Marek S. Kopacz

Moral injury: A new challenge for complementary and alternative medicine

Moral injury represents an emerging clinical construct recognized as a source of morbidity in current and former military personnel. Finding effective ways to support those affected by moral injury remains a challenge for both biomedical and complementary and alternative medicine. This paper introduces the concept of moral injury and suggests two complementary and alternative medicine, pastoral care and mindfulness, which may prove useful in supporting military personnel thought to be dealing with moral injury. Research strategies for developing an evidence-base for applying these, and other, complementary and alternative medicine modalities to moral injury are discussed.

Providing Pastoral Care Services in a Clinical Setting to Veterans At-Risk of Suicide

The value of enhanced spiritual wellbeing has largely been overlooked as part of suicide prevention efforts in Veterans. The aim of this qualitative study is to examine the clinical pastoral care services provided by VA Chaplains to Veterans at-risk of suicide. This study was conducted using in-depth interviews with five Chaplains affiliated with a medical center located in upstate New York. This study was able to show that some at-risk individuals do actively seek out pastoral care, demonstrating a demand for such services. In conclusion, a pastoral care framework may already exist in some clinical settings, giving at-risk Veterans the opportunity to access spiritual care.

Suicidal behavior and spiritual functioning in a sample of Veterans diagnosed with PTSD

Abstract: Background: Spiritual well-being has been lauded to exert a protective effect against suicidal behavior. This study examines the characteristics of spiritual functioning and their association with a self-reported history of suicidal thoughts and behavior in a sample of Veterans being treated for post-traumatic stress disorder (PTSD). Methods: The sample includes 472 Veterans admitted to a PTSD Residential Rehabilitation Program. Measures included the Brief Multidimensional Measure of Religiousness and Spirituality, PTSD Checklist – Military Version, Combat Experiences Scale, and individual items pertaining to history of suicidal thoughts and attempts, spiritual practices, and select demographics. Results: Problems with forgiveness and negative religious coping were uniquely associated with suicide risk, above and beyond age, gender, or ethnicity, combat exposure, and severity of PTSD symptomatology. Organizational religiousness was associated with decreased risk for thinking about suicide in the presence of these covariates. Daily spiritual experiences were inversely associated with suicidal thoughts. Differences in spirituality factors did not distinguish Veterans with both suicidal ideation and prior attempts from those who had ideations absent any prior attempts. Conclusions: The findings suggest that enhanced or diminished spiritual functioning is associated with suicidal thoughts and attempts among Veterans dealing with PTSD.

The spiritual health of veterans with a history of suicide ideation.

Introduction: In recent years, considerable empirical attention has been devoted to examining the increased risk of suicide observed in some Veteran populations. This has led to a renewed focus on developing novel support options which can be used to respond to Veterans in distress, reducing their risk of suicide. Spirituality and religion, however, have been largely absent from any public discourse related to suicide prevention, not least of all in Veteran populations. Aim: The aim of this cross-sectional study is to compare the self-rated spiritual health of Veterans with and without suicide ideation. Identifying differences which may exist between these two groups could highlight the relevance of spiritual well-being to Veteran suicide prevention efforts. Materials and Methods: Data were collected using pencil-and-paper surveys, called Spiritual Assessments, distributed within the general population of in- and outpatients at a U.S. Department of Veterans Affairs Medical Center. Using Likert-type scales, this study examines the self-rated spiritual health, spiritual devotion, and significance ascribed to spirituality in a sample of 5378 Veterans. Statistical analysis took place using chi-squared to examine differences in the distribution of responses between ideators and non-ideators. Results: Ideators significantly more often rated their spiritual health as worse than that of non-ideators. Even with similar levels of spiritual devotion or significance ascribed to spiritual life, ideators continued to significantly more often rate their spiritual health as worse than that of non-ideators. Conclusion: The results show that Veterans with suicide ideation more often rate their spiritual health as worse than that of Veterans without suicide ideation. This suggests that spiritual well-being may indeed be relevant to suicide prevention efforts in Veteran populations.

Mental Health and Self-directed Violence Among Student Service Members/Veterans in Postsecondary Education

Abstract. Objectives: Using a sample of student service members/veterans, the current study aimed to examine the prevalence of psychiatric diagnoses and suicide-related outcomes and the association of hazardous duty with mental health. Participants: Data are from the Fall 2011 National College Health Assessment (N = 27,774). Methods: Logistic regression was used to examine (1) the association of student service member/veteran status with mental health outcomes and (2) the association of hazardous duty with mental health outcomes among student service members/veterans (n = 706). Results: Student service members/veterans had higher odds of self-harm than students without military experience. Among student service members/veterans, hazardous duty was positively associated (odds ratio [OR] = 2.00, 95% confidence interval [CI] [1.30, 3.07]) with having a psychiatric diagnosis but negatively associated (OR = 0.41, 95% CI [0.20, 0.85]) with suicidal ideation. Conclusions: Self-harm may be a unique phenomenon among service members/veterans. Suicide prevention with this population should include information about self-harm, and future research should explore whether suicidal intent underlies self-harm.

Moral injury--a war trauma affecting current and former military personnel.

I commend Carta, Moro, and Bass (2014) on their recently published article ‘explor[ing] the theme of the traumatic consequences of war and its impact on mental health’. As briefly mentioned in their article, military personnel very often share the traumatic consequences of war. In recent years, attention has been particularly drawn to the experience of moral injury in current and former military personnel, especially as a potential risk factor for suicidal behavior in some Veteran populations (Maguen et al., 2012). Carta and colleagues very effectively highlight the many mental health challenges faced by civilian and refugee populations in times of war. Moral injury in military personnel should also warrant mention. Moral injury is conceptualized as ‘perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations’ (Litz et al., 2009). In addition to life-threatening situations, military personnel may also have to deal with morally injurious events, examples of which include witnessing the aftermath of violence, coming to grips with a painful loss, and having one’s moral/ethical beliefs contravened (Nash et al., 2013; Stein et al., 2012). Moral injury has been compared to a primary psychological trauma which may not necessarily be encompassed by a diagnosis of post-traumatic stress disorder (Drescher & Foy, 2008; Shay, 2011). Following exposure to trauma, military personnel will sometimes look to pastoral care providers for support in an effort to realign their existential beliefs and reaffirm the meaning and purpose of life (Fontana & Rosenheck, 2004, 2005). To this end, pastoral care providers may be in a unique position to illustrate the mental health burden of moral injury. All Veterans who seek healthcare services through medical centers run by the US Department of Veterans Affairs (VA) have the option of requesting pastoral care services from clinical chaplains. As part of an online survey, VA chaplains were asked ‘What do you see as being the primary emotional component of moral/spiritual injury in Veterans at-risk of suicide?’ (see Kopacz, McCarten, & Pollitt (in press) for a detailed description of this study). Of the 117 chaplains who responded to this question, 58.12% cited despair or hopelessness, 21.37% life having no meaning or purpose, 12.68% guilt, 4.27% anger or resentment and 2.56% sadness or grief (χ2(4) = 149.64, p < .0001). Although still in its empirical infancy, moral injury represents a war trauma impacting the mental health of military personnel. As research develops in this field, it stands to reason that moral injury may also be found to impact the mental health of civilian and refugee populations. Evidence-based strategies for dealing with moral injury are just starting to develop (Gray et al., 2012). Interestingly, healthcare providers are also becoming ever more mindful of the role religion and spirituality may play in supporting the mental health of their patients (Budd, 1999). Perhaps this is what Carta and colleagues meant by rediscovering the humanistic approach of the Greek, Latin and Islamic medical traditions to improve the lives of those affected by war?

Lectio Divina: A Preliminary Evaluation of a Chaplaincy Program

This participant outcome evaluation serves as a preliminary investigation into the effects of lectio divina, a chaplaincy service representing a form of focused Scripture reading. A sample of n = 19 patients who participated in this service at a Department of Veterans Affairs Medical Center in upstate New York was screened at baseline and 30-days follow-up using the Duke University Religion Index, Berg Spiritual Injury Scale, and a screening question for thoughts of harming self or others. These measures were used to assess the intended outcomes of enhanced religiosity, ameliorated spiritual injury, and decreased thoughts of violence. Data were collected through retrospective clinical chart reviews. The outcomes of enhanced religiosity or decreased thoughts of violence were not observed in this sample population. Ameliorated spiritual injury was observed in veterans with substantial engagement in lectio divina (>2 sessions) as well as those who endorsed thoughts of harming self or others.

Chaplains' Engagement with Suicidality among Their Service Users: Findings from the VA/DoD Integrated Mental Health Strategy

Chaplains play an important role in supporting the mental health of current and former military personnel; in this study, the engagement of Department of Veterans Affairs (VA), Army, Navy, and Air Force chaplains with suicidality among their service users were examined. An online survey was used to collect data from 440 VA and 1,723 Department of Defense (DoD) chaplains as part of the VA/DoD Integrated Mental Health Strategy. Differences were noted for demographics, work setting characteristics, encountering suicidality, and self-perceived preparation for dealing with suicidality. Compared to DoD chaplains, VA chaplains encounter more at-risk service users, yet feel less prepared for dealing with suicidality.

A preliminary study for exploring different sources of guilt in a sample of veterans who sought chaplaincy services.

Limited research has suggested that experiencing guilt may contribute to the risk of suicidal behavior in some veteran populations. Using data collected by chaplains, this study compared the frequency with which 94 veterans with a history of suicide ideation experienced guilt relative to 670 veterans without a history of ideation. We then compared main sources of guilt reported by ideators and nonideators. Ideators reported experiencing guilt significantly more often than nonideators. No differences were noted for the source of guilt among those who reported frequently experiencing this emotion. Ideators with an infrequent experience of guilt significantly more often named life and the military as the main source of this emotion. Clinicians should be mindful of the need to appropriately assess for and address guilt among veterans at increased risk of suicide. A variety of sources, not limited only to military experiences, may contribute to a veteran’s sense of guilt.

Delivering Chaplaincy Services to Veterans at Increased Risk of Suicide

The present study quantitatively examines the delivery of chaplaincy services to Veterans at increased risk of suicide as well as how chaplains collaborate with other healthcare providers. An on-line survey was distributed to the nationwide network of U.S. Department of Veterans Affairs chaplains, yielding a response rate of 11.91% (N = 118). Most chaplains reported some form of training in suicide prevention, approximately half were involved in safety planning, and the majority reported not engaging in firearm safety counseling. Chaplaincy services were usually delivered through in-person, group, and phone consultations. Respondents were generally satisfied with their collaboration with other healthcare providers, most often collaborating with psychologists, social workers, and counselors. As a descriptive study, the findings serve to inform the delivery of chaplaincy services to at-risk Veterans. Recommendations include expanding service delivery options, developing competency in safety planning and counseling, as well as increasing institutional awareness of chaplaincy services.