Building Spiritual Strength:
Evolving Treatment for PTSD and
Moral Injury/Spiritual Distress
J. IRENE HARRIS, PH.D., L.P.
CHRISTOPHER R. ERBES, PH.D., L.P.
TIMOTHY USSET, M.DIV., BCC, LMFT
MINNEAPOLIS VA HEALTH CARE SYSTEM
Making PTSD Treatment Accessible
 While highly effective, evidence-based treatments for
PTSD are accessed by only 11%1,2 of combat veterans,
and of those, almost half drop out of treatment3-5.
 Building Spiritual Strength is a spiritually-integrated
model for treating PTSD designed to reach veterans who
will not access conventional mental health services.
Building Spiritual Strength Intervention
 Session 1: Orientation to group rules, limits of





confidentiality, “storytelling;” establishing rapport
Sessions 2-3: Developing skills and tools for
communication with a Higher Power
Session 4: Theodicy
Session 5: Meditative and prayer coping
Sessions 6-7: Forgiveness
Session 8: Consolidation of gains, identification of
future resources.
Signs of Moral Injury/Spiritual Distress
Loss
of previously held spiritual beliefs
Struggle or conflict in relationship with a
Higher Power
Difficulty forgiving self, others, or a Higher
Power
Feeling that there is no meaning or purpose in
life
Reduced trust in others
Inappropriate guilt and shame
Consequences of Moral Injury/Spiritual Distress
 Increased risk for suicidal ideation and attempts
 Reduced mental health resilience
 Loss of social support from community of faith,
family and values-based activities
Previous Pilot Study9
 56 Veterans with PTSD randomized to BSS or a wait-list
control group.
 Significant improvements in PTSD symptoms, depression
symptoms, and positive religious coping as compared to
the wait list.
 Data trend suggests BSS is more effective for minority
veterans.
Current Study
 Determine if BSS can be as effective as Present Centered
Group Therapy
 Assess effects of BSS on moral injury/spiritual distress
 Larger sample size (138)
 Chaplains with mental health training as therapists
Study Results
 Average age 58.33 (SD=13.00)
 14% female
 70% Caucasian, 8% African-American, 3% Hispanic, 1% each
Asian, Native American, Multiracial, 17% Unreported
 38 Catholic, 84 Protestant, 5 Agnostic, 13 Spiritual but not
Religious, 1 Sufi, 2 Jewish, 1 Native American Spiritualty, 1
Shinto (note that some participants reported multiple faith
affiliations)
 67 randomized to Present Centered Group therapy, 71
randomized to Building Spiritual Strength
 No significant differences in PTSD symptoms or spiritual distress
across groups at baseline
Study Results-PTSD Symptoms
 No differences in rates of treatment completion across
groups.
 Reduction in PTSD symptoms were the same for both
PCGT and BSS
 68% of BSS clients and 70% of PCGT clients had
clinically significant reduction in PTSD symptoms based
on the Clinician Administered PTSD Scale.
Study Results-Spiritual Distress
 Tested for differences in the subscales of the Religious
and Spiritual Struggles Scale (Divine, Demonic,
Interpersonal, Moral, Ultimate Meaning, and Doubt)
 Of these scales, those in BSS demonstrated statistically
significant decreases in the Divine subscale as compared
to those in PCGT. This scale measures distress in one’s
relationship with a Higher Power. (Condition: t = 2.65, p
= .009, Time x Condition: t = -1.60, p = .001)
Results: Changes in Spiritual Distress
(Relationship with the Divine)
Figure 1. Change in Divine
12.000
11.000
10.000
PCGT
BSS
9.000
8.000
7.000
6.000
Pre
Post
Follow-up
Conclusions
 BSS appears to be as effective as PCGT for PTSD
symptoms at the end of treatment.
 BSS is more effective than PCGT in treating spiritual
distress.
 To our knowledge, this is the only clinical trial of a
treatment for moral injury/spiritual distress that
documents reduction of spiritual distress.
 Further study of psychospiritual development is indicated.
Additional Resources
 Brett Litz: Adaptive Disclosure
 Everett Worthington: Forgiveness
 Good Goats: Healing Our Image of God
 www.ptsd.va.gov
Contact Information
 J. Irene Harris: [email protected]
 Timothy Usset: [email protected]
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
Mott, J.M., Mondragon, S., Hundt, N., Beason-Smith, M. Grady, R.H. & Teng, E.J. (2014). Characteristics of veterans who initiate and
complete Cognitive Processing therapy and Prolonged Exposure for PTSD. Journal of Traumatic Stress, 27, 265—273.
Shiner, B., D’Avelio, L.W., Nguyen, T.M., Zayed, M.H., Yong-Xu, Y., Desai, R.A., Schnurr, P.P., Fiore, LD. & Watts, B.V. (2012).
Measuring use of evidence based psychotherapy for posttraumatic stress disorder. Administration and Policy in Mental Health and Mental
Health Services Research, 40, 311-318.
Schnurr, P.P., Friedman, M.F., Engel, C.C., Foa, E.B., Shea, M.T., Chow, B.K., Resick P.A., Thurston V., Orsillo S.M., Haug, R., turner, C., &
Bernardy, N. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial. JAMA, 297, 82—
30.
Kehle-Forbes, S.M., Meis, L.A., Polusny, M.A. (2014). Treatment initiation and dropout from Prolonged Exposure and Cognitive Processing
Therapy in a VA Outpatient Clinic
Suris, A., Link-Malcolm, J., Chard, K., Ahn, C. & North, C. (2013). A randomized clinical trial of Cognitive Processing Therapy for Veterans
with PTSD related to military sexual trauma. Journal of Traumatic Stress, 26, 1-10.
Tanielian, T.R. & Jaycox, L.H. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to
assist recovery. RAND Corporation, Santa Monica, CA.
Visco, R. (2009). Postdeployment self-reporting of mental health problems and barriers to care. Perspectives in Psychiatric Care, 45, 240-253.
Litz, B.T., Stein, N., Delaney, E., Lebowitz, L., Nash, W.P., Silva, C. & Maguen, S. (2009). Moral injury and moral repair in war veterans: A
preliminary model and intervention strategy. Clinical Psychology review, 29, 695-706.
Harris, J.I., Erbes., C.R., Engdahl., B.E., Thuras, P., Murray-Swank, N, Grace, D., Ogden, H., Olson, R.H.A., Winskowski, A.M., Bacon, R.,
Malec, C., Campion, K., & Le, TuVan (2011). The effectiveness of a trauma focused spiritually integrated intervention for veterans exposed to
trauma. Journal of Clinical Psychology, 67, 1-14.