There is increasing acknowledgement of both fear-based post-traumatic stress disorder (PTSD) symptoms and moral injury based PTSD symptoms. The symptoms associated with moral injury include guilt, shame, and social alienation. Prevalence estimates for moral injury being chosen as the event that causes the most distress in active duty soldiers being treated for PTSD range from 24-33%. Exposure-based treatments are effective for fear-based PTSD symptoms but less effective for moral injury based PTSD symptoms. One important component for the treatment of moral injury symptoms is the need for forgiveness. Mental health clinicians are typically not recognized as experts or trained to help patients work toward forgiveness. However, clergy (broadly defined as ordained and lay leaders across a broad range of faith traditions) are recognized and trained to help individuals work toward forgiveness. The intervention being tested (Mental health Clinician and Community Clergy Collaboration or MC4) is built on pilot work where input was collected from relevant stakeholder groups. A VA chaplain will act as the mediator between the mental health clinician, patient, and community clergy. The intervention will also leverage existing trainings for community clergy on topics of moral injury and Veteran mental health that are supported by the VA Clergy Partnership (VCP) project, VA National Chaplain Center Community Clergy Training Program (CCTP), and the Arkansas Department of Health safeTALK suicide awareness and prevention training sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).
The objectives of this study are to 1) Formalize the community clergy network and training, 2) Conduct a single arm study to examine feasibility, credibility, and acceptability of MC4 intervention, and 3) Refine MC4 intervention in preparation for future RCT.
For Aim 1 we will talk with the 50-60 community clergy who have received the trainings listed above and identify those who are willing to receive referrals from the pilot study. We expect that we will need at least 20 clergy on the list from a variety of spiritual traditions. Prior to enrolling patients in the study we will schedule two to three conference calls to review the MC4 Training Manual and other resources referenced in the Training Manual. For Aim 2, we will recruit 24 Veterans in treatment for PTSD who have residual symptoms consistent with moral injury. The MC4 intervention VA chaplain will match the Veteran with a community clergy from a spiritual tradition of the Veteran's choosing. The study design will be a single arm study (no control group). The primary outcomes for the pilot study will be intervention feasibility, credibility, and acceptability. MC4 intervention acceptability will be measured using semi-structured qualitative interviews with patients, mental health clinicians, VA chaplain, and community clergy to assess what worked well/not so well, what was helpful/not so helpful, and what changes need to be made to the intervention to make it better. Secondary outcomes will include mental health symptom and community engagement outcome data collected at baseline and 3-months. Pilot data will be analyzed using descriptive quantitative and descriptive qualitative methods. For Aim 3, research staff and pilot study stakeholders and partners will use the results from Aim 2 to refine the MC4 intervention.
The primary aims of this pilot were MC4 feasibility, credibility, and acceptability. For feasibility, 24 Veterans were recruited and 14 enrolled (58%). For the Veterans who requested more information about the study and then refused to participate, most reported that they were not ready to participate in a spiritual intervention at this time. In terms of Veterans meeting with their spiritual mentors, there were 14 Veterans who met with 14 different mentors. Ten (71%)of the Veterans experienced a minimum threshold of contact with their mentor either in-person and/or over the phone. For the 4 Veterans who did not have adequate contact with their mentors, 3 appeared to be due to lack of mentor availability and one may have been due to the Veteran and mentor not being able to meet face to face. The credibility of the intervention was measured using the Expectancy Rating Scale. The Veterans who achieved the minimum threshold for mentor contact on average reported 31 out of 40 possible (77%). Acceptability was measured using qualitative data and Veteran, mentor, and mental health clinician responses were overwhelming positive. The barriers that were identified are being addressed in an updated version of the MC4 intervention.
Results from this pilot study are being used to inform a subsequent VA HSR&D proposal that will test the refined MC4 intervention in a randomized controlled trial. Because community re-integration is a significant part of the MC4 intervention, experience from this study could also inform other studies that are proposing to partner with community resources.
- Pyne JM, Rabalais A, Sullivan S. Mental Health Clinician and Community Clergy Collaboration to Address Moral Injury in Veterans and the Role of the Veterans Affairs Chaplain. Journal of health care chaplaincy. 2019 Jan 1; 25(1):1-19.