Utilizing Acceptance and Commitment Therapy to Aid Chaplains in Addressing Moral Injury

Jason A. Nieuwsma, PhD,1,2 Jennifer Wortmann,1 Rebecca Morris, MDiv,3

Jaimie Lusk, PhD,3 Janet Hanson, MDiv,3 & Keith G. Meador, MD, ThM, MPH1,4

1 . M e n t a l H e a l t h a n d C h a p l a i n c y , V H A2 . D u k e U n i v e r s i t y M e d i c a l C e n t e r

3 . P o r t l a n d V A M e d i c a l C e n t e r4 . V a n d e r b i l t U n i v e r s i t y

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Colleagues and Collaborators(in addition to co-authors)

Bill Cantrell, MDiv, BCC

Keith Ethridge, MDiv, BCC, CPE Supervisor

Robyn Walser, PhD

Steve Hayes, PhD

Kelly Wilson, PhD

Kent Drescher, PhD, MDiv

Jacob Farnsworth, PhD

Many chaplains across VA, DoD, and elsewhere

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Disclosures

The views expressed in this presentation are those of the presenters and do not necessarily represent the views of the funding agencies.

Jason Nieuwsma, Robyn Walser, &

Steve Hayes receive royalties from New Harbinger publications for a book co-edited on a topic similar to the subject of this presentation.

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Background

ChaplainsMoral Injury

ACT

1. Nieuwsma, J.A., Walser, R.D., Farnsworth, J.K., Drescher, K.D., Meador, K.G., & Nash, W. (2015). Possibilities within acceptance and commitment therapy for approaching moral injury. Current Psychiatry Reviews, 11, 193-206.

2. Meador, K.G. & Nieuwsma, J.A. (2018). Moral injury: Contextualized care. Journal of Medical Humanities, 39, 93-99.

3. Nieuwsma, J.A., Walser, R.D., & Hayes, S.C. (Eds.). (2016). ACT for clergy and pastoral counselors: Using acceptance and commitment therapy to bridge psychological and spiritual care. Oakland, CA: Context Press / New Harbinger Publications.

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Do chaplains perceive their work as synergistic with ACT?

CPE Supervisors Survey(N = 36)

How often do chaplains see moral injury?

VA/DoD Chaplain Survey(N = 2,163)

Empirical Questions

Question Data Source

Do chaplains trained in ACT use it?

MHICS Trained Chaplains(N = 81)

Are chaplains using ACT to address moral injury?

VA Chaplain Moral Injury Survey(N = 361)

What can a chaplain/psychologist moral injury ACT group look like?

Intervention Overview from Portland VA Medical Center

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16%

14%

14%

46%

60%

63%

58%

47%

0% 20% 40% 60% 80% 100%

Air Force Chaplains(n = 359)

Navy Chaplains(n = 308)

Army Chaplains(n = 964)

VA Chaplains(n = 421)

How often do you see Veterans with moral injury?

Frequently Sometimes

1. Nieuwsma, J. A., Rhodes, J. E., Cantrell, W. C., Jackson, G. L., Lane, M. B., DeKraai, M. B., Bulling, D. J., Fitchett, G., Milstein, G., Bray, R. M., Ethridge, K., Drescher, K. D., Bates, M. J., & Meador, K. G. (2013). The intersection of chaplaincy and mental health care in VA and DoD: Expanded report on VA / DoD Integrated Mental Health Strategy, Strategic Action #23. Washington, DC: Department of Veterans Affairs and Department of Defense.

2. Nieuwsma, J.A., Buck, P.J., King, H.A., Jackson, G.L., Cantrell, W.C., & Meador, K.G. (November 2015). On the front line addressing moral injury: A survey of VA/DoD chaplains and implications for mental health collaboration. In J. Currier (Chair) and J.A. Nieuwsma (Discussant), Moral injury, spirituality, and military trauma: Probing into the clinical implications of treating morally injured patients . Symposium conducted at the International Society for Traumatic Stress Studies Annual Conference, New Orleans, LA.

57%

70%

61%

66%

40%

30%

36%

32%

0% 20% 40% 60% 80% 100%

Air Force Chaplains(n = 359)

Navy Chaplains(n = 311)

Army Chaplains(n = 963)

VA Chaplains(n = 422)

How well has your training prepared you to care for Veterans with moral

injury?

Very prepared Somewhat prepared

Scale = Frequently; Sometimes; Rarely Scale = Very prepared; Somewhat prepared; Not prepared

How Often do Chaplains SeeMoral Injury?1,2

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Do Chaplains Perceive Their Workas Synergistic with ACT?1

1 2 3 4 5 6 7

Psychodynamic

Humanistic

Cognitivebehavioral

Family systems

Integrative

ACT

Strongly Neutral StronglyDisagree Agree

Overt Familiarity(N = 36 CPE Supervisors)

Familiar with Incorporate w/ chaplaincy

1 2 3 4 5 6 7

Understand that it is okay toremember something unpleasant.

Live a life they value despitepainful experiences and memories.

Acknowledge fear of feelings andfeel them anyway.

Let go of worry about not beingable to control their worries and…

Understand that they canexperience painful memories but…

Accept that they cannot controlevery aspect of life.

Recognize that the experience ofemotion itself is not necessarily a…

Stop comparing their lives toothers'.

Stop their worries from getting inthe way of their success.

Not let their thoughts and feelingsget in the way of how they want…

Strongly Neutral StronglyDisagree Agree

Covert Familiarity*(N = 36 CPE Supervisors)

* Items adapted from the Acceptance and Action Questionnaire II (AAQ-II).1. Nieuwsma, J.A. & McMahan, J. (2016). Using ACT in the context of healthcare chaplaincy. In J.A. Nieuwsma, R.D. Walser, & S.C. Hayes (Eds.), ACT for clergy and pastoral counselors:

Using acceptance and commitment therapy to bridge psychological and spiritual care. Oakland, CA: Context Press / New Harbinger Publications.

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Do Chaplains Trained in ACT use it?

N = 81 MHICS Trained Chaplains

Pre Time 1 Time 2 Time 3 Time 4 Time 5 Time 6 Time 7 Time 8 Post

ACT Used 12% 48% 92% 85% 84% 91% 80% 80% 85% 83%

MI Used 21% 35% 42% 82% 60% 66% 79% 75% 82% 79%

PST used 17% 30% 37% 59% 56% 60% 54% 59% 69% 75%

Any EBP Used 31% 59% 94% 93% 87% 93% 85% 87% 96% 86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% o

f C

ha

pla

ins

Us

ing

EB

P i

n P

as

t W

ee

k

Timepoint

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Are Chaplains using ACT toAddress Moral Injury?

Elements Rated as Most Essential for Moral Injury Care*(N = 361 VA Chaplains)

1. Forgiving self (56.2%)

2. Developing compassion for self (51.8%)

3. Emotional processing (48.2%)

4. Developing trusting relationships (47.4%)

5. Willingness to live life even with painful memories (46.0%)

6. Reconnecting with values (44.0%)

* Scale included 23 items. Items endorsed as “Essential in all cases” by at least 40% of respondents are displayed in rank order.

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What can a Chaplain/Psychologist Moral Injury ACT Group Look Like?1

1. Lusk, J. & Morris, R. (nd). ACT for moral injury: A psycho-spiritual journey of self-compassion. Therapist manual, Portland VA PTSD Outpatient Clinic, Portland, OR.

You are not your moral injuryPart 1• Class 1: Present moment awareness• Class 2: Defusing from the “moral injury monster”• Class 3: Defusing

Moving forward with compassionPart 2• Class 4: Acceptance and compassion• Class 5: To forgive or not to forgive• Class 6: Shame exposure

Your wound becomes your giftPart 3• Class 7: Values (revisiting our values exercise)• Class 8: Wounded soldier reassigned to a new mission: Roles & creating ritual• Class 9: Launching: Performing ritual

Summary Future Directions

Mapping moral injury

Clinical evaluation

Collaborative care Mental health &

chaplaincy

Community engagement

Interdisciplinary discussions

Discussion

J A S O N N I E U W S M A

J A S O N . N I E U W S M A @ V A . G O V

J A S O N . N I E U W S M A @ D U K E . E D U

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