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Journal of Traumatic Stress February 2015, 28, 57–64

Spirituality Factors in the Prediction of Outcomes of PTSD Treatment for U.S. Military Veterans

Joseph M. Currier,1 Jason M. Holland,2 and Kent D. Drescher3,4 1University of South Alabama, Psychology Department, Mobile, Alabama, USA

2University of Nevada, Las Vegas (UNLV), Department of Psychology, Las Vegas, Nevada, USA 3National Center for PTSD, VA Palo Alto Healthcare System, Menlo Park, California, USA

4The Pathway Home–California Transition Center for the Care of Combat Veterans, Yountville, California, USA

Spirituality is a multifaceted construct that might affect veterans’ recovery from posttraumatic stress disorder (PTSD) in adaptive and maladaptive ways. Using a cross-lagged panel design, this study examined longitudinal associations between spirituality and PTSD symptom severity among 532 U.S. veterans in a residential treatment program for combat-related PTSD. Results indicated that spirituality factors at the start of treatment were uniquely predictive of PTSD symptom severity at discharge, when accounting for combat exposure and both synchronous and autoregressive associations between the study variables, βs = .10 to .16. Specifically, veterans who scored higher on adaptive dimensions of spirituality (daily spiritual experiences, forgiveness, spiritual practices, positive religious coping, and organizational religiousness) at intake fared significantly better in this program. In addition, possible spiritual struggles (operationalized as negative religious coping) at baseline were predictive of poorer PTSD outcomes, β = .11. In contrast to these results, PTSD symptomatology at baseline did not predict any of the spirituality variables at posttreatment. In keeping with a spiritually integrative approach to treating combat-related PTSD, these results suggest that understanding the possible spiritual context of veterans’ trauma-related concerns might add prognostic value and equip clinicians to alleviate PTSD symptomatology among those veterans who possess spiritual resources or are somehow struggling in this domain.

Spirituality might be relevant in treating combat-related post- traumatic stress disorder (PTSD). Research has documented that many people draw on spiritual teachings, beliefs/values, and practices in coping with trauma (e.g., Pargament, Koenig, & Perez, 2000; Pargament, Smith, Koenig, & Perez, 1998). In this way, spirituality represents a multidimensional construct that covers a range of intrapersonal or communal aspects that might aid recovery from PTSD. For example, engagement in a church or other organization can encourage healthy behav- ioral norms and proscribe maladaptive forms of coping that can create additional problems for traumatized individuals (e.g., substance misuse). Spirituality can also enhance coping skills and provide a frame of intelligibility to support one’s con- structive reappraisals of trauma (e.g., accepting finite nature of human existence; Park, 2013). Other survivors derive comfort from a relationship with God or Higher Power and incorporate practices such as prayer or meditation for transcending their symptoms and experiencing positive emotions amid struggles

Correspondence concerning this article should be sent to Joseph M. Currier, Psychology Department, University of South Alabama, Mobile, AL 36608. E-mail: [email protected]

Published 2015. This article is a US government work and is in the public domain in the USA. View this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21978

with PTSD (e.g., peace, joy). Recent meta-analytic evidence by Davis, Worthington, Hook, and Hill (2013) also indicated that spirituality factors were consistently associated with a propen- sity to forgive oneself and others after perceived acts of wrong- doing, a topic of increasing attention in the military trauma literature (Litz et al., 2009; Maguen & Litz, 2012; Worthington & Langberg, 2012).

Other empirical findings similarly support the possible rele- vance of a spiritually integrative model for working with mili- tary populations. Descriptive results from over 24,000 active duty personnel revealed that stronger spiritual beliefs were concurrently linked with less PTSD symptomatology (Hourani et al., 2012). Currier, Drescher, and Harris (2014) similarly found inverse correlations between PTSD symptomatology and several adaptive dimensions of spirituality (e.g., daily spir- itual experiences, private practices, organizational religious- ness) among clinical samples of veterans from the Vietnam and Iraq/Afghanistan eras. In contrast, other cross-sectional studies found that several indices of spiritual struggle were linked with poorer posttraumatic adjustment; namely, engage- ment in negative religious coping (feeling abandoned by God or Higher Power, appraisal of one’s problem as divine pun- ishment; Currier, Drescher et al., 2014; Ogden et al., 2011; Witvliet, Phillips, Feldman, & Beckham, 2004) and forgiveness problems (Currier, Drescher et al., 2014; Witvliet et al., 2004)

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58 Currier, Holland, and Drescher

were each associated with greater PTSD symptom severity. In general, these findings indicate that varying aspects of spiritu- ality might help or hinder veterans’ recovery from PTSD.

Consistent with findings from nonmilitary samples (Falsetti, Resick, & Davis, 2003; Seirmarco et al., 2012), research also suggests that military traumas might disrupt spirituality and that negative changes in this domain contribute to veterans’ decisions to seek treatment in many cases. When compared to demographically-matched counterparts from the commu- nity, Currier, Drescher et al. (2014) found that Vietnam and Iraq/Afghanistan veterans presenting for PTSD treatment had lower scores on adaptive aspects of spirituality while simul- taneously endorsing greater forgiveness problems and nega- tive religious coping. Focusing on another treatment-seeking sample of veterans, Fontana and Rosenheck (2004) found that weakening of religious faith was linked with higher utilization of mental health services in the Veterans Health Administra- tion (VHA) in the presence of PTSD. These results led Fontana and Rosenheck (2004) to conclude that “[Veterans] appear to be looking to their therapists . . . to provide the answers and a sense of belonging to a larger whole that is no longer being fulfilled sufficiently by their religious faith. The possibility that veterans’ continued pursuit of mental health services is driven in part by their search for meaning raises the broader issue of whether spirituality should be more central to the treatment of PTSD” (p. 582).

Whether working with trauma survivors or otherwise, clini- cians seldom receive formal training for addressing spirituality in their work (Shafranske & Cummings, 2013). In addition, from a traditional psychological standpoint, spiritual concerns are typically viewed as being on the periphery of PTSD and not affecting the symptoms, underlying mechanisms of the condi- tion, or overall recovery process. As such, when treating veter- ans who are struggling with spiritual concerns or ruminating on distressing existential questions, clinicians could anticipate that the severity of PTSD is the best prognostic factor for gauging outcome and conceptualize any issues in this domain as em- anating from trauma-related symptomatology. When treating veterans for whom spirituality provides a source of solace and possible motivation for therapeutic change, clinicians might similarly fail to affirm the importance of spirituality and possi- bly incorporate these resources in treatment. Although improv- ing spiritual functioning would not be a key goal, clinicians may hypothesize that if a veteran’s PTSD symptomatology can be alleviated, then any struggles in this domain will also abate.

An alternate way of approaching veterans presenting for PTSD treatment would be to assess their spiritual background and view concerns or resources in this domain as being more intrinsically intertwined with PTSD and the recovery process. From this spiritually integrative perspective, an understanding of the spiritual context of the trauma might help in developing a prognosis for achieving successful outcomes in certain cases. For example, if a veteran reported a strong commitment to a religious tradition or adaptive spiritual beliefs and practices, clinicians might somehow tailor their interventions with these

resources in mind. Alternatively, in cases in which a veteran was experiencing a spiritual or existential crisis of some sort, clinicians might appraise the diagnostic picture as being more complex, such that alleviation of PTSD could be more diffi- cult without somehow addressing these concerns. Longitudinal evidence with nonveterans in fact suggests that spiritual strug- gles can predict a more symptomatic course of PTSD (Harris et al., 2012; Wortmann, Park, & Edmondson, 2011). Whether focusing on veterans or otherwise, however, research has not tested whether different aspects of spirituality can predict PTSD outcomes (and vice versa) in a treatment context.

Examining these possibilities could have implications for addressing spirituality in PTSD treatment. We therefore relied on clinical information from a VHA PTSD residential pro- gram to examine the longitudinal associations between veter- ans’ pre- and posttreatment spirituality and PTSD symptom severity using a cross-lagged panel design. In these models, synchronous effects (cross-sectional associations between spir- ituality dimensions and PTSD), autoregressive effects (effect of a variable predicting itself at later time point), as well as cross-lagged effects (effects of spirituality at the start of treat- ment on PTSD at posttreatment and vice versa) are taken into account. Hence, this strategy provides a way of examining the unique associations between varying dimensions of spirituality and PTSD outcomes across time, and statistically accounting for synchronous and autoregressive effects. Such a model al- lows for a clearer examination of the temporal relations among variables. Specifically, we examined two models in this study: (a) a psychologically oriented model that would suggest that PTSD symptom severity plays a central role and spiritual re- sources and struggles are peripheral to achieving successful outcomes, and (b) a spiritually integrative model, which would hypothesize that spirituality variables might also uniquely pre- dict PTSD outcomes over the course of treatment.

Method

Participants and Procedure

This study utilized clinical information for 532 veterans who completed a 60–90 day residential VHA PTSD treatment pro- gram between 2002 and 2007. This site houses two PTSD Resi- dential Rehabilitation Programs (PRRPs) that provide treatment to veterans from all service eras, consisting of a 45-bed program for men and 10-bed program for women. Patients reside in a therapeutic setting in each program in which they participate in a range of psychological interventions (e.g., discussing traumas via exposure, anger management, communication skills, stress reduction, parenting skills, interpersonal process groups, recre- ation therapy). Treatment was exclusively provided in a group format and adhered to a cognitive–behavioral framework.

Admissions to these two programs were based on clinician referrals for veterans with severe PTSD who had not improved sufficiently through less intensive options. Exclusion criteria included psychotic symptoms, alcohol/drug misuse within the

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Spirituality and PTSD Treatment 59

previous 14 days, and medical conditions that would inter- fere with treatment activities or procedures. Participants had a current diagnosis of PTSD from VHA providers on the basis of clinical interviews and the support of commonly used as- sessment instruments (e.g., PTSD Checklist–Military version; PCL-M). Diagnostic information for other psychiatric disor- ders was not available for most of the sample. In cases where veterans had more than one admission, we only incorporated information from their first admission.

The average age was 50.59 years (SD = 10.52), and this sample predominantly comprised men (88.3%) and persons who self-identified as Caucasian (57.7%). Other ethnicities in- cluded African American (16.9%), Latino/a (15.4%), Asian American (2.3%), Native American (2.4%), and other minority groups (4.9%). Nearly half were divorced (32.3%) or separated (9.2%), 25.4% had never been married, 22.5% were married or living with a domestic partner, and 6.8% were widowed. On average, participants had 11.61 years (SD = 1.31) of formal education. The median annual income ranged from $20,000 to $30,000. The sample largely included Vietnam veterans; 9.6% had served in Iraq and/or Afghanistan. Nearly a quarter in- dicated no affiliation to a formal religious group or reported themselves to be an agnostic or atheist (23.2%). Of the sample, 26.9% identified as Christian Protestant, 20.1% were Roman Catholic, 1.9% were Mormon, 1.5% were Buddhist, 0.6% were Eastern Orthodox, 0.6% were Jewish, 0.4% were Muslim, 0.2% were Hindu, and the remaining quarter (24.6%) were affiliated with other nonspecified groups.

All measures that formed the basis of this study were com- pleted primarily for clinical decision making and quality man- agement of the PRRPs. Prior to the collection of data, however, a consent process was approved by Stanford University’s in- stitutional review board (IRB) for Human Subjects in Medical Research and the VA Research and Development Committee that allowed these veterans to provide written permission on the pretreatment questionnaire for their clinical assessments to be used for research purposes. In 2007, this protocol was closed and a de-identified data set was approved by the Stanford IRB and R & D Committee for the analyses that form the basis of this study.

So as to address the current aims, we focused on veterans who completed assessments of both PTSD and spirituality at intake or discharge from the program. The multidimensional instrument for assessing spirituality was not included from the outset of the larger investigation. Hence, when compared to earlier publications that focused on veterans over the full study period (e.g., Currier, Holland, & Drescher, 2014), we omitted 273 cases in which veterans did not provide information on spirituality in the treatment planning and evaluation process.

Measures

The Brief Multidimensional Measure of Religiousness and Spirituality (BMMRS; Fetzer Institute, 1999; Idler et al., 2003) was utilized to provide a broad-based picture of spiritual

functioning among the veterans at a baseline assessment during the first week of the program and discharge. The BMMRS was developed by the Fetzer Institute and National Institute on Aging for assessing several crucial dimensions of spirituality in behavioral health research with religiously heterogeneous groups. We used a 6-item version of Underwood and Teresi’s (2002) Daily Spiritual Experiences Scale for assessing ordi- nary, day-to-day experiences of spirituality. Forgiveness was measured with three questions pertaining to self-forgiveness, interpersonal forgiveness, and forgiveness from God (Mauger et al., 1992). Private spiritual practices were assessed with items assessing engagement in prayer and meditation. We also incorporated scales for assessing positive and negative forms of religious coping (Pargament et al., 1998, 2000). Organizational religiousness was measured with items assessing involvement in a church or other formal religious groups (e.g., Strawbridge, Cohen, Shema, & Kaplan, 1997). Responses were coded such that higher scores indicated higher levels for each spirituality factor. Internal consistencies of BMMRS subscales ranged from .58 to .92 at intake and .70 to .92 at discharge.

Veterans also completed the PCL-M (Blanchard, Jones- Alexander, Buckley, & Forneris, 1996; Weathers & Ford, 1996) for capturing the severity of PTSD symptomatology associ- ated with their warzone experiences at baseline and discharge. The PCL-M is a self-report instrument assessing distress for each of the 17 symptoms of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychiatric Association, 1994) over the past month, including reexperiencing (five items), avoidance (seven items), and hyperarousal (five items). Veterans rated items on a 5-point scale, with anchor points of 1 = not at all to 5 = extremely, such that higher scores indicated more symptoms. Internal consisten- cies for the PCL-M were .90 and .94 at baseline and discharge, respectively.

Keane et al.’s (1989) Combat Experiences Scale (CES) was also incorporated at the baseline assessment to gauge veter- ans’ exposure to combat-related activities/circumstances (e.g., taking incoming fire, firing weapon, perceived threat of in- jury/death). The CES is another well-established measure that includes seven items scored on a 5-point scale, with anchor points from 1 = never to 5 = 51+ times, such that higher scores indicate greater exposure to stressors.

Data Analysis

The major focus of this study was on the predictive relation- ships among veterans’ PTSD symptomatology and spiritual functioning. As such, we implemented two-wave, cross-lagged panel analyses, in which PTSD and spirituality were assessed at baseline and discharge. Six separate analyses were performed, one for each of the spirituality variables of interest. Each of these analyses included (a) two synchronous effects (i.e., cross-sectional associations between PTSD and spirituality variables at baseline and discharge), (b) two autoregressive effects (i.e., PTSD at baseline predicting PTSD at discharge and

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

60 Currier, Holland, and Drescher

spirituality variables at baseline predicting spirituality variables at discharge), and (c) two cross-lagged effects (i.e., PTSD at baseline predicting a spirituality variable at discharge and a spirituality variable at baseline predicting PTSD at discharge). Combat exposure was also included as a variable in all of these analyses. Change scores were computed by subtracting the score at intake from the veterans’ discharge assessments.

We were primarily interested in the statistical significance of the cross-lagged effects and the extent to which the two cross-lagged effects were different from one another. A sig- nificant cross-lagged effect in the model would indicate that even after accounting for synchronous and autoregressive ef- fects, one variable at baseline could uniquely predict the other at discharge. In addition, equality of the two cross-lagged ef- fects was assessed using a Wald test. A significant Wald test indicated that the two cross-lagged effects in a model were significantly different from one another, such that we could offer statements about whether PTSD or spirituality variables displayed significantly stronger effects.

In evaluating the overall fit of the models, we relied upon a variety of fit indices, including the χ2 goodness-of-fit test, comparative fit index (CFI; Bentler, 1990), Tucker-Lewis in- dex (TLI; Tucker, 1973), and the root mean square error of approximation (RMSEA; Browne & Cudeck, 1993). CFI and TLI values > .90 are generally regarded as favorable (Hu & Bentler, 1999). Likewise, RMSEA values � .05 are considered close approximate fit, values between .05 and .08 suggest rea- sonable fit, and values � .10 are indicative of poor model fit (Browne & Cudeck, 1993). Parameters were estimated using a maximum likelihood robust (MLR) procedure, given evidence of nonnormality for the spirituality variables and PTSD at both baseline and discharge. Missing data were handled using multi- ple imputation; however, analyses were also repeated using the more conservative listwise deletion to ensure that this method of handling missing data did not substantially bias the results. All analyses were performed in MPlus, version 6.11 (Muthén & Muthén, 1998–2010).

Results

Bivariate correlations between spirituality and PTSD outcomes were calculated to provide an initial picture of the data (see Table 1). Spirituality factors were concurrently linked with posttraumatic symptomatology at the two assessments in antic- ipated directions. Veterans’ baseline levels of spirituality were also linked with PTSD symptomatology following treatment, but baseline PTSD was conversely not associated with spiritu- ality at discharge. In examining associations between changes in spirituality and PTSD, there was also evidence that improved spirituality (i.e., increases in adaptive dimensions, reduced neg- ative religious coping) co-occurred with an alleviation of vet- erans’ PTSD symptomatology.

All six cross-lagged models provided reasonable to good fit to the data (see Table 2). Furthermore, a similar pattern of

Table 1 Bivariate Correlations Between Spirituality Variables and PTSD Symptom Severity

PTSD

Variable B D C

Daily spiritual experiences B −.13** −.18** −.11 D −.04 −.31*** −.30*** C .08 −.23*** −.32***

Forgiveness B −.22*** −.25*** −.11* D −.08 −.44*** −.42*** C .11 −.23*** −.35***

Private practices B −.08* −.20** −.14* D −.03 −.24*** −.23*** C .08 −.11 −.19**

Positive religious coping B −.10* −.18** −.11* D −.01 −.24*** −.25*** C .14* −.10 −.22***

Negative religious coping B .13** .13* .09 D .11 .35*** .29***

C .04 .21** .20**

Organizational religiousness B −.14** −.19** −.08 D −.03 −.24*** −.24*** C .16** −.07 −.21***

Note. N = 532. PTSD = posttraumatic stress disorder; B = baseline; D = discharge; C = change score. Lower change scores in PTSD symptoms represent better treatment outcomes. Higher change scores indicate improvement in the spirituality dimensions with the exception of negative religious coping. *p < .05. **p < .01. ***p < .001.

results emerged for each of the spirituality factors. Though not a primary focus of this study, all autoregressive effects across the six analyses were statistically significant for PTSD symptomatology (βs = .46 to .48, all ps < .001) and spirituality domains assessed in this study (βs = .45 to .83, all ps < .001). Likewise, all of the synchronous effects were in the expected direction and all but one (spiritual practices and PTSD at baseline) were statistically significant, with effects somewhat smaller at baseline (|βs| = .08 to .22; ps = .060 to < .001) than at discharge (|βs| = .24 to .44, all ps < .001).

With regard to the cross-lagged effects, in all six of the tested models the spirituality factors at baseline uniquely and sig- nificantly predicted PTSD symptom severity at discharge in the theorized directions (see Table 2). Specifically, adaptive dimensions of spirituality (i.e., daily spiritual experiences, for- giveness, positive religious coping, spiritual practices, organi- zational religiousness) at baseline were inversely linked with

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Spirituality and PTSD Treatment 61

Table 2 Summary of Two-Wave, Cross-Lagged Panel Analyses for Spirituality and PTSD Symptoms

β B-PTSD: β B-SP: Variable χ2 RMSEA CFI TLI D-SP D-PTSD Wald test

Daily spiritual experiences 4.32 .05 1.00 .99 .03 −.10* 5.60* Forgiveness 4.89 .05 .99 .98 .01 −.16** 9.54** Private practices 8.04* .08 .99 .97 .02 −.16*** 17.42*** Positive religious coping 4.89 .05 1.00 .98 .08 −.13* 5.45* Negative religious coping 7.68* .07 .98 .94 .07 .11** 6.27**

Organizational religiousness 4.79 .05 .99 .98 .05 −.14** 7.51**

Note. N = 532. RMSEA = root mean square error of approximation; CFI = comparative fit index; TLI = Tucker-Lewis index; PTSD = posttraumatic stress disorder; B = baseline; D = discharge; SP = spirituality. *p < .05. **p < .01. ***p < .001.

PTSD at the discharge assessment, whereas negative religious coping at intake was associated with worse symptomatology at discharge. In contrast, PTSD at baseline did not predict any of the spirituality variables at discharge across the analyses. Figure 1 presents a pictorial representation of the two-wave, cross-lagged panel analysis when daily spiritual experience was examined as the variable of interest.

Statistically significant Wald tests across all analyses re- vealed that the cross-lagged effects for the spirituality factors at baseline predicting PTSD at discharge were significantly larger than the cross-lagged effects for PTSD at baseline predicting the spirituality variables at discharge (see Table 2). Stated differ- ently, these analyses consistently pointed to spirituality factors at the start of treatment as important and unique predictors of PTSD outcomes at the time of discharge. PTSD at baseline, however, did not appear to similarly function as a unique pre- dictor of spirituality at discharge.

Analyses were repeated using listwise deletion, and a highly similar pattern of results was found. When list- wise deletion was used, however, in three instances cross- lagged effects that had been statistically significant failed to achieve statistical significance, including daily spiritual expe- riences (p = .065), positive religious coping (p = .057), and

organizational religiousness (p = .058) at baseline predicting PTSD at discharge.

Analyses were also repeated adjusting for age, race/ethnicity, and gender. The overall fit of the models decreased in these analyses largely because these demographic variables were rel- atively weak predictors of PTSD and the spirituality variables. Even in the presence of these additional variables, however, all of the spirituality factors still predicted PTSD symptomatol- ogy at discharge. In addition, all of the Wald tests were still statistically significant, indicating that the cross-lagged effects for spirituality factors at baseline predicting PTSD symptom severity at discharge were larger than cross-lagged effects for PTSD at baseline predicting spirituality factors at discharge. Thus, it does not appear that the pattern of results observed in this study can be explained by demographic confounds.

Discussion

Different dimensions of spirituality have been associated with adaptive and maladaptive responses to trauma among military veterans (e.g., Currier, Drescher et al., 2014; Fontana & Rosen- heck, 2004; Ogden et al., 2011; Witvliet et al., 2004). Bivariate

Daily spiritual experiences at

discharge

Daily spiritual experiences at

baseline

PTSD at discharge

PTSD at baseline

-.10*

.03

-.13** -.38***

.46***

.76***

Figure 1. Cross-lagged results for daily spiritual experiences. Note. N = 532. This model depicts partial correlations and partial standardized regression coefficients between daily spiritual experience and posttraumatic stress disorder (PTSD) symptom severity at baseline and discharge. Although not shown in this model, severity of combat exposure was included in the model. *p < .05. **p < .01. ***p < .001.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

62 Currier, Holland, and Drescher

results again revealed that spirituality variables were concur- rently associated with veterans’ PTSD symptom severity (at baseline and discharge assessments). In addition, improvements in spiritual functioning (i.e., higher adaptive aspects, less neg- ative religious coping) were linked with reductions of PTSD symptomatology during this program. Drawing on a cross- lagged panel design, the purpose of this study was to disen- tangle the temporal associations between veterans’ spirituality and PTSD outcomes.

Consistent with a spiritually integrative model, results of this analysis suggest that spirituality factors at baseline were uniquely predictive of later PTSD symptom severity, after ac- counting for combat exposure and both synchronous (cross- sectional) and autoregressive (stability in same construct over time) associations. In keeping with a traditional psychological model, baseline levels of PTSD symptomatology also emerged as a salient predictor of treatment outcomes. Baseline PTSD symptom severity, however, did not predict veterans’ spiritual- ity at discharge. These findings support a spiritually integrative approach to treating combat-related PTSD. In particular, these results suggest that understanding the possible spiritual con- text of veterans’ trauma-related concerns might add prognostic value and equip clinicans to alleviate PTSD symptomatology among those who possess spiritual resources or are somehow struggling in this domain.

In keeping with a multidimensional understanding of spiri- tuality, the pattern of cross-lagged associations varied between adaptive and maladaptive dimensions. Several dimensions were predictive of positive outcomes; namely, veterans who endorsed more daily spiritual experiences, practiced prayer or meditation in a more regular manner, endorsed greater levels of forgive- ness (for self, others, and from God or Higher Power), incor- porated positive religious coping strategies (e.g., collaborating with God or Higher Power to solve problems, look to divine realm for strength), or were engaged in a church or other com- munity all showed lower levels of PTSD symptomatology at discharge. Although the mechanisms of these relations are un- clear, it appears that pre-existing spiritual beliefs/behaviors of a healthy nature provided resources for many veterans’ recovery in such a manner that enhanced the benefits of PTSD treatment procedures/activities in many cases.

An opposite pattern emerged for negative religious coping in the sample. In contrast to the other spirituality dimensions assessed in this study, this subscale gauged the degree to which veterans were struggling with their spirituality. Results for these items indicate that veterans who began the program feeling that they were abandoned by God or a Higher Power, punished for perceived acts of wrongdoing or spiritual weakness, and attempting to disengage from God or a Higher Power fared worse in the program. Given the role of spiritual traditions in shaping many people’s meaning systems (Park, 2013), negative religious coping would tend to occur when veterans experi- enced a weakening in spiritual beliefs/values and could not reconcile the reality of their traumas with their global meaning system. Researchers have also suggested that these maladaptive

ways of drawing upon spirituality in the coping process could be a warning sign for moral injury, which is characterized by a pervasive constellation of inappropriate guilt, shame, anger, self-recrimination and self-handicapping behaviors and alien- ation that emerges after witnessing or participating in warzone events that challenge one’s basic sense of humanity (e.g., Litz et al., 2009; Maguen & Litz, 2012; Worthington & Langberg, 2012).

From a clinical standpoint, there are several options for ad- dressing spiritual concerns in treating combat-related PTSD. First, mental health clinicians might assume a multidisciplinary approach and seek support from chaplains or other ministry professionals in their work. A large survey of VHA chaplains suggests that they continue to play important roles in caring for the multi-faceted needs of veterans (Nieuwsma et al., 2013). In such cases, clinicians might work in tandem with these pro- fessionals to address the varying psychological and spiritual aspects of PTSD recovery. A second option would be to refer the veteran for an adjunctive intervention that explicitly aims to enhance spiritual functioning. Outcome trials of a meditation- based mantram (sacred word) intervention (Bormann, Thorp, Wetherell, Golshan, & Lang, 2012) and Building Spiritual Strength (Harris et al., 2011), a multicomponent, group-based program, each yielded encouraging results for reducing PTSD symptomatology. Although more research is needed on these complementary strategies, they may represent viable options for addressing spiritual concerns alongside best practice psy- chologically oriented approaches for alleviating combat-related PTSD (e.g., prolonged exposure [PE]; Eftikhari et al., 2013).

A final integrative option is for clinicians to develop compe- tencies for directly addressing spiritual concerns in the context of evidence-based interventions for PTSD. For example, when implementing PE with spiritually oriented veterans, in vivo exercises could be developed with an appreciation for spiri- tual beliefs/values and goals (e.g., attending a religious ser- vice or other social gathering). In cases of spiritual struggle, clinicians could explore spiritually oriented appraisals or mal- adaptive cognitions about God or a Higher Power when work- ing through imaginal exposures. Clinicians are rarely prepared, however, to address spiritual concerns in this more advanced manner (Shafranske & Cummings, 2013). Similar to addressing multicultural concerns in general, working from a spiritually integrative perspective requires training (for proposed list of competencies, see Vieten et al., 2013). Developing proficiency along these lines is therefore necessary to equip clinicians for knowing when and how to address spiritual concerns, refrain from intervening in a harmful manner when veterans are strug- gling with their spirituality, and harness veterans’ inner and outer resources in the spiritual domain that might enhance the efficacy of the PTSD treatment (Vieten et al., 2013).

Several limitations should be highlighted when considering this study’s implications. Given the period of data collec- tion, the sample predominantly consisted of male veterans from the Vietnam era, such that results might not apply to Iraq/Afghanistan veterans and changing demographics in the

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Spirituality and PTSD Treatment 63

military. We also exclusively focused on one PTSD residential treatment program in the VHA, and these results may not apply to nonclinical populations or veterans who pursue PTSD treatment in other contexts. Similarly, these results might not apply to veterans in other countries where varying cultural norms/traditions might lead to other attitudes/approaches to spirituality. Finally, we lacked detailed information on how spirituality was actually addressed for veterans in the sample and could not test the relations between specific treatment procedures/activities and changes in spirituality and PTSD symptomatology. Notwithstanding these key limitations, this study supports the utility of a spiritually integrative perspective on combat-related PTSD and represents the first attempt to demonstrate that domains of spirituality have important prog- nostic value for persons seeking treatment for this condition.

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