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Pastoral Narrative Disclosure: The Development and Evaluation of an Australian Chaplaincy Intervention Strategy for Addressing Moral Injury

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Abstract

This paper describes the development and initial chaplaincy user evaluation of ‘Pastoral Narrative Disclosure’ (PND) as a rehabilitation strategy developed for chaplains to address moral injury among veterans. PND is an empirically informed and integrated intervention comprising eight stages of pastoral counselling, guidance and education that was developed by combining two previously existing therapeutic techniques, namely Litz et al's (2017) 'Adaptive Disclosure' and ‘Confessional Practice’ (Joob & Kettunen, 2013). The development and results of PND can be categorized into five phases. Phase 1: PND Strategy Formation—based upon extensive international research demonstrating that MI is a complex bio-psycho-social-spiritual syndrome with symptoms sufficiently distinct from post-traumatic stress disorder. The review also provided evidence of the importance of chaplains being involved in moral injury rehabilitation. Phase II: Development and Implementation of ‘Moral Injury Skills Training’ (MIST)—which involved the majority of available Australian Defence Force (ADF) Chaplains (n = 242/255: 94.9%) completing a basic ‘Introduction to Moral Injury’ (MIST-1) as well as an ‘Introduction to PND’ (MIST-2). Phase III: MIST-3-PND-Pilot evaluation—involved a representative chaplaincy cohort (n = 13) undergoing the PND eight-stage strategy to ensure the integrity and quality of PND from a chaplaincy perspective prior to wider implementation. The pilot PND evaluation indicated a favourable satisfaction rating (n = 11/13: 84.6%; M = 4.73/5.0 satisfaction). Phase IV: MIST-3-PND Implementation—involved a larger cohort of ADF Chaplaincy participants (n = 210) completing a revised and finalized PND strategy which was regarded favourably by the majority of ADF Chaplains (n = 201/210: 95.7%; M = 4.73/5.0 satisfaction). Phase V: Summation. In conclusion the positive satisfaction ratings by a significant number of ADF chaplaincy personnel completing MIST-3-PND, provided evidence that chaplains evaluated PND as a suitable counselling, guidance and education strategy, which affirmed its utilisation and justifies further research for using PND to address MI among veterans, that may also prove valuable for other chaplains working in community health and first responder contexts.

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Notes

  1. DSM-5-TR explanation for ‘intrusions’ includes: (a). Recurrent, involuntary, and intrusive distressing memories of the traumatic events. (b) Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic events. (c) Dissociative reactions (e.g. flashbacks) in which the individual feels or acts as if the traumatic events were recurring. (d) Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic events. (e) Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic events.

  2. DSM-V-TR Z-code Z65.8: Religious or Spiritual Problem: This category can be used when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith or questioning of other spiritual values that may not necessarily be related to an organized church or religious institution (DSM-V-TR, APA 2022 p. 834).

  3. DUREL: Duke University Religion Index (Koenig & Büssing, 2010).

  4. SIS: Spiritual Injury Scale (Berg, 1994) [Also called: ‘Berg Spiritual Injury Scale’].

  5. Richardson et al., (2020a, 2020b): While providing statistical evidence challenging the utility of the MIES to measure ‘moral injury’, nevertheless Richardson et al. make little distinction as to what is meant by alternative terms such as ‘moral pain’ compared to the term ‘moral injury’.

  6. EMIS-M: Expression of Moral Injury Scale: Currier et al (2017).

  7. MISS: Moral Injury Symptom Scale—is currently used within the ADF Moral Injury Quick-Book as a self-assessment guide (Koenig et al., 2018).

  8. MIOS: Moral Injury Outcome Scale—is currently used by some Australian veteran associations/groups and is available for psychologists and social workers to utilize (Yeterin et al., 2019).

  9. MSWOs: The newly created category of secular Maritime Spiritual Wellbeing Officers (MSWO) formed part of the Chaplaincy cohort MIST/PND training. As MSWOs constituted a small number (n = 6), their size effect would not greatly impact the overall statistical summation and thus were included as part of the evaluation.

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Acknowledgements

The authors wish to acknowledge the contributions of Senior Chaplain Dan Hynes, RAN, and COL (Rtd) Mark Francis, RFD (Directorate of Spiritual Health and Wellbeing, Mental Health and Wellbeing Branch, Australian Defence Force) and Chaplain Andrew Watters, RAN (ADF Joint Health Command). Appreciation is also expressed to Chaplain (COL) Charles Vesely (Director Chaplaincy—Joint Training, Australian Defence College), Chaplain (COL) Sarah Gibson (Command Chaplain, Australian Army Forces Command) and Principal Navy Chaplain Andrew Lewis (Royal Australian Navy).

Disclaimer

The content, findings and views expressed within this paper are the opinions of the authors and do not necessarily reflect the official perspective of the Australian Defence Force, nor are the views formally endorsed by the Australian Department of Veteran Affairs, or the Commonwealth of Australia.

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Authors and Affiliations

  1. Palliative Care Unit, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, 3083, Australia

    Lindsay B. Carey

  2. Australian Institute of Ethics and Society, University of Notre Dame, Sydney, Australia

    Lindsay B. Carey

  3. Brisbane Central Clinical School of Medicine, University of Queensland, Brisbane, Queensland, Australia

    Matthew Bambling

  4. School of Historical and Philosophical Enquiry, University of Queensland, Brisbane, QLD, Australia

    Timothy J. Hodgson

  5. Moral Injury Australia, Brisbane, Queensland, Australia

    Nikki Jamieson

  6. School of Psychology, The University of Queensland, St Lucia, Brisbane, Australia

    Melissa G. Bakhurst

  7. Duke University Medical Center, Durham, North Carolina, USA

    Harold G. Koenig

  8. King Abdulaziz University, Jeddah, Saudi Arabia

    Harold G. Koenig

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Correspondence to Lindsay B. Carey.

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Conflict of interest

LBC and TJH are both fully qualified and endorsed chaplains and allied health researchers. They are co-authors of the ‘Pastoral Narrative Disclosure’ training manual (Hodgson & Carey, 2022a, 2022b. NJ is a social worker/suicidologist and mental health wellbeing researcher and author of the book ‘Darkest before Dawn’ (Jamieson, 2023). MB is a clinical psychologist. MGB is a mental health and wellbeing researcher. HGK is a psychiatrist, mental health researcher and co-author of ‘Spiritual readiness: Essentials for military leaders and chaplains’ (Koenig et al., 2023a) and ‘Moral injury: A handbook for military chaplains’ (Koenig et al., 2023c).

Ethical Approval

All research cited within this paper, which involved human participants, was checked for verifiable institutional approval from the respective human research ethics committees. As this review involved the reporting and initial assessment of a professional development program for training chaplains, ethics approval was not required. Nevertheless, data collection procedures were followed in accordance with the Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects and subsequent amendments (WMA, 1964–2013). Approval for chaplaincy participants to undertake PND professional development was gained from the Director General of each Chaplaincy Branch (Navy, Army and Air Force), and additional approval was granted by the relevant departmental directors and/or military commanders permitting their chaplains to engage in the PND training and evaluation.

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Appendices

Appendix 1

See Table 6.

Table 6 Examples of treatment/rehabilitation methods utilized for moral injury
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Appendix 2

See Fig. 3.

Fig. 3
figure 3

Proposed moral injury criteria and PTSD symptom criteria overlap

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Appendix 3

See Table 7.

Table 7 Summary statements of AD and PND stages—differences and similarities
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Appendix 4

Moral Injury Events Scale (MIES)

figure a

Introduction

The Moral Injury Events Scale (MIES) is used to screen for Moral Injury (MI), defined as ‘a trauma related syndrome caused by the physical, psychological, social and spiritual impact of grievous moral transgressions, or violations, of an individual’s deeply held moral beliefs and/or ethical standards’ (ADF, 2021). MI can be caused by: (i) an individual perpetrating, failing to prevent, bearing witness to or learning about inhumane acts which result in the pain, suffering or death of others, and which fundamentally challenges the moral integrity of an individual, organization or community, and/or (ii) the subsequent experience and feelings of utter betrayal of what is right caused by trusted individuals who hold legitimate authority.

Instructions

Completing this scale is not mandatory but would be beneficial to assist chaplains in assessing your well-being in relation to potentially morally injurious events. Please circle a number to indicate how much you agree or disagree with each of the following statements about your experiences during your time on deployment/since joining the military (*).

figure b

Appendix 5

See Table 8.

Table 8 MIST-3-PND implementation evaluation
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Carey, L.B., Bambling, M., Hodgson, T.J. et al. Pastoral Narrative Disclosure: The Development and Evaluation of an Australian Chaplaincy Intervention Strategy for Addressing Moral Injury. J Relig Health 62, 4032–4071 (2023). https://doi.org/10.1007/s10943-023-01930-4

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