgressing personal morals and values-in understanding the psychological harm and occupational impairment experienced by HCPs. To date, MI treatments have largely been developed for military personnel and veterans and rely on in-person one-on-one psychotherapy.

PURPOSE

This project aims to explore the feasibility and acceptability of an evidence-informed online Acceptance and Commitment Therapy-based group therapy for MI in HCPs called "Accepting Moral Pain and Suffering for Healthcare Providers" (AMPS-HCP).

METHOD

This feasibility and acceptability study included three separate phases with the first two phases focused on the development of the psychotherapeutic intervention and the third phase focused on the evaluation of the psychotherapeutic intervention. Eight participants (including registered nurses, practical nurses and respiratory therapists) completed seven 90-min sessions in an online group format. The focus of these sessions included ACT and MI psychoeducation and experientials. Qualitative semi-structured interview data was thematically analyzed while demographic and quantitative self-reported outcome data underwent descriptive analysis and non-parametric testing.

RESULTS

Results show that the intervention was highly feasible and acceptable to healthcare providers who worked on the frontline during COVID-19. Feasibility (referrals, eligibility, retention, participation engagement) was strong (8 out of 10 participants; 80% vs. desired >70% eligibility) and overall, 80% of participants completed 71% of the intervention. Data further supported the applicability and acceptability of the intervention. Preliminary data suggests that AMPS-HCP may supports HCPs to address MI.

DISCUSSION

This study is the first to report on the development and evaluation of an online MI group intervention for registered nurses, registered practical nurses, and respiratory therapists working during COVID-19. Results showed the use of both the online and group components of the intervention were acceptable and feasible during the third wave of COVID-19.

Differences and Similarities in Motives to Decrease Drinking, and to Drink in General Between Former and Current Heavy Drinkers-Implications for Changing Own Drinking Behaviour

The evidence on why people initiate or cease drinking is vast; however, little is known regarding why people change their frequency and amount of drinking from intense (heavy or dependent drinking) to recreational (with little risk). Therefore, the purpose of this study was to investigate how drinking motives and motives to decrease drinking differ between former heavy drinkers (problematic and dependent), current dependent, and current recreational drinkers. Data were obtained from four groups of individuals (n = 263) using alcohol with different severity. The participants were Polish young adults aged between 18 and 35 years. About 53% of the sample were women. The Alcohol Use Disorder Identification Test (AUDIT) was used to assess the level of drinking; the Drinking Motive Questionnaire-Revised Short Form (DMQ-R SF) was used to assess drinking motives (social, coping, enhancement, and conformity). The reasons for abstaining and limiting drinking (RALD) instrument was used to assess the RALD. Additionally, a set of questions regarding motives to decrease drinking were analysed. The results show that differences were observed between the investigated groups: the current dependent group scored significantly higher on all the dimensions of drinking motives than the current low-risk group and significantly higher on coping, social, and enhancement motives than former heavy drinkers (both groups). The two groups of former heavy drinkers did not differ from each other on drinking motives. The investigated groups differed on the motives to reduce drinking-low-risk users scored the lowest on all the motives, whereas current dependent-the highest. The differences in motives to decrease drinking between current-depended and former heavy drinkers indicate which motives can be associated with the prevention strategies, programmes, and therapeutic approaches.

Executive Functioning: Assessing the Role of Perceived Paranormal Ability

This study examined whether scores on self-report measures of executive functions varied in accordance with level of self-professed paranormal ability. The investigators compared three groups varying in attribution of paranormal facilities: practitioners (Mediums, Psychics, Spiritualists and Fortune-Tellers), self-professed ability and no ability. Consistent with recent research on cognitive-perceptual factors allied to delusional formation and thinking style, the researchers anticipated that practitioners would score higher on paranormal belief and self-reported executive function disruption. Correspondingly, the investigators also hypothesised that the self-professed ability group would demonstrate greater belief in the paranormal and higher levels of executive function disruption than the no ability group. A sample of 499 (219 males, 279 females) respondents completed the measures online. Multivariate analysis of variance (MANOVA) found a large effect size, alongside significant differences on all variables apart from Cognitive Reappraisal. Pairwise comparisons indicated that Paranormal Belief increased as a function of level of ability; practitioners scored higher than self-professed, who in turn scored higher than the no ability group. For executive functioning, significant differences emerged only for the no ability vs. self-professed ability and no ability vs. practising groups. Collectively, outcomes indicated that perception of ability, regardless of intensity of paranormal conviction, influenced subjective appraisal of executive functions. Failure to find consistent differences between practitioner and self-professed ability groups suggested that discernment of ability was sufficient to heighten awareness of executive functioning disruptions.

Christian Accommodative Mindfulness: Definition, Current Research, and Group Protocol

More clinicians are using mindfulness-based therapeutic strategies; however, Evangelical Christian clients sometimes worry about the Buddhist origins of these treatments. Christian accommodative mindfulness (CAM) attempts to address these concerns with culturally sensitive adaptations to mindfulness methods. We present a definition of CAM and propose some worldview adjustments to typical mindfulness constructs when working with these clients. The empirical research on Christian-derived meditation strategies and Christian-adapted mindfulness strategies will then be reviewed. We introduce a four-session group CAM protocol currently being researched that focuses on scripture meditation, breath meditation, body awareness, and loving-kindness meditation. Sample scripts are included.

Christian Mindfulness and Mental Health: Coping through Sacred Traditions and Embodied Awareness

Mindfulness is increasingly implemented as a tool in mental health practice for coping and self-care. Some Christians worry that these practices might be in conflict with their own tradition, while other Christian contexts are reclaiming the contemplative aspects of the faith. Though clinicians are not trained to teach on religious topics and ethically must avoid pushing religion onto clients, conceptualization and research extend the benefits of mindfulness practices for religious clients. This paper will discuss the evidence for using mindfulness in mental health treatment and connect mindfulness to the Christian tradition. The authors explore how intentional awareness and embodiment of the present moment are supported in Christian theology through the incarnation of Jesus and God’s attention of the physical body in the Christian scriptures. The authors also discuss how sacraments and prayer naturally overlap with mindfulness practices for the dual purposes of emotional healing and spiritual growth. To bolster the benefits of mindfulness in the psychological and religious realms, the purpose of this paper is to empower therapists to address client concerns of whether mindfulness is in conflict with Christianity, support clients in expanding current Christian religious coping, and provide Christian leaders with more information about how mindfulness elements are already present in Christian rituals and beliefs.

The Efficacy of a Forgiveness Bibliotherapy: A Randomized Controlled Trial with Nursing Students

Purpose of study: The need for forgiveness education for nursing self-care and forgiveness facilitation has risen. Therefore, the present pilot study tested the efficacy of an 8-week forgiveness bibliotherapy with a small number of undergraduate nursing students. Design of study: Matched pairs of nursing students were randomly assigned to either the experimental group or no-contact control group. The experimental group, using 8 keys to forgiveness by R. Enright (2015) as the treatment manual, read one chapter a week for 8 weeks and provided weekly reflections. Forgiveness and forgiveness-related outcome measures were administered at pretest, posttest, and one-month follow-up. Findings: At the posttest, the experimental group had significantly greater improvement in forgiveness compared to the control group with a large effect size, which was maintained at one month follow-up. There was no other significant difference between the two groups. Within-group comparisons of the experimental group showed improvement in forgiveness, anxiety, depression, and fatigue from pre to post testing periods and forgiveness, anger, anxiety, depression, and fatigue from pre to follow-up testing periods. Conclusion: Use of bibliotherapy may be a cost-effective way to promote the virtue of forgiveness for students in nursing programs.

Relations Among Locus of Control, Religiosity, and Resiliency in Collegiate Football Players

Resiliency in athletes is related to effective coping strategies. Expectedly, during the COVID-19 pandemic, this attribute was highlighted in collegiate football players. To date, the relations among locus of control (LOC), strength of religious beliefs (i.e., religiosity), and resiliency in collegiate football players have not been explored in the literature. Exploring the relation of LOC and religious beliefs to resiliency may shed light on avenues to foster resiliency in football players, which in turn can determine players' behaviors, performance, and actions during adverse times. The purpose of this study was to gain a more in-depth understanding of the relations among LOC, religiosity, and resiliency in NCAA Division II football players at a public university located in the southwestern United States. A structured online survey containing the Rotter's Locus of Control Scale (Rotter in Psychological Monographs: General and Applied, 80(1), 1-28, 1966), the Santa Clara Strength of Religious Faith Questionnaire (Plante & Boccaccini in Pastoral Psychology, 45(6), 429-437, 1997), and the Conner Davidson Resilience Scale (Connor & Davidson in Depression and Anxiety, 18(2), 76-82, 2003) was completed by 91 Division II football players. Statistically significant correlations were found between LOC and resiliency (r = -.42) as well as religiosity and resiliency (r = .26). Regression analysis indicated, on average, that football players with greater internal LOC and higher strength of religious beliefs had a higher level of resiliency than players with higher external LOC and lower strength of religious beliefs.

The impact of perceived relationship to ancestors on the association between self-transcendence and psychopathology: A cross-cultural examination

Self-transcendence has been associated with lower levels of psychopathology. Most studies of self-transcendence have focused on samples of Western participants, and used scales addressing such concepts as self-awareness and feelings of oneness with the larger universe. However, a common Eastern notion of transcendence-perception of ongoing relationships with ancestors-has not been studied. We conducted a cross-cultural investigation of the association between self-transcendence, perceived degree of relationship to ancestors and depression and anxiety in the United States (N = 1499), China (N =  3,150), and India (N = 863). Degrees of perceived relationship to ancestors differed across countries, with the highest rates in India and China, and lowest rates in the United States. Self-transcendence was negatively associated with risks for depression and anxiety in the United States. In India, self-transcendence was also negatively associated with risks for depression and anxiety, and a strong perceived relationship with ancestors had further protective benefit. In China, those with a high level of perceived relationship to ancestors and a high level of self-transcendence exhibited lower levels of psychopathology. Results suggest that measures of relationship to ancestors might be included in future cross-cultural studies of transcendence.

The effectiveness of cognitive developmental hypnotherapy on differentiation of self, meaning in life and marital conflicts in married women

The aim of the present study is to investigate the effectiveness of Cognitive Developmental Hypnotherapy (CDH) on Differentiation of Self, Meaning in Life and Marital Conflicts in married women. The method is quasi-experimental pretest and posttest with a control group. The statistical population of this study includes married women who came to FUM Counseling and Psychological Services Center to receive psychological services. The sample of this study included 40 married women who were selected by targeted sampling method and randomly assigned to two experimental and control groups. Participants in the pretest and posttest study answered the Differentiation of Self Inventory, the Marital Conflicts questionnaire by Sanaei, and the Meaning in Life questionnaire. The research data were analyzed using ANCOVA and MANCOVA with SPSS-21. The findings showed CDH led to an increase in Differentiation of Self and Meaning in life, and a reduction in Marital Conflicts in women. Accordingly, CDH through using techniques such as induction and empowerment of the Ego is effective in marital conflicts of married women. Therefore, using it as a means to improve the quality of married women's lives is recommended.

Forgiveness: A Key Component of Healing From Moral Injury?

Service members and veterans can be exposed to potentially traumatic and morally injurious experiences (PMIEs) including participating in, witnessing, or failing to prevent an act(s) that transgresses their core beliefs. Violation of one's deeply held morals and values can be profoundly distressing and shatter one's sense of self at the deepest level. Relationships with self, others, the world, and for some, the Sacred, can also be fractured. Post-Traumatic Stress Disorder (PTSD) and/or Moral Injury (MI) can result. Left unresolved, MI can leave individuals struggling with guilt, shame, cognitive dissonance, and negative self-attributions. A holistic approach that addresses the psychological and spiritual harm associated with MI is warranted. We wonder if forgiveness can help individuals struggling with MI to address the harm caused by actions or inactions, release negative emotions, and mend relationships. Commonly used by Spiritual/Religious (S/R) Leaders, forgiveness practices are increasingly being explored by Mental Health Professionals as a complement to evidence-based treatment approaches. This article provides case examples that illustrate the use of forgiveness practices that promote recovery and identifies programs used in clinical practice that incorporate forgiveness. Research is yet needed to better understand the importance of forgiveness in the treatment and healing of PTSD and/or MI. This requires an interdisciplinary discourse between Mental Health Professionals and S/R Leaders working in the field of MI. Such engagement and integrated use of forgiveness practices may yield improved outcomes not only for service members and veterans, but for all those struggling as a result of PTSD and/or MI.

Moral Injury and Suicide Ideation Among Israeli Combat Veterans: The Contribution of Self-Forgiveness and Perceived Social Support

Modern warfare within a civilian setting may expose combatants to severe moral challenges. Whereas most of these challenges are handled effectively, some potentially morally injurious events (PMIEs) may have deleterious psychological, spiritual, and interpersonal effects among them, which may increase the risk for suicide ideation and behaviors (SIB). In this study, we aimed to examine the protective role of self-forgiveness and perceived social support on the relationship between exposure to PMIEs and SIB among combat veterans. A sample of 191 Israeli combat veterans completed validated self-report questionnaires in a cross-sectional design study, tapping moral injury, SIB, perceived social support, and self-forgiveness. Veterans with a history of SIB revealed higher levels of exposure to PMIEs and lower levels of self-forgiveness and perceived social support than veterans with no SIB history. Moreover, beyond the contributions of the PMIE dimensions, significant contributions of self-forgiveness and perceived social support to current suicide ideation (SI) were found. Importantly, the moderating model indicated that higher social support moderated the link between PMIEs and current SI. Based on the current findings, it can be suggested that self-forgiveness and perceived social support are important contributors to lower SI levels among veterans with PMIEs. It can be further suggested that interpersonal support may help veterans develop a sense of belongingness and bonding, which is a plausible basis for diminishing the risk of SI following PMIE exposure.

Higher frequency of mantram repetition practice is associated with enhanced clinical benefits among United States Veterans with posttraumatic stress disorder

BACKGROUND

There is increasing support for the use of meditation-based treatments for US military Veterans with posttraumatic stress disorder (PTSD). The Mantram Repetition Program (MRP), which is a portable meditative practice that features mindful repetition of a sacred phrase, is associated with significant reductions in PTSD symptom severity. Although regular practice is emphasized in meditation-based interventions, associations between frequency of practice and clinical outcomes are often not reported.

OBJECTIVES

This study will examine whether the frequency of mantram repetition is associated with greater improvements in clinical outcomes.

METHODS

Veterans with PTSD participating in MRP (N = 160; combined experimental groups from two randomized controlled trials). Participants completed pre- and post-treatment self-report measures of anger and well-being and a clinician-administered interview of PTSD severity (CAPS-IV-TR). Veterans also reported average daily mantram repetition practice at post-treatment. We conducted a series of hierarchal multiple regression analyses.

RESULTS

When controlling for race/ethnicity and pre-treatment severity, higher frequency of mantram repetition practice was associated with significantly greater improvements (small effect sizes) in PTSD symptom severity (F(3,128) = 6.60, p < .001, β = .21, p = .007), trait anger (F(3,128) = 31.23, p < .001, β = .25, p < .001), state anger (F(3,110)  = 17.62, p < .001, β = .16, p = .04), mental health well-being (F(3,128) = 28.38, p < .001, β = .14, p = .04), and spiritual well-being (F(3,127) = 13.15, p < .001, β = .23, p = .003), but not physical health well-being.

CONCLUSIONS

Higher frequency of mantram repetition practice appears to have beneficial effects on clinical outcomes for Veterans with PTSD. Strategies that promote skills practice may be an important target for improving clinical outcomes for meditation-based interventions.

HIGHLIGHTS

Higher frequency of meditation practice during Mantram Repetition Program was associated with greater reductions in PTSD symptoms and anger as well as improvements in well-being.Strategies to promote at-home meditation practice may optimize the benefits of MRP.

Toward a dual process model of moral injury and traumatic illness

Moral injury has emerged as a topic of significant research and clinical interest over the last decade. However, much work remains to be done to comprehensively define the moral injury construct, with implications for understanding the etiology and maintenance of moral injury, its symptoms, associations with and distinctions from traumatic illness, and treatment approaches. We provide a brief overview of the existing moral injury literature and introduce a novel dual process model (DPM) of moral injury and traumatic illness. The DPM posits an event exposure which may satisfy DSM-5 posttraumatic stress disorder (PTSD) criterion A, potential morally injurious event (PMIE) criteria, or both, followed by individual role appraisal as a perpetrator through action or inaction, a witness, a victim, or a combination of the these. Role appraisal influences symptoms and processes across biological, psychological, behavioral, social, spiritual/religious, as well as values, character, and identity domains to support a label of traumatic illness, moral injury, or both. The DPM provides a flexible analytical framework for evaluating symptoms associated with moral injury and traumatic stress and has important implications for treatment. The most thoroughly reviewed evidence-based interventions for traumatic stress hinge on exposure and habituation mechanisms to manage dysregulation of fear and memory systems, but these mechanisms often do not address core domains of moral injury identified in the DPM, including spiritual, religious, values, character, and identity domains as these exist largely outside of the putative fear network. We provide brief vignettes to illustrate the practical application of the DPM and argue that adjunct and stand-alone approaches which address values and character domains, leveraging principles of Stoicism, non-judgment of experience, acceptance, and values-oriented action, are more likely than traditional trauma treatment approaches to positively affect moral injury symptoms.

A "Viral Epistolary" and Psychosocial Spirituality: Restoring Transcendental Meaning During COVID-19 Through a Digital Community Letter-Writing Project

This article outlines the results of a three-month-long community letter-writing and letter-sharing project called "Viral Epistolary" (VE), which we completed online in Italy during the first wave of COVID-19 lockdowns. In it, we collected 340 digital letters from all over the country and connected thousands of people through epistolary exchanges. We used the genre of letters as a mediating, meaning-making, and (auto)biographical tool whereby people could share their experiences of domestic isolation and physical distancing, thus creating a community of support. Based on a well-documented understanding of meaning-making as a core human endeavor, especially in times of social disruption and personal crisis, this article frames sense-making as a transcendental and even spiritual process that yields broad principles for organizing life. Thus, the research adopts a psychosocial perspective on spirituality and applies thematic analysis to qualitatively analyze written narratives. The results reveal that many respondents underwent a three-part, not-necessarily-sequential process of collapsing, self-distancing, and transcending during lockdown, which allowed them to rearrange themselves according to the new total social fact of the pandemic. Through this process, respondents negotiated themes of semiotic crisis, striving for meaning, and beyond meaning (the essential). Finally, the article discusses the role of meaning as a transcendental component of psychosocial meaning-making coping processes and tries to highlight how shared writing experiences can stimulate personal and communal healing processes in the wake of social crises.

Refining our understanding of depressive states and state transitions in response to cognitive behavioural therapy using latent Markov modelling

BACKGROUND

It is increasingly recognized that existing diagnostic approaches do not capture the underlying heterogeneity and complexity of psychiatric disorders such as depression. This study uses a data-driven approach to define fluid depressive states and explore how patients transition between these states in response to cognitive behavioural therapy (CBT).

METHODS

Item-level Patient Health Questionnaire (PHQ-9) data were collected from 9891 patients with a diagnosis of depression, at each CBT treatment session. Latent Markov modelling was used on these data to define depressive states and explore transition probabilities between states. Clinical outcomes and patient demographics were compared between patients starting at different depressive states.

RESULTS

A model with seven depressive states emerged as the best compromise between optimal fit and interpretability. States loading preferentially on cognitive/affective v. somatic symptoms of depression were identified. Analysis of transition probabilities revealed that patients in cognitive/affective states do not typically transition towards somatic states and vice-versa. Post-hoc analyses also showed that patients who start in a somatic depressive state are less likely to engage with or improve with therapy. These patients are also more likely to be female, suffer from a comorbid long-term physical condition and be taking psychotropic medication.

CONCLUSIONS

This study presents a novel approach for depression sub-typing, defining fluid depressive states and exploring transitions between states in response to CBT. Understanding how different symptom profiles respond to therapy will inform the development and delivery of stratified treatment protocols, improving clinical outcomes and cost-effectiveness of psychological therapies for patients with depression.

Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium

Potentially morally injurious events (PMIEs) entail acts of commission (e.g., cruelty, proscribed or prescribed violence) or omission (e.g., high stakes failure to protect others) and bearing witness (e.g., to grave inhumanity, to the gruesome aftermath of violence), or being the victim of others' acts of commission (e.g., high stakes trust violations) or omission (e.g., being the victim of grave individual or systemic failures to protect) that transgress deeply held beliefs and expectations about right and wrong. Although there is a proliferation of interest in moral injury (the outcome associated with exposure to PMIEs), there has been no operational definition of the putative syndrome and no standard assessment scheme or measure, which has hampered research and care in this area. We describe an international effort to define the syndrome of moral injury and develop and validate the Moral Injury Outcome Scale (MIOS) in three stages. To ensure content validity, in Stage I, we conducted interviews with service members, Veterans, and clinicians/Chaplains in each country, inquiring about the lasting impact of PMIEs. Qualitative analysis yielded six operational definitions of domains of impact of PMIEs and components within domains that establish the parameters of the moral injury syndrome. From the domain definitions, we derived an initial pool of scale items. Stage II entailed scale refinement using factor analytic methods, cross-national invariance testing, and internal consistency reliability analyses of an initial 34-item MIOS. A 14-item MIOS was invariant and reliable across countries and had two factors: Shame-Related (SR) and Trust-Violation-Related (TVR) Outcomes. In Stage III, MIOS total and subscale scores had strong convergent validity, and PMIE-endorsers had substantially higher MIOS scores vs. non-endorsers. We discuss and contextualize the results and describe research that is needed to substantiate these inaugural findings to further explore the validity of the MIOS and moral injury, in particular to examine discriminant and incremental validity.

Posttraumatic Growth in Youth, Young Adults, and Caregivers Who Experienced Solid Organ Transplant

OBJECTIVE

To explore posttraumatic growth (PTG) in pediatric patients who have undergone solid organ transplant (SOT) and their caregivers, and to examine potential correlates of PTG.

METHOD

Youth and young adults with a history of SOT (heart, kidney, liver) at least 1 month prior to participation and caregivers completed measures of PTG, demographic, and medical factors. In total, 59 youth (M = 12.68 years, SD = 1.91), 21 young adults (M = 19.37, SD = 0.82), and 95 caregivers (M = 37.95 years, SD = 9.37) participated.

RESULTS

Overall, 67% of youth, 76% of young adults, and 89% of caregivers reported PTG within the medium to very high range. Appreciation of Life was the highest PTG subscale across all groups. Youth and caregiver PTG scores were significantly positively correlated. Religious affiliation and religious coping were positively associated with PTG for caregivers, and the relationship yielded large effect sizes for young adults. Caregivers of children with kidney transplants endorsed lower PTG than other organ types and caregivers of children who had an acute medical condition endorsed greater PTG than caregivers of children who had chronic illness.

CONCLUSION

Findings suggest the pediatric SOT experience can yield positive changes such as a greater appreciation of life. Although small sample sizes may have led to reduced power for detecting significant findings for some analyses, results suggest religious, medical, and parent-child relationship factors are likely related to PTG in pediatric SOT and warrant future investigation.

Clergy Perceptions of Mental Illness and Confronting Stigma in Congregations

Mental illness and stigma are key concerns in congregations and represent important threats to community health. Clergies are considered influential in how congregants think about and respond to mental health issues, especially in African American congregations. In-depth interviews with 32 African American and White clergies were conducted to understand their unique perspectives on mental health and how they interact with their congregations based on those perspectives. Findings include six themes related to mental health stigma, namely, holistic definitions of health; African Americans and different conceptions of mental health (only reported by African American clergies); code words and language; depression as a special case; perceptions of mental health counseling and treatment; and clergy strategies for addressing mental health stigma. The clergies in this study recognized their influence on ideas related to mental health in their congregations, and most expressed active efforts toward discussing mental health and reducing stigma.

Religiosity and Depression at Midlife: A Prospective Study

Objectives:

Previously, authors found high personal importance of religion/spirituality (R/S) in early adulthood to predict a 75% decreased risk of recurrence of major depression in middle adulthood. Here, the authors follow up the original study sample to examine the association between R/S and major depression from middle adulthood into midlife.

Method:

Participants were 79 of 114 original adult offspring of depressed and non-depressed parents. Using logistic regression analysis, three measures of R/S from middle adulthood (personal importance, frequency of religious service attendance, and denomination) were used to predict Major Depressive Disorder (MDD) in midlife.

Results:

High R/S importance in middle adulthood was prospectively associated with risk for an initial onset of depression during the period of midlife. Frequency of attendance in middle adulthood was associated with recurrence of depression at midlife in the high-risk group for depression, as compared to the low-risk group.

Conclusion:

Findings suggest that the relation between R/S and depression may vary across adult development, with risk for depression associated with R/S at midlife potentially revealing a developmental process.

Psychological first aid (PFA) and disasters

A disaster is commonly thought of as an occurrence that results in property damage and physical injuries that exceed the response capabilities of local resources. History teaches that disasters also result in a surge in demand for psychological support amongst survivors and disaster responders. This surge quickly exceeds local response capacities and has the potential to exceed even the mental health resources that may be imported from neighbouring jurisdictions and disaster relief agencies. Efficient and effective acute mental health intervention is, therefore, needed. However, the effectiveness of traditional multi-session counselling during and shortly after disasters has been questioned. Instead, the utilization of efficient and effective crisis-focussed psychological interventions has been suggested as acute phase alternatives. This paper asserts psychological first aid (PFA) may be considered a specific crisis-focussed disaster mental health intervention for use during and after disasters. PFA is designed for use in assessing and mitigating acute distress, while serving as a platform for psychological triage complementing more traditional psychological and psychiatric interventions. PFA may be employed by mental health clinicians as well as 'peer responders'.

Religion, spirituality, and risk for incident posttraumatic stress disorder, suicidal ideation, and hazardous drinking in U.S. military veterans: A 7-year, nationally representative, prospective cohort study

While religion and spirituality (R/S) have been linked to positive mental health outcomes, most studies have employed cross-sectional designs, which do not allow one to evaluate the utility of R/S in predicting these outcomes. To address this gap, this study analyzed data from a 7-year nationally representative, prospective cohort study of U.S. military veterans to examine the effects of R/S on the development of incident mental health outcomes in this population. Specifically, we examined the association between organizational religious activity (ORA), non-organizational religious activity (NORA), and intrinsic religiosity (IR), and the risk of incident PTSD, suicidal ideation (SI), and hazardous drinking (HD). Multivariable logistic regression analyses revealed that ORA predicted a lower incidence of PTSD and SI; NORA a greater risk of developing HD; and IR a lower risk of developing HD. These results suggest that religion and spirituality, assessed in a nationally representative sample of military veterans, predict risk of developing PTSD, SI, and HD, over and above sociodemographic factors and perceived social support. Clinical implications and strategies for incorporating R/S into mental health assessment and interventions in this population are discussed.

Collaborative spiritual care for moral injury in the veterans Affairs Healthcare System (VA): Results from a national survey of VA chaplains

The psychospiritual nature of moral injury invites consideration regarding how chaplains understand the construct and provide care. To identify how chaplains in the VA Healthcare System conceptualize moral injury, we conducted an anonymous online survey (N = 361; 45% response rate). Chaplains responded to a battery of items and provided free-text definitions of moral injury that generally aligned with key elements in the existing literature, though with different emphases. Over 90% of chaplain respondents indicated that they encounter moral injury in their chaplaincy care, and a similar proportion agreed that chaplains and mental health professionals should collaborate in providing care for moral injury. Over one-third of chaplain respondents reported offering or planning to offer a moral injury group. Separately, nearly one-quarter indicated present or planned collaboration with mental health to provide groups that in some manner address moral injury. Previous training in evidence-based and collaborative care approaches appears to contribute to the likelihood of providing integrated psychosocial-spiritual care. Results and future directions are discussed, including a description of moral injury that may be helpful to understand present areas of emphasis in VA chaplains' care for moral injury.

Smartphone Time Machine: Tech-Supported Improvements in Time Perspective and Wellbeing Measures

Individuals with a balanced time perspective, which includes good thoughts about the past, awareness of present constraints and adaptive planning for a positive future, are more likely to report optimal wellbeing. However, people who have had traumas such as adverse childhood experiences (ACEs) are likely to have less balanced time perspectives and lower overall wellbeing when compared to those with fewer or no ACEs. Time perspective can be improved via time-travel narratives that support people in feeling connected to a wise and loving future version of themselves, an approach that has until now only been provided in counseling contexts. Our team used an iterative inclusive design process to shape a scalable time-travel narrative tool – a responsive and progressive web application called Time Machine. Among other functionalities, Time Machine allowed people to record and listen to messages as if they were from and to their past and future selves. Using pre-planned as well as post-hoc analyses, we analyzed quantitative and qualitative data from 96 paid design partners (participants) who were taken through a 26-day pilot study of the technology. Among other effects, the results revealed: (1) high engagement throughout the design process, (2) improvements in self-reported time perspective and overall wellbeing scores that were greater for those using Time Machine during an optional-use period, (3) twice as much improvement in overall wellbeing scores for design partners with high ACEs (16%) versus low ACEs (8%), and (4) feelings of unconditional love apparently mediating the relationship between scores on time perspective and overall wellbeing measures. We discuss the limitations of these results as well as implications for the future role of spiritually informed scalable time-travel narrative technologies in healthcare and wellness.

Character Strengths Beatitudes: A Secular Application of Ancient Wisdom to Appreciate Strengths for Spiritual Happiness and Spiritual Growth

A beatitude is a blessing. It is a form of appreciation that can be directed toward others or oneself. Theologically speaking, some frame the original beatitudes from The Sermon on the Mount in the Gospel of Matthew as pertaining to “spiritual happiness”, and recent scholars have offered a compelling argument that they are a call to flourishing. The focus here involves the creation and description of 24 blessings, or beatitudes, using the lens of one of the foundational and most researched areas in the sciences of flourishing, well-being, and positive psychology, which is the science of character strengths. Recent research has framed the 24 universal character strengths as spiritual strengths, hence particularly aligned for secular and nonsecular contexts of spiritual blessings. Each of the 24 character strengths was created into a blessing using the structure of the original beatitudes—with an opening description of the personal quality or attribute that is blessed and a follow-up outcome or core benefit that arises from the expression of that quality. In this way, these character strength beatitudes or character strength blessings offer an opportunity to appreciate the best positive qualities of others. These blessings are framed as primarily a mechanism of appreciating the character strengths of others, resting theoretically in both the grounding path and the sanctification path, the two types of integration of character strengths and spirituality that researchers have proposed. They are discussed, secondarily, as applied to the individual, for self-understanding, insight, and growth. These two purposes are relevant to the deepening of the spiritual journey, providing support as individuals pursue meaning in life and/or the sacred as they go deeper within themselves, up and beyond themselves, and sideways and interconnected to others. Practical applications, based in science, are discussed and point to avenues by which these character strengths beatitudes might both foster the appreciating of others’ strengths and support one’s own spiritual happiness, spiritual coping, and spiritual growth.

Psychological Resilience in West Point Graduates: Results From a Nationally Representative Study

Background: The purpose of this study was to examine factors associated with psychological resilience in a nationally representative sample of West Point graduates. Aims: The aims of this study were to (a) employ a dimensional approach to operationalizing psychological resilience in a trauma-exposed population that had been highly trained and educated in persisting in the face of stress, was previously unstudied, and in which we could examine correlates of resilience, (b) identify key psychosocial factors, character traits, health variables, military experiences, and coping strategies as potential correlates of psychological resilience; and (c) examine whether reported gender moderated any of these associations in this population. Methods: A nationally representative sample of 1342 West Point graduates after gender integration from classes 1980 to 2011 were surveyed. Psychological resilience was operationalized using a discrepancy-based approach in which a measure of composite psychological distress (current posttraumatic stress disorder, generalized anxiety and depression symptoms) was regressed on measures of cumulative trauma burden. A multivariable linear regression model was then employed to identify factors that were independently associated with psychological resilience scores. Results: Purpose in life (29.8% of relative variance explained [RVE]), fewer perceived negative experiences in the military (20.6% RVE), social support (9.6% RVE), and grit (9.5% RVE) were the strongest correlates of psychological resilience scores for both women and men. Time in service was positively associated with resilience in women only. Conclusion: This study identifies key correlates of psychological resilience in West Point graduates, individuals who are highly trained to persevere in the face of stress and then were trauma-exposed. Most of these factors are modifiable and can be targeted in stress prevention and treatment interventions, especially for high-stress professions such as the military, frontline health care providers, and first responders.

Manifesting hope in despair: Exploring prosocial behavioural outcomes of COVID-19

The novel coronavirus (COVID-19) outbreak has resulted into global devastation. This study attempts to explore the positive phenomenal impact of perceived pandemic anxiety resulting in prosocial behaviour (PB) through the mechanisms of self-awareness and spiritual transformation using terror management theory (TMT). The study also examines the moderating impact of conscious state expansion (CSE) on the self-awareness and spiritual transformation relationship, and the impact of this moderation effect is further tested separately on two gender groups. The data (N = 573) for the study were collected from the Punjab state of India during the ascending phase of outbreak. The results of PLS-SEM analysis reveal the significant influence of variables under study on prosocial behavioural outcomes. Taking insights from the findings of the study it becomes clear that during dreadful situations, when people experience the possibility of loss of life, their self-awareness level increases, which in turn results in their spiritual transformation. Such mechanism is observed more in the people possessing higher spiritual consciousness. The study concludes by recognising the positive role played by spiritual transformation (ST) in the evolution of the attributes of care and compassion for others, resulting in positive social consequences. The discussion, implications, limitations, and future directions are presented and discussed.

Psychiatry's pursuit of euthymia: another wild goose chase or an opportunity for principle-based facilitation?

The authors are encouraged that the field of psychiatry is moving towards including euthymia and its components (e.g., well-being, flourishing and resilience) as well as dysfunction (i.e., psychopathology and its symptoms) in its assessment and treatment. We are concerned, however, that to guide its pursuit of euthymia, psychiatry appears to be adopting the same 'outside-in' paradigm as positive psychology; that the positive must be 'put into' people via assisting them to adopt new positive beliefs and persistently practice psychotherapeutic techniques. We fear that if psychiatry continues to view the positive through this 'outside-in' lens, its pursuit of euthymia will bear small fruit. In this editorial, we posit that mental health and psychopathology can be viewed from the same basis because both are created in the same way; from the 'inside-out' via people's use of three psycho-spiritual Principles-Universal Mind, Consciousness and Thought. We posit that people can use these Principles in a way that either creates distressing symptoms or releases innate euthymia. We further posit that via awareness and sufficient insight-based understanding of how these Principles manifest within everyone, psychiatry can achieve a deeper understanding of the source of all psychological experience that will facilitate its pursuit of euthymia.

A case-control study on physical activity preferences, motives, and barriers in patients with psychiatric conditions

BACKGROUND

Physical activity in individuals diagnosed with psychiatric conditions (patients) has antidepressant and anxiolytic effects, but levels of physical activity are still low in this population. This study aimed to identify physical activity preferences, motives, and perceived barriers in patients compared to individuals without a diagnosed psychiatric condition (controls).

METHODS

A total of 230 patients (age = 39.5 ± 14.0 years, 80% female) with major depression (34%), anxiety disorders (38%), or post-traumatic stress disorder (28%) completed a cross-sectional online survey to assess preferences, motives, and perceived barriers to physical activity (measured by the EMI-2). This group consisted of 100 patients with a clinical diagnosis (clinical subset) and 130 with self-reported psychiatric conditions (confirmed by the PHQ-4) from online help forums (online subset). Comparisons between patients of the clinical and the online subsets were performed and are referenced whenever significant. The patients group was compared to a healthy control group matched by sex and age (n = 230, age = 39.4 ± 14.9 years, 80% female).

RESULTS

More patients reported insufficient physical activity levels and more daily sitting hours (measured by the IPAQ) compared to controls. Patients reported lower preference in more ambitious types of physical activity, such as hiking, cycling, and running. The commonly most preferred type of physical activity in both groups was walking and yoga. Patients had fewer motives and more perceived barriers to physical activity in comparison to the control group. Some differences in motives and perceived barriers to physical activity were also found between patients of the clinical and the online subset.

CONCLUSIONS

Findings of low physical activity levels in patients are consistent with the literature. Due to the patients' lack of motivation and perception of barriers, health care providers should consider offering different and individualized forms of physical activity. Easier types of physical activity, such as walking and yoga, appear to be the most feasible and provide a good starting point to overcome perceived barriers to physical activity.

Empowerment of nurses for integrating clients' religion/spirituality into clinical practice: outcomes of an online training program

Background

Integration of clients’ religion/spirituality (R/S) into nursing practice can have effective outcomes in clients’ health. In this regard, nurses’ lack of competency can disrupt this process and interfere with the treatment process. Limited studies examined the impact of training programs on nurses’ competency in spiritual care and integration of clients’ R/S into clinical practice. This study aimed to investigate the impact of an online training program on nurses’ empowerment for integrating clients’ R/S into clinical practice.

Methods

In the present interventional study, 80 nurses were selected by stratified sampling from two hospitals in the southeastern Iran. Nurses were randomly divided into the intervention (n = 40) and control (n = 40) groups. An online training program was performed for the intervention group in four 2-hour sessions during three weeks. Data were collected from all participants using the R/S Integrated Practice Assessment Scale (RSIPAS) before and one month after the intervention.

Results

Prior to the intervention, scores of integrating clients’ R/S into clinical practice were not significantly different between the intervention and control groups (t = 0.23, p = 0.81). However, after the training program, these scores increased significantly with a very large effect size compared to the control group (t = 4.31, p = 0.001). Although the control group scores improved significantly after the intervention compared to the pre-intervention stage, the effect size was very small (t = -2.55, p = 0.01).

Conclusions

The online training program had a positive effect on nurses’ competency for integrating clients’ R/S into clinical practice in the intervention group. Due to the importance of integrating clients’ R/S into clinical practice, nurses’ competency should be strengthened in this area. Managers are suggested to consider appropriate strategies in order to empower nurses in integrating clients’ R/S into clinical practice. Nurse educators can benefit from our experiences in application of online training programs in nursing schools.

The Effectiveness of a Centering Meditation Intervention on College Stress and Mindfulness: A Randomized Controlled Trial

Background: Mental health concerns are climbing steadily on college campuses, and universities do not have the staffing and financial resources to address the overwhelming needs of students seeking counseling services. College counselors generally must place students on waitlists or refer them to external resources. Further, during the COVID-19 pandemic, university counselors have been working tirelessly to treat students through online formats. Alternative, online, evidence-based interventions offer college counselors a significant advantage in effectively treating their students. We seek to expand the empirical evidence for mindfulness interventions through online formats for the college population. We registered the study (ISRCTN13587045) at www.isrctn.com. Objective: We examined the effectiveness of a unique online centering meditation and its impact on stress and trait mindfulness in the college population. Methods: Through a randomized controlled trial, the treatment group participated in a 4-week intervention of centering for 10 min each morning and night. We measured stress and mindfulness in both groups through the Perceived Stress Scale and Cognitive and Affective Mindfulness Scale-Revised at baseline, 2 weeks, and 4 weeks. Results: The centering meditation treatment had a statistically significant positive impact on stress and mindfulness compared to a waitlist control group. The meditation group had an average of 64% adherence rate. Conclusion: The study findings indicate that individuals who participate in a 4-week online centering intervention showed improved levels of stress and trait mindfulness over time. Clinical Trial Registration: WHO International Clinical Registry Platform, identifier: ISRCTN13587045.

Self-Transcendence as a Buffer Against COVID-19 Suffering: The Development and Validation of the Self-Transcendence Measure-B

The age of COVID-19 calls for a different approach toward global well-being and flourishing through the transcendence suffering as advocated by existential positive psychology. In the present study, we primarily explained what self-transcendence is and why it represents the most promising path for human beings to flourish through the transformation of suffering in a difficult and uncertain world. After reviewing the literature on self-transcendence experiences, we concluded that the model of self-transcendence presented by Frankl is able to integrate both of the characteristics associated with self-transcendence. Afterward, we discussed how the self-transcendence paradigm proposed by Wong, an extension of the model by Frankl, may help awaken our innate capacity for connections with the true self, with others, and with God or something larger than oneself. We presented self-transcendence as a less-traveled but more promising route to achieve personal growth and mental health in troubled times. Finally, we presented the history of the development and psychometrics of the Self-Transcendence Measure-Brief (STM-B) and reported the empirical evidence that self-transcendence served as a buffer against COVID-19 suffering. The presented data in the current study suggested that the best way to overcome pandemic suffering and mental health crises is to cultivate self-transcendence.

COVID-19 related moral injury: Associations with pandemic-related perceived threat and risky and protective behaviors

BACKGROUND

The coronavirus-2019 (COVID-19) pandemic is associated with increased potential for morally injurious events, during which individuals may experience, witness, or learn about situations that violate deeply held moral beliefs. However, it is unknown how pandemic risk and resilience factors are associated with COVID-related moral injury.

METHODS

Individuals residing in the U.S. (N = 839; M_age = 37.09, SD = 11.06; 78% women; 63% White; 33% PTSD) participating in an online survey reported on COVID-19 related moral injury (modified Moral Injury Events Scale), perceived current and future threat of pandemic on life domains (social, financial, health), and COVID-19 risky and protective behaviors. Multivariate linear regressions examined associations of perceived threat and risky and protective behaviors on type of COVID-19 related moral injury (betrayal, transgression by others, self).

RESULTS

Participants endorsed MI betrayal (57%, N = 482), transgression by other (59%, N = 497), and by self 17% (N = 145). Adjusting for sociodemographics, only future threat of COVID-19 to health was significantly associated with betrayal (B = 0.21, p = .001) and transgression by other (B = 0.16, p = .01), but not by self. In contrast, high frequency of risky behaviors was associated with transgressions by self (B = 0.23, p < .001). Sensitivity analyses showed PTSD did not moderate the observed effects.

CONCLUSIONS

Betrayal and transgression by others was associated with greater perceived future threat of COVID-19 to health, but not financial or social domains. Stronger endorsement of transgression by self was associated with more frequently engaging in risky behaviors for contracting COVID-19. These findings may suggest the need for individual, community, and system level interventions to address COVID-19 related moral injury.

Moral Injury and the Absurd: The suffering of moral paradox

Drawing upon qualitative and construct validity evidence within MI research and the oral histories of combat-exposed Veterans, this paper explores the role of moral paradox (MP) as a precondition of moral injury (MI). Research is recommended to clearly delineate MP as a causative factor leading to more intractable cases of MI in the definitional literature, beyond the recognized impact of perpetration and betrayal-based conditions. Veteran stories collected during the normal course of providing spiritual care to combat-exposed Veterans and used by permission will provide insight into the theoretical concepts and interrelations of MP; proposed here as: circumstances in which moral obligations and/or ethical values come into conflict, forcing a choice between sides, none of which can be honored without violating the other. Acquainted with religious traditions that elucidate the perplexity and liberating effects of paradox, the work of Chaplains will also be recommended to address the problem of MP in wartime situations, highlighting the efficacy of acceptance-based spiritual interventions and therapeutic programs. Psychological and spiritual interventions that facilitate self-transcendence and non-dual awareness through experiential acceptance and a subscale measuring paradox-induced injury will be recommended for future research as well.

Moral Injury, Australian Veterans and the Role of Chaplains: An Exploratory Qualitative Study

Military personnel deployed to war zones or assigned to other morally challenging military duties are likely to be exposed to potentially morally injurious events (PMIE) that may inflict a moral injury (MI). This qualitative study formed 'Phase 1' of a larger study into PMIEs experienced by Australian veterans and the potential pastoral/spiritual care role of chaplains. Two seminars were conducted that involved 10 veterans being interviewed and audio recorded about their deployment experiences to evaluate whether there was any evidence among Australian veterans of a PMIE. Narrative data analysis indicated that all participants had been exposed to, or were involved in, a PMIE of one kind or another. Seven key themes were identified from the analyzed qualitative data: (i) immoral acts, (ii) death and injury, (iii) betrayal, (iv) ethical dilemmas, (v) disproportionate violence, (vi) retribution and (vii) religious/spiritual issues. Given this preliminary PMIE evidence identified, there is a need for further research, as well as the development of a suitable moral injury assessment scale appropriate for Australian veterans. Furthermore, given the ethical, moral, and spiritual issues involved, the implementation of a rehabilitation program suitable for Australian veterans which can be provided by chaplains is also suggested-namely 'Pastoral Narrative Disclosure.' It is argued that moral injury needs to be recognized, not just as an issue affecting individual personnel and their families, but is also a community health, organizational and government responsibility.

Investigating the Influence of Self-Compassion-Focused Interventions on Posttraumatic Stress: A Systematic Review and Meta-Analysis

Objectives

Self-compassion-focused interventions may be able to decrease posttraumatic stress symptoms. However, previous studies demonstrated mixed effects in which a series of confounders were not systematically quantified. In this study, a systematic review with meta-analysis was conducted to quantify the effects of self-compassion-focused therapies on posttraumatic stress disorder.

Methods

Twelve eligible studies were included after a systematic search of databases. Outcome measures were extracted for posttraumatic stress disorder.

Results

Our data indicated a medium protective effect on posttraumatic stress symptoms (SMD =  − 0.65), with most of the studies (8/12) coming from clinical settings. More importantly, longer interventions were associated with better posttraumatic stress outcomes (p < 0.001). Baseline or changes in self-compassion scores were not associated with posttraumatic stress outcomes post-interventions.

Conclusions

Overall, findings from this meta-analysis quantified the complex influence of self-compassion-focused interventions on posttraumatic stress symptoms and may provide insights for optimizing intervention strategies. 

Systematic Review and Meta-analysis Registration: PROSPERO CRD42020208663.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12671-021-01732-3.

Do Involvement in Alcoholics Anonymous and Religiousness Both Directly and Indirectly through Meaning in Life Lead to Spiritual Experiences?

Spirituality is a key element of Alcoholics Anonymous (AA) recovery. However, little is known about the potential religious and secular sources of spiritual experiences in AA fellowship. The aim of the study was to verify if in a sample of AA participants, meaning in life mediates the relationship between their religiousness and spiritual experiences, as well as between their involvement in AA and spiritual experiences. The study sample consisted of 70 Polish AA participants, and the following tools were used: the Alcoholics Anonymous Involvement Scale (AAIS); Santa Clara Strength of Religious Faith Questionnaire (SCSORFQ); Purpose in Life Test (PIL); two one-item measures regarding frequency of prayer and Mass attendance; and the Daily Spiritual Experiences Scale (DSES) duration of AA participation, which was positively related to involvement in addiction self-help groups and religiousness. Involvement in AA and religiousness were positively related to meaning in life, which in turn positively correlated with spiritual experiences. This research indicated that in a sample of AA participants, finding meaning in life partially mediates the relationship between religiousness and spiritual experiences, as well as fully mediating the relationship between involvement in AA and spiritual experiences. The theoretical and practical implications are discussed.