Moral Injury
Integrating Mental Health and Chaplaincy to Heal and Repair Moral Injury
Moral injury is consistently described as having both psychosocial and spiritual dimensions. The degree to which a person’s spirituality is central to their experience of moral injury may vary, yet there is implicit understanding that a betrayal by self or others of one’s deeply held, foundational beliefs and commitments may be existentially or spiritually disorienting. Thus, it is both conceptually responsible and practical to engage those with expertise in spiritual care in responding to the distress of moral injury. Within the VA, the professionals with expertise in spiritual care are chaplains.
Who are Chaplains?
Chaplains represent a subset of religious leaders who are often assigned to work in secular (rather than religious) contexts, such as the military, healthcare settings, prisons, and schools. Chaplains who work in the VA have had additional clinical training, called clinical pastoral education (CPE), which consists of a combination of training and hands-on experience in clinical settings. CPE training augments chaplains’ religious or theological expertise with distinctive skills in providing care to diverse persons in clinical settings. While chaplains in the VA setting are endorsed by a religious body, their primary role in the healthcare setting is as a care provider rather than a religious leader. Thus, VA chaplains can meet with and provide care to any veteran, regardless of the chaplain’s or veteran’s particular religious beliefs or lack thereof.
Chaplains care for universal forms of human suffering, such as grief, interpersonal conflict, and struggles with meaning and purpose. They are not diagnostically driven professionals. The experience of moral injury is typically marked by broken relationships, a lost sense of community, and loss of one’s sense of identity and place in the world. The inclusion of chaplains in moral injury care can help care approaches move beyond a focus on symptom reduction or skills acquisition to include meaning-oriented interventions that regard the experience of moral injury as something to integrate existentially rather than resolve.
Why Provide Collaborative Care?
Collaborative mental health and chaplain care serves veterans by not requiring them to compartmentalize the “psychological” and “spiritual” aspects of their experience. Rather, they can address these coexisting and perhaps intersecting elements with the input of diverse professionals within a single care context. This is the essence of whole-person care.
Mental health professionals trained in evidence-based psychotherapies are critical to involve in providing moral injury care. They help to ensure that mental health needs are being attended to, can integrate their professional training in psychotherapy and/or medication management, and can discern how moral injury might be interacting with other psychosocial challenges. Involving chaplains in moral injury care sends the message that an individual’s religion/spirituality is important. Chaplains can also bring specific spiritual care practices to bear in addressing moral injury, such as exploring different aspects of forgiveness, facilitating lament, engaging community members as appropriate, incorporating ritual into moral injury care, and integrating evidence-based practices within the spiritual care they provide.
Integrative Mental Health
Because moral injury frequently involves both psychosocial and spiritual challenges, it makes sense to integrate mental health and chaplain services as part of care provision. Since 2008, VA’s Integrative Mental Health (IMH) program has been focusing on and facilitating the integration of these care services. As a result of years of intensive training, facilitation, and consultation with teams of mental health providers and chaplains across the VA, IMH has begun to identify distinct yet complementary contributions of mental health and spiritual care providers when addressing moral injury in veterans. IMH provides moral injury consultation to the field of VA providers, with a particular emphasis on chaplains and mental health providers engaged in collaborative care. To learn more, visit https://www.mirecc.va.gov/IMH/CollaborativeCare.asp.
Building Through Spiritual Strength (BSS)
Building Through Spiritual Strength (Harris et al., 2011), designed to address spiritual- and faith-based wounds that may result from military trauma exposure, is a manualized, eight-session, two-hour group intervention led by a Chaplain. The sessions consist of prayer (or meditation for nontheists) to establish communication with a Higher Power for spiritual coping as well as discussions of theodicy, forgiveness, and conflict resolution. BSS attempts to help patients to identify and heal areas of spiritual distress as well as leveraging religious resources to promote meaning-making. A randomized control trial of 138 Veterans (Harris et al., 2018) compared BSS (n = 71) to Present Centered Group Therapy (n =67). 60.6% of the BSS group completed treatment compared to 67.2% of the PCGT group. The two groups did not significantly differ in PCL or CAPS scores from pre- to post-treatment, but BSS was associated with greater gains in spiritual distress.
For references, see the Bibliography page.
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