Acceptance and forgiveness therapy for veterans with moral injury: spiritual and psychological collaboration in group treatment

Addressing spiritual needs of Veterans post-incarceration: a needs assessment

The Veterans Health Administration (VHA) offers spiritual supports to Veterans nationally through its Chaplaincy Service and its Whole Health initiative. There are no systematic efforts to extend spiritual supports to Veterans re-entering community post-incarceration, however. Thus, the full potential of spiritual supports in bolstering well-being and minimizing recidivism during re-entry may not be fully realized. To explore this potential and ways to optimize it for re-entry Veterans, we conducted an exploratory needs assessment. We interviewed six re-entry Veterans and six staff members who work in re-entry to explore perceived spiritual needs in re-entry and ways to address such needs; we analyzed interview data thematically. Several themes emerged: 1) Spirituality as pluralistic; 2) Positive impacts of spirituality; 3) Tensions around the immediacy of spiritual needs; 4) Current spiritual supports and their limitations; and 5) Suggested improvements. We propose initiatives which VHA might pursue to verify and support re-entry Veterans' spiritual needs.

Enhancing the Utility of the Moral Injury Experience Wheel: Manualized Applications for Diverse Contexts

Moral injury has emerged as an important construct for understanding the distress experienced in the aftermath of a moral violation, initially among combat veterans and increasingly among other populations, such as healthcare workers and first responders. While numerous measures have been validated to assess for exposure to potentially morally injurious events and/or sequelae, additional tools are needed to facilitate nuanced discussion of the experience of moral injury in therapeutic encounters. The Moral Injury Experience Wheel (MIEW; Fleming, 2023) is an infographic instrument that is designed to elicit precise language and help differentiate feelings in an effort to process morally perplexing circumstances. This paper describes the contents and potential clinical applications of a newly developed manual to guide the use of the MIEW. The MIEW and manual are designed to be used independently or alongside existing moral injury interventions. A case study featuring the use of the MIEW and manual demonstrates how the tools can be used in a professional healthcare setting. Recommendations for moral injury care practitioners are provided.

ACTing Spiritually: Integrating Spiritual Care and Mental Health Care within a US Department of Veterans Affairs Inpatient Psychiatric Unit

As a part of the VA's interprofessional fellowship in psychosocial rehabilitation, the authors developed an 8-week spirituality group manual, ACTing Spiritually, which incorporates principles of acceptance and commitment therapy (ACT) into a spirituality group protocol. The group, administered weekly as possible for 28 weeks on an inpatient psychiatric unit at a veterans affairs (VA) medical center in West Haven, CT, aimed to incorporate veterans' spirituality into their mental health treatment through concepts of acceptance, values, mindfulness, and committed action. ACTing Spiritually ran in tandem with a basic ACT group and the two groups had comparable average group sizes, suggesting interest in ACTing Spiritually similarly compares to interest in a basic ACT group in this context. In addition, development of the group yielded several qualitative findings, including a discussion of the similarities and differences between ACT and spiritual care, clinical gains for chaplains conducting the group, and clinical tensions that arose through the process of integration. The study provided preliminary evidence of the potential feasibility and acceptability of ACTing Spiritually. Next steps should include a formal evaluation of its potential efficacy.

6-Fold path to self-forgiveness: an interdisciplinary model for the treatment of moral injury with intervention strategies for clinicians

Conscience is the indestructible core of one's personal identity and their sense of agency in the world. When it passes judgment against them, it generates inner conflict (i.e., moral injury). At its core, moral injury is about trust and sacred relationships, particularly the loss of safe connection with self, society, God/Divine/a Higher Power, and the world. The clash between a person's conscience and overwhelming existential or psychospiritual experiences, which uniquely defines moral injury, alienates them from life-sustaining relationships. Healing requires more than reordering fractured belief systems. Reestablishing bonds of self-worth, trust, and life-sustaining relationships are essential. This paper presents the 6-Fold Path to Self-Forgiveness (6-FPSF), an interdisciplinary, narrative-based healing writing process for the treatment of moral injury, particularly self-induced moral injury. Self-forgiveness has been associated with psychospiritual and relational well-being. The protocol draws upon theoretical literature, evidence-based psychological interventions, spiritual-oriented practices, creative arts, and somatic exercises for mental health counseling and spiritual/religious ministration. In addition to describing the 6-component therapeutic model, the author offers intervention strategies for clinicians.

An open trial of VA CONNECT: Caring for Our Nation's Needs Electronically during the COVID-19 Transition

The COVID-19 pandemic impacted emotional well-being due to safety concerns, grief, employment impacts, and social interaction limitations. Face-to-face mental health treatment restrictions were especially impactful to veterans who often gain social enrichment from Veterans Health Administration (VHA) care. We present results from a novel group-based telehealth intervention, VA Caring for Our Nation's Needs Electronically during the COVID-19 Transition (VA CONNECT), which integrates skills training and social support to develop a COVID-19 Safety & Resilience Plan. Veterans (n ​= ​29) experiencing COVID-related stress participated in an open trial of this 10-session, manualized group VHA telehealth intervention. We examined whether COVID-19-related stress, adjustment disorder symptoms, and loneliness decreased, and coping strategy use increased after participation in VA CONNECT. Between baseline and two-month follow-up, participants reported a significant reduction in perceived stress and adjustment disorder symptoms, and an increase in planning coping skills use. Significant changes were not observed in loneliness or other specific coping strategies. Findings may support the utility of VA CONNECT as an intervention for pandemic-related stress and improving certain coping skills. Future research should explore group-based telehealth interventions like VA CONNECT with other populations within and outside of the VA, which have value during major disruptions to face-to-face mental healthcare access.

The Impact of Faith-Based Pastoral Care in Decreasingly Religious Contexts: The Australian Chaplaincy Advantage in Critical Environments

This article considers the contribution of faith-based chaplains who provide holistic pastoral and spiritual care within critical environments such as the military, first responders, and hospitals. The contribution of faith-based chaplains can sometimes be taken for granted or not properly understood, particularly in some Western countries which are currently experiencing a decline in religiosity. Following on from a previous paper regarding chaplaincy utilization (Layson et al. 2022), this article presents an alternative argument to the secularist-humanist perspective by noting five ways by which the faith based chaplaincy model provides best practice service and builds a capability advantage for organizations that engage faith-based chaplaincy services. The first section discusses faith-based chaplaincy and organizational holistic care; the second section considers the role of faith-based chaplains-much of which is largely unknown and poorly appreciated; the third section considers the unique capability of faith-based chaplains to provide spiritual and religious care to those of faith and for those of none; the fourth section explores how faith-based chaplains can leverage the positive impact of religious organizations to provide additional low-cost resources for other organizations and their staff; and lastly, the operational advantage of faith-based chaplains on the world stage is considered, particularly in light of culturally and linguistically diverse populations to whom religiosity is increasingly important.

The Moral Injury Experience Wheel: An Instrument for Identifying Moral Emotions and Conceptualizing the Mechanisms of Moral Injury

This paper introduces an infographic tool called The Moral Injury Experience Wheel, designed to help users accurately label moral emotions and conceptualize the mechanisms of moral injury (MI). Feeling wheels have been used by therapists and clinical chaplains to increase emotional literacy since the 1980s. The literature on the skill of emotion differentiation shows a causal relationship between identifying emotions with specificity and emotional and behavioral regulation. Emerging research in moral psychology indicates that differentiating moral emotions with precision is related to similar regulatory effects. Based on this evidence, it is proposed that increasing moral emotional awareness through use of an instrument that visually depicts moral emotions and their causal links to MI will enhance appraisal and flexible thinking skills recognized to reduce the persistent dissonance and maladaptive coping related to MI. Design of the wheel is empirically grounded in MI definitional and scale studies. Iterative evaluative feedback from Veterans with features of MI offers initial qualitative evidence of validity. Two case studies will show utility of the wheel in clinical settings and present preliminary evidence of efficacy.

Core Components of Moral Injury Groups Co-Facilitated by Mental Health Providers and Chaplains

Despite increasing interest in moral injury, there is not yet consensus around what it is (and is not), who can have it and under what circumstances, or the degree and form of distress necessary to distinguish moral injury from other psychological and spiritual difficulties. The novelty of moral injury has created space for frontline Veterans Health Administration mental health and spiritual care providers to creatively apply their core professional skills and identities to moral injury. This paper presents findings of a core components analysis (CCA) derived from seven co-led chaplain-mental health moral injury group facilitation teams that were involved in a 16-month quality improvement endeavor of the Dynamic Diffusion Network (DDN). The DDN initiative engages providers in collaborative and iterative refinement of practices to promote rapid improvements in care for complex problems that lack a codified evidence base. Using CCA, we identified 10 core components of co-facilitated moral injury group care. Components include a clear conceptualization of moral injury, an inclusive approach to spirituality, and exploration of forgiveness, among others. This paper offers guidance that can be widely applied and readily adapted as our collective understanding of moral injury continues to expand and clarify. The core components are articulated here as principles for ongoing review and revision in response to future moral injury advances in the DDN and elsewhere.

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.