Staff Perspective: Faith Heals - Integrating Spirituality to Treat Moral Injury Associated with Combat-Related PTSD
“Spirituality has the potential to be a positive and protective resource or an exacerbating factor for PTSD or both.”
“In a recent multisite study, nearly three-quarters of 427 Veterans indicated that religion was important or very important in their lives, over 80% indicated this for spirituality, and more than two-thirds indicated that they would definitely engage in or be open to engaging in a spiritually integrated treatment such as SICPT. (Koenig et al., 2017)”
- Both quoted from within Pearce et al. (2018) in discussing Spiritually Integrated Cognitive Processing Therapy
Can Spiritual Integration and Tools help Moral Injury/PTSD?
During my recent research on Post-Traumatic Stress Disorder (PTSD) treatments, I have been spending more time reading about moral injury and reflecting on therapeutic practices that incorporate tools such as forgiveness and spirituality into the healing process. I found that within the text on Adaptive Disclosure, a treatment developed by Litz et al. to treat Moral Injury (MI), that forgiveness, of self and others, played an important role in healing. This was not surprising to me given my own past research on forgiveness and sexual trauma, which showed a significant relationship between reported mental well-being following trauma and self-forgiveness, in particular. Soon after, I ran across the article “Spiritually Integrated Cognitive Processing Therapy (SICPT): A New Treatment for Post-traumatic Stress Disorder That Targets Moral Injury”. This article points out that, with the exception of SICPT, there are no other evidence-based treatments for PTSD and moral injury that specifically incorporates use of the client’s spirituality and spiritual resources. SICPT does so by adding religion specific supplemental materials for Buddhism, Christianity, Hinduism, Islam, and Judaism to the standard CPT sessions. Given the residual impact of PTSD with lingering MI negatively impacting recovery, that many of my clients face, I was very interested to learn more.
Obviously, it would take several blogs for me to adequately discuss the specifics about spiritually congruent practices designed to treat MI, such as Spiritually Integrated Cognitive Processing Therapy, Adaptive Disclosure, or ACT for Moral Injury, so here I will spend time sharing more about what this might look like in one’s own practice. It’s a starting point for the conversation. I find stories help. Let me begin with a story from long ago about a Veteran battling PTSD, moral injury, and his own spiritual crisis…
Moral Injury Meets a Crisis of Faith:
“Josh” is a 28-year old Caucasian male, Army Veteran who served several back-to-back tours in Afghanistan. Despite some improvement in his PTSD symptoms within our VA Operation Enduring Freedom/Operation Iraqi Freedom Clinic, he remains chronically depressed, sometimes contemplates suicide and is plagued with isolation, grief, and self-loathing, all related to being a soldier and experiences in theater. While he was clearly skilled as a decorated leader in combat and proud to have served his country, he is also riddled with an all-consuming guilt concerning actions he either supported or directly participated in. You see, Josh is a self-professed “man of faith”, as many of the Veterans I worked with were, most presenting to our clinic from the surrounding areas in Kentucky and Tennessee. He shared that he himself enjoyed the pastime study of theology and that his father and grandfather were both Christian ministers, serving in the pastorate. For Josh, memories of combat-inflicted deaths and the commandment that “Thou shalt not kill” haunt him. While not a conscientious objector, he did not feel prepared for the full weight that killing might have on his conscience. He lives in an emotional space of self-condemnation supported by guilty thoughts culled from his own spiritual beliefs. Josh meets with me weekly in the hopes of “finding some peace”, although our sessions do, at times, begin to take on more of a confession and absolution tone versus a standard cognitive restructuring format.
For Josh, as with many other combat Veterans I have worked with, one particular incident remained burned into his memory and is on a constant, looped replay in his mind’s eye. Although not his first time killing in combat, this memory has had the greatest impact; it has made him question himself, humanity, and God, as he knows Him. In vivid detail, Josh is able to recall an incident in which he shot and killed an Afghani man during an attack. Very soon after, townspeople, including the man’s distraught wife and small children, came to look for him. Josh recalls the family begging for his assistance in locating the man, who was both a young husband and devoted father. As a married man himself, and as the father of small children, Josh identifies acutely with this man and his life. He thinks to himself had it not been for war, he might have been very good friends with this man. As a result, Josh feels unworthy of his own life. Why should he deserve to live and enjoy another day with his loved ones, when he has denied this privilege to this other family? Although he does contemplate suicide at times, he also states this is incongruent with his own beliefs and that “Only God has the right to take a life”.
Given my therapeutic style of balancing empathic validation and irreverent challenging, the work we do in sessions vacillates from being lighthearted and philosophically contemplative to more challenging and weighted with a compassionate gravity. Josh insists on quoting the Bible in support of all the reasons why he is a bad person, does not deserve to live, does not deserve happiness, and shouldn’t be with his own family. With his permission, I dig deep into the same Bible (which I am familiar with given my own faith and training in providing spiritually-congruent treatments) and begin to gently challenge some of what he brings into session informing his core beliefs.
He has made it clear that he is a firm believer in “Bible truth” and has agreed to our take on cognitive restructuring by challenging scripture with scripture. I do my best to meet him where he’s at:
Josh: “King David danced and celebrated after he killed his tens of thousands. Why can’t I [don’t feel like] doing the same?”
Me: “Well, David also wrote ‘All night long I flood my bed with weeping and drench my couch with tears.’ What do you think that might say about the rest of his experience?” What might that have have been about?
Or on another occasion,
Josh: “The Bible says ‘Thou shalt not kill’. It’s that simple. I have no right to break God’s law. I killed a man. I don’t deserve to live. It’s a life for a life, an eye for an eye, you know.”
Me: “I hear what you are saying. It does say that; however, I also want to gently point out – only because you have allowed me and asked me to do so – that the Bible also states that ‘to every thing there is a season, and a time to every purpose under heaven … a time of war, and a time of peace.’ Also, ‘a time to kill, and a time to heal’.…What does it say about God and forgiveness for when we have felt we have done something wrong?”
Forgiveness, particularly God’s right and ability to forgive us, seemed to hit a chord that deeply resonated with Josh in a way nothing else had up to that point in treatment. While he found it easy to forgive others, he refused to forgive himself for what he had done. We began to incorporate forgiveness work into sessions, with Josh seeking and finding evidence for this practice within his Bible readings. When it became difficult, we employed empty chair and some psychodrama techniques to help him fully process his thoughts and work through his emotions.
Also, we collaborated on ways Josh could make amends in memory of the man he killed. In the end, he became re-immersed into his church community and he and his wife volunteered regularly to support other families in their Army community who had lost a parent or loved one to the war. He became more engaged with others and his wife and children, noting he felt an “obligation to that man’s family to take good care of others and my own [family].”
Eventually, Josh’s depression symptoms improved to subclinical levels. He still had his good days and bad days, but was able to continue to improve and to engage in his own gentle self-questioning in a spiritually-informed CBT sort of manner. Josh was a success story and I felt fortunate for that, for at times I was afraid things might go terribly awry. We joked about that. At that point, we thanked each other for the experience of working with one another and Josh was referred to chaplaincy to continue processing some issues of grief and loss. During our last sessions Josh repeatedly stated “I know God sent you to me to help me.” Well, Josh, the feeling is mutual, as you taught me so much and sojourning together with you through your experience was both an immense privilege and unforgettable gift and learning opportunity. I consider therapy a sacred process and it was no small thing to me that Josh trusted me enough to continue working with me when things got really tough. I have a feeling that, wherever he is, that Josh is doing a world of good for many.
Spiritual Integration & Spiritual “Tools” or Concepts
Since that time sitting with Josh many years ago, I have worked with clients of different faith backgrounds and those embracing different spiritual practices. Even when working with a client who reports that they are Christian, I am careful to ask questions in order to assess what this means to the individual, as I know my own Christian faith expression and experience may be very different from their own. I have worked with clients who are Buddhist, Islamic, Jewish, Wiccan and all have taught me a great deal and we have worked well together. If a client tells me their faith is important to them and wishes we integrate it into treatment, we work on this. I also make sure to get consultative support as needed.
With respectful curiosity and reverent engagement, I make it very clear that I am not a spiritual director, clergy person, or soul guide. I am simply a psychologist, able and willing to sit humbly as a compassionate witness to one’s traumas and experience and companion during one’s healing journey. While engaging in the use of evidence-based treatments, I am able to help clients explore how their own spiritual beliefs might facilitate healing. Given the existential questions many of our patients with PTSD have, this approach may be helpful in beginning to address the moral injury associated with PTSD.
If looking to provide spiritually-congruent treatments to one’s clients, it is important to consider the following for oneself, as a provider: Does the client identify as spiritual or religious? If so, how important is spirituality to the client as a cultural factor informing their thinking or way of living? What is the difference between spirituality and religion – do I know this first? Do I feel competent to provide this type of therapy or will I train up in a therapy that is evidence-based and integrates spiritual beliefs to facilitate healing? Who may I consult with to help with this practice? How much does the client lean on their faith as a source of strength and comfort?
Other questions one may want to consider and discuss with one’s clients: What is the client’s view of their Higher Power or God? Is it loving or punitive? What is the client’s view of mental illness and healing, as informed by their spiritual or faith background? Will any of these beliefs help or hinder the healing process?
Do I, the clinician, believe that spirituality and faith expression are multicultural factors that may add significantly to the therapeutic process and progress of one’s clients?
Spiritual Tools or Concepts one may employ and explore may include discussion of the client’s Higher Power/God image? How does the client view their relationship with their Higher Power; the Higher Power’s view of the client, pre and post-trauma? Emotions experienced about one’s Higher Power or perceived punishment or anger felt from one’s God? What about the concepts and practices of forgiveness and compassion for self and others, confession and absolution, repentance and atonement? What about the giving and receiving of blessings – healing and otherwise? Each one of these concepts deserves it’s own more in-depth study.
One may even wish to examine one’s own spiritual or religious beliefs and how they might impact one’s thoughts on illness, healing and one’s practice, as well.
In conclusion, my experiences and readings to date leave me with many more questions than answers, as I investigate my own thoughts on spirituality, trauma, moral injury, and the therapeutic practice. However, I am glad to suffer this, as it has been so helpful for my clients. In addition to reading about MI and different spiritually-integrated treatments, I have found the VA National Center for PTSD’s tools for clergy members very informative and helpful. Anything to come alongside my clients and assist with their healing. After all, some sages of wisdom have said that being compassionate does truly mean to share in the suffering of another, while also having a strong desire to alleviate that suffering. It’s why we, as mental health providers, do what we do – to the best of our ability - with love.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Kimberly A. Copeland, Psy.D., is a Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology at Uniformed Services University of the Health Sciences in Bethesda, MD. Dr. Copeland is based at the Naval Medical Center in Portsmouth, VA.
References & Resources:
Koenig, HG, Boucher, NA, Youssef, N, Oliver, JP, Currier, JM, Pearce, MJ. Spiritually-oriented cognitive processing therapy for moral injury in active duty military and Veterans with posttraumatic stress disorder. J Nerv Ment Dis. 2017; 205(2): 147–153.
Litz, BT, Lebowitz, L, Gray, MJ, Nash, WP. Adaptive Disclosure: A New Treatment for Military Trauma, Loss, and Moral Injury, New York, NY: Guilford Press, 2015.
National Center for PTSD Website: Clergy toolkits.
From Internet: https://www.ptsd.va.gov/professional/treat/care/toolkits/clergy/index.asp
Pearce, M., Haynes, K., Rivera, N. R., & Koenig, H. G. (2018). Spiritually Integrated Cognitive Processing Therapy: A New Treatment for Post-traumatic Stress Disorder That Targets Moral Injury. Global Advances in Health and Medicine.
“Spirituality has the potential to be a positive and protective resource or an exacerbating factor for PTSD or both.”
“In a recent multisite study, nearly three-quarters of 427 Veterans indicated that religion was important or very important in their lives, over 80% indicated this for spirituality, and more than two-thirds indicated that they would definitely engage in or be open to engaging in a spiritually integrated treatment such as SICPT. (Koenig et al., 2017)”
- Both quoted from within Pearce et al. (2018) in discussing Spiritually Integrated Cognitive Processing Therapy
Can Spiritual Integration and Tools help Moral Injury/PTSD?
During my recent research on Post-Traumatic Stress Disorder (PTSD) treatments, I have been spending more time reading about moral injury and reflecting on therapeutic practices that incorporate tools such as forgiveness and spirituality into the healing process. I found that within the text on Adaptive Disclosure, a treatment developed by Litz et al. to treat Moral Injury (MI), that forgiveness, of self and others, played an important role in healing. This was not surprising to me given my own past research on forgiveness and sexual trauma, which showed a significant relationship between reported mental well-being following trauma and self-forgiveness, in particular. Soon after, I ran across the article “Spiritually Integrated Cognitive Processing Therapy (SICPT): A New Treatment for Post-traumatic Stress Disorder That Targets Moral Injury”. This article points out that, with the exception of SICPT, there are no other evidence-based treatments for PTSD and moral injury that specifically incorporates use of the client’s spirituality and spiritual resources. SICPT does so by adding religion specific supplemental materials for Buddhism, Christianity, Hinduism, Islam, and Judaism to the standard CPT sessions. Given the residual impact of PTSD with lingering MI negatively impacting recovery, that many of my clients face, I was very interested to learn more.
Obviously, it would take several blogs for me to adequately discuss the specifics about spiritually congruent practices designed to treat MI, such as Spiritually Integrated Cognitive Processing Therapy, Adaptive Disclosure, or ACT for Moral Injury, so here I will spend time sharing more about what this might look like in one’s own practice. It’s a starting point for the conversation. I find stories help. Let me begin with a story from long ago about a Veteran battling PTSD, moral injury, and his own spiritual crisis…
Moral Injury Meets a Crisis of Faith:
“Josh” is a 28-year old Caucasian male, Army Veteran who served several back-to-back tours in Afghanistan. Despite some improvement in his PTSD symptoms within our VA Operation Enduring Freedom/Operation Iraqi Freedom Clinic, he remains chronically depressed, sometimes contemplates suicide and is plagued with isolation, grief, and self-loathing, all related to being a soldier and experiences in theater. While he was clearly skilled as a decorated leader in combat and proud to have served his country, he is also riddled with an all-consuming guilt concerning actions he either supported or directly participated in. You see, Josh is a self-professed “man of faith”, as many of the Veterans I worked with were, most presenting to our clinic from the surrounding areas in Kentucky and Tennessee. He shared that he himself enjoyed the pastime study of theology and that his father and grandfather were both Christian ministers, serving in the pastorate. For Josh, memories of combat-inflicted deaths and the commandment that “Thou shalt not kill” haunt him. While not a conscientious objector, he did not feel prepared for the full weight that killing might have on his conscience. He lives in an emotional space of self-condemnation supported by guilty thoughts culled from his own spiritual beliefs. Josh meets with me weekly in the hopes of “finding some peace”, although our sessions do, at times, begin to take on more of a confession and absolution tone versus a standard cognitive restructuring format.
For Josh, as with many other combat Veterans I have worked with, one particular incident remained burned into his memory and is on a constant, looped replay in his mind’s eye. Although not his first time killing in combat, this memory has had the greatest impact; it has made him question himself, humanity, and God, as he knows Him. In vivid detail, Josh is able to recall an incident in which he shot and killed an Afghani man during an attack. Very soon after, townspeople, including the man’s distraught wife and small children, came to look for him. Josh recalls the family begging for his assistance in locating the man, who was both a young husband and devoted father. As a married man himself, and as the father of small children, Josh identifies acutely with this man and his life. He thinks to himself had it not been for war, he might have been very good friends with this man. As a result, Josh feels unworthy of his own life. Why should he deserve to live and enjoy another day with his loved ones, when he has denied this privilege to this other family? Although he does contemplate suicide at times, he also states this is incongruent with his own beliefs and that “Only God has the right to take a life”.
Given my therapeutic style of balancing empathic validation and irreverent challenging, the work we do in sessions vacillates from being lighthearted and philosophically contemplative to more challenging and weighted with a compassionate gravity. Josh insists on quoting the Bible in support of all the reasons why he is a bad person, does not deserve to live, does not deserve happiness, and shouldn’t be with his own family. With his permission, I dig deep into the same Bible (which I am familiar with given my own faith and training in providing spiritually-congruent treatments) and begin to gently challenge some of what he brings into session informing his core beliefs.
He has made it clear that he is a firm believer in “Bible truth” and has agreed to our take on cognitive restructuring by challenging scripture with scripture. I do my best to meet him where he’s at:
Josh: “King David danced and celebrated after he killed his tens of thousands. Why can’t I [don’t feel like] doing the same?”
Me: “Well, David also wrote ‘All night long I flood my bed with weeping and drench my couch with tears.’ What do you think that might say about the rest of his experience?” What might that have have been about?
Or on another occasion,
Josh: “The Bible says ‘Thou shalt not kill’. It’s that simple. I have no right to break God’s law. I killed a man. I don’t deserve to live. It’s a life for a life, an eye for an eye, you know.”
Me: “I hear what you are saying. It does say that; however, I also want to gently point out – only because you have allowed me and asked me to do so – that the Bible also states that ‘to every thing there is a season, and a time to every purpose under heaven … a time of war, and a time of peace.’ Also, ‘a time to kill, and a time to heal’.…What does it say about God and forgiveness for when we have felt we have done something wrong?”
Forgiveness, particularly God’s right and ability to forgive us, seemed to hit a chord that deeply resonated with Josh in a way nothing else had up to that point in treatment. While he found it easy to forgive others, he refused to forgive himself for what he had done. We began to incorporate forgiveness work into sessions, with Josh seeking and finding evidence for this practice within his Bible readings. When it became difficult, we employed empty chair and some psychodrama techniques to help him fully process his thoughts and work through his emotions.
Also, we collaborated on ways Josh could make amends in memory of the man he killed. In the end, he became re-immersed into his church community and he and his wife volunteered regularly to support other families in their Army community who had lost a parent or loved one to the war. He became more engaged with others and his wife and children, noting he felt an “obligation to that man’s family to take good care of others and my own [family].”
Eventually, Josh’s depression symptoms improved to subclinical levels. He still had his good days and bad days, but was able to continue to improve and to engage in his own gentle self-questioning in a spiritually-informed CBT sort of manner. Josh was a success story and I felt fortunate for that, for at times I was afraid things might go terribly awry. We joked about that. At that point, we thanked each other for the experience of working with one another and Josh was referred to chaplaincy to continue processing some issues of grief and loss. During our last sessions Josh repeatedly stated “I know God sent you to me to help me.” Well, Josh, the feeling is mutual, as you taught me so much and sojourning together with you through your experience was both an immense privilege and unforgettable gift and learning opportunity. I consider therapy a sacred process and it was no small thing to me that Josh trusted me enough to continue working with me when things got really tough. I have a feeling that, wherever he is, that Josh is doing a world of good for many.
Spiritual Integration & Spiritual “Tools” or Concepts
Since that time sitting with Josh many years ago, I have worked with clients of different faith backgrounds and those embracing different spiritual practices. Even when working with a client who reports that they are Christian, I am careful to ask questions in order to assess what this means to the individual, as I know my own Christian faith expression and experience may be very different from their own. I have worked with clients who are Buddhist, Islamic, Jewish, Wiccan and all have taught me a great deal and we have worked well together. If a client tells me their faith is important to them and wishes we integrate it into treatment, we work on this. I also make sure to get consultative support as needed.
With respectful curiosity and reverent engagement, I make it very clear that I am not a spiritual director, clergy person, or soul guide. I am simply a psychologist, able and willing to sit humbly as a compassionate witness to one’s traumas and experience and companion during one’s healing journey. While engaging in the use of evidence-based treatments, I am able to help clients explore how their own spiritual beliefs might facilitate healing. Given the existential questions many of our patients with PTSD have, this approach may be helpful in beginning to address the moral injury associated with PTSD.
If looking to provide spiritually-congruent treatments to one’s clients, it is important to consider the following for oneself, as a provider: Does the client identify as spiritual or religious? If so, how important is spirituality to the client as a cultural factor informing their thinking or way of living? What is the difference between spirituality and religion – do I know this first? Do I feel competent to provide this type of therapy or will I train up in a therapy that is evidence-based and integrates spiritual beliefs to facilitate healing? Who may I consult with to help with this practice? How much does the client lean on their faith as a source of strength and comfort?
Other questions one may want to consider and discuss with one’s clients: What is the client’s view of their Higher Power or God? Is it loving or punitive? What is the client’s view of mental illness and healing, as informed by their spiritual or faith background? Will any of these beliefs help or hinder the healing process?
Do I, the clinician, believe that spirituality and faith expression are multicultural factors that may add significantly to the therapeutic process and progress of one’s clients?
Spiritual Tools or Concepts one may employ and explore may include discussion of the client’s Higher Power/God image? How does the client view their relationship with their Higher Power; the Higher Power’s view of the client, pre and post-trauma? Emotions experienced about one’s Higher Power or perceived punishment or anger felt from one’s God? What about the concepts and practices of forgiveness and compassion for self and others, confession and absolution, repentance and atonement? What about the giving and receiving of blessings – healing and otherwise? Each one of these concepts deserves it’s own more in-depth study.
One may even wish to examine one’s own spiritual or religious beliefs and how they might impact one’s thoughts on illness, healing and one’s practice, as well.
In conclusion, my experiences and readings to date leave me with many more questions than answers, as I investigate my own thoughts on spirituality, trauma, moral injury, and the therapeutic practice. However, I am glad to suffer this, as it has been so helpful for my clients. In addition to reading about MI and different spiritually-integrated treatments, I have found the VA National Center for PTSD’s tools for clergy members very informative and helpful. Anything to come alongside my clients and assist with their healing. After all, some sages of wisdom have said that being compassionate does truly mean to share in the suffering of another, while also having a strong desire to alleviate that suffering. It’s why we, as mental health providers, do what we do – to the best of our ability - with love.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Kimberly A. Copeland, Psy.D., is a Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology at Uniformed Services University of the Health Sciences in Bethesda, MD. Dr. Copeland is based at the Naval Medical Center in Portsmouth, VA.
References & Resources:
Koenig, HG, Boucher, NA, Youssef, N, Oliver, JP, Currier, JM, Pearce, MJ. Spiritually-oriented cognitive processing therapy for moral injury in active duty military and Veterans with posttraumatic stress disorder. J Nerv Ment Dis. 2017; 205(2): 147–153.
Litz, BT, Lebowitz, L, Gray, MJ, Nash, WP. Adaptive Disclosure: A New Treatment for Military Trauma, Loss, and Moral Injury, New York, NY: Guilford Press, 2015.
National Center for PTSD Website: Clergy toolkits.
From Internet: https://www.ptsd.va.gov/professional/treat/care/toolkits/clergy/index.asp
Pearce, M., Haynes, K., Rivera, N. R., & Koenig, H. G. (2018). Spiritually Integrated Cognitive Processing Therapy: A New Treatment for Post-traumatic Stress Disorder That Targets Moral Injury. Global Advances in Health and Medicine.