Spiritually Integrated Cognitive Processing Therapy: A New Treatment for Post-traumatic Stress Disorder That Targets Moral Injury

Helpful and Harmful Approaches to Integrating Religion and Spirituality into Mental Health Care: A National Survey of Current Clients' Experiences in the United States

This article describes a national sample of 989 current mental health clients' views regarding whether and how their mental health care providers integrated the client's religion/spirituality (RS) into treatment. Within the online Qualtrics survey, two open-ended items asked respondents what (if anything) the client perceived their therapist having done regarding the client's RS that was (1) helpful/supportive or (2) hurtful/harmful. Participants also reported various ways therapists included the topic of RS in practice, if any. Nearly half freely described helpful ways their providers integrated the client's RS, and half indicated it was not discussed or applicable. Although 9.6% described hurtful experiences, most indicated their provider had not done anything harmful related to integrating RS. Implications for practice and training across mental health disciplines are discussed.

The effects of Religiosity, Spirituality, and sense of purpose on posttraumatic stress disorder treatment outcomes among Veterans

BACKGROUND

Religion/spirituality (R/S) is an important and commonly used resource for coping with difficult experiences and has been shown to reduce the development of posttraumatic stress disorder (PTSD) symptoms following a trauma. However, it is not clear how R/S affects response to treatment of PTSD.

OBJECTIVE

The aim of this paper was to understand how Veterans' R/S and sense of purpose were related to clinical outcomes when engaging in Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE). It was predicted that Veterans identifying as R/S would have a higher sense of purpose, be more likely to complete treatment, and have greater symptom change during treatment.

METHOD

The study included 91 military Veterans from a VA Medical Center outpatient PTSD Clinical Team who initiated CPT or PE and responded to a question about the importance of R/S in their lives at intake.

RESULTS

Forty nine percent of the Veterans in this sample reported R/S were important to them and had mixed feelings about whether their life had a clear sense of purpose. Neither R/S nor sense of purpose were associated with treatment completion or response to PTSD treatment.

CONCLUSION

These findings suggest that once PTSD has developed, R/S or sense of purpose may not play a significant role in completion of or response to evidence-based psychotherapies (EBPs) for PTSD. EBPs for PTSD are equally effective for Veterans identifying as R/S and those who do not, which may be reflective of administering EBPs in a culturally responsive manner.

Military Perspectives on the Provision of Spiritual Care in the Australian Defence Force: A Cross-Sectional Study

A module to explore perspectives on chaplaincy services was included in an online enterprise survey randomly distributed to members of the Australian Defence Force (ADF) during 2021. Up to eight questions were answered by 2783 active military personnel relating to their perception of chaplain activities and the impact of chaplaincy services. Of those military participants answering the question on religious status (n = 1116), a total of 71.6% (n = 799) of respondents identified as non-religious while 28.4% (n = 317) identified as holding a religious affiliation. Approximately 44.2% (n = 1230) of participants had sought support from a chaplain, of which 85.3% (n = 1049) found chaplaincy care to be satisfactory or very satisfactory. While the data suggest there is a lack of clarity around the multiple roles undertaken by chaplaincy, nevertheless respondents were just as likely to prefer chaplains for personal support (24.0%), as they were to seek help from non-chaplaincy personnel such as a non-ADF counsellor (23.2%), their workplace supervisor (23.1%) or a psychologist (21.8%). This evidence affirms that the spiritual care provided by military chaplaincy remains one of several preferred choices and thus a valued part of the holistic care provided by the ADF to support the health and wellbeing of its members.

The relationship between combat exposure and suicide risk in U.S. military veterans: Exploring the role of posttraumatic stress symptoms and religious coping

BACKGROUND

Rising suicide rates in the U.S. veteran population are a growing concern. Combat exposure has been identified as a potential predictor of suicide risk, but factors that may mediate the relation between combat exposure and suicide risk, and the role of potential coping mechanisms remain largely understudied. To address this gap, this study examined the association between lifetime combat exposure and current suicide risk; whether this association is mediated by posttraumatic stress disorder (PTSD) symptoms; and whether direct and/or indirect associations with combat exposure are moderated by organizational, non-organizational, and intrinsic religiosity.

METHODS

Data were analyzed from the National Health and Resilience in Veterans Study (2019-2020; n = 3843). Ordinary least squares and conditional process analyses were conducted to evaluate the conditional direct and indirect predictors of suicide risk.

RESULTS

PTSD symptoms significantly mediated the association between combat exposure and suicide risk. Intrinsic religiosity showed significant moderation and reduced the coefficient of PTSD symptoms predicting suicide risk but increased the coefficient of combat exposure predicting PTSD symptoms.

LIMITATIONS

In this cross-sectional, observational study, no conclusions can be made regarding causality.

CONCLUSIONS

Results of this study suggest a multifaceted relationship between combat exposure, PTSD, religiosity/spirituality, and suicide risk in U.S. veterans, and underscore the importance of PTSD and religious coping as part of ongoing suicide prevention efforts in this population.

Veterans' experiences of moral injury, treatment and recommendations for future support

INTRODUCTION

Moral injury (MI) significantly impacts the lives of many UK military veterans however, there is a lack of manualised treatment to address the needs of this population. To develop future treatments that are acceptable and well tolerated, veterans should be consulted on their experiences of existing psychological treatments and suggestions for future treatments.

METHODS

10 UK military veterans were interviewed about their experiences of receiving treatment for psychological difficulties after MI, and beliefs about core components of future treatments. Thematic analysis of these interviews were conducted.

RESULTS

2 superordinate themes were identified: experiences of previous mental health treatment and perceptions of the proposed treatments. Reflections on cognitive behavioural therapy were mixed, with some describing that it did not ameliorate their guilt or shame. In future treatments, focusing on values, using written letters and including therapy sessions with close companions were considered beneficial. Veterans reported that a strong rapport with therapist was key for MI treatment.

CONCLUSION

Findings provide a useful account of how current post-trauma treatments may be experienced by patients with MI. Although limited by sample size, the results highlight therapeutic approaches that may be helpful in future and provide important considerations for therapists treating MI.

Post-traumatic stress disorder and its associated factors among survivors of 2015 earthquake in Nepal

BACKGROUND

Natural disasters cause long term psychological consequences, especially post-traumatic stress disorders. It has been regarded as the most prevalent of psychiatric disorders after a natural disaster. The purpose of this study is to estimate the prevalence of Post-Traumatic Stress Disorder (PTSD) and determine its associated factors in adult survivors three years after the 2015 Nepal earthquake.

METHODS

A cross-sectional descriptive design was used where 1076 adults within the age range of 19-65 were randomly selected and interviewed from four adversely affected districts due to the 2015 earthquake. Instruments included a demographic questionnaire, an earthquake exposure questionnaire, the Oslo Social Support Scale (OSSS), and the Post-traumatic Stress Disorder Checklist-Civilian Version (PCL-C). Descriptive and inferential statistics were applied using Statistical Package for Social Science (SPSS) Version 16 for data analysis.

RESULTS

The prevalence of PTSD among earthquake survivors was 18.9%. The multivariate logistic regression showed that gender, ethnicity, education, occupation, social support and severity of damage to house and property were significantly associated with PTSD. Odds of having PTSD was 1.6 times higher among females (AOR = 1.6, 95% CI: 1.1-2.3) and nearly 2 times higher amongst illiterate survivors (AOR = 1.9, 95% CI: 1.2-2.8). Participants from the Janajati ethnic group and those who had a business occupation had a 50% lower risk of having PTSD. Around 39% of the participants had moderate social support and had 60% lower odds of having PTSD compared to those with poor social support (AOR = 0.4, 95%CI: 0.2-0.5, p < 0.001). Participants with medium and very high-level damage to personal property were more likely to have PTSD.

CONCLUSION

Post-traumatic stress disorder remained prevalent amongst survivors three years after the 2015 Nepal Earthquake. It is important to provide psychological and social support for survivors to decrease the health burden from PTSD. Socio-demographic characteristics such as females, farmers, those survivors who endured significant personal property damage were at higher risk.

Moral Injury and Recovery in Uniformed Professionals: Lessons From Conversations Among International Students and Experts

Introduction

In the course of service, military members, leaders, and uniformed professionals are at risk of exposure to potentially morally injurious events (PMIEs). Serious mental health consequences including Moral Injury (MI) and Post-traumatic stress disorder (PTSD) can result. Guilt, shame, spiritual/existential conflict, and loss of trust are described as core symptoms of MI. These can overlap with anxiety, anger, re-experiencing, self-harm, and social problems commonly seen in PTSD. The experiences of General (retired) Romeo Dallaire and other international experts who have led in times of crisis can help us better understand MI and recovery.

Objectives

In honor of Dallaire, online opportunities were created for international students and leaders/experts to discuss topics of MI, stigma, and moral codes in times of adversity as well as the moral impact of war. We aimed to (1) better understand MI and moral dilemmas, and (2) identify key insights that could inform prevention of and recovery from MI.

Materials and Methods

Webinars and conversations of 75-90 min duration on MI and recovery were facilitated by Leiden University, the University of Alberta and the Dallaire Institute for Children, Peace and Security between General Dallaire, world experts, and graduate students. Sessions were recorded, transcribed and thematically analyzed with NVivo using standard qualitative methodology.

Results

Ninety four participants engaged in conversations. Student engagements were attended by participants [N = 51; female (29), male (22)] from the Netherlands and Canada. Conversations were held with international experts [N = 43; female (19) and male (24)] from North America, Europe, Australia and the global south. Themes included: (1) recognizing the impact of exposure to PMIEs, (2) reducing stigma around MI, and (3) embracing the spiritual depth of humanity.

Conclusion

Exposure to PMIEs can have devastating impacts on military members, leaders and other uniformed professionals. This may lead to development of MI and PTSD. Recognizing MI as honorable may reduce stigma and psychological harm, and facilitate help-seeking among uniformed personnel and other trauma-affected populations. Salient efforts to address MI must include use of accurate measurements of MI and integrated holistic therapeutic approaches, inclusive of spiritual and social components. Urgency remains regarding the prediction, identification and treatment of MI.

Moral Injury, Betrayal and Retribution: Australian Veterans and the Role of Chaplains

This paper presents additional qualitative results from Phase 1 of a larger study examining potentially morally injurious events/experiences (PMIE) and/or moral injury (MI) among Australian veterans (Hodgson et al. in J Relig Health 60(5):3061-3089, 2021). It makes specific reference to (1) betrayal and (2) retribution experienced or perpetrated by Australian military veterans during military conflicts and peacekeeping missions. During two veteran seminars conducted in Adelaide, South Australia, a total of 50 veterans were recruited, 10 of whom were willing to be interviewed and audio-recorded about their deployment experiences. Narrative data analysis of veteran transcripts indicated that all participants had engaged in or were exposed to a PMIE/MI of one kind or another, and all had experienced betrayal and/or witnessed or perpetrated retribution. Given the ethical, moral and spiritual issues involved, the role of chaplains in addressing moral injury for the benefit of veterans through the use of 'Pastoral Narrative Disclosure' (PND) is suggested-with a specific focus upon 'restoration' and 'ritual'. Additional research is recommended with regard to acts of betrayal and retribution among veterans, as well as the further development of PND to address PMIE/MI.

Moral Injury, Chaplaincy and Mental Health Provider Approaches to Treatment: A Scoping Review

The aim of this research was to describe the evidence examining the approaches taken by mental health providers (MHPs) and chaplains to address symptoms related to moral injury (MI) or exposure to potentially morally injurious events (PMIEs). This research also considers the implications for a holistic approach to address symptoms related to MI that combines mental health and chaplaincy work. A scoping review of literature was conducted using Medline, PsycINFO, Embase, Central Register of Controlled Trials, Proquest, Philosphers Index, CINAHL, SocINDEX, Academic Search Complete, Web of Science and Scopus databases using search terms related to MI and chaplaincy approaches or psychological approaches to MI. The search identified 35 eligible studies: 26 quantitative studies and nine qualitative studies. Most quantitative studies (n = 33) were conducted in military samples. The studies examined interventions delivered by chaplains (n = 5), MHPs (n = 23) and combined approaches (n = 7). Most studies used symptoms of post-traumatic stress disorder (PTSD) and/or depression as primary outcomes. Various approaches to addressing MI have been reported in the literature, including MHP, chaplaincy and combined approaches, however, there is currently limited evidence to support the effectiveness of any approach. There is a need for high quality empirical studies assessing the effectiveness of interventions designed to address MI-related symptoms. Outcome measures should include the breadth of psychosocial and spiritual impacts of MI if we are to establish the benefits of MHP and chaplaincy approaches and the potential incremental value of combining both approaches into a holistic model of care.

Encountering children and child soldiers during military deployments: the impact and implications for moral injury

Background: During a deployment, soldiers must make seemingly impossible decisions, including having to engage with child soldiers. Such moral conflicts may continue to affect service members and veterans in the aftermath of a deployment, sometimes leading to severe moral distress, anguish, and personal crises. Service providers have increasingly argued that as a diagnosis, Post-Traumatic Stress Disorder (PTSD) cannot account for these deeply personal and painful moral conflicts. In light of this, the concept of moral injury has been introduced to better capture the profound forms of guilt and shame that may be experienced by service members and veterans. Objective: This paper addresses encounters with children and child soldiers during military deployments, as well as the risk for moral injury during and following these encounters, and their implications. This exploratory paper brings together existing literature on the topic to introduce, illustrate, and offer potential and promising interventions. Results: Given the potential moral conflicts that may ensue, military personnel who encounter child soldiers during a military deployment may be at risk for moral injury during and following these encounters. The introduction of the concept of moral injury provides a way for these largely unnamed personal and painful moral conflicts and violations to be recognized, addressed, and with appropriate care, remedied. Although there is limited research into their effectiveness at treating moral injury, individual and group-based interventions have been identified as potentially beneficial. Conclusion: As encounters with children during deployments are likely to continue, systematic research, training, healing interventions and prevention strategies are vital to support and protect children in conflict settings, as well as to ensure the mental health and well-being of service members and veterans. HIGHLIGHTS Profound moral conflicts may affect service members and veterans in the aftermath of a military deployment, sometimes leading to severe moral distress, anguish, and personal crises. The concept of moral injury has been introduced to better capture the profound forms of guilt and shame that may be experienced by service members and veterans.Encountering children and child soldiers during a military deployment, may present unique challenges, stress, and moral crises leading to potentially moral injurious events. In particular, transgression-based events which result from an individual perpetrating or engaging in acts that contravene his or her deeply held moral beliefs and expectations such as harming children, and betrayal-based events, which results from witnessing or falling victim to the perceived moral transgressions of others, may lead to lasting psychological, biological, spiritual, behavioural and social impairments.Interventions applied in both an individual-based context such as Cognitive Processing Therapy, Impact of Killing, Adaptive Disclosure, and a group-based context such as Acceptance and Commitment Therapy and Resilience Strength Training, have been identified as potentially beneficial to addressing moral injury. However, more research is required to ascertain appropriate and effective intervention and healing strategies.

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.

The Forgiveness Interview Protocol: A Narrative Therapy Writing-Process Model for the Treatment of Moral Injury

During psychotherapy assessments clinicians may recognize that some of their injured and traumatized clients may be wrestling with issues related to a lack of forgiveness linked to Moral Injury (MI). This paper presents the Forgiveness Interview Protocol (FIP), a narrative therapy writing-process model for the treatment of Moral Injury, drawing upon the philosophical work of Margaret Holmgren: "Forgiveness and the Intrinsic Value of Persons" (1993) now linked to a variety of evidence-based psychological sources. The FIP utilizes three distinct theoretical and clinical disciplines to arrive at a semi-structured interview intended for mental health counseling, and religious and spiritual care.

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.

Moral Injury: An Increasingly Recognized and Widespread Syndrome

Moral injury (MI), originally discussed in relationship to transgressing moral beliefs and values during wartime among military personnel, has expanded beyond this context to include similar emotions experienced by healthcare professionals, first responders, and others experiencing moral emotions resulting from actions taken or observations made during traumatic events or circumstances. In this article, we review the history, definition, measurement, prevalence, distinctiveness, psychological consequences, manifestations (in and outside of military settings), and correlates of MI in different settings. We also review secular psychological treatments, spiritually integrated therapies, and pastoral care approaches (specific for clergy and chaplains) used to treat MI and the evidence documenting their efficacy. Finally, we examine directions for future research needed to fill the many gaps in our knowledge about MI, how it develops, and how to help those suffering from it.

Addressing Moral Injury in Emergency Medicine

BACKGROUND

Moral injury, which is described as the psychological distress that results from actions, or lack of them, that go against one's beliefs or values, has become front and center among issues facing the practice of emergency medicine. Although it predates the COVID-19 outbreak, the pandemic has played a significant role in the increased rate of burnout, and even suicide, among emergency physicians.

CASE REPORTS

This paper includes several clinical vignettes to highlight incidents that may occur in the emergency department (ED) when physicians experience violations of their moral codes, leading to distress and moral injury. These scenarios explore the conflicts posed between competing bioethical principles such as beneficence, nonmaleficence, end-of-life decision-making, medical futility, respect for self-determination (autonomy), resource scarcity and triage, duty to care, and physician impairment.

DISCUSSION

There are significant similarities between moral injury and post-traumatic stress disorder (PTSD), with some authors describing moral injury as a subset of PTSD. We explore these commonalities to provide coping mechanisms and mitigation strategies for those suffering from moral injury.

CONCLUSION

Physicians experiencing moral injury may benefit from the many available evidence-based treatments for PTSD to identify and manage moral injury and to support patient care and personal well-being.

Spirituality, moral injury and mental health among Chinese health professionals

BACKGROUND

Moral injury has been found to be prevalent among healthcare professionals during the COVID-19 public health crisis.

AIMS

The present study examines the relationship between spirituality, moral injury, and mental health among physicians and nurses in mainland China during the COVID-19 pandemic.

METHOD

An online cross-sectional study was conducted involving 3006 physicians and nurses in mainland China, where the COVID-19 pandemic has caused high rates of hospital admission and death. The Moral Injury Symptoms Scale-Health Professional was administered, along with measures of mental health and spirituality. Hierarchical linear regression modelling was used to examine the mediating and moderating role of moral injury in the relationship between spirituality and mental health.

RESULTS

Spirituality was positively correlated with moral injury (β = 2.41, P < 0.01), depressive symptoms (β = 0.74, P < 0.01) and anxiety symptoms (β = 0.65, P < 0.01) after controlling sociodemographic variables. Moral injury significantly mediated the relationship between spirituality and both depression and anxiety, explaining 60% (0.46/0.76) of the total association between spirituality and depression and 58% (0.38/0.65) of the association with anxiety. No moderating effect of moral injury was found on the spirituality-mental health relationship.

CONCLUSIONS

Although they were the findings of a cross-sectional study, these results suggest that concern over transgressing moral values during the pandemic may have been a driving factor for negative mental health symptoms among Chinese health professionals for whom spirituality was somewhat important. Future longitudinal studies are needed to determine the causal nature of these relationships.

Moral injury, mental health and behavioural health outcomes: A systematic review of the literature

Despite a burgeoning of research on moral injury in the past decade, existing reviews have not explored the breadth of consequences and the multitude of pathways through which moral injury and potentially morally injurious experiences (PMIEs) influence mental and behavioural health outcomes. This study aimed to identify associations between moral injury on mental and behavioural health. Literature searches of psychological and medical databases were conducted through April 2020. Eligible studies measured moral injury or PMIEs, and health outcomes (e.g., depression, substance use and suicidality). Fifty-seven publications representing 49 separate samples were included. Studies examined the impact of moral injury on post-traumatic stress disorder (PTSD) (n = 43); depression (n = 32); anxiety (n = 15); suicide (n = 15); substance use (n = 14); and 'other' health outcomes, including pain, burnout, sleep disturbance and treatment-seeking behaviours (n = 11). The majority of studies found significant positive associations between moral injury-related constructs, mental health and behavioural health outcomes; however, the majority were also cross-sectional and focused on military samples. Proposed mediators included lack of social support, negative cognitions and meaning-making. Moderators included self-compassion, pre-deployment mental health education and mindfulness. Moral injury is associated with a variety of negative health outcomes. Research is needed to determine the mechanisms by which moral injury may influence these outcomes over time.

Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans?

Background: It has been suggested that current frontline posttraumatic stress disorder (PTSD) treatments are not effective for the treatment of moral injury and that individuals who have experienced morally injurious events may respond differently to treatment than those who have not. However, these claims have yet to be empirically tested. Objective: This study evaluated the rates of morally injurious event exposure and morally injurious index trauma and their impact on PTSD (PCL-5) and depression symptom (PHQ-9) reductions during intensive PTSD treatment. Method: Data from 161 USA military combat service members and veterans (91.3% male; mean age = 39.94 years) who participated in a 3-week Cognitive Processing Therapy (CPT)-based intensive PTSD treatment programme (ITP) was utilized. Morally injurious event exposure was established via the Moral Injury Event Scale (MIES). Index traumas were also coded by the treating clinician. Linear mixed effects regression analyses were conducted to examine if differences in average effects or trends over the course of treatment existed between veterans with morally injurious event exposure or index trauma and those without. Results: Rates of morally injurious event exposure in this treatment sample were high (59.0%-75.2%). Morally injurious event exposure and the type of index trauma did not predict changes in symptom outcomes from the ITP and veterans reported large reductions in PTSD (d = 1.35-1.96) and depression symptoms (d = 0.95-1.24) from pre- to post-treatment. Non-inferiority analyses also demonstrated equivalence across those with and without morally injurious event exposure and index events. There were no significant gender differences. Conclusions: The present study suggests that PTSD and depression in military veterans with morally injurious event exposure histories may be successfully treated via a 3-week CPT-based ITP.

Post-traumatic Stress Disorder and Post-traumatic Growth Among Muslim CPR Survivors

The present study was conducted to compare post-traumatic growth (PTG) and post-traumatic stress (PTSD) in CPR survivors in Shia and Sunni. In a cross-sectional study, the results showed that the mean score of PTSD in Sunni (n = 74) was more than that of Shia (n = 89). There was no difference between Shia and Sunni in the mean score of PTG. Regarding the useful role of religion on PTG, the use of religious coping strategies in post-traumatic life-threatening situations can be helpful. It is recommended that further studies be conducted on the cultural, social, and psychological factors affecting PTG and PTSD in different societies.

Resilience: Safety in the Aftermath of Traumatic Stressor Experiences

The relationship between adverse experiences and the emergence of pathology has often focused on characteristics of the stressor or of the individual (stressor appraisals, coping strategies). These features are thought to influence multiple biological processes that favor the development of mental and physical illnesses. Less often has attention focused on the aftermath of traumatic experiences, and the importance of safety and reassurance that is necessary for longer-term well-being. In some cases (e.g., post-traumatic stress disorder) this may be reflected by a failure of fear extinction, whereas in other instances (e.g., historical trauma), the uncertainty about the future might foster continued anxiety. In essence, the question becomes one of how individuals attain feelings of safety when it is fully understood that the world is not necessarily a safe place, uncertainties abound, and feelings of agency are often illusory. We consider how individuals acquire resilience in the aftermath of traumatic and chronic stressors. In this respect, we review characteristics of stressors that may trigger particular biological and behavioral coping responses, as well as factors that undermine their efficacy. To this end, we explore stressor dynamics and social processes that foster resilience in response to specific traumatic, chronic, and uncontrollable stressor contexts (intimate partner abuse; refugee migration; collective historical trauma). We point to resilience factors that may comprise neurobiological changes, such as those related to various stressor-provoked hormones, neurotrophins, inflammatory immune, microbial, and epigenetic processes. These behavioral and biological stress responses may influence, and be influenced by, feelings of safety that come about through relationships with others, spiritual and place-based connections.

Identifying Moral Injury in Healthcare Professionals: The Moral Injury Symptom Scale-HP

This study aims to develop and assess the psychometric properties of a measure of moral injury (MI) symptoms for identifying clinically significant MI in health professionals (HPs), one that might be useful in the current COVID-19 pandemic and beyond. A total of 181 HPs (71% physicians) were recruited from Duke University Health Systems in Durham, North Carolina. Internal reliability of the Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP) was examined, along with factor analytic, discriminant, and convergent validity. A cutoff score was identified from a receiver operator curve (ROC) that best identified individuals with significant impairment in social or occupational functioning. The 10-item MISS-HP measures 10 theoretically grounded dimensions of MI assessing betrayal, guilt, shame, moral concerns, religious struggle, loss of religious/spiritual faith, loss of meaning/purpose, difficulty forgiving, loss of trust, and self-condemnation (score range 10-100). Internal reliability of the MISS-HP was 0.75. PCA identified three factors, which was confirmed by CFA, explaining 56.8% of the variance. Discriminant validity was demonstrated by modest correlations (r's = 0.25-0.37) with low religiosity, depression, and anxiety symptoms, whereas convergent validity was evident by strong correlations with clinician burnout (r = 0.57) and with another multi-item measure of MI symptoms (r = 0.65). ROC characteristics indicated that a score of 36 or higher was 84% sensitive and 93% specific for identifying MI symptoms causing moderate to extreme problems with family, social, and occupational functioning. The MISS-HP is a reliable and valid measure of moral injury symptoms in health professionals that can be used in clinical practice to screen for MI and monitor response to treatment, as well as when conducting research that evaluates interventions to treat MI in HPs.

A Spirituality Mind-Body Wellness Center in a University Setting; A Pilot Service Assessment Study

Increasing rates of mental illness among college students over the past 10 years suggest a collective deficit in meaning and purpose unattended to by many university campuses. Psychopathology among young adult college students is associated with developmental tasks such as spiritual individuation, suggesting that interventions aimed at spiritual wellbeing may support the stated need for comprehensive mental health services. The aim of this pilot service assessment study is to investigate the feasibility, acceptability, and helpfulness of spiritually integrated programs at a Spirituality Mind Body (SMB) Wellness Center at a graduate-level academic institution. Wellness Center demographic and attendance data of N = 305 adult graduate students (M = 27.7 years, SD = 6.05) were used to assess acceptability and feasibility. To evaluate helpfulness, measures assessing symptoms of depression, anxiety, post-traumatic stress (PTS), spirituality, mindfulness, and psychological inflexibility were completed before and after eight-week programs on a subset of participants (n = 141). SMB users completed a total of 64% of sessions and reported significant pre/post gains in spirituality and mindfulness and decreases in psychological inflexibility, symptoms of depression and PTS. The preliminary findings of this open-trial are encouraging but inherently limited by the design; foremost, the results offer support for future research, which might draw on a larger sample and a study design involving a comparison group.

The sacred versus the secular in UK psychiatry

I comment on two papers by Koenig and colleagues that advocate the integration of religion into routine psychiatric practice. In my opinion, their selective overview of research, although useful, lacks balance. It omits any mention of the literature on worldwide scandals over child sex abuse (and other abuses of power) perpetrated and facilitated by religious authority within several faith groups. There is no mention of damaging ‘religiously informed’ treatments such as sexual orientation conversion therapy, which is still practised in the UK despite widespread condemnation. Their recommendations for clinical practice conflate association with causation. They do not offer practice guidance on managing the impact of power imbalances associated with religion in multicultural societies. In summary, despite more than a decade of research and debate, there are still no generally accepted ways of avoiding boundary violations where psychiatrists introduce religion into their clinical practice.

The Warrior's Journey Intervention: A Chaplain-Led Motivational, Preparatory Exercise for Enhancing Treatment Success

Outcome literature has shown poor treatment engagement in efficacious, evidence-based post-traumatic stress disorder (PTSD) programs among returning veterans with combat-related psychological symptoms and calls for the development of motivational, preparatory exercises that circumvent stigma-related barriers and are delivered before or during the orientation phase of treatment. The psychological states of hope, meaning, and guilt have been found to impact motivation for treatment and the development and maintenance of post-trauma pathology and symptom severity. Given a chaplain's less stigmatized role, as compared to mental health providers, and proficiency in assessing these states and providing interventions that mediate change, often before a veteran is enrolled in a PTSD treatment program, this paper introduces a brief, chaplain-led, preparatory exercise called the "Warrior's Journey Intervention" (WJI). This narrative based, meaning-making exercise is designed to improve motivation for treatment and mitigate post-trauma symptoms by impacting hope, meaning, and guilt through use of a universally shared, metaphoric story of trauma recovery. A case study will demonstrate use of the intervention, observe its effects, and analyze mechanisms of change. Research is recommended at the end of the article to test the hypothesis that the intervention promotes motivation for treatment and reduces symptoms of PTSD and Moral Injury (MI). A standardized manual for the exercise is available from author.

Moral injury from war and other severe trauma

Moral injury (MI) is a relatively new syndrome among military personnel with symptoms of post-traumatic stress disorder (PTSD). While MI has received considerable attention in the psychological sciences, the syndrome has received relatively little notice within psychiatry. MI has been defined as the negative emotions that emerge from transgressing moral boundaries by military personnel during combat such as killing enemy combatants or innocent civilians, failing to protect innocents or fellow combatants, or observing others transgress moral boundaries. MI may also be frequent among civilians and health professionals, although, as in military personnel, is often unrecognized.

Religion and psychiatry: recent developments in research

The evidence base on the relationship between religion and mental health is growing rapidly, and we summarise the latest research on the topic. This includes studies on religious involvement and depression, bipolar disorder, suicide, post-traumatic stress disorder (PTSD), substance use disorders, personality disorder, chronic psychotic disorder, marital/family stability, social support and psychological well-being. We also review a relatively new topic in psychiatry, moral injury, which often accompanies PTSD and may interfere with its treatment. We describe a theoretical model that explains how religion might affect mental health and briefly discuss its applications in clinical practice, including a discussion of religiously integrated therapies for depression, anxiety and other emotional problems. Overall, studies indicate that religious involvement often serves as a powerful resource for patients, one that can be integrated into psychiatric care. At times, however, religion may impede or complicate treatment. This article will help clinicians determine, on the basis of the latest research, whether religion is an asset or a liability for a particular patient.

Religion and psychiatry: clinical applications

In an earlier article we reviewed the latest research on the relationship between religious involvement and mental health, the effects of religiosity on mental health and well-being over time and the impact of religious interventions. Here we focus on clinical applications that may be useful to psychiatrists and other mental health professionals. We discuss general clinical applications relevant to all patients (e.g. taking a spiritual history, supporting/encouraging religious beliefs, referring to clergy), violations of clinician–patient boundaries and the need to ensure that religious/spiritual interventions are patient-centred. We describe evidence-based religious interventions and how to identify appropriate patients for this approach. Finally, we explore situations in which religious beliefs and practices may be a problem, not a resource, and make recommendations on how to address such cases. Case vignettes illustrate clinical situations that mental health professionals are likely to encounter. Although the focus is on the North American context, we note how practice and culture in the UK may differ.

Hope, Religiosity, and Mental Health in U.S. Veterans and Active Duty Military with PTSD Symptoms

INTRODUCTION

Many studies have linked hope with better mental health and lower risk of suicide. This is especially true in those who have experienced severe physical or emotional trauma. Religious involvement is associated with greater hope. We examine here the relationship between hope, religiosity, and mental health in a sample of Veterans and Active Duty Military (ADM) with PTSD symptoms.

MATERIALS AND METHODS

A cross-sectional multi-site study was conducted involving 591 Veterans and ADM from across the United States. Inclusion criteria were having served in a combat theater and the presence of PTSD symptoms. Measures of religiosity, PTSD symptoms, depression, and anxiety were administered, along with a single question assessing the level of hope on a visual analog scale from 1 to 10. Bivariate and multivariate relationships were examined, along with the moderating effects of religiosity on the relationship between hope and symptoms of PTSD, depression, and anxiety.

RESULTS

Hope was inversely related to PTSD, depression, and anxiety symptoms (r = -0.33, -0.56, and -0.40, respectively, all p < 0.0001), but was positively related to religiosity (r = 0.32, p < 0.0001). Religiosity remained significantly related to hope (p < 0.0001) after controlling for demographics, military characteristics, as well as PTSD, depression, and anxiety symptoms, and this relationship was partly but not entirely mediated by social factors (marital status, relationship quality, community involvement). Religiosity did not, however, moderate the strong inverse relationships between hope and PTSD, depression or anxiety symptoms.

CONCLUSION

Hope is inversely related to PTSD, depression, and anxiety in Veterans and ADM with PTSD symptoms. Although religiosity is positively related to hope, independent of demographic, military, social, and psychological factors, it does not buffer the negative relationships between hope and PTSD, depression, or anxiety. While further research is warranted, particularly longitudinal studies capable of addressing questions about causality, providing support for the existing religious beliefs of current and former military personnel may help to enhance hope and mental health in the setting of severe combat-related trauma.

Who sees the chaplain? Characteristics and correlates of behavioral health care-seeking in the military

Chaplains have a critical role in the military organization and health care. Using the 2015 Health-Related Behavior Survey, we compared Service Members' (SM) use of chaplaincy services to their use of other behavioral health (BH) services: 26.2% used any BH service and 8.0% met with a chaplain/clergyperson for BH. Among the 36.5% of SM who self-identified needing counseling, percentages of SMs receiving counseling were lower among those perceiving stigma associated with BH services (51.0%) than those not perceiving stigma (66.7%). Of SM who sought counseling: many used multiple counseling sources (48.0%), with the most common sources being a BH professional (71.6%), a medical doctor (37.5%), and a chaplain or clergyperson (30.2%). SM who met with a chaplain or clergyperson had more severe histories of abuse, were more likely to have a mental health diagnosis, and had fewer positive health behaviors than SM who sought other sources of counseling.

Rumination as a Mediator of the Associations Between Moral Injury and Mental Health Problems in Combat-Wounded Veterans

Moral injury is hypothesized to develop from witnessing or engaging in events that violate one's beliefs about themselves and has been shown to be associated with negative mental health symptoms. Although there has been an increase in research examining moral injury among military veterans, mechanisms that link moral injury to mental health outcomes are not well understood. The present study examined rumination subcomponents (problem-focused thoughts, counterfactual thinking, repetitive thoughts, and anticipatory thoughts) as possible mediators of the associations between moral injury (both self-directed and other-directed symptoms) and negative mental health symptoms (i.e., depression, anxiety, suicidality, sleep disturbance, memory problems, and posttraumatic stress disorder symptoms). Participants were 189 combat wounded veterans (180 men; Mean age = 43.14 years) who had experienced one or more deployments (defined as 90 days or more). Nearly all participants reported a service-connected disability (n = 176, 93.1%), with the average participant reporting a 90% total VA disability ranking, and most participants had received a purple heart (n = 163, 86.2%). Within our comprehensive mediation model, we found eight significant mediation effects with the most consistent mediator being problem-focused thoughts. Specifically, both self-directed and other- directed moral injury were associated with increased problem-focused thoughts, which in turn was associated with higher reported symptoms of depression, anxiety, and posttraumatic stress disorder. Taken together, rumination, and in particular, problem-focused thoughts, is relevant to understand the increased vulnerability of military veterans to exhibit poor mental health outcomes when experiencing moral injury.

Spirituality and Moral Injury Among Military Personnel: A Mini-Review

Introduction: Moral injury (MI) results when military personnel are exposed to morally injurious events that conflict with their values and beliefs. Given the complexity of MI and its physical, emotional, social, and spiritual impact, a holistic approach is needed. While the biopsychosocial aspects of MI are more commonly addressed, less is known of the spiritual dimension and how to incorporate it into treatment that facilitates restoration of one's core self and mending of relationships with self, others, and the sacred/Transcendent. The purpose of this study was to gain a greater understanding of the relationship between spirituality/religion (S/R) and MI as experienced by military members and veterans and to consider how S/R might be better integrated into prevention and treatment strategies. Methods: A mini-review of peer-reviewed articles published between January 2000 and April 2018 regarding the relationship between spirituality and MI among military personnel and veterans was conducted. Results: Twenty-five articles were included in the final review. Five themes were identified and explored, including i) Spirituality: A potential cause of and protective factor against MI, ii) Self and identity: Lost and found, iii) Meaning-making: What once was and now is, iv) Spirituality as a facilitator of treatment for MI, and v) Faith communities: Possible sources of fragmentation or healing. Discussion: Findings identified a cyclical relationship between S/R and MI, whereby S/R can both mitigate and exacerbate MI, as well as be affected by it. Seen as a type of S/R struggle, the use of S/R-specific strategies [e.g., forgiveness, review of S/R beliefs, engagement in S/R practices, and (re)connection with S/R communities], integration of S/R perspectives into general interventions, and help from chaplains may support healing, self-regulation, and mending of relationships, moral emotions, and social connection. Further research is yet needed, however, regarding i) S/R orienting systems, interventions, practices, and rituals/ceremonies that might protect against and treat MI; ii) features of individuals who do/do not experience MI; iii) S/R assessment tools and interventions; and iv) ways to maximize the positive contributions of faith communities.

Assessment of Moral Injury in Veterans and Active Duty Military Personnel With PTSD: A Review

Background: Moral injury (MI) involves distress over having transgressed or violated core moral boundaries, accompanied by feelings of guilt, shame, self-condemnation, loss of trust, loss of meaning, and spiritual struggles. MI is often found in Veterans and Active Duty Military personnel with posttraumatic stress disorder (PTSD). MI is widespread among those with PTSD symptoms, adversely affects mental health, and may increase risk of suicide; however, MI is often ignored and neglected by mental health professionals who focus their attention on PTSD only. Methods: A review of the literature between 1980 and 2018 conducted in 2018 is presented here to identify scales used to assess MI. Databases used in this review were PsychInfo, PubMed (Medline), and Google Scholar. Search terms were "moral injury," "measuring," "screening," "Veterans," and "Active Duty Military." Inclusion criteria were quantitative measurement of MI and health outcomes, Veteran or Active Duty Military status, and peer-review publication. Excluded were literature reviews, dissertations, book chapters, case reports, and qualitative studies. Results: Of the 730 studies identified, most did not meet eligibility criteria, leaving 118 full text articles that were reviewed, of which 42 did not meet eligibility criteria. Of the remaining 76 studies, 34 were duplicates leaving 42 studies, most published in 2013 or later. Of 22 studies that assessed MI, five used scales assessing multiple dimensions, and 17 assessed only one or two aspects (e.g., guilt, shame, or forgiveness). The remaining 20 studies used one of the scales reported in the first 22. Of the five scales assessing multiple dimensions of MI, two assess both morally injurious events and symptoms and the remaining three assess symptoms only. All studies were cross-sectional, except three that tested interventions. Conclusions: MI in the military setting is widespread and associated with PTSD symptom severity, anxiety, depression, and risk of suicide in current or former military personnel. Numerous measures exist to assess various dimensions of MI, including five multidimensional scales, although future research is needed to identify cutoff scores and clinically significant change scores. Three multidimensional measures assess MI symptoms alone (not events) and may be useful for determining if treatments directed at MI may both reduce symptoms and impact other mental health outcomes including PTSD.

The relationship among psychopathology, religiosity, and nicotine dependence in Croatian war veterans with posttraumatic stress disorder

Aim

To examine relationships among combat exposure, posttraumatic stress disorder (PTSD) symptoms, depression, suicidality, nicotine dependence, and religiosity in Croatian veterans.

Methods

This cross-sectional study used Combat Exposure Scale (CES) to quantify the stressor severity, PTSD Checklist 5 (PCL) to quantify PTSD severity, Duke University Religion Index to quantify religiosity, Montgomery Asberg (MADRS) and Hamilton Depression (HAM-D) rating scales to measure depression/suicidality, and Fagerstrom Test for Nicotine Dependence to assess nicotine dependence. Zero-order correlations, cluster analysis, multivariate regression, and mediation models were used for data analysis.

Results

Of 69 patients included, 71% met “high religiosity” criteria and 29% had moderate/high nicotine dependence. PTSD was severe (median PCL 71), depression was mild/moderate (median MADRS 19, HAM-D 14), while suicidality was mild. A subset of patients was identified with more severe PTSD/depression/suicidality and nicotine dependence (all P < 0.001). Two “chains” of direct and indirect independent associations were detected. Higher CES was associated with higher level of re-experiencing and, through re-experiencing, with higher negativity and hyperarousal. It also showed “downstream” division into two arms, one including a direct and indirect association with higher depression and lower probability of high religiosity, and the other including associations with higher suicidality and lower probability of high nicotine dependence.

Conclusions

Psychopathology, religiosity, and nicotine dependence are intertwined in a complex way not detectable by simple direct associations. Heavy smoking might be a marker of severe PTSD psychopathology, while spirituality might be targeted in attempts of its alleviation.

Oxford Centre for Evidence-based Medicine level of evidence: 3