MRE Guidelines for Practice

Spirituality, Moral Injury, and Trauma in Military Life

Mark A. Stebnicki, Ph.D., LCMHC, DMHCS, CRC, CMCC

INTRODUCTION

There is a growing body of literature in military psychology, moral injury, and trauma which suggests a strong association between having good spiritual well-being and military resiliency and readiness (Doehring, 2019; Smith-MacDonald et al., 2017). Extraordinary stressful and traumatic events in military life have long-term implications for service members’ and veterans’ mental, physical, and spiritual well-being. There are many experiences in warfighting that service members and veterans will never disclose to others outside their units or as reflected in after-action reports. Exposure to frequent killing of enemy combatants, the threat of being attacked, killed, or captured, witnessing death and injury, and handling the injured and dead bodies of unit members, civilians, and enemy combatants change the military service member in a profound psychological way.

Consequently, service members and veterans are challenged spiritually, ethically, and morally by these warfighting experiences (Knoblock, Owens, Matheson, & Dodson, 2019; Smith-MacDonald, Norris, Raffin-Bouchal, & Sinclair, 2017; Tick, 2014; Wortmann et al., 2017). 

Healing the mind, body, and spirit of service members and veterans is enhanced by integrating the individuals’ spiritual and religious belief system into the therapeutic process. The use of psychospiritual approaches in therapy enhances the service members’ ability to cope with military life stressors, depression, suicidality, engagement in spiritual care activities, and increase one's awareness for good emotional, social, psychological health, and resiliency (Sterner & Jackson-Cherry, 2015; Thomas, McDaniel, Albright, Fletcher, & Koenig, 2018). 

Spiritual care when dealing with military moral injury must consider the service member and veteran’s unique religious and spiritual worldview. Competent and ethical practitioners utilize their training and out-of-session resources to provide multiple opportunities for healing trauma of the mind, body, and spirit. Relying solely on psychotherapy approaches, without understanding the resources that chaplains, pastoral counselors, and religious leaders can bring to the service member and veteran’s life, risks “medicalizing” the individual’s moral injury as a mental health condition (Graham, 2017).

The beneficial effects of increased spiritual well-being help bring meaning to ones’ military career particularly during the loss and grief associated with combat-related death and warfighting (Doehring, 2019; Ramsay, 2019; Tick, 2014). Accordingly, integrating spirituality within military mental health counseling practice, emerges as one of the most powerful approaches for healing military trauma and moral injury. This chapter explores the implications of integrating psychospiritual practices with the intention of healing moral injury and military trauma. Guidelines for practitioners are offered for exploring spiritual healing resources. 

CONCEPTUALIZING SPIRITUALITY IN CLINICAL PRACTICE

Integrating spirituality and religiosity in mental health counseling is one of the most misunderstood areas in therapeutic practice. Many clinicians believe that issues related to spirituality should be addressed primarily by those trained in theology (e.g., pastors, rabbis, priests) or military Chaplains. No doubt military Chaplains do play an important role in dealing with issues of spirituality, clarifying religious beliefs and values, performing rituals, and dealing with matters related to moral injury and trauma. However, it becomes problematic when coordination of therapeutic effort is not maximized across the various disciplines. Thus, coordination of care can be enhanced by multiple disciplines, viewpoints, and therapeutic approaches when healing trauma and moral injury of the mind, body, and spirit.

Spirituality is a subjective experience that exists in the hearts and minds of all cultures (Stebnicki, 2016a; Vaughan, 1991). In contrast to religion, spirituality describes the relationship between the person and a transcendent being or higher power. Spirituality has no universal language or way to communicate ones’ spirituality like in religious practices (i.e., religious texts, references, rituals performed). Thus, many individuals have an emotional experience as they describe their spiritual belief system (Csordas, 1990). 

The American Counseling Association’s (ACA) division of the Association for Spiritual, Ethical, and Religious Values (ASERVIC, 2019) has published a White Paper to assist in clarifying the definition, meaning, and construct of spirituality for clinical mental health practitioners. Delineated in ASERVIC’s definition and construct are the principles related to (a) a life force that expands beyond individual consciousness, (b) the integration of naturally occurring events within one’ environment, (c) individual and cultural meaning of spiritual events, (d) one's personal growth and development feed by love, transcendence, connectedness, compassion, wellness, wholeness, and creativity, and (d) integrating a specific system of beliefs, values, and practices.

Early researchers and psychotherapists contend that spirituality is a natural part of being human (Assagioli, 1965; Assagioli, 1971; Jung, 1937/1973; Worthington, 1988). It is interwoven within the individual’s physical, mental, cognitive, and emotional psyche (Ellison & Smith, 1991; Myers et al., 2000). Spirituality is present in all human beings. It is a way to construct personal meaning and purpose regarding ones’ life and culture (Frankl, 1959; Myers et al., 2000; Stebnicki, 2016a; Stebnicki, 2016b; Tillich, 1952). Spirituality oftentimes becomes paradoxical for the individual because it is difficult for the therapist to observe their client’s spirituality (Hayes, 1984). Spirituality is the courage to look within oneself, to trust a transcendent spiritual being, or to have a deep sense of belonging, wholeness, connectedness, and openness to the infinite (Schafranske & Gorsuch, 1984). 

Religiosity has a more direct meaning because it involves ascribing to a set of religious beliefs, doctrines, and rituals. It can be observed by others and are typically institutionally based in a church, temple, mosque, or religious faith-based organization (Shafranske & Maloney, 1990; Vaughan, 1991). Religion is recognized as being a part of the individual’s spiritual belief system and is the expression of one's spirituality (Myers et al., 2000). 

The psychology and counseling literature indicate that clients who have religious and spiritual concerns oftentimes bring these issues into therapeutic settings (Francis, 2016). Yet, few therapists address spiritual concerns with their clients. The search for personal meaning in one’s chronic illness, disability, or traumatic experience is an existential and spiritual pursuit (Stebnicki, 2016a). Thus, possessing the awareness, knowledge, and skills of how to integrate spiritual practices within the therapeutic environment is essential for working optimally within a multicultural counseling perspective (Association for Spiritual, Ethical, and Religious Values; ASERVIC, 2019; Meyers & Sweeney, 2008; Miller, 2003; Moodly & West, 2005; Schneider Corey, & Corey, 2016; Shannonhouse, Meyers, & Sweeney, 2016; Stebnicki, 2008; Stebnicki, 2016a Stebnicki & Cubero, 2008;). 

INTEGRATING SPIRITUALITY IN CLINICAL MILITARY COUNSELING

Spirituality and faith-based practices has emerged as a unique topic of interest within military psychology, mental health counseling, and its related disciplines (i.e., pastoral and chaplaincy psychology, military medicine and psychiatry, veteran health care). More recently, integrating psychospiritual practices within the therapeutic environment has been deemed worthy for empirical study by the Department of Defense (DoD). The clinical application of psychospiritual practices can be found in current evidence-based treatment programs and are part of multiple military wellness and resiliency programs (Knobloch et al., 2019; Smith-MacDonald, 2017; Thomas, 2018). 

The resurgence of religious and spiritual values represents a growing trend in psychology and counseling for service members and veterans. Complementary and integrative health approaches that incorporate spiritual based strategies provide opportunities outside traditional psychotherapy and include such healing arts as yoga, meditation, mindfulness stress reduction, acupuncture, expressive arts, and animal assisted therapy to name a few. Spiritual health is an important issue for military service members and veterans who are challenged by extraordinary stressful and trauma events that create trauma and moral injury. Making sense and meaning of military service for many is a spiritual journey given the existential nature of war. 

Integrating psychospiritual approaches in military psychology and counseling practice has been slow in its development. Several explanations offered for this. First, as with any specific counseling theory or strategy the integration of psychospiritual approaches may be dependent upon the mental health practitioner’s level of interest, motivation for its use, and advanced training they may or may not have acquired. Second, some agencies, organizations, and/or clinical program directors may perceive psychospiritual approaches as being overly religious or too faith-based for their secular mental health practice or clinic. 

Lastly, it is recognized there are few resources outside of pastoral, chaplain, and theological education where mental health practitioners have training opportunities for integrating psychospiritual practices within the therapeutic environment. Interestingly, spiritually based programs (i.e., AA, NA, Celebrate Recovery, 28-day rehabilitation treatment programs) have been offered by clinical mental health and addiction counselors to non-military clients for decades as seen in substance abuse outpatient and residential treatment programs (Benshoff & Janikowski, 1999; Goodwin, 2002; Juhnke, Watts, Guerra, & Hsieh, 2009; Robertson, 2016).

In military life there are multiple extraordinary stressful and traumatic events that can be life altering causing serious psychological problems leading to spiritual and moral injury (Bremault-Phillips, Pike, Scarcella, & Cherwick, 2019; Ramsay, 2019). Consequently, trauma and moral injury negatively impacts the individuals’ spiritual well-being. One instrument developed by early researchers to measure spiritual well-being is the Spiritual Well-being scale (SWBS; Paloutzian & Ellison, 1982). The SWBS is considered the most extensively researched subjective measure of spiritual well-being (Ellison & Smith, 1991; Ledbetter, Smith, Vosler-Hunter, & Fischer, 1991; Watson, Morris, & Hood, 1990). It consists of 20 items evenly divided in two subscales of religious well-being (RWB) and existential well-being (EWB). This self-report instrument has been used in a variety of settings, including colleges, universities, seminaries, hospitals, recreational therapy practices, mental health clinics, and in prisons. There are a number of studies that have shown a positive correlation between SWBS and increased psychological health among persons with chronic medical illness and life-threatening disabilities (Baldwin, 1995; Campbell, 1988; Carson, 1990; Carson, Soeken, Shanty, & Toms, 1990; Granstrom, 1987; Heintzman, 1999; Kaczorowski, 1989; Kohlbry, 1986; Malinakova et al., 2017Richter, 2001; Riley, Perna, Tate, Forchheimer, Anderson, & Luera, 1998). The interested reader will want to consult the references for more details.

One of the few studies available (Johnson, Bormann, & Glaser, 2015), using a small sample of veterans diagnosed with posttraumatic stress disorder (PTSD) receiving services from the VA, utilized two versions of the Functional Assessment Chronic Illness Therapy- Spiritual Well-being Scale (FACIT-Sp), which is a 12-item scale to measure spiritual well-being in the veteran population. The interested readers will want to consult this study for greater detail. This complex design utilized a 3-factor model (Peace, Meaning, and Faith) and 2-factor model (Peace combined with Meaning and Faith) then compared this to a 4-factor model (Peace, Meaning, Faith, and Spirituality) and the 3-factor model. Results indicate that the 3-factor model (Peace, Meaning, and Faith) reported the best fit to measure veteran spiritual well-being. The results and conclusion of this study suggests that treatment of veterans with PTSD should include the evaluation of the person’s spiritual well-being. This could potentially be integrated with veteran medical and mental health services because of the influence spiritual well-being has on treating veteran complex trauma. 

Fundamentally, integrating psychospiritual approaches in military counseling settings are relevant and should be a high priority for healing the wounds of trauma and moral injury. For psychospiritual research, theory, and practice to advance in clinical military counseling settings it is essential that researchers and practitioners learn how to evaluate and integrate relevant psychospiritual intervention with military cultural concerns. 

For the last 30 years, from a human growth and development perspective, research in psychology and counseling has defined, evaluated, measured, and clinically described developmental characteristics of ones’ spirituality, faith, religious, and moral beliefs (Meyers et al., 2000; Worthington, 1989). This body of research has resulted in other paradigms that have led to the development of wellness theories and its application for mental health practice. Wellness models have the intention to cultivate optimal functioning for the individual and human potential for everyday life. The shift in utilizing one's religious and spiritual beliefs, values, and practices into therapy is culturally sensitive and is pivotal in the psychospiritual wellness movement in clinical mental health counseling. Wellness theories have provided a means to communicate the principles of integrative healing approaches tapping into the unused potentials of the mind, body, and spirit. The unique wisdom offered in clinical practice suggests that wellness practices can be utilized in everyday life for everyday people; not just for those with chronic and persistent medical and mental health conditions (American Counseling Association; ACA, 2006; Shannonhouse, Meyers, & Sweeney, 2016). 

The shift to current models of wellness began with Meyers and her colleagues’ foundational work in the Wheel of Wellness (WoW) (Meyers et al, 2000). The WoW is a theoretical model which combines empirical research from 17 specific areas of health, longevity, and quality of life. This model suggests there are five life tasks central to healthy human functioning which includes: (a) work, (b) friendship (c) love, (d) self, and (e) spirituality. Although there are 17 categories of wellness in the WoW model, spirituality is hypothesized to be the most essential aspects of wellness and healthy human functioning (Meyers et al., 2000). 

Wellness programs in the military culture offers opportunities for health prevention related to one's medical, physical, mental, cognitive, behavioral, psychological, social, emotional, behavioral, vocational/occupational, and spiritual health. The DoD and Veterans Administration has devoted time and money into the development of wellness programs for over 20 years because of its success in medical, physical, and mental health prevention. The positive results in wellness research suggests there is evidence that prevention and treatment on the front end of therapy, serves as a cost-saving measure on the back end after the service member or veteran goes into a medical or mental health crisis (Carrola & Corbin-Burdick, 2015; Parker et al., 2001). 

The U.S. Army’s Comprehensive Soldier Fitness (CSF2, 2019) program is one example of a wellness model approach that serves as a key component of the Army’s readiness and resiliency objectives with intention to promote optimal resiliency in the service members’ medical, physical, and mental well-being. The Army’s Master Resiliency Training Course, part of the CSF2 program focus on five core areas (i.e., physical, emotional, social, family, spiritual) of leadership training to assist in building mental toughness, character, strength, and strong relationships which is modeled to others in the unit and military community. Other programs based on this DoD directorate, known as Army Sharp, Ready & Resilient (SR2) implements wellness strategies for enhancing soldier personal readiness through building connections with mental and physical health providers (i.e., military crisis hotline, safe helpline for sexual assault support, psychological health and TBI). The program has six core components: (a) health assessment utilizing a wellness questionnaire, (b) physical fitness, (c) healthy nutrition, (d) stress management utilizing stress education, and biofeedback, (e) general wellness education, and (f) tobacco education. The intention behind these and other programs focus on military life and the impact of combat operational stress that can lead to co-occurring medical and mental health conditions such as posttraumatic stress, depression, suicidality, and TBI.

The Comprehensive Soldier and Family Fitness training program (U.S. Army, 2014), based on U.S. Army policy regulation 350-53, is another example of the implementation of wellness training programs for the military. This program includes five core areas related to physical, emotional, social, spiritual, and family. These core areas are aligned with other wellness models and particularly advocate for spiritual and religious practices as a pathway to optimal functioning in mind, body, and spirit.

Overall, successful coping, adaptation, and adjustment to medical, physical, mental, psychological, emotional, social, spiritual, and moral injury requires a coordinated effort by military medical and mental health practitioners. Service members and veterans have multiple resources by which they can reach out and take responsibility for their personal wellness.  

SPIRITUALITY AND MORAL INJURY 

This section explores the relationship between spirituality and moral injury from a biopsychosocial and spiritual perspective. Given the complex nature of moral injury, researchers and practitioners alike have little guidance for the assessment, yet alone treatment, for an ambiguous collection of clinically significant symptoms that mirror multiple diagnostic categories such as posttraumatic stress, depression, and anxiety disorders. Presently, there is a lack of agreement within the mental health profession about the specific symptoms associated with moral injury and its development after extraordinary stressful and traumatic events (Currier et al., 2019). One area that most researchers and practitioners would agree on is that moral injury appears to have clinically significant symptoms of an unhealthy medical, physical, social, emotional, and spiritual nature. It is the invisible wound of war unlike visible physical disabilities sustained during combat operations.

There is a plethora of research that demonstrates how religiosity and spirituality enhance military and non-military mental, physical, and spiritual well-being after acquired trauma. As for warfighters, religion and spirituality may help mediate the relationship between morally injurious experiences that increase the symptoms associated with PTSD, depression, and other co-occurring mental health conditions that reach a level of clinical crisis. 

Traumatic exposure from warfighting creates a type of soul wound or morally injurious trauma. There is thought to be a deep inner psychospiritual wound that occurs as the result of one’s battlefield experiences (Tick, 2014). The excruciating struggle in the search for meaning in this soul wounding experience has led contemporary researchers to try and identify the unique set of clinically significant symptoms that differentiates moral injury from other trauma experiences. 

The term moral injury is believed by some, to be first used in print by Shay (1991). It is described as “A betrayal of what’s right by someone who holds legitimate authority (in the military- a leader) in a high stakes situation” (Shay, 2012, p. 59; Shay, 2014, p. 183). Litz et al. (2009) offers another definition that includes perpetrating, failing to prevent, witnessing, or learning about acts of humanity that violate deeply held moral beliefs. Inferred in most definitions of moral injury is the invisible wound that often becomes visible by the service member’s behaviors and actions. This may be exhibited by service members who become disloyal to the Uniform Code of Military Justice, lack dedication to the mission, exhibit loss of confidence by dishonoring unit leadership and command, perpetrating crimes against humanity, and questioning one's religious-spiritual beliefs. Thus, moral injury is contextualized within the warrior ethos of the military culture. 

The impact of trauma and war is described by Tick (2014) as the reshaping of our essential self and soul. War is humanity at its worst. The outcome is expressed by the warfighter’s anger, rage, isolation from family, friends, society, and has the overall risk of suicidality. However, if moral injury does not defeat the individual then it can provide the impetus for posttraumatic growth. The impact of trauma and war on the soul has potential to transform the warfighter’s identity through the attunement of others’ feelings, emotions, and experiences. A journey into healing moral injury increases our compassion for all humanity. It is manifested by the warfighter’s level of social and emotional intelligence.

The construct of the soul and soul wounding has deep theological, psychospiritual, and cultural indigenous meaning and significance. For many spiritual leaders, shamans, sages, and mystics, the soul is the seat of emotional and moral consciousness (Stebnicki, 2016a). In indigenous North American Indian cultures, soul loss results from multiple traumas experienced both individually and by tribal members. Modern psychology and counseling have elucidated the clinical identification, assessment, diagnosis, and treatment of traumas. However, the historical trauma experienced by indigenous tribes and other racial and ethnic minority groups, are difficult to describe within a clinical diagnostic framework. Hence, moral injury as prompted by ones’ traumatic experiences is also difficult to assess and treat. Primarily, moral injury is not a diagnostic category with clinical symptomology to be reported as a diagnosable condition.

From a classical and traditional spiritual-religious perspective, the traumatized person’s soul has disappeared into nonordinary states of consciousness and has been lost to the dark side of an unseen spirit world. Therefore, a shaman would be appointed to perform a soul retrieval due to soul wounding or loss. Shamans navigate the multidimensional spirit world to journey for healing spirits that assist in patient healing and retrieving one’s soul that has been lost to extraordinary stressful and traumatic events (Ingerman, 1991). In many indigenous cultures, religious-spiritual rituals are performed both with the tribe and individual with intentions for healing the mind, body, spirit, and soul. 

The military unit is a modern-day version of an indigenous tribe that fights and heals together. Except today, military service members and veterans attend the rituals of psychotherapy and are prescribed psychiatric medications to treat their trauma and soul loss. The competent and skilled psychotherapist partners with other resources (e.g., chaplains, spiritual leaders) to assist their clients in mending the fragmented self. Interestingly, many North American Indian tribes use sweat lodge ceremonies within the veteran Indian culture to heal traumas. Traditional healing approaches are utilized alongside evidence-based treatment received by the VA system of healthcare. Currently, service members and veterans are utilizing complementary and integrative spiritually based health approaches (i.e., mindfulness, meditation, yoga) at more frequent rates than any other military generation. 

So how do modern day medicine men and women evaluate and treat soul loss that results from morally injurious behaviors that mirrors posttraumatic stress disorders? Inquiring into these issues are critical for healing moral injury among the military community. The human spirit and soul are at-stake for service members who might be involved in disaster relief or combat operations. The serious psychological conditions associated with moral injury that are clinically significant and are debilitating for the individual, includes intrusive thoughts that are negative and disturbing, impulsivity that turns to rage and anger, suicidal ideation, sleep disturbances, substance misuse, avoiding and socially isolating oneself due to specific internal and external triggers, self-harming, and demoralizing behaviors (Bremault-Phillips et al., 2019; Frankfurt & Frazier, 2016; Koening et al., 2018; Ramsey, 2019; Tick, 2014). 

From a qualitative perspective, interviews with combat veterans who identify with the experience of moral injury report that they have an identifiable loss, question the meaning of the mission, are disillusioned by their faith, and question the presence and acceptance of a higher power or God (Doehring, 2015). Consequently, many veterans lack an understanding of their experience of moral injury. Most veterans experience a significant shift in their spiritual-religious values, beliefs, practices, and behaviors. Given the complex traumas associated with warfighting, it is critical to measure the veterans’ experience of moral injury to prevent further development of the clinically distressing symptoms with intentions to treat this unique and complex mental health condition. 

More recently, on the instrument development-side of research, current tools to measure the experience and expression of moral injury among the military culture has shown promise. One example is the development of a 17-item Expressions of Moral Injury Scale- Military version (EMIS-M; Currier, Farnsworth, Drescher, McDermott, Sims, & Albright, 2018) screening tool. This measure has been constructed based on the theoretical, empirical, and qualitative literature related to moral injury. The interested reader will want to consult the references for an in-depth review of the EMIS-M. Currier and his colleagues note that the EMIS-M can be utilized as a brief initial assessment of military moral injury. The EMIS-M can be offered alongside other functional measures (e.g., PTSD, anxiety) to complete a comprehensive clinical assessment on military clients.

Another example of a recent tool for measuring moral injury is the short form of the 45-item Moral Injury Symptom Scale- Military Version (MISS-M; Koenig et al., 2018). The MISS-M as a brief screening tool to assist clinicians in measuring the service member and veterans’ feelings and experiences of moral injury. The MISS-M consists of 10 subscales that comprehensively assess the clinical symptoms reported by the veteran. These subscales all relate to the veterans’ betrayal, guilt, shame, moral concerns, loss of trust, loss of meaning, difficulty in forgiving, feelings of failure, religious struggles, and loss of religious faith. The short form version is reported to be strongly correlated with the symptoms related to posttraumatic stress, depression, and anxiety disorders. The interested reader will want to consult the references for a complete review. 

Specific themes from qualitative researchers, factors in scale development studies, and the literature conceptualizing the constructs of moral injury, all report areas for therapists to screen military clients for morally injurious experiences acquired during military life. The following is offered as an abbreviated list of common themes and clinically relevant symptoms that merit follow up evaluation of your service member and veterans’ experience of moral injury:

• Feelings and experiences of shame, guilt, anger towards self and others in witnessing or perpetrating the injury or death related to civilian children, adults, and conscripted enemy combatants.
• Non-disclosure (due to operational security issues) to others outside the special operations unit of critical events related to injuring and killing enemy and non-enemy combatants, torture, rape, and other traumas witnessed or perpetrated by the individual.
• Disassociation, rejection, repression, or denial of traumatic events witnessed or perpetrated during combat operations or humanitarian missions.
• Loss of meaning of self, with the increased experiences of guilt, shame, failure as a human being.
• Decreased ability to feel a sense of forgiveness by self and others, for engaging in, or completing a mission that resulted in injury, death, and other horrors of war.
• Loss of meaning and/or feelings of disgust with ones’ military career, occupational specialty, mission purpose, and overall military life.
• Questioning of combat-related orders, the mission, and distrust of unit and command leadership. 
• Feelings of personal failure and operational failure that manifests as guilt, shame, moral concerns.
• Struggles with and loss of religious faith and spiritual practices that lead to a soul wounding experience.
• Manifestation of clinically significant symptoms related to the diagnostic categories of posttraumatic stress, anxiety, depression, and substance use disorders, as well as suicidality.

Healing the mind, body, spirit, and soul from war requires a transformative experience by the service member and veteran. For some, it may require a soul retrieval to heal the invisible wounds of war. For others, it may require reaching out to a competent mental health practitioner who can guide them in their personal journey, from a dark night of the soul, to facilitating a pathway into the light. The dehumanizing aspects of war, the grief and loss of human life, and the suffering of ones’ soul, are all part of the ambiguous experience of moral injury. Integrating psychospiritual approaches in therapeutic interactions is another channel for a healing journey. 

INTEGRATING PSYCHOSPIRITUAL ISSUES IN THERAPY

One of the most intriguing areas of scientific inquiry relates to the long term medical and mental health impact that extraordinary stressful and traumatic events have on military service members and veterans. Quantitative analysis works well using biophysiological and psychological measures of one's physical and mental health. However, mapping the pathways for the psychospiritual healing of moral injury and traumas requires qualitative approaches (e.g., phenomenological, ethnographic, case studies, historical, narrative models) to unravel the psychological, social, emotional, cognitive, behavioral, chronic and persistent stressors that ensues during and after military life.

Indeed, spirituality plays a prominent role in the lives of individuals from most world cultures and is integrated within the identity of the culture itself (Stebnicki, 2016a). Therefore, to work effectively with the individual’s spiritual identity and worldview, many in psychology and counseling have advocated for quite some time, that mental health practitioners need to intentionally inquire about the client’s spiritual health during session (Bishop, Avila-Juarbe, & Thumme, 2003; Cashwell & Young, 2004; Myers, Sweeney, & Witmer, 2000; Myers & Williard, 2003; 2000; Pargament & Zinnbauer, 2000; Polanski, 2003; Richards & Bergin, 1997; Shafranske & Gorsuch, 1984; Shannonhouse et al., 2016; Stebnicki, 2006). Many times, spiritual health circles back to one's mental and physical health and well-being. From a military life perspective, integrating the service member and veteran’s religious and spiritual beliefs are foundational for healing medical, physical, and psychological injury (Bremault-Phillips et al., 2019; Doehring, 2019; Knobloch et al., 2019; Sterner & Jackson-Cherry, 2015).   

The therapeutic relationship and earning the circle of trust with military clients is pivotal in developing a strong working alliance. Paramount to this relationship is the communication dynamics that emerges consciously and unconsciously as the therapist examines their own attitudes, perceptions, values, and beliefs about military life. Consequently, practitioners must be aware of the meta-transference and countertransference that takes place within the therapeutic relationship because of the potential conflict that may arise in the client-counselor working alliance. The following guidelines are offered for consideration for the exploration and integration of your military clients’ religious-spiritual beliefs:

• Earn the circle of trust first, before integrating any religious-spiritual approaches.
• Invite clients to explore any religious-spiritual beliefs, values, and practices. Often opening this door gives permission for clients to discuss deeply held religious-spiritual beliefs, values, and concerns.  
• Be open and honest with clients regarding your own religious-spiritual beliefs, values, and practices.
• Explore the positive and negative impact that your own religious-spiritual values and beliefs may have on the therapeutic relationship.
• Disclose to clients any professional formal or informal training you received related to the integration of psychospiritual practices (i.e., professional credentials, spiritual-based assessments, therapy practices in faith-based settings and programs). 
• Explore personal and professional growth opportunities for continuing education and training for the purpose of increasing cultural competence with religious-spiritual treatment issues.
• Organize and manage resources that provide clients with ample referrals outside of therapy that may include a list of local churches to attend, faith-based counseling services available in the area, or contacts for spiritual leaders and Chaplains.
• Seek consultation from religious-spiritual teachers, leaders, clergy, or chaplains that could assist in the integration of psychospiritual issues in session.

The following religious-spiritual questions are offered with intention to integrate in the military client initial intake interview, exploration of religious-spiritual values, beliefs, and practices, and probes that may be explored for future therapy sessions: 

* How would you describe or characterize your religious-spiritual beliefs and values? 

* Do you practice any rituals, observe any religious holidays, or find any other types of religious-spiritual practices comforting? 

* What role, meaning, or purpose does your religious-spiritual beliefs play in your life? 

* Are there any religious-spiritual beliefs that cause you anxiety or confusion? 

* What do you believe your God (Higher Power) has to teach you in life? 

* Are there particular religious-spiritual texts/practices that speak to you or bring deep meaning? 

* What kind of religious-spiritual growth do you see yourself making in your future? 

* What are some of your earliest memories of religious-spiritual practices? 

* Have you ever had any transpersonal or transformational experiences that were extraordinary (i.e., prayers answered, peak experiences bringing about resolve, comfort, or a deeper knowledge that ever before, contacts with positive spirit entities such as angels)? 

* What challenges exist for you connecting with religious-spiritual resources? 

* Where are you at now on your spiritual journey?

CONCLUDING REMARKS

The search for personal meaning in ones’ traumatic experiences is an existential or spiritual pursuit. The experiences of warfighting places military clients at-risk for moral injury which is an invisible wound that has a profound sense of soul loss or soul wounding. Openness to integrating religious-spiritual practices in psychotherapy sessions is vital to practice within a multicultural counseling framework. Exploration of the client’s religious-spiritual beliefs, values, and practices open the door to healing opportunities. Overall, integrating psychospiritual practices assists practitioners in increasing client coping and resiliency skills. Advancing complementary and integrative spiritually based practices inside and outside the therapeutic environment provides other channels for healing complex trauma.   

REFERENCES

American Counseling Association (2006). ACA’s task force on wellness and impairment. Retrieved from https://www.counseling.org/news/updates/2006/02/23/aca's-taskforce-on-counselor-wellness-and-impairment

Assagioli, R.  (1965).  Psychosynthesis: A manual of principles and techniques.  New York: Viking Press.

Assagioli, R.  (1971).  Pyschosynthesis.  New York: Viking Press.

Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) (2019). Home page. Retrieved from: http://www.aservic.org/resources/aservic-white-paper-2/ 

Baldwin, L.C. (1995). Spirituality, health, and occupational therapy. Conference Abstracts and Resources (p.165-166). Bethesda, MD: American Occupational Therapy Association, Inc.

Benshoff, J.J., & Janikowski, T.P. (1999). The rehabilitation model of substance abuse counseling. Pacific Heights, CA: Brooks-Cole.

Bremault-Phillips, S., Pike, A., Scarcella, F., & Cherwick, T. (2019). Spirituality and moral injury among military personnel: A mini-review. Frontiers in Psychiatry, 10(276), 1-9.

Campbell, C.D.  (1988).  Coping with hemodialysis:  Cognitive appraisals, coping behaviors, spiritual well-being, assertiveness, and family adaptability and cohesion as correlates of adjustment (Doctoral Dissertation, Western Conservative Baptist Seminary, 1983).  Dissertation Abstracts International, 49, 538B.

Carson, V.B.  (1990).  The relationships of spiritual well-being, selected demographic variables, health indicators, and AIDS related activities to hardiness in persons who were serum positive for the human immune deficient virus or were diagnosed with acquired immune deficient syndrome.  Unpublished doctoral dissertation, University of Maryland, School of Nursing.

Carson, V.B., Soeken, K.L., Shanty, J., & Toms, L.  (1990).  Hope and spiritual well-being: Essentials for living with AIDS.  Perspectives in Psychiatric Care, 26(2), 28-34.

Carrola, P., & Corbin-Burdick, M.F. (2015). Counseling military veterans: Advocating for culturally competent and holistic interventions. Journal of Mental Health Counseling, 37(1), 1-14.

Csordas, T.J.  (1990).  The psychotherapy analogy and charismatic healing.  Psychotherapy, 27(1), 79-90.

Currier, J.M., Farnsworth, J.K., Drescher, K.D., McDermott, R.C, Sims, B.M., & Albright, D.L. (2018). Development and evaluation of the Expressions of Moral Injury Scale Military Version. Clinical Psychology & Psychotherapy, 25, 474-488.

Currier, J.M., Isaak, S.L., & McDermott, R.C. (2019). Validation of the expressions of Moral Injury Scale-Military Version-Short Form. Clinical Psychology & Psychotherapy. Retrieved from https://doi10.1002/cpp.2407  

Doehring, C. (2015). Resilience as the relational ability to spiritually integrate moral stress. Pastoral Psychology, 64(5), 635-649.

Doehring, C. (2019). Military moral injury: An evidence-based and intercultural approach to spiritual care. Pastoral Psychology, 68, 15-30.

Ellison, C.W., & Smith, J.  (1991).  Toward an integrative measure of health and well-being.  Journal of Psychology and Theology, 19(1), 35-48.

Francis, P.C. (2016). Religion and spirituality in counseling. In I. Marini & M. Stebnicki (Eds.), The Professional Counselors' Desk Reference (2nd ed., pp. 559-570). New York:  Springer Publishing.

Frankfurt, S., & Frazier, P. (2016). A review of research on moral injury in combat veterans. Military Psychology, 28(5), 318-330.

Frankl, V. (1959). Man’s search for meaning. New York: Pocket Books.

Goodwin, L.B. (2002). The button therapy book: A practical psychological self-help book & holistic cognitive counseling manual for mental health professionals. British Columbia, CA: Trafford Publishing.

Graham, K.L. (2017).  Moral injury: Restoring wounded souls. Nashville, TN: Abingdon.

Granstrom, S.L.  (1987, November).  A comparative study of loneliness, Buberian religiosity and spiritual well-being in cancer patients.  Paper presented at the conference of the National Hospice Organization.

Hayes, S.C.  (1984).  Making sense of spirituality.  Behaviorism,12(2), 99-110.

Heintzman, P. (1999). Spiritual wellness: Theoretical links with leisure. Journal of Leisurability, 26(2). Retrieved from http://benefitshub.ca/entry/spiritual-wellness-theoretical-links-with-leisure/

Ingerman, S. (1991). Soul retrieval: Mending the fragmented self. San Francisco, CA: HarperSanFrancisco.

Johnson, B.D., Bormann, J.E., & Glaser, D. (2015). Validation of the Functional Assessment Chronic Illness Therapy- Spiritual Well-being Scale in veterans with PTSD. Spirituality in Clinical Practice, 2(1), 35-45.

Juhnke, G.A., Watts, R.E., Guerra, N.S., & Hsieh, P. (2009). Using prayer as an intervention with clients who are substance abusing and addicted and who self-identify personal faith in God and prayer as recovery resources. Journal of Addictions and Offender Counseling, 30, 16-23.

Jung, C.G.  (1973).  Psychology and religion: East and west.  In W. McGuire & R.F.C. Hull (Ed. and Trans.), The collected works of C.G. Jung (Vol. 11, pp. 5-105).  Princeton NJ: Princeton University Press. (Original work published 1937)

Kaczorowski, J.M.  (1989).  Spiritual well-being and anxiety in adults diagnosed with cancer.  The Hospice Journal, 5(3-4), 105-116.

Knobloch, L.K., Owens, J.L., Matheson, L.N., & Dodson, M.B. (2019). Evaluating the effectiveness of REBOOT Combat Recovery: A faith-based combat trauma resiliency program. Military Psychology, 31(4), 306-314.

Koening, H., Ames, D., Youssef, N.A., Oliver, J.P., Volk, F., Teng, E.J., … Pearce, M. (2018). Screening for moral injury: The Moral Injury Symptom Scale-Military version short form. Military Medicine, 183(11/12), 659-665.

Kohlbry, P.W.  (1986).  The relationship between spiritual well-being and hope/hopelessness in chronically ill clients.  Unpublished master's thesis, Marquette University, College of Nursing, Milwaukee, WI.

Ledbetter, M.F., Smith, L.A., Vosler-Hunter, W.L., & Fischer, J.D.  (1991).  An evaluation of the research and clinical usefulness of the spiritual well-being scale.  Journal of Psychology and Theology, 19(1), 49-55.

Litz, B.T., Stein, Delaney, E. Lebowitz, L., Nach, W.P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair of war veterans. A preliminary model and intervention strategy. Clinical Psychology Review, 29, 69-706.

Malinakova, K., Kopcakova, J., Kolarcik, P., Madarasove Geckova, A., Polackova Solcova, I., Husek, V., …Tavel, P. (2017). The spiritual well-being scale: Psychometric evaluation of the shortened version in Czech adolescents.  Journal of Religious Health, 56(2), 697-705.

Meyers, J. E., & Sweeney, T.J. (2008). Wellness counseling: The evidence base for practice. Journal of Counseling & Development, 86, 482-493.

Miller, G. (2003). Incorporating spirituality in counseling and psychotherapy: Theory and technique.  Hoboken, NJ: John Wiley & Sons.

Moodley, R. & West, W. (2005). Integrating traditional healing practices into counseling and psychotherapy. Thousand Oaks, CA: Sage Publications.

McCarthy, M.M. (2016). An exploratory study of moral injury as experienced by combat veterans. Dissertations & Thesis 317. Retrieved from file:///C:/Users/19102/Documents/ACA.Book.Research2/Moral%20Injury.pdf 

Myers, J. E., Sweeney, T.J., & Witmer, J.M. (2000). The wheel of wellness, counseling for wellness: A holistic model for treatment planning. Journal of Counseling and Development, 78, 251-266.

Myers, J.E., & Williard, K. (2003). Integrating spirituality into counselor preparation: A developmental wellness approach. Counseling and Values, 47(2), 142-155.

Paloutzian, R.F., & Ellison, C.W.  (1982).  Loneliness, spiritual well-being, and the quality of life.  In L.A. Peplau, & D. Perlman (Eds.), Loneliness: A sourcebook of current theory, research, and therapy.  New York: Wiley.

Pargament, K.L., & Zinnbauer, B.J. (2000). Working with the sacred: Four approaches to religious and spiritual issues in counseling. Journal of Counseling and Development, 78, 162-171.

Parker, M.W., Fuller, G.F., Koenig, H.G., Vaitkus, M.A., Bellis, J.M., Barko, W.F., … Call, V.R. (2001). Soldier and family wellness across the life course: A developmental model of successful aging, spirituality, and health promotion. Military Medicine, 166(6), 485-489.

Polanski, P.J. (2003). Spirituality and supervision. Counseling and Values, 47(2), 131-141.

Ramsay, N.J. (2019). Moral injury as loss and grief with attention to ritual resources for care. Pastoral Psychology, 68, 107-125.

Richards, P.S., & Bergin, A.E. (1997). A spiritual strategy for counseling and psychotherapy. Washington, DC: American Psychological Association

Riley, B.B., Perna, R., Tate, D.G., Forchheimer, M., Anderson, C., & Luera, G. (1998). Types of spiritual well-being among persons with chronic illness: Their relation to various forms of quality of life. Archives of Physical Medicine & Rehabilitation, 79(3), 258-264.

Robertson, H.C. (2016). Spirituality, substance use, and the military. Vistas Online, 95, 1-15.

Shafranske, E.P., & Gorsuch, R.L.  (1984).  Factors associated with the perception of spirituality in psychotherapy.  Journal of Transpersonal Psychology, 16, 231-241.

Shafranske, E.P., & Malony, H.N. (1996). Religion and the clinical practice of psychology: The case for inclusion. In E.P. Shafranske (Ed., pp. 561-586), Religion and the clinical practice of psychology: A case for inclusion. Washington, D.C.: American Psychological Association.

Shafranske, E., & Malony, H.N.  (1990).  Clinical psychologists' religious and spiritual orientations and their practice of psychotherapy.  Psychotherapy, 27, 72-78.

Shannonhouse, L.R., Myers, J.E., & Sweeney, T.J. (2016). Counseling for Wellness. In I. Marini & M. Stebnicki (Eds.), The Professional Counselors' Desk Reference (2nd ed., pp. 617-623). New York:  Springer Publishing.

Shay, J. (1991). Learning about combat stress from Homer’s Iliad. Journal of Traumatic Stress, 4(4), 561-579.

Shay, J. (2012). Moral injury. Intertexts, 16(1), 57-66.

Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 189-191.

Smith-MacDonald, L., Norris, J.M., Raffin-Bouchal, S., & Sinclair, S. (2017). Spirituality and mental well-being in combat veterans: A systematic review. Military Medicine, 182, 920-940.

Schneider Corey, M., & Corey, G. (2016). Becoming a helper (7th ed.). Boston, MA: Cengage Learning.

Stebnicki, M.A. (2008). Empathy fatigue: Healing the mind, body, and spirit of professional counselors. New York, NY: Springer Publishing.

Stebnicki, M.A. (2006) Integrating spirituality in rehabilitation counselor supervision. Rehabilitation Education, 20(2), 115-132.

Stebnicki, M.A. & Cubero, C. (2008). A content analysis of multicultural counseling syllabi from rehabilitation counseling programs. Rehabilitation Education, 22 (2), 89-99. 

Stebnicki, M.A. (2016a). Integrative approaches in counseling and psychotherapy. In I. Marini & M. Stebnicki (Eds.), The Professional Counselors' Desk Reference (2nd ed., pp. 593-604). New York:  Springer Publishing.

Stebnicki, M.A. (2016b). From empathy fatigue to empathy resilience. In I. Marini & M. Stebnicki (Eds.), The Professional Counselors' Desk Reference (2nd ed., pp. 533-545). New York:  Springer Publishing.

Sterner, W.R., & Jackson-Cherry, L.R. (2015). The influence of spirituality and religion on coping for combat-deployed military personnel. Counseling and Values, 60, 48-60.

Thomas, K.H., McDaniel, J.T., Albright, D.L., Fletcher, K.L., & Koenig, H.G. (2018). Spiritual fitness for military veterans: A curriculum review and impact evaluation using the Duke Religion Index (DUREL). Journal of Religion and Health, 57, 1168-1178.

Tick, E. (2014). The warrior’s return: Restoring the soul after war. Boulder, CO: Sounds True.

Tillich, P.  (1952).  The courage to be.  New Haven, MA: Yale University Press.

U.S. Army Comprehensive Soldier and Family Fitness (2014). Training: Comprehensive soldier and family fitness. Retrieved from https://readyandresilient.army.mil/CSF2/supportdocs/r350_53.pdf

U.S. Army’s Comprehensive Soldier Fitness (CSF2) (2019). Army sharp, ready & resilient (SR2) directorate. Retrieved from https://readyandresilient.army.mil/

Vaughan, F.  (1991). Spiritual issues in psychotherapy.  Journal of Transpersonal Psychology, 23(2), 105-119.

Watson, P.J., Morris, R.J., & Hood, R.W.  (1990).  Intrinsicness, self-actualization, and the ideological surround.  Journal of Psychology and Theology, 18, 40-53.

Worthington, E.L., Jr.  (1988).  Understanding the values of religious clients: A model and

its application to counseling.  Journal of Counseling Psychology, 35(2), 166-174.

Worthington, E.L. (1989). Religious faith across the life span: Implications for counseling and research. Counseling Psychologist, 17(4), 555-612.

Wortmann, J.H., Eisen, E., Hundert, C., Jordan, A.H., Smith, M.W., Nash, W.P., & Litz, B.T. (2017). Spiritual features of war-related moral injury: A primer for clinicians. Spirituality in Clinical Practice, 4, 249-261.