Building Spiritual Strength - PowerPoint Presentation

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Building

Spiritual

Strength

Training for Chaplains and Therapists

May 15, 10:30 am -6:30 pm, Eastern Time

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Your TrainersJ. Irene Harris, Ph.D., L.P.

U. of MinnesotaResearch in psychology of religion for over 20 years, focus on trauma for 15 years.Over 30 publications in the peer-reviewed research literatureTimothy J. Usset, MDiv, MPH, LMFT, BCCArmy Reserve Chaplain, 7 yearsFellow, Transforming Chaplaincy projectMost experienced BSS chaplain facilitator in the USA

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Disclosure

Presenters have no relevant financial or non-financial relationships to disclose relating to the content of this activity; or presenter(s) must disclose the type of affiliation/financial interest (e.g. employee, speaker, consultant, principal investigator, grant recipient) with company name(s) included. The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of Defense, not the U.S. Government.

This continuing education activity is managed and accredited by the Defense Health Agency J-7 Continuing Education Program Office (DHA J-7 CEPO). DHA J-7 CEPO and all accrediting organizations do not support or endorse any product or service mentioned in this activity.

DHA J-7 CEPO staff, as well as activity planners and reviewers have no relevant financial or non-financial interest to disclose. Commercial support was not received for this activity.

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Disclaimer

I am a VHA employee, and some of the research to be presented here is based on VHA funding, but the views expressed in this presentation are not necessarily those of VHA.

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Case Study: “Robert”

Deployed 13 times over 10 years in Special Forces. Recently lost his military position due to posttraumatic stress disorder (PTSD) symptoms. Veteran underrepresented his suicide risk to enter study.

Described losing all sense of purpose, felt that he was unable to do what God would want him to do; care for his military unit, forgive ex-wife, pursue meaningful helping career. Strong sense of self as “unforgivable.”

This Photo by Unknown Author is licensed under CC BY-SA-NC

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Robert, p. 2Session 2: Robert developed a new sense of a relationship with G-d as one that loves him intensely, and does not require him to be perfect to do so.

Session 6: Robert discriminates forgiveness from reconciliation, and finds new ways to set boundaries in relationship with his ex-wife.

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Robert, p. 3

Robert now works as a licensed mental health provider, in a thriving private practice that focusses primarily on veterans managing PTSD.

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Target Conditions:

Posttraumatic Stress Disorder Moral Injury/Spiritual Distress

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At the end of the activity, participants will be able to:1. Describe basic symptoms and types of PTSD.

2. Define the symptoms of moral injury.

3. Discriminate internalizing vs. externalizing presentations of moral injury.4. Describe relationships between spiritual distress and trauma outcomes.

Learning Objectives

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Posttraumatic Stress Disorder (PTSD)

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Subtypes of PTSD

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Moral Injury/Spiritual Distress

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Signs of Moral InjuryLoss of previously held spiritual beliefs

Struggle or conflict in relationship with a Higher PowerDifficulty forgiving self, others, or a Higher PowerFeeling that there is no meaning or purpose in lifeReduced trust in othersInappropriate guilt and shame

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z

Examples of Moral Injury

He said he would only fill my requisition for gun turret shields if I slept with him. People in my unit will die without those.

The crowd threw an infant in front of the convoy to stop us. I had orders not to stop.

My c.o. could have kept this from becoming a firefight, but he didn’t and 3 of my best friends died.

I know whatever team I assigned to that position for this battle was likely to die.

They were all calling “Medic!” but I could not get to all of them. I had to let some of them die.

This Photo

by Unknown Author is licensed under

CC BY

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Circumstances that Can Precipitate Moral Injury

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Living in Multiple Moral Contexts

This Photo

by Unknown Author is licensed under

CC BY-SA

This Photo by Unknown Author is licensed under CC BY

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Consequences of Moral Injury

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Alternative Treatments for Moral Injury

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Moral Injury and Psychospiritual Development

Harris, J. I., Park, C. L., Currier, J. M., Usset, T. J., & Voecks, C. D. (2015). Moral injury and psycho-spiritual development: Considering the developmental context. Spirituality in Clinical Practice, 2(4), 256.

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Developmental Expectations

Stage 4 is NOT related to being theological liberal or conservative; it is an internally responsible

process

for spiritual reasoning

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Dimensions of Moral Injury

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Assessing Psychospiritual Development

Fowler Religious Attitudes Scale

Concerns about accurate results for apostates

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Clinical Assessment of Psychospiritual Development

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Why Use Building Spiritual Strength or Spiritually Integrated Care?

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Making PTSD Treatment Accessible

While highly effective, evidence-based treatments for PTSD are accessed by

only 11%

1,2

of combat veterans, and of those,

almost half drop out of treatment3-5.

Building Spiritual Strength is a spiritually-integrated model for treating PTSD designed to reach veterans who will not access conventional mental health services.

Dropout rates for BSS range from 6% to 14%

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Addressing Spiritual Components of PTSD

Interventions targeting spiritual distress have effects on PTSD symptoms.

Those who lose faith in the context of trauma have more psychopathology and use more mental health services, even 30 years later.

Increasing research links spiritual distress to

PTSD symptoms

Longer, more severe course of PTSD

Suicide risk in veterans managing PTSD

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Previous Pilot Study

9

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Second Study

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Study Design

Randomized Clinical Trial comparing BSS to Present Centered Group Therapy (PCGT)

Treatment nested within therapists

Manualized in both conditions with fidelity monitoring

Clinician Administered PTSD Scale (CAPS) (Pre and Post) and PTSD Checklist (PCL) (Pre, Post, Follow-up) for PTSD

Religious and Spiritual Struggles Scale (RSSS) for moral injury/spiritual distress

71 randomized to BSS, 67 randomized to PCGT

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Participants

Average age 58.33 (SD=13.00)14% female70% Caucasian, 8% African-American, 3% Hispanic, 1% each Asian, Native American, Multiracial, 17% Unreported

38 Catholic, 84 Protestant, 5 Agnostic, 13 Spiritual but not Religious, 1 Sufi, 2 Jewish, 1 Native American Spiritualty, 1 Shinto (note that some participants reported multiple faith affiliations)

Harris, J. I., Usset, T., Voecks, C., Thuras, P., Currier, J., & Erbes, C. (2018). Spiritually integrated care for PTSD: A randomized controlled trial of “Building Spiritual Strength”. Psychiatry research,

267, 420-428.

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Study Results-PTSD Symptoms

Clinician Administered PTSD Scale (CAPS)PTSD Checklist (PCL)

F[1,78] = 1.44, p = .23, η2 = .02t (condition) = 1.62, p = .107

t (time x condition) = -0.873, p = .384

Harris, J. I., Usset, T., Voecks, C., Thuras, P., Currier, J., & Erbes, C. (2018). Spiritually integrated care for PTSD: A randomized controlled trial of “Building Spiritual Strength”. Psychiatry research, 267, 420-428.

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Study Results-Spiritual Distress

Divine

DoubtUltimate Meaning

t (time x condition) = -3.24, p = .001t (time x condition) = -0.30, p = .764

t (time x condition) = 0.23, p = .821

Moral

InterpersonalDemonict (time x condition) = -1.10, p = .276t (time x condition) = -0.22, p = .830t

(time x condition) = -0.95, p = .346

Harris, J. I., Usset, T., Voecks, C., Thuras, P., Currier, J., & Erbes, C. (2018). Spiritually integrated care for PTSD: A randomized controlled trial of “Building Spiritual Strength”. Psychiatry research, 267, 420-428.

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Attributes of Divine Distress Scale

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Correlates of Divine Distress Scale

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Previous Research in Divine Distress

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Conclusions

No statistically significant differences between BSS and an active control condition (PCGT) in treating PTSD symptoms

BSS is

more effective

than PCGT

in treating spiritual distress.To our knowledge, this is the only clinical trial of a treatment for moral injury/spiritual distress that documents reduction of spiritual distress.Further study of psychospiritual development is indicated.

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Techniques

AND

Foundations

PART II

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Theory and Foundations for BSS

https://www.youtube.com/watch?v=AEnAe5cn6yA&list=PLnh2PvQFlZsnaxU0sPA-8W24OsHxdgqFo&index=2&t=0s

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Learning Objectives

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Building Spiritual Strength Intervention

Session 1:

Orientation to group rules, limits of confidentiality, “storytelling;” establishing rapport

Sessions 2-3:

Developing skills and tools for communication with a Higher PowerSession 4: TheodicySession 5:

Meditative and prayer copingSessions 6-7: ForgivenessSession 8: Consolidation of gains, identification of future resources.

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Ethics Concerns

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Scope of Practice

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Intake: Appropriateness for Group Intervention

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If Safety Concerns Emerge…

What is your plan?

Do you have the materials you need to enact the plan?

When do you plan to do this?

Are there reasons you would not do this?

DOConnect with appropriate services instead of BSS (Consult with local mental health leadership before meeting with clients to identify specific services.)

DON’TManage threat of harm to self or others alonePromise to keep a secret (know mandatory reporting laws in your state)

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Critical Counseling Skills-Individual

Unconditional positive regard

Think about this in a client with externalizing moral injury

Reflective listening

Open ended questions

VALIDATION

ReframingParadoxical intervention

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Critical Counseling Skills-Group

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Logistics

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Ground Rules

(p 12)

This is an interfaith environment. Many different approaches to faith will be represented. We will respect each others’ beliefs, experiences, and feelings; we do not have to agree with a belief to respect it. Members and leaders all are empowered to address difficulties in respecting each other. No one will be asked to accept any doctrine that is inconsistent with their faith.

All of us have endured difficult experiences. If we have chosen to be in this group, we are likely seeking to make some changes in our relationship with Higher Power. All of us have the right to change our mind about our beliefs. And change it again, or change it back. Our relationship with Higher Power is likely to change as we grow just as our relationships with people change as we grow.

Material we discuss in group is confidential. Our peers in group should not share information about others in group outside of this setting. It is OK to share what you personally are experiencing in group in any environment you feel is safe for you.

Activities will be presented to facilitate your faith development. If you do not want to participate in an activity, that is your choice. Leaders will ask about your feelings and barriers to your participation to help you get the most out of group, but you do not have to do anything you do not want to do.

If you cannot be at a group session, please let a leader know in advance.

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Learning Objectives

At the end of the activity, the participants will be able to:

Review the theoretical basis for Building Spiritual Strength.

Identify the goals for each of the 8 sessions in the BSS protocol.

Identify relevant ethics considerations for both BSS and spiritually integrated care.

Practice basic interviewing and counseling skills.

Identify the practical/logistical requirements for a BSS program.Identify the goals for each of the 8 sessions in the BSS protocol.Describe techniques for establishing ground rules and behavioral norms for BSS groups.Practice the “Empty Chair” technique.

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Session 1

(Page 14)

Greetings/Introductions

Workbooks (Higher Power or Traditional Version)

Plan group formats

Review of last week

Discuss homeworkNew material

Group decisions; Opening/closing ritual? Breaks? Prayer/Silent Meditation?Rapport Development ActivitiesEncourage veterans to find common experiencesGoal Setting

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Sessions 2-3

(page 17)

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Sessions 2-3 Continued

(Page 19)

2- Way Prayer/Meditation Log

One concern at a time

If Higher Power’s response is painful, bring to group

If “stuck” or “radio silence” from Higher Power, bring to group

Use log entries as springboard to repeat empty chair exercise as often as possible.

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Session 4: Theodicy

(page 26)

Ritual as determined by group

Check in with logs

Empty chair exercise as indicated

You need reserve only 30-40 minutes for theodicy material; focus more on logs

Explore personal theodicies, theodicies in workbookRed-flag theodicies

G-d is punishing me or othersG-d is showing powerAbandoning a G-d that is inconsistent with Fowler 2 or 3 G-d concepts

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Session 5: Communication/Meditative and Prayer Coping

(page 29)

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Session 5,

con’t

Teach about prayer/meditative coping strategies

Seeking Calm and Focus

Seeking Assistance

Seeking Acceptance

Setting it Aside (deferring)

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Sessions 6 & 7

(page 32)

Ritual as determined by group

Check in with logs

Empty chair exercise as indicatedBasic Themes for Instruction

Forgiveness is voluntaryPretending it did not happen is not forgivenessReconciliation is not the same as forgivenessForgiveness is a process, not an eventhttps://www.youtube.com/playlist?list=PLnh2PvQFlZsnaxU0sPA-8W24OsHxdgqFo

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Session 8

(page 40)

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Key Takeaways

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References

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Questions/Discussion?