Enjoying the violence of war: Association with posttraumatic symptomatology in U.S. combat veterans.

OBJECTIVE: Engaging in war-related violence can have a devastating impact on military personnel, with research suggesting that injuring or killing others can contribute to posttraumatic stress disorder (PTSD), depression, and moral injury. However, there is also evidence that perpetrating violence in war can become pleasurable to a substantial number of combatants and that developing this "appetitive" form of aggression can diminish PTSD severity. Secondary analyses were conducted on data from a study of moral injury in U.S., Iraq, and Afghanistan combat veterans, to examine the impact of recognizing that one enjoyed war-related violence on outcomes of PTSD, depression, and trauma-related guilt. METHOD: Three multiple regression models evaluated the impact of endorsing the item, "I came to realize during the war that I enjoyed violence" on PTSD, depression, and trauma-related guilt, after controlling for age, gender, and combat exposure. RESULTS: Results indicated that enjoying violence was positively associated with PTSD, ß (SE) = 15.86 (3.02), p < .001, depression, ß (SE) = 5.41 (0.98), p < .001, and guilt, ß (SE) = 0.20 (0.08), p < .05. Enjoying violence moderated the relationship between combat exposure and PTSD symptoms, ß (SE) = -0.28 (0.15), p < .05, such that there was a decrease in the strength of the relationship between combat exposure and PTSD in the presence of endorsing having enjoyed violence. CONCLUSIONS: Implications for understanding the impact of combat experiences on postdeployment adjustment, and for applying this understanding to effectively treating posttraumatic symptomatology, are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Chaplain Training in Evidence-Based Practices to Promote Mental Health and Improve Care for Suicidality in Veterans and Service Members.

OBJECTIVE: Chaplains are key care providers in a comprehensive approach to suicide prevention, which is a priority area for the U.S. Department of Veterans Affairs (VA) and the Department of Defense (DoD). In a cohort of 87 VA and military chaplains who completed the Mental Health Integration for Chaplain Services (MHICS) training-an intensive, specialty education in evidence-based psychosocial and collaborative approaches to mental health care-we assessed chaplains' self-perceptions, intervention behaviors, and use of evidence-based practices, including Acceptance and Commitment Therapy (ACT), Problem-Solving Therapy (PST), and Motivational Interviewing (MI), in providing care for suicidality. METHOD: Chaplains responded to a battery of items Pre- and Post-training and provided deidentified case examples describing their use of evidence-based practices in spiritual care for service members and veterans (SM/V) on various levels of a suicide prevention continuum. RESULTS: Post-training, chaplains reported increased abilities to provide care and mobilize collaborative resources. Over the course of MHICS, 87% of chaplains used one or more evidence-based practices with a SM/V at risk for suicide or acutely suicidal. Fifty-six percent of chaplains reported intervening with an acutely suicidal SM/V by using principles from ACT, 36% PST, and 48% MI. With persons at risk for suicide, 81% used principles from ACT, 66% PST, and 71% MI. Cases exemplified diverse evidence-based practice applications. CONCLUSIONS: Findings indicate chaplains trained in evidence-based practices report effective application in caring for SM/V who are suicidal, thus offering a valuable resource to meet needs in a priority area for VA and DoD.HIGHLIGHTSChaplains provide essential care for SM/V who are at risk for suicide or acutely suicidalTraining helps chaplains mobilize interdisciplinary and community resources in suicide careEvidence-based practices can effectively integrate within the scope of chaplaincy practice for suicide care.

Measuring morality: Analyzing the factor structure of the moral foundations questionnaire in veterans.

OBJECTIVES: Moral reasoning is an underexamined and potentially useful area of research relative to the care of moral injury in veterans. However, the most widely used measure of moral reasoning, the moral foundations questionnaire (MFQ), has not been validated in this population. METHODS: Post-9/11 veterans (N = 311) completed questionnaires which included the MFQ. Veterans' scores were compared to the general US population. Confirmatory factor analysis was used to test existing models of the MFQ in the sample. Exploratory factor analysis (EFA) was also used to examine potentially improved model fits. RESULTS: The two leading, preexisting MFQ models were both poor fits for the data. EFA results produced a four-factor model for the veteran sample using 25 of the original 30 items of the MFQ. CONCLUSIONS: Measuring moral reasoning among veterans may be important in understanding the experience of moral injury. However, the most widely used scale (MFQ) performs poorly among a sample of post-9/11 veterans, indicating that veterans may respond differently to the measure than the general US population. Military culture may uniquely influence veterans' moral reasoning, suggesting the need for military specific measures for this construct.

Increasing chaplain support for veterans at high risk for suicide through targeted outreach: A quality improvement initiative.

The Department of Veterans Affairs (VA) has prioritized improving the identification of veterans at risk for suicide and ensuring adequate staffing of personnel to assist veterans in need. It is imperative that suicide prevention efforts make use of the full range of available resources, including diverse professionals with distinctive skillsets. Chaplains are engaged in suicide prevention efforts in VA, but the literature lacks examples of chaplain-involved suicide prevention efforts that clearly describe how chaplains are engaged, the training and/or qualifications chaplains possess in the area of suicide prevention, and the reach and impact of such efforts. The purpose of this report is to describe the development and implementation of a novel, innovative, and ongoing chaplain-led suicide prevention outreach initiative for veterans at high risk for suicide. Results indicated the program was feasible and supported at the systems level, and chaplains were able to collaboratively sustain outreach efforts over the course of a year. Chaplain suicide prevention outreach was found to be acceptable to veterans, who overwhelmingly indicated openness to and appreciation for outreach. Chaplains can address the spiritual crisis underlying suicidality, bolster spiritual protective factors, and are a part of holistic care. Considerations for implementation and future investigation are discussed.

Core Components of Moral Injury Groups Co-Facilitated by Mental Health Providers and Chaplains.

Despite increasing interest in moral injury, there is not yet consensus around what it is (and is not), who can have it and under what circumstances, or the degree and form of distress necessary to distinguish moral injury from other psychological and spiritual difficulties. The novelty of moral injury has created space for frontline Veterans Health Administration mental health and spiritual care providers to creatively apply their core professional skills and identities to moral injury. This paper presents findings of a core components analysis (CCA) derived from seven co-led chaplain-mental health moral injury group facilitation teams that were involved in a 16-month quality improvement endeavor of the Dynamic Diffusion Network (DDN). The DDN initiative engages providers in collaborative and iterative refinement of practices to promote rapid improvements in care for complex problems that lack a codified evidence base. Using CCA, we identified 10 core components of co-facilitated moral injury group care. Components include a clear conceptualization of moral injury, an inclusive approach to spirituality, and exploration of forgiveness, among others. This paper offers guidance that can be widely applied and readily adapted as our collective understanding of moral injury continues to expand and clarify. The core components are articulated here as principles for ongoing review and revision in response to future moral injury advances in the DDN and elsewhere.

Collaborative spiritual care for moral injury in the veterans Affairs Healthcare System (VA): Results from a national survey of VA chaplains.

The psychospiritual nature of moral injury invites consideration regarding how chaplains understand the construct and provide care. To identify how chaplains in the VA Healthcare System conceptualize moral injury, we conducted an anonymous online survey (N = 361; 45% response rate). Chaplains responded to a battery of items and provided free-text definitions of moral injury that generally aligned with key elements in the existing literature, though with different emphases. Over 90% of chaplain respondents indicated that they encounter moral injury in their chaplaincy care, and a similar proportion agreed that chaplains and mental health professionals should collaborate in providing care for moral injury. Over one-third of chaplain respondents reported offering or planning to offer a moral injury group. Separately, nearly one-quarter indicated present or planned collaboration with mental health to provide groups that in some manner address moral injury. Previous training in evidence-based and collaborative care approaches appears to contribute to the likelihood of providing integrated psychosocial-spiritual care. Results and future directions are discussed, including a description of moral injury that may be helpful to understand present areas of emphasis in VA chaplains' care for moral injury.

Examining faith-based collaboration in U.S. States' suicide prevention guidelines.

Faith-based communities (FBCs) are recognized by most states as key players within systematic suicide prevention efforts. The aim of the present study was to conduct a thematic analysis of documents that detail the suicide prevention efforts of individual states with respect to the role(s) delegated to FBCs. Thematic analysis is recognized as a useful methodology for identifying implications for policy and practice. Documents were procured from all states, with the exception of New Mexico (n = 49). The findings suggest six areas relevant to collaboration with FBCs: suicide prevention training for the FBC, suicide prevention training for individual faith leaders, community engagement, faith leaders as gatekeepers, culturally sensitive suicide prevention, and postvention support. These state guideline documents consistently affirm the importance of engaging FBCs in suicide prevention efforts and cover a range of recommendations, though generally lack specifics with respect to how FBCs can optimally engage.

Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment-seeking military service members.

The Posttraumatic Stress Disorder Checklist (PCL-5; Weathers et al., 2013) was recently revised to reflect the changed diagnostic criteria for posttraumatic stress disorder (PTSD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). We investigated the psychometric properties of PCL-5 scores in a large cohort (N = 912) of military service members seeking PTSD treatment while stationed in garrison. We examined the internal consistency, convergent and discriminant validity, and DSM-5 factor structure of PCL-5 scores, their sensitivity to clinical change relative to PTSD Symptom Scale-Interview (PSS-I; Foa, Riggs, Dancu, & Rothbaum, 1993) scores, and their diagnostic utility for predicting a PTSD diagnosis based on various measures and scoring rules. PCL-5 scores exhibited high internal consistency. There was strong agreement between the order of hypothesized and observed correlations among PCL-5 and criterion measure scores. The best-fitting structural model was a 7-factor hybrid model (Armour et al., 2015), which demonstrated closer fit than all other models evaluated, including the DSM-5 model. The PCL-5's sensitivity to clinical change, pre- to posttreatment, was comparable with that of the PSS-I. Optimally efficient cut scores for predicting PTSD diagnosis were consistent with prior research with service members (Hoge, Riviere, Wilk, Herrell, & Weathers, 2014). The results indicate that the PCL-5 is a psychometrically sound measure of DSM-5 PTSD symptoms that is useful for identifying provisional PTSD diagnostic status, quantifying PTSD symptom severity, and detecting clinical change over time in PTSD symptoms among service members seeking treatment. (PsycINFO Database Record

Assessing quality of life in young adult cancer survivors: development of the Survivorship-Related Quality of Life scale.

PURPOSE: Scientific advances in treatments and outcomes for those diagnosed with cancer in late adolescence and early adulthood depend, in part, on the availability of adequate assessment tools to measure health-related quality of life (HRQOL) for survivors in this age group. Domains especially relevant to late adolescence and young adulthood (LAYA; e.g., education and career, committed romantic relationships, worldview formation) are typically overlooked in studies assessing the impact of cancer, usually more appropriate for middle-aged or older survivors. Current HRQOL measures also tend to assess issues that are salient during or shortly after treatment rather than reflecting life years after treatment. METHODS: To develop a new measure to better capture the experience of LAYA cancer survivors in longer-term survivorship (the LAYA Survivorship-Related Quality of Life measure, LAYA-SRQL), we completed an extensive measure development process. After a literature review and focus groups with LAYA cancer survivors, we generated items and ran confirmatory factor and reliability analyses using a sample of 292 LAYA cancer survivors. We then examined validity using existing measures of physical and mental health, quality of life, and impact of cancer. RESULTS: The final model consisted of two domains (satisfaction and impact), each consisting of ten factors: existential/spirituality, coping, relationship, dependence, vitality, health care, education/career, fertility, intimacy/sexuality, and cognition/memory. Confirmatory factor analysis and validity analyses indicated that the LAYA-SRQL is a psychometrically sound instrument with good validity. CONCLUSION: The LAYA-SRQL fills an important need in survivorship research, providing a way to assess HRQOL in LAYAs in a developmentally informed way.

The impact of Yoga upon young adult cancer survivors.

This study explored the use of Yoga by using a cross-sectional analysis of 286 young adult cancer survivors. The aim was to explore yoga practice, reasons for using this therapy; predictors of yoga use and any potential relationship between yoga use and well-being. Ninety one participants (32.82%) reported practicing yoga from their initial diagnosis. Practitioners reported a relatively high intensity (mean: 7.46 h/month) and length (25.88 months) of practice. The most common reasons given for undertaking yoga were to maintain flexibility and promote relaxation. Sociodemographic predictors of yoga use included gender, higher education with increased yoga use generally related to enhanced feelings of well-being. Results suggest that yoga use is more commonly used by cancer survivors with greater resources. Understanding more about the use of yoga by cancer survivors may facilitate the development and promotion of yoga-based interventions.

Cognitive and emotional aspects of fear of recurrence: predictors and relations with adjustment in young to middle-aged cancer survivors.

OBJECTIVE: We investigated predictors of emotional (worry) and cognitive (perceived risk) dimensions of fear of recurrence (FOR) and their relationships with psychological well-being in a sample of young and middle-aged adult cancer survivors. METHODS: Eligible participants were survivors between 18 and 55 years old and diagnosed from 1 to 3 years prior. A total of 250 participants were recruited, and 167 responded to a 1-year follow-up. Demographic and psychosocial variables were assessed at baseline, and FOR and psychological well-being were assessed at follow-up. RESULTS: Race was associated with the cognitive dimension of FOR (such that minority race perceived less risk of recurrence), but no demographics were associated with the emotional dimension. Hierarchical regression analyses showed that spirituality was the only predictor of perceived risk independent of the effect of race, even when worry about general health was controlled. For the emotional dimension of FOR, avoidance coping predicted higher worry, but when controlling for a general tendency to worry about one's health, none of the psychosocial variables predicted worries about cancer's return. In addition, only worry about cancer's return predicted negative affect and intrusive thoughts. CONCLUSIONS: These results suggest that FOR comprises distinct dimensions, each of which has different implications for adjustment. These findings may have important clinical implications in developing interventions to deal with both FOR and more general health anxieties in cancer survivors.

Religious struggle as a predictor of subsequent mental and physical well-being in advanced heart failure patients.

Patients with congestive heart failure (CHF) often report high levels of religiousness, which may mitigate the stressfulness of their condition. However, religious struggle, reflecting negative attitudes toward God and a strained meaning system, may be detrimental to well-being. Little is known about religious struggle in those with CHF, particularly in relation to physical health and well-being over time. We examined associations of religious struggle and subsequent mental and physical well-being in 101 endstage CHF patients who completed questionnaires twice over 3 months. Religious struggle predicted higher number of nights subsequently hospitalized, higher depression, and marginally lower life satisfaction. When controlling for baseline levels of well-being, effectively assessing change in those outcomes, religious struggle remained a significant predictor of hospitalization and also emerged as a marginally significant predictor of lower physical functioning. Struggle was unrelated to health-related quality of life. Post-hoc analyses suggest that these effects were particularly strong for those endorsing greater religious identification. Religious struggle appears to have a potentially negative impact on well-being in advanced CHF; therefore, helping patients to address issues of struggle may meaningfully lessen the personal and societal costs of CHF.

Trauma and PTSD Symptoms: Does Spiritual Struggle Mediate the Link?

Because exposure to potentially traumatic events is common (Kessler, Sonnega, Bromet, & Hughes, 1995), the mechanisms through which post-traumatic stress disorder (PTSD) symptoms develop is a critical area of investigation (Ozer, Best, Lipsey, & Weiss, 2003). Among the mechanisms that may predict PTSD symptoms is spiritual struggle, a set of negative religious cognitions related to understanding or responding to stressful events. Although prominent theories emphasize cognitive factors in the development and maintenance of PTSD symptoms, they have not explicitly addressed spiritual struggle. The present prospective study tested the role of spiritual struggle in the development and maintenance of PTSD symptoms following trauma. We assessed exposure to trauma and non-trauma events during the first year of college, spiritual struggle due to the most stressful event, and PTSD symptoms resulting from the index event. Spiritual struggle partially mediated the relationship between trauma and PTSD symptoms. Interestingly, some individual subscales of spiritual struggle (specifically, Punishing God Reappraisal, Reappraisal of God's Powers, and Spiritual Discontent) partially mediated the relationship between trauma and PTSD symptoms; however, reappraisal of the event to evil forces did not relate to PTSD symptoms. These results suggest that spiritual struggle is an important cognitive mechanism for many trauma victims and may have relevance for cognitive therapy for PTSD.

Religion and spirituality in adjustment following bereavement: an integrative review.

Surprisingly little research has examined the widely held assumption that religion and spirituality are generally helpful in adjusting to bereavement. A systematic literature search located 73 empirical articles that examined religion/spirituality in the context of bereavement. The authors describe the multidimensional nature of religion/spirituality and use this framework to organize and integrate the findings of these empirical articles. Overall, results suggest that relations between religion and adjustment to bereavement are generally positive but inconsistent and vary depending in part on how religion/spirituality is measured. The authors conclude with a critique of the current research and directions for future research.

Death without God: religious struggle, death concerns, and depression in the terminally ill.

Religious worldviews often provide comfort near the end of life, but they can cause distress if life circumstances are perceived as evidence of God's disfavor. This study, the first to test terror management theory (TMT) with terminally ill participants, examined the hypothesis that concerns about death mediate the relationship between religious struggle (and religious comfort) and depression in the terminally ill. Ninety-eight patients with end-stage congestive heart failure (CHF) completed measures of religious comfort, religious struggle, belief in an afterlife, concerns about death, and depression. In separate hierarchical linear regression models that controlled for degree of belief in an afterlife, death concerns fully mediated the relationships between religious struggle and depression and between religious comfort and depression. These findings suggest that religious struggle is a breakdown in the terror management system that leaves the individual vulnerable to the terror of death, and that properly functioning religious worldviews offer comfort by buffering the individual against death concerns.