Assessing Moral Injury in Veterans as part of a Chaplain-Delivered Spiritual Assessment: Implications for Social and Community Rehabilitation

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In recent years, moral injury has been recognized as a source of mental health morbidity in some Veteran populations and conceptually distinct from existing mental health diagnoses. It represents a constellation of negative affect, chiefly guilt, shame, anger, and disgust. Moral injury has been associated with a variety of negative health outcomes, including suicide risk. It has also been theorized to impact select rehabilitation outcomes. In VA facilities, mental health care providers are the chief source of support for affected Veterans. Still, moral injury is not routinely assessed or addressed in formal clinical-therapeutic settings. VA chaplains serve as a source of support for some Veterans affected by moral injury. For example, preliminary findings suggest that VA chaplaincy service users report a high intensity of potentially morally injurious events. As a matter of routine practice, chaplains administer pencil-and-paper surveys, called spiritual assessments, intended to inform chaplaincy services. This project is designed to create a standardized spiritual assessment tool, comprised of empirically validated instruments, which would simultaneously serve as a vehicle for focused secondary data collection. The immediate goals of this project are to develop and administer a new standardized SA tool in VA chaplaincy service with the goal of rapidly identifying individuals with MI and/or problematic rehabilitation outcomes (e.g., suicide risk) and who are in need of services to address MI. Aim 1 of this study is to qualitatively examine the feasibility, logistics, and practical implications of developing and applying a standardized SA tool in VA chaplaincy settings. Aim 2 of this study is to design a standardized SA tool that (a) meets the stated needs of chaplains and (b) can be used to collect data about moral injury and rehabilitation outcomes in individual veterans. Focus groups conducted with 8 chaplains and 4 Veterans will be used to examine (a) how they identify moral injury concerns, (b) incorporating assessment of moral injury with other aspects of a spiritual assessment, (c) feasibility and logistics of using a standardized spiritual assessment tool in the chaplains' typical work setting, (d) documentation and procedures to move from assessment to support for moral injury, and (e) moving from assessment to support for moral injury. We will use focus groups to assess the feasibility of having VA chaplains use a standardized spiritual assessment tool, informing the choice of which (a) moral injury instrument(s) is/are most appropriate for inclusion in a standardized spiritual assessment tool and (b) instruments are most appropriate for examining outcomes relevant to social functioning, community reintegration, and suicide risk in chaplaincy settings. The standardized spiritual assessment tool will be developed in collaboration with the VA National Chaplain Center, which oversees chaplaincy services across all VA facilities. Once approved for use, the standardized spiritual assessment tool will be administered to a sample of 25 chaplaincy service users from the mental health care line at the Atlanta VA Medical Center. This project represents a critical opportunity both for developing a viable avenue for systematically assessing for moral injury as well as informing understandings of how moral injury affects health and rehabilitation outcomes in Veteran populations. Other practical implications include signaling to the chaplain that a service user may be at increased risk of adverse outcomes (e.g., suicide). This could highlight a need for a referral for clinical-therapeutic support from a formal VA health care provider, thereby also informing interdisciplinary collaboration between chaplains and clinicians in support of Veterans affected by moral injury.