Preventing dropout in spiritually integrated psychotherapies: What are the effective methods of attending to clients' spirituality?

The purpose of this study was to examine associations between clinicians' use of varying types of spiritual interventions in the first session of spiritually integrated psychotherapies (SIPs) and clients' likelihood of returning for a second session. In total, 154 practitioners of SIPs from 33 settings in a practice-research network reported on their implementation of different methods for addressing clients' religion/spirituality on an after-session summary checklist. Roughly 80% or more of the clinicians implemented at least one spiritual intervention in the first session; on average, clinicians used 3.26 (SD = 3.66) of the interventions on the checklist. Occurring with 20% or more of the 1,094 clients, the most commonly used spiritual interventions included listening to spiritual issues, discussing compassion and hope, affirming clients' divine worth and attempts to trust God. In total, nearly one in five clients did not return for a second session. Focusing on interventions that were empirically linked with clients' engagement in a second session in bivariate analyses, discussion of spiritual dimensions of clients' problems and solutions was associated with a 118% greater probability that clients engaged in SIPs; in contrast, discussion of hope was linked with a 40% decrease in treatment engagement. In conclusion, findings highlight the potential opportunities and risks for implementing interventions that attend to clients' spirituality and/or religious faith at the start of SIPs. Research is needed to understand factors associated with the effective use of spiritual interventions and methods of training clinicians accordingly. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Practice-based evidence for spiritually integrated psychotherapies: Examining trajectories of psychological and spiritual distress.

The aims of this practice-based evidence study were to (a) examine clients' trajectories of psychological and spiritual distress over the course of spiritually integrated psychotherapies (SIPs) and (b) explore the role of varying types of spiritual interventions in these outcomes. In total, 164 practitioners of SIPs from 37 settings in a practice-research network administered the Clinically Adaptive Multidimensional Outcome Survey (Sanders et al., 2018) at each session with 1,227 clients and reported their use of theoretical orientations and spiritual interventions on an after-session summary checklist. Focusing on sessions over an initial 12-week period, latent growth curve modeling analyses revealed that clients, on average, experienced significant reduction of psychological distress during their engagement in SIPs with improvements occurring most sharply in the first month. Further, other findings revealed a salient reciprocal interplay with spiritual distress throughout treatment, such that clients who were struggling with their religious faith and/or spirituality were more psychologically distressed and displayed a more attenuated and gradual pattern of symptom reduction. In such cases, clinicians frequently utilized spiritual interventions involving basic skills (e.g., spiritual assessment), virtues (e.g., discuss self-control), and religious attachment (e.g., encourage acceptance of divine love) that were uniquely associated with clients' rate and duration of decline in psychological and spiritual distress. The present findings affirm the routine effectiveness of SIPs along with highlighting the potential value of certain spiritual interventions in supporting holistic recovery among clients who want clinicians to be culturally responsive to their spiritual and/or religious identities. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Temporal associations between meaning in life, ultimate meaning struggles, and mental health outcomes in a spiritually integrated inpatient program.

BACKGROUND: Meaning in life is a benchmark indicator of flourishing that can likely mitigate the severity of depression symptoms among persons seeking mental healthcare. However, patients contending with serious mental health difficulties often experience a painful void or absence of ultimate meaning in their lives that might hinder recovery. This two-wave longitudinal study examined temporal associations between perceived presence of meaning in life, struggles with ultimate meaning, flourishing, and depression symptoms among adults in a spiritually integrated inpatient treatment program. METHODS: Of the 242 patients assessed at intake, 90% (N = 218; 40% Cisgender male; 57% Cisgender female; 3.0% nonbinary) completed validated measures of these meaning-related factors and mental health outcomes at discharge. RESULTS: Cross-sectional analyses revealed perceptions of meaning in life and ultimate meaning struggles were inversely linked with one another along with being associated with indices of positive and negative mental health in varying ways at the start and end of treatment. Drawing upon a two-wave cross-lagged panel design, longitudinal structural equation modeling analyses supported a Primary Meaning Model whereby having a subjective sense of meaning in life at intake was prospectively linked with lower levels of ultimate meaning struggles and greater flourishing at discharge. However, baseline levels of mental health outcomes were not predictive of the meaning-related factors in this sample. CONCLUSION: Findings highlight the utility of assessing patients' perceived meaning in life and ultimate meaning struggles in spiritually integrated programs and for clinicians to be prepared to possibly address these meaning-related concerns in the treatment process.

Civilian Moral Injury and Amygdala Functional Connectivity During Attention to Threat.

BACKGROUND: Moral injury references emotional and spiritual/existential suffering that may emerge following psychological trauma. Despite being linked to adverse mental health outcomes, little is known about the neurophysiological mechanisms of this phenomenon. In this study, we examined neural correlates of moral injury exposure and distress using the Moral Injury Exposure and Symptom Scale for Civilians. We also examined potential moderation of these effects by race (Black vs. White individuals) given the likely intersection of race-related stress with moral injury. METHODS: Forty-eight adults ages 18 to 65 years (mean age = 30.56, SD = 11.93) completed the Moral Injury Exposure and Symptom Scale for Civilians and an affective attentional control measure, the affective Stroop task (AS), during functional magnetic resonance imaging; the AS includes presentation of threat-relevant and neutral distractor stimuli. Voxelwise functional connectivity of the bilateral amygdala was examined in response to threat-relevant versus neutral AS distractor trials. RESULTS: Functional connectivity between the right amygdala and left postcentral gyrus/primary somatosensory cortex was positively correlated with the Moral Injury Exposure and Symptom Scale for Civilians exposure score (voxelwise p < .001, cluster false discovery rate-corrected p < .05) in response to threat versus neutral AS distractor trials. Follow-up analyses revealed significant effects of race; Black but not White participants demonstrated this significant pattern of amygdala-left somatosensory cortex connectivity. CONCLUSIONS: Increased exposure to potentially morally injurious events may lead to emotion-somatosensory pathway disruptions during attention to threat-relevant stimuli. These effects may be most potent for individuals who have experienced multilayered exposure to morally injurious events, including racial trauma. Moral injury appears to have a distinct neurobiological signature that involves abnormalities in connectivity of emotion-somatosensory paths, which may be amplified by race-related stress.

Exploring the role of moral injury outcomes in intimate relationship functioning among U.S. combat veterans.

OBJECTIVE: Moral injury entails psychological, social, and possible spiritual issues that might interfere with veterans' functioning in romantic or intimate relationships. To date, research has not examined the contribution of moral injury outcomes in this core functional domain in many veterans' lives. METHOD: In total, 65 combat veterans who were engaging in a peer-led intervention for moral injury in a Veteran Service Organization completed the Expressions of Moral Injury Scale, posttraumatic stress disorder (PTSD) checklist for DSM-5, and the romantic relationship subscale of the Inventory of Psychosocial Functioning Scale. RESULTS: Bivariate analyses revealed that moral injury and PTSD symptoms were each associated with worse relationship functioning among the veterans. When including moral injury and PTSD symptoms as predictors in a multivariate analysis, only moral injury was uniquely linked with poorer relationship functioning. CONCLUSIONS: Overall, these findings suggest that moral injury could play a pernicious role in many veterans' issues in relationship problems with their spouses or partners. Future research needs to examine the potential utility of addressing moral injury among veterans who are struggling to meet demands for intimacy and connection in their intimate or romantic relationships. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Civilian moral injury: associations with trauma type and high-frequency heart rate variability in two trauma-exposed community-based samples.

BACKGROUND: Moral injury exposure (MIE) and distress (MID) may indirectly affect the relationship between trauma exposure and alterations in autonomic regulation [assessed via high-frequency heart rate variability (hfHRV)] in civilians, but this has not been tested in prior research. We conducted two exploratory studies to examine trauma types' associations with MIE and MID among civilian medical patients (Study 1) and explore how these facets may indirectly affect the relationship between trauma type and hfHRV among civilians seeking mental health services (Study 2). METHODS: Participants recruited from a public hospital and/or community advertisements (Study 1, n = 72, 87.5% Black, 83.3% women; Study 2, n = 46, 71.7% Black, 97.8% women) completed measures assessing trauma type, MIE, and MID. In Study 1, trauma types that emerged as significant correlates of MIE and MID were entered into separate linear regression analyses. Trauma types identified were included as predictors in indirect effects models with MIE or MID as the mediator and resting hfHRV (assayed via electrocardiography) as the outcome. RESULTS: Childhood sexual abuse emerged as the only significant predictor of MIE, b = 0.38, p < 0.001; childhood sexual abuse, b = 0.26, p < 0.05, and adulthood sexual assault, b = 0.23, p < 0.05 were significant predictors of MID. Participants with greater MIE and MID demonstrated lower hfHRV. Adulthood sexual assault showed an indirect effect on hfHRV through MID, B = -0.10, s.e. = 0.06, 95%CI (-0.232 to -0.005). CONCLUSIONS: Moral injury was uniquely associated with sexual violence and lower hfHRV in civilians. Data highlight moral injury as a pathway through which autonomic dysregulation may emerge and its salience for trauma treatment selection.

Moral injury appraisals and dissociation: Associations in a sample of trauma-exposed community members.

Appraisal of trauma is a critical factor in the development of impairing post-traumatic stress symptoms, such as dissociation. Individuals may appraise trauma as morally injurious (i.e., moral injury exposure [MIE]) and experience subsequent moral distress related to this exposure (i.e., moral injury distress [MID]). To date, however, investigation into the relations between moral injury appraisals and dissociation has been limited, particularly within community populations. This study investigated MIE and MID in relation to six facets of dissociation (disengagement, depersonalization, derealization, memory disturbances, emotional constriction, identity dissociation) in a sample of trauma-exposed community members (n = 177, 58.2% Black, 89.3% female) recruited from a public hospital and/or community advertisements. Participants completed measures assessing trauma exposure, MIE, MID, dissociation, and posttraumatic stress disorder (PTSD) symptoms. Partial correlation analyses revealed that after controlling for PTSD symptoms, MIE was correlated with disengagement, r = .23, p ≤ .025, and depersonalization, r = .25, p ≤ .001, and MID was correlated with depersonalization, r = .19, p ≤ .025. Sex moderated each association, with stronger associations observed for female participants. Findings suggest that moral injury appraisals are linked to more severe dissociative symptoms among female civilians, and as such, may need to be specifically targeted in empirically supported treatments.

Examining the outcomes and acceptability of a peer-led spiritual intervention for moral injury in a veteran service organization.

The purpose of this proof-of-concept study was to examine the outcomes and acceptability of a spiritual intervention for moral injury led by veteran peers in a Veteran Service Organization (VSO), called "Heroes to Heroes." From baseline to 1-year follow-up, 101 veterans who participated in the intervention completed the evaluation surveys at four time points assessing psychological outcomes (moral injury, posttraumatic stress disorder [PTSD] symptoms, and life satisfaction), spiritual outcomes (spiritual struggles and spiritual transcendence), and their perceived helpfulness of the program. In addition, we conducted four focus groups with six to eight alumni to more fully understand veterans' views and experiences of the program. Focusing on the longitudinal surveys, latent growth modeling analyses revealed veterans generally improved across the psychological and spiritual outcomes in the study. Specifically, veterans reported steady decreases in moral injury outcomes, PTSD symptoms, and spiritual struggles along with increased life satisfaction and spiritual transcendence over the 1-year period. An inductive content analysis of veterans' responses to open-ended items in the surveys and focus group interviews revealed four possible mechanisms or facilitators of these outcomes: (a) social connectivity and belonging (e.g., shared vulnerability and camaraderie); (b) behavioral engagement in core aspects of their spirituality (e.g., sacred practices and visiting sacred places); (c) spiritual transformation and growth (e.g., closeness with God and divine forgiveness); and (d) appreciation for diversity (e.g., religious and military). Overall, these findings affirm the potential effectiveness and acceptability of the VSO's peer-led spiritual intervention for promoting the holistic healing among veterans who are contending with emotional and spiritual wounds of war. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Enhancing competencies for the ethical integration of religion and spirituality in psychological services.

Advancement of Spiritual and religious competencies aligns with increasing attention to the pivotal role of multiculturalism and intersectionality, as well as shifts in organizational values and strategies, that shape the delivery of psychological services (e.g., evidence-based practice). A growing evidence base also attests to ethical integration of peoples' religious faith and/or spirituality (R/S) in their mental care as enhancing the utilization and efficacy of psychological services. When considering the essential attitudes, knowledge, and skills for addressing religious and spiritual aspects of clients' lives, lack of R/S competencies among psychologists and other mental health professionals impedes ethical and effective practice. The purpose of this article is to discuss the following: (a) skills for negotiating ethical challenges with spiritually integrated care; and (b) strategies for assessing a client's R/S. We also describe systemic barriers to ethical integration of R/S in mental health professions and briefly introduce our Spiritual and Religious Competencies project. Looking ahead, a strategic, interdisciplinary, and comprehensive approach is needed to transform the practice of mental health care in a manner that more fully aligns with the values, principles, and expectations across our disciplines' professional ethical codes and accreditation standards. We propose that explicit training across mental health professions is necessary to more fully honor R/S diversity and the importance of this layer of identity and intersectionality in many peoples' lives. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Moral injury and chronic pain among military veterans in an integrated behavioral health clinic.

OBJECTIVE: Military service may place veterans at increased risk for perpetrating, witnessing, or failing to prevent events that violate deeply held moral values. In some cases, veterans may develop moral injury (MI) symptoms that transcend and/or overlap with mental health conditions such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Further, PTSD and MDD are 2 established risk factors for chronic pain. However, research has not examined the association between MI symptoms and chronic pain. METHOD: We tested whether MI would emerge as a salient correlate of concurrent reports of chronic pain in the presence of PTSD and MDD symptom severity among 59 veterans seeking integrated behavioral health care. RESULTS: Findings indicated the severity of MI symptoms was significantly linked with veterans' concurrent reports of chronic pain. Self-directed MI symptoms emerged as a correlate of worse pain in the presence of PTSD and MDD. CONCLUSIONS: Preliminary findings demonstrate possible associations between MI and chronic pain among veterans with a need for holistic health care. Future research should examine mechanisms for an apparent MI-chronic pain link. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Perceptions of Divine Forgiveness, Religious Comfort, and Depression in Psychiatric Inpatients: A Mixed Methods Study.

Understanding how forgiveness relates to mental health outcomes may improve clinical care. This study assessed 248 adult psychiatric inpatients, testing associations of forgiveness, religious comfort (RC), religious strain (RS), and changes in depressive symptomatology from admission to discharge. Experiencing divine forgiveness and self-forgiveness was both directly associated with RC and inversely associated with RS. Using structural equation modeling, the path from divine forgiveness to depression through RC was significant, ß = - .106, SE = .046, z = - 2.290, p = .022, bootstrapped 95% CI = - .196 to - .015. Qualitative findings illustrated patients' changed perspectives on divine forgiveness during hospitalization.

Understanding religious attachment among christians seeking spiritually integrated psychotherapies: A mixed methods study.

OBJECTIVE: This mixed methods study aimed to understand ways of viewing and experiencing religious attachment among Christians in spiritually integrated psychotherapies. METHOD: In total, 190 Christian-affiliated clients completed narrative responses about religious and parental attachment along with validated measures of spiritual and psychological functioning toward the start of treatment. RESULTS: An inductive content analysis revealed ten ways in which clients were viewing and experiencing God. Although painful themes were expressed, clients more frequently discussed comforting themes related to religious attachment. Additional analyses demonstrated convergence with parental attachment and quantitative measures of spirituality and mental health. CONCLUSION: Religious attachment appears to primarily provide a sense of strength and comfort for Christians seeking care. Findings also indicate clients view and experience God in similar ways as their parents or caregivers. As such, assessing and affirming clients' faith may facilitate positive changes in how they view and experience themselves and others in treatment.

Moral injury in civilians: associations with trauma exposure, PTSD, and suicide behavior.

Background: Moral injury (MI) describes emotional, spiritual, and social suffering that can arise following psychological trauma. Prior research in military pop ulations indicates the relevance of MI to adverse psychological outcomes, such as post-traumatic stress disorder (PTSD) and suicidal behaviours, and shows evidence for MI as a unique construct. Minimal studies of MI have been implemented in civilians, usually restricted to small samples with a specific set of traumatic experiences, despite the conceptual relevance of MI to non-military trauma reactions more broadly (e.g. feelings of betrayal towards a perpetrator of sexual abuse). Objective: To address this problem, we assessed MI in trauma-exposed civilians to examine ways in which this construct was related to and distinct from trauma and traumatic stress-related problems, including PTSD and depression. Method: We adapted an existing MI scale, Moral Injury Events Scale (MIES) and administered this measure to 81 men and women along with measures of trauma exposure, PTSD and depression, and also asked participants about past suicide attempts. Results: We observed that both greater exposure and distress related to potentially morally injurious events were associated with higher trauma exposure, particularly childhood maltreatment, as well as post-traumatic and depressive psychopathology. However, even after accounting for current PTSD and depression symptoms, MI exposure (F = 6.05, p = .017) was significantly higher among participants who had previously attempted suicide. Conclusions: These pilot data reveal the ways in which MI is associated with trauma exposure, PTSD and depression and highlight the salience of MI in civilians. Similarly, these data demonstrate the unique relevance of MI to suicide behaviours, independent of post-traumatic psychopathology, indicating that this construct may be an understudied contributor to suicide risk in civilians.

Antecedentes: El daño moral (DM) describe el sufrimiento emocional, espiritual y social que puede surgir después de un trauma psicológico. Investigaciones previas en poblaciones militares indican la relevancia del DM para los desenlaces psicológicos adversos, como trastorno de estrés postraumático (TEPT) y las conductas suicidas, y muestran evidencia de que el DM es un constructo único. Se han implementado mínimos estudios de DM en civiles, usualmente restringidos a pequeñas muestras con un conjunto específico de experiencias traumáticas, a pesar de la relevancia conceptual de DM para las reacciones de trauma no militares más amplias (p.Ej., Sentimientos de traición hacia un perpetrador de abuso sexual).Objetivo: Para abordar este problema, evaluamos el DM en civiles expuestos a trauma para examinar las formas en que este constructo se relacionaba y se diferenciaba de los problemas relacionados con el trauma y el estrés traumático, incluidos el trastorno de estrés postraumático y la depresión.Método: Adaptamos una escala de DM existente, la Escala de eventos de daños morales y administramos esta medida a 81 hombres y mujeres junto con medidas de exposición al trauma, TEPT y depresión, y también preguntamos a los participantes sobre intentos suicidas pasados.Resultados: Observamos que tanto una exposición mayor como la angustia relacionada con eventos de potencial daño moral se asociaron con mayor exposición a trauma, particularmente al maltrato infantil, así como a psicopatología postraumática y depresiva. Sin embargo, incluso después de tener en cuenta los síntomasde TEPT actuales y depresión, la exposición a DM (F = 6.05, p = .017) fue significativamente mayor entre los participantes que habían intentado suicidio previamente.Conclusiones: Estos datos piloto revelan las formas en que el DM se asocia con la exposición al trauma, TEPT y depresión y resaltan la importancia del DM en la población civil. De manera similar, estos datos demuestran la relevancia única del DM para los comportamientos suicidas, independientemente de la psicopatología postraumática, lo que indica que este constructo puede ser un contribuyente subestudiado del riesgo de suicidio en la población civil.

Own soul's warning: Moral injury, suicidal ideation, and meaning in life.

OBJECTIVE: Moral injury (an inner conflict [or cognitive dissonance] used to describe psychological, ethical, and/or spiritual conflict experienced when an individual's basic sense of humanity is violated) has been associated with suicidal ideation among military populations. However, mechanisms linking moral injury to suicidal ideation, particularly variables that may protect against suicidal ideation, have received limited attention. This study examined whether two domains of meaning in life (presence of meaning in life and searching for meaning in life) mediated the links between self- and other-directed moral injury and suicidal ideation. METHOD: Participants were a community sample of 269 predominantly recent-era former service members who completed an online, anonymous voluntary survey. RESULTS: When examined in separate models, self-directed moral injury and other-directed moral injury were found to associate with higher suicidal ideation via a lower presence of meaning in life (no significant associations with searching for meaning in life). When examined in an exploratory combined model (i.e., both self-directed and other-directed moral injury entered in the same model), only the association between self-directed moral injury and suicidal ideation via the presence of meaning in life remained statistically significant. CONCLUSIONS: Our findings suggest that the presence of meaning in life may serve as a protective factor for veterans experiencing moral injury (particularly self-directed moral injury) that is associated with suicidal ideation. It is possible that guiding veterans with moral injury symptoms to develop more meaning or purpose in their lives may reduce suicidal ideation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Gratitude and patience moderate meaning struggles and suicidal risk in a cross-sectional study of inpatients at a Christian psychiatric hospital.

OBJECTIVE: Suicidal behavior is a leading cause of injury and death, so research identifying protective factors is essential. Research suggests gratitude and life hardships patience are character strengths that might protect against the deleterious association of struggles with ultimate meaning and suicide risk. However, no studies have evaluated their utility among people experiencing acute/severe mental health concerns. METHOD: We tested the protective function of gratitude and life hardships patience with cross-sectional data from adults (Mage  = 31.83 years; SD = 14.84; range = 18-82) hospitalized in a Christian psychiatric inpatient facility (Mstay  = 6.37 days, SD = 4.64). RESULTS: Gratitude and life hardships patience moderated the positive relation between meaning struggles and suicide risk. Specifically, gratitude and life hardships patience protected against meaning struggles as a risk factor for suicide through mechanisms separate from ameliorating depressive symptoms. CONCLUSIONS: Findings provide initial support for gratitude and patience interventions as an adjunct to standard psychiatric treatment for minimizing suicide risk.

Moral injury and ICD-11 complex PTSD (CPTSD) symptoms among treatment-seeking veterans in the United Kingdom.

OBJECTIVE: Military veterans often encounter events with chronic or repeated traumas of an interpersonal nature that might lead to emotional, relational, and spiritual suffering. Research is needed to assess whether and/or how emerging conceptions of moral injury (MI) align with existing trauma-related conditions. METHOD: Focusing on 173 veterans from the United Kingdom who had recently pursued mental health treatment, we examined associations between self- and other-directed outcomes related to MI and the World Health Organization's International Classification System for Diseases, 11th version (ICD-11), criteria for posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) in two ways. RESULTS: First, drawing on validated tools for assessing MI and PTSD/CPTSD, analyses of variance revealed 57.2% of veterans in the sample who possibly met criteria for CPTSD reported greater MI related to perpetration- and betrayal-based events compared to those with and without possible PTSD. Second, latent profile analysis revealed two distinct classes based on symptom severity of MI and CPTSD. Specifically, when we examined the six symptom clusters for CPTSD dimensionally, four in five veterans endorsed high levels of distress related to all indicators of MI and CPTSD symptoms compared to a group with lower scores. CONCLUSIONS: Overall, the two sets of findings suggest the special relevance of MI among veterans who are struggling with CPTSD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Religiousness, meaning, and quality of life: Test of a mediational model among adults seeking a spiritually integrated inpatient program.

OBJECTIVE: Religious beliefs and practices may augment a sense of meaning in life that could support quality of life (QOL) in physical, social, and emotional domains amid mental health crises. However, these associations have not been thoroughly tested among persons with serious mental illness (SMI). METHODS: Focusing on 248 adults who had recently enrolled in a spiritually integrated acute psychiatric hospitalization program, we incorporated structural equation modeling to examine whether (1) religiousness would be associated with better overall QOL; and (2) inpatients' sense of meaning in life would at least partially account for the religiousness-QOL link. RESULTS: Religiousness was linked indirectly with QOL at the time of admission: religiousness was associated with greater meaning in life, and a higher degree of meaning in life was associated with QOL. CONCLUSIONS: Findings underscore the crucial role of religiousness for meaning and wellness among many individuals with SMI who seek stabilization and healing.

A practice-based evidence investigation of God representations in spiritually integrated psychotherapies.

OBJECTIVE: This practice-based evidence study examined trajectories of God representations and psychological distress among Christians participating in spiritually integrated psychotherapies (SIPs). METHODS: In total, 17 clinicians practicing SIPs in a mid-sized city on the US Gulf Coast implemented session-to-session assessments of these outcomes with 158 clients over a 4-month period and also reported their use of specific spiritual interventions after each session (e.g., affirmed client's divine worth). RESULTS: Multivariate growth modeling revealed clients' psychological distress decreased over the study period whereas authoritarian God representations increased and benevolent God representations remained stable. In addition, clients who increased in benevolent representations of God had a greater likelihood of experiencing alleviation of psychological distress. CONCLUSION: These findings affirm the potential efficacy of SIPs and cultural importance of belief in a benevolent deity as a source of strength, identity, and potential healing among Christians clients who prefer a spiritually integrated approach in psychotherapy.

Understanding Preferences for Addressing Spirituality Among Adults Seeking Outpatient Mental Health Care.

Focusing on 472 religiously heterogenous adult patients seeking psychotherapy at a university-based outpatient clinic, this brief report examined (1) these patients' preferences about clinicians appreciating their religion and/or spirituality (R/S) backgrounds (spiritually affirming) and addressing spiritual concerns in treatment (spiritually integrated) and (2) role of demographic factors and psychological functioning in predicting preferences for R/S integration. Analyses revealed that more than half of patients reported moderate or greater importance for spiritually affirming care and one-third hoped to address spiritual issues. Furthermore, these factors emerged as indicators of stronger preferences for R/S integration: female sex, racial minority status (African American, Native American), history of marriage (past and present), affiliation to organized religion (Christianity, Islam), and importance placed on R/S. In general, findings suggest that most patients seeking psychotherapy in a university-based clinic in southern Alabama might desire a spiritually affirming approach, and a smaller subset prefer an approach in which R/S is integrated into treatment.

Validation of the Expressions of Moral Injury Scale-Military version-Short Form.

Military personnel may encounter morally injurious events that lead to emotional, social, and spiritual suffering that transcend and/or overlap with mental health diagnoses (e.g., post-traumatic stress disorder [PTSD]). Advancement of scientific research and potential clinical innovation for moral injury (MI) requires a diversity of measurement approaches. Drawing on results from the bifactor model in Currier et al.'s (2017) psychometric evaluation of the Expressions of Moral Injury Scale-Military version (EMIS-M), this study validated a four-item short form of the instrument with two samples of veterans with a history of war-zone service. Namely, despite the reduced number of items, the EMIS-M-Short Form (SF) yielded favourable internal consistency and comparable levels of convergent validity with theoretically related constructs (e.g., PTSD and struggles with morality and ultimate meaning) as the full-length version. Notwithstanding the possible utility of distinguishing between self- and other-directed forms of MI, factor analytic results further revealed that the EMIS-M-SF was best conceptualized with a unidimensional factorial model that might allow for a general assessment of MI-related outcomes. Overall, these initial results suggest that the EMIS-M-SF may hold promise as a short, reliable, and valid assessment of overall outcomes related to a possible MI.