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Spiritually Integrated Interventions for PTSD and Moral Injury: a Review

  • PTSD (SK Creech and LM Sippel, Section Editors)
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Abstract

Purpose of review

The scope of this article is to summarize (a) what is known about the relationships between spirituality and trauma outcomes and (b) outline options for spiritually integrated trauma care.

Recent findings

Research on relationships between spirituality and psychological trauma outcomes has advanced to the point that there is no doubt that interventions addressing spiritual distress can provide critically needed help to trauma survivors who want spiritually integrated care. There are now many options for providing spiritually integrated care for trauma, including both implicitly and explicitly spiritually integrated options, group and individual options, and options for chaplaincy and mental health providers.

Summary

This review focused on spiritually integrated interventions for posttraumatic stress disorder that have at least one randomized controlled trial in the peer-reviewed literature. Eight interventions with that level of evidence are described with a review of clinical recommendations for their use.

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References

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

  2. Gray MJ, Litz BT, Hsu JL, Lombardo TW. Psychometric properties of the life events checklist. Assessment. 2004;11(4):330–41.

    Article  PubMed  Google Scholar 

  3. Jinkerson JD. Defining and assessing moral injury: a syndrome perspective. Traumatology. 2016;22(2):122.

    Article  Google Scholar 

  4. Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695–706.

    Article  PubMed  Google Scholar 

  5. Exline JJ, Pargament KI, Grubbs JB, Yali AM. The religious and spiritual struggles scale: development and initial validation. Psychol Relig Spiritual. 2014;6(3):208.

    Article  Google Scholar 

  6. Fontana A, Rosenheck R. Trauma, change in strength of religious faith, and mental health service use among veterans treated for PTSD. J Nerv Ment Dis. 2004;192(9):579–84.

    Article  PubMed  Google Scholar 

  7. Harris JI, Erbes CR, Engdahl BE, Olson RH, Winskowski AM, McMahill J. Christian religious functioning and trauma outcomes. J Clin Psychol. 2008;64(1):17–29.

    Article  PubMed  Google Scholar 

  8. Kopacz MS, Currier JM, Drescher KD, Pigeon WR. Suicidal behavior and spiritual functioning in a sample of veterans diagnosed with PTSD. J Injury Violence Res. 2016;8(1):6.

    Google Scholar 

  9. Ter Kuile H, Ehring T. Predictors of changes in religiosity after trauma: trauma, religiosity, and posttraumatic stress disorder. Psychol Trauma Theory Res Pract Policy. 2014;6(4):353.

    Article  Google Scholar 

  10. Bryan AO, Bryan CJ, Morrow CE, Etienne N, Ray-Sannerud B. Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatology. 2014;20(3):154.

    Article  Google Scholar 

  11. Bryan AO, Theriault JL, Bryan CJ. Self-forgiveness, posttraumatic stress, and suicide attempts among military personnel and veterans. Traumatology. 2015;21(1):40.

    Article  Google Scholar 

  12. Currier JM, Farnsworth JK, Drescher KD, McDermott RC, Sims BM, Albright DL. Development and evaluation of the expressions of moral injury scale—military version. Clin Psychol Psychother. 2018;25(3):474–88.

    Article  PubMed  Google Scholar 

  13. Raines AM, Currier J, McManus ES, Walton JL, Uddo M, Franklin CL. Spiritual struggles and suicide in veterans seeking PTSD treatment. Psychol Trauma Theory Res Pract Policy. 2017;9(6):746.

    Article  Google Scholar 

  14. Saunders SM, Miller ML, Bright MM. Spiritually conscious psychological care. Prof Psychol Res Pract. 2010;41(5):355.

    Article  Google Scholar 

  15. Park CL, Currier JM, Harris JI, Slattery JM. Trauma, meaning, and spirituality: translating research into clinical practice. American Psychological Association; 2017.

    Book  Google Scholar 

  16. Ash M, Harrison T, Pinto M, DiClemente R, Negi LT (2019) A model for cognitively-based compassion training: theoretical underpinnings and proposed mechanisms. Social Theory Health. 1–25.

  17. Currier JM, Holland JM, Drescher KD. Spirituality factors in the prediction of outcomes of PTSD treatment for US military veterans. J Trauma Stress. 2015;28(1):57–64.

    Article  PubMed  Google Scholar 

  18. Harris JI, Erbes CR, Engdahl BE, Ogden H, Olson RH, Winskowski AMM, Campion K, Mataas S. Religious distress and coping with stressful life events: a longitudinal study. J Clin Psychol. 2012;68(12):1276–86.

    Article  PubMed  Google Scholar 

  19. Ben-Ezra M, Palgi Y, Sternberg D, Berkley D, Eldar H, Glidai Y, Moshe L, Shrira A. Losing my religion: a preliminary study of changes in belief pattern after sexual assault. Traumatology. 2010;16(2):7–13.

    Article  Google Scholar 

  20. Harris JI, Meis L, Cheng ZH, Voecks C, Usset T, Sherman M. Spiritual distress and dyadic adjustment in veterans and partners managing PTSD. Spiritual Clin Pract. 2017;4(4):229.

    Article  Google Scholar 

  21. Sherman MD, Usset T, Voecks C, Harris JI. Roles of religion and spirituality among veterans who manage PTSD and their partners. Psychol Relig Spiritual. 2018;10(4):368.

    Article  Google Scholar 

  22. Evans WR, Stanley MA, Barrera TL, Exline JJ, Pargament KI, Teng EJ. Morally injurious events and psychological distress among veterans: examining the mediating role of religious and spiritual struggles. Psychol Trauma Theory Res Pract Policy. 2018;10(3):360.

    Article  Google Scholar 

  23. Wortmann JH, Park CL, Edmondson D. Trauma and PTSD symptoms: does spiritual struggle mediate the link? Psychol Trauma Theory Res Pract Policy. 2011;3(4):442.

    Article  Google Scholar 

  24. Usset TJ, Gray E, Griffin BJ, Currier JM, Kopacz MS, Wilhelm JH, Harris JI. Psychospiritual developmental risk factors for moral injury. Religions. 2020;11(10):484.

    Article  Google Scholar 

  25. Harris JI, Usset T, Voecks C, Thuras P, Currier J, Erbes C. Spiritually integrated care for PTSD: a randomized controlled trial of “Building Spiritual Strength.” Psychiatry Res. 2018;267:420–8.

    Article  PubMed  Google Scholar 

  26. Fowler JW, Dell ML (2006) Stages of faith from infancy through adolescence: reflections on three decades of faith development theory. The Handbook of Spiritual Development in Childhood and Adolescence, 34–45.

  27. Beck D, Cosco Holt L, Burkard J, Andrews T, Liu L, Heppner P, Bormann JE. Efficacy of the mantram repetition program for insomnia in veterans with posttraumatic stress disorder. Adv Nurs Sci. 2017;40(2):E1–12.

    Article  Google Scholar 

  28. Held, P., Klassen, B. J., Steigerwald, V. L., Smith, D. L., Bravo, K., Rozek, D. C., ... & Zalta, A. (2021). Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans? Eur J Psychotraumatol. 12(1):1877026.

  29. Frankfurt SB, Coady A. Bringing philosophy to bear on moral injury and posttraumatic stress disorder construct validation: commentary on Farnsworth (2019). J Trauma Stress. 2019;32(4):639–41.

    Article  PubMed  Google Scholar 

  30. Smith-MacDonald L, Norris JM, Raffin-Bouchal S, Sinclair S. Spirituality and mental well-being in combat veterans: a systematic review. Mil Med. 2017;182(11–12):e1920–40.

    Article  PubMed  Google Scholar 

  31. Smith-MacDonald LA, Morin JS, Brémault-Phillips S. Spiritual dimensions of moral injury: contributions of mental health chaplains in the Canadian armed forces. Front Psych. 2018;9:592.

    Article  Google Scholar 

  32. Bormann JE, Smith TL, Becker S, Gershwin M, Pada L, Grudzinski AH, Nurmi EA. Efficacy of frequent mantram repetition on stress, quality of life, and spiritual well-being in veterans: a pilot study. J Holist Nurs. 2005;23(4):395–414.

    Article  PubMed  Google Scholar 

  33. Lang AJ, Strauss JL, Bomyea J, Bormann JE, Hickman SD, Good RC, Essex M. The theoretical and empirical basis for meditation as an intervention for PTSD. Behav Modif. 2012;36(6):759–86.

    Article  PubMed  Google Scholar 

  34. Nash WP. Commentary on the special issue on moral injury: unpacking two models for understanding moral injury. J Trauma Stress. 2019;32(3):465–70.

    Article  PubMed  Google Scholar 

  35. Bormann JE, Gifford AL, Shively M, Smith TL, Redwine L, Kelly A, Becker S, Gershwin M, Bone P, Belding W. Effects of spiritual mantram repetition on HIV outcomes: a randomized controlled trial. J Behav Med. 2006;29(4):359–76.

    Article  PubMed  Google Scholar 

  36. Bormann JE, Liu L, Thorp SR, Lang AJ. Spiritual wellbeing mediates PTSD change in veterans with military-related PTSD. Int J Behav Med. 2012;19(4):496–502.

    Article  PubMed  Google Scholar 

  37. Bormann JE, Gershwing M, Wittry RJ, Kelly A, Belding W, Warren KA (2014). Mantram repetition program: all purpose manual. San Diego: VA San Diego Health Care System.

  38. Bormann JE, Thorp SR, Smith E, Glickman M, Beck D, Plumb D, Zhao S, Ackland PE, Rodgers CS, Heppner P, Herz LR, Elwy AR. Individual treatment of posttraumatic stress disorder using mantram repetition: a randomized clinical trial. Am J Psychiatry. 2018;175(10):979–88.

    Article  PubMed  Google Scholar 

  39. Crawford JN, Talkovsky AM, Bormann JE, Lang AJ. Targeting hyperarousal: mantram repetition program for PTSD in US veterans. Eur J Psychotraumatol. 2019;10(1):1665768.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Weinrich SP, Bormann JE, Glaser D, Hardin S, Barger M, Lizarraga C, del Rio J, Allard CB. Mantram repetition with homeless women. Holist Nurs Pract. 2016;30(6):360–7.

    Article  PubMed  Google Scholar 

  41. Bormann JE, Thorp S, Wetherell JL, Golshan S. A spiritually based group intervention for combat veterans with posttraumatic stress disorder: feasibility study. J Holist Nurs. 2008;26(2):109–16.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Plumb D, Bormann J, Beck D, Glickman M, Zhao S, Osei-Bonsu P, Johnston J, Elwy R. Meditation-based mantram repetition program for veterans with PTSD: a randomized controlled trial in the VA healthcare system. J Altern Complement Med. 2014;20(5):A10–A10.

    Article  Google Scholar 

  43. Possemato K, Bergen-Cico D, Treatman S, Allen C, Wade M, Pigeon W. A randomized clinical trial of primary care brief mindfulness training for Veterans with PTSD. J Clin Psychol. 2016;72:179–93.

    Article  PubMed  Google Scholar 

  44. Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol Sci Pract. 2003;10:144–56.

    Article  Google Scholar 

  45. Kearney DJ, McDermott K, Malte C, Martinez M, Simpson TL. Effects of participation in a mindfulness program for Veterans with posttraumatic stress disorder: a randomized controlled pilot study. J Clin Psychol. 2013;69:14–27.

    Article  PubMed  Google Scholar 

  46. Kimbrough E, Magyari T, Langenberg P, Chesney M, Berman B. Mindfulness intervention for child abuse survivors. J Clin Psychol. 2010;66:17–33.

    PubMed  Google Scholar 

  47. Gallegos AM, Crean HF, Pigeon WR, Heffner KL. Meditation and yoga for posttraumatic stress disorder: a meta- analytic review of randomized controlled trials. Clin Psychol Rev. 2017;58:115–24.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Dell; 2013.

    Google Scholar 

  49. Earley MD, Chesney MA, Frye J, Greene PA, Berman B, Kimbrough E. Mindfulness intervention for child abuse survivors: a 2.5-year follow-up. J Clin Psychol. 2014;70:933–41.

    Article  PubMed  Google Scholar 

  50. Kearney DJ, McDermott K, Malte C, Martinez M, Simpson TL. Association of participation in a mindfulness program with measures of PTSD, depression, and quality of life in a Veteran sample. J Clin Psychol. 2012;68:101–16.

    Article  PubMed  Google Scholar 

  51. Davis LL, Whetsell C, Hamner MB, Carmody J, Rothbaum BO, Allen RS, Bartolucci, A… & Bremner, J. D. A multisite randomized controlled trial of Mindfulness-Based Stress Reduction in the treatment of posttraumatic stress disorder. Psychiatr Res Clin Pract. 2019;1:39–48.

    Article  PubMed  Google Scholar 

  52. Polusny MA, Erbes CR, Thuras P, Moran A, Lamberty GJ, Collins RC, Rodman JL, Lim KO. Mindfulness-Based Stress Reduction for posttraumatic stress disorder among Veterans: A randomized clinical trial. JAMA. 2015;314:456–65.

    Article  CAS  PubMed  Google Scholar 

  53. Niles BL, Klunk-Gillis J, Ryngala DJ, Silberbogen AK, Paysnick A, Wolf EJ. Comparing mindfulness and psychoeducation treatments for combat-related PTSD using a telehealth approach. Psychol Trauma Theory Res Pract Policy. 2012;4(5):538–47.

    Article  Google Scholar 

  54. Davis LW, Schmid AA, Daggy JK, Yang Z, O’Connor CE, Schalk N, Do AL, Danka M, Lazarick D, Knock H. Symptoms improve after a yoga program designed for PTSD in a randomized controlled trial with veterans and civilians. Psychol Trauma Theory Res Pract Policy. 2020;12(8):904–12.

    Article  Google Scholar 

  55. Reinhardt KM, Noggle Taylor JJ, Johnston J, Zameer A, Cheema S, Khalsa SBS. Kripalu yoga for military veterans with PTSD: a randomized trial. J Clin Psychol. 2018;74(1):93–108.

    Article  PubMed  Google Scholar 

  56. Nguyen-Feng VN, Hodgdon H, Emerson D, Silverberg R, Clark CJ. Moderators of treatment efficacy in a randomized controlled trial of trauma-sensitive yoga as an adjunctive treatment for posttraumatic stress disorder. Psychol Trauma Theory Res Pract Policy. 2020;12(8):836.

    Article  Google Scholar 

  57. Mitchell KS, Dick AM, DiMartino DM, Smith BN, Niles B, Koenen KC, Street A. A pilot study of a randomized controlled trial of yoga as an intervention for PTSD symptoms in women. J Trauma Stress. 2014;27(2):121–8.

    Article  PubMed  Google Scholar 

  58. van der Kolk Laura BA, West J, Rhodes A, Emerson D, Suvak M, Spinazzola J. Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. J Clin Psychiatry. 2014;75(6):559–65.

    Article  Google Scholar 

  59. Carter J, Gerbarg PL, Brown RP, Ware RS, D’ambrosio, C. Multi-component yoga breath program for Vietnam veteran post-traumatic stress disorder: randomized controlled trial. J Traum Stress Disord Treat. 2013;2(3):1–10.

    Article  Google Scholar 

  60. Gray M, J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing, A., Maglion, M., Lang, A. J., & Litz, B. T. . Adaptive disclosure: an open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behav Ther. 2012;43(2):407–15.

    Article  PubMed  Google Scholar 

  61. Litz BT, Lebowitz L, Gray MJ, Nash WP (2017). Adaptive disclosure: a new treatment for military trauma, loss, and moral injury. Guilford Publications.

  62. Litz B, Carney JR. Employing Loving-kindness Meditation to promote self-and other-compassion among war veterans with posttraumatic stress disorder. Spirituality in Clinical Practice. 2018;5(3):201.

    Article  Google Scholar 

  63. Salzberg, S. (2002). Lovingkindness: the revolutionary art of happiness. Shambhala Publications.

  64. Maguen S, Burkman K, Madden E, Dinh J, Bosch J, Keyser J, Schmitz M, Neylan TC. Impact of killing in war: a randomized, controlled pilot trial. J Clin Psychol. 2017;73(9):997–1012.

    Article  PubMed  Google Scholar 

  65. Litz BT, Rusowicz-Orazem L, Doros G, Grunthal B, Gray M, Nash W,  Lang AJ (2021). Adaptive disclosure, a combat-specific PTSD treatment, versus cognitive-processing therapy, in deployed marines and sailors: a randomized controlled non-inferiority trial. Psychiatry Research, 297, 113761.

  66. Harris JI, Park CL, Currier JM, Usset TI, Voecks CD. Moral injury and psycho-spiritual development: considering the developmental context. Spiritual Clin Pract. 2015;2(4):256–66.

    Article  Google Scholar 

  67. Fowler JW, Levin RW. Stages of faith: the psychology of human development and the quest for meaning. Int J Philos Relig. 1984;15(1):89–92.

    Google Scholar 

  68. Harris, J. I., Erbes, C. R., Engdahl, B. E., Thuras, P., Murray-Swank, N., Grace, D., ... & Le, T. (2011). The effectiveness of a trauma focused spiritually integrated intervention for veterans exposed to trauma. J Clin Psychol. 67(4):425-438.

  69. Kearney DJ, Malte CA, McManus C, Martinez ME, Felleman B, Simpson TL. Loving-kindness Meditation for posttraumatic stress disorder: A pilot study. J Trauma Stress. 2013;26(4):426–34.

    Article  PubMed  Google Scholar 

  70. Kearney DJ, McManus C, Malte CA, Martinez ME, Felleman B, Simpson TL. Loving-kindness Meditation and the broaden-and-build theory of positive emotions among veterans with posttraumatic stress disorder. Med Care. 2014;52(12 suppl 5):S32–8.

    Article  PubMed  Google Scholar 

  71. Kearney DJ, Malte CA, Storms M, Simpson TL. Loving-kindness Meditation vs Cognitive Processing therapy for posttraumatic stress disorder among veterans: a randomized clinical trial. JAMA Netw Open. 2021;4(4):e216604–e216604.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Burkman K, Maguen S, Purcell N (2021). Impact of killing: a treatment program for military veterans with moral injury. In J. M. Currier, K. D. Drescher, & J. Nieuwsma (Eds.), Addressing Moral Injury in Clinical Practice (p. 203–221). American Psychological Association. https://doi.org/10.1037/0000204-012

  73. Burkman K, Purcell N, Maguen S. Provider perspectives on a novel moral injury treatment for veterans: initial assessment of acceptability and feasibility of the Impact of Killing treatment materials. J Clin Psychol. 2019;75(1):79–94.

    Article  PubMed  Google Scholar 

  74. Purcell N, Burkman K, Keyser J, Fucella P, Maguen S. Healing from moral injury: a qualitative evaluation of the impact of killing treatment for combat veterans. J Aggress Maltreat Trauma. 2018;27(6):645–73.

    Article  Google Scholar 

  75. Lang AJ, Malaktaris AL, Casmar P, Baca SA, Golshan S, Harrison T, Negi L. Compassion meditation for posttraumatic stress disorder in veterans: a randomized proof of concept study. J Trauma Stress. 2019;32(2):299–309.

    Article  PubMed  Google Scholar 

  76. Gonzalez-Hernandez E, Romero R, Campos D, Burychka D, Diego-Pedro R, Baños R, Negi LT, Cebolla A. Cognitively-based compassion training (CBCT®) in breast cancer survivors: a randomized clinical trial study. Integr Cancer Ther. 2018;17(3):684–96.

    Article  PubMed  PubMed Central  Google Scholar 

  77. LoParo D, Mack SA, Patterson B, Negi LT, Kaslow NJ. The efficacy of cognitively-based compassion training for African American suicide attempters. Mindfulness. 2018;9(6):1941–54.

    Article  Google Scholar 

  78. Reddy SD, Negi LT, Dodson-Lavelle B, Ozawa-de Silva B, Pace TW, Cole SP, Raison CL, Craighead LW. Cognitive-based compassion training: a promising prevention strategy for at-risk adolescents. J Child Fam Stud. 2013;22(2):219–30.

    Article  Google Scholar 

  79. CBCT® teacher Certification: Emory University: Atlanta GA. (n.d.). Retrieved April 19, 2021, from https://compassion.emory.edu/cbct-compassion-training/certified-teachers/index.html. Accessed 19 Apr 2021.

  80. Lang AJ, Casmar P, Hurst S, Harrison T, Golshan S, Good R, Essex M, Negi L. Compassion meditation for veterans with posttraumatic stress disorder (PTSD): a nonrandomized study. Mindfulness. 2020;11(1):63–74.

    Article  PubMed  Google Scholar 

  81. Swift JK, Callahan JL, Vollmer BM. Preferences. J Clin Psychol. 2011;67(2):155–65.

    Article  PubMed  Google Scholar 

  82. Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). Brunner/Mazel psychosocial stress series, No. 18. Trauma and the Vietnam war generation: report of findings from the National Vietnam Veterans Readjustment Study. Philadelphia, PA, US: Brunner/Mazel

  83. Koo KH, Hebenstreit CL, Madden E, Maguen S. PTSD detection and symptom presentation: racial/ethnic differences by gender among veterans with PTSD returning from Iraq and Afghanistan. J Affect Disord. 2016;189(1):10–6.

    Article  PubMed  Google Scholar 

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Harris, J.I., Chamberlin, E.S., Engdahl, B. et al. Spiritually Integrated Interventions for PTSD and Moral Injury: a Review. Curr Treat Options Psych 8, 196–212 (2021). https://doi.org/10.1007/s40501-021-00248-w

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