Spirituality has been acknowledged as an essential part of nursing practice for centuries. Nevertheless, there is debate about including spirituality in the daily work of mental healthcare professionals (Wilding, Muir-Cochrane, & May, 2006). Undoubtedly, the spiritual concerns of a special population, that of veterans, requires attention. Currently, millions of military personnel actively protect the United States. Numerous veterans who have a history of deployment voice challenges with spiritual beliefs. For many, it causes their first serious thoughts of spiritual apprehension. In others, the experience strengthens their belief system, whether spiritual or not. Fortunately, the Veterans Health Administration (VHA) is making strides to address the spiritual stressors veterans face from being in combat.
Currently, the VHA has acknowledged the necessity of making spiritual and pastoral care available to veterans. During all initial assessments, veterans are screened for the desire for spiritual and pastoral care and are connected to resources that meet the needs of their faith tradition. When indicated, veterans are referred to a clinical chaplain whose spiritual and pastoral care and counseling is characterized by: (a) an extensive assessment, evaluation, and treatment of veterans; (b) incorporation into the overall healthcare and treatment plan of the facility; and (c) sound interprofessional working relationships (We Honor Veterans, n.d.). The clinical chaplain uses a spiritual assessment tool to evaluate the veteran's desires, needs, hopes, spiritual needs, and resources for the purpose of planning care. Clinical chaplains are employed at each VHA medical center to establish programs which:
- Ensure every veteran's constitutional right to free exercise of religion.
- Provide opportunities for religious worship, sacramental ministry, pastoral care, and counseling.
- Protect all veterans from unwanted imposition of religious beliefs or activities (proselytization) from any source while in VHA facilities (We Honor Veterans, n.d., para. 1).
In addition, collaborative efforts with healthcare providers throughout the federal Department of Veterans Affairs (VA) are essential to ensure the provision of appropriate spiritual interventions specific to the needs and desires of the veterans.
VETERANS' MENTAL & SPIRITUAL HEALTH
In a one-year period, more than one million veterans with mental illness sought services through the VHA (Petrakis, Rosenheck, & Desai, 2011). Furthermore, approximately a fourth of veterans who have had tours in Iraq and Afghanistan suffer from mental illnesses (Seal, Bertenthal, Miner, Sen, & Marmar, 2007). Mental health practitioners—professionals such as nurses, nurse practitioners, physicians, and physician assistants who specialize in mental health—are the ideal providers to incorporate spirituality into mental healthcare, collaborate with clinical chaplains, and to aide veterans in integrating spiritual care into their lives.
Among veterans, religious behaviors are exhibited in various ways. Wansink and Wansink (2013) found that the intensity of prior combat had an impact on a veteran's spiritual behavior. Specifically, combat was linked to increased religious activity among those who professed their war experience was negative. In response to the trauma, many veterans have presented with signs and symptoms of moral injury, such as social and spiritual issues, loss of trust, a sense of betrayal, psychological symptoms, and self-deprecation (Drescher et al., 2011). An extensive study of veterans of World War II found that as combat became more frightening, prayer increased (Stouffer et al., 1949). Bogan, Just, and Wansink (2013) suggested that those who participated in heavy combat and viewed wartime experiences as negative attended church more often than veterans who had little or no participation in combat. Additionally, increases in existential spiritual well-being, such as repeating sacred words or phrases, proved to reduce the severity of posttraumatic stress disorder (PTSD) symptoms in veterans with traumatic experiences (Bormann, Liu, Thorp, & Lan, 2012). The opportunity for veterans to integrate spiritual experiences with interventions has shown to improve the ability to cope with the symptoms of PTSD, leading to recommendations to use patients' spiritual values during treatment (Sirati Nir, Ebadi, Fallahi Khoshknab, & Tavallae, 2013).
According to Bonner et al. (2013), a large number of veterans are open to seeking help for emotional issues from spiritual counselors, primary care providers, psychiatrists, and other mental health practitioners. Yet, in many instances, the impact of integrating spirituality into a comprehensive healthcare plan for veterans is overlooked. As a result, a veteran may not be afforded holistic care that balances his or her physical, environmental, mental, emotional, social, and spiritual concerns.
NEED FOR MENTAL HEALTH PRACTITIONERS
Considered the largest integrated healthcare system in the United States, the Veterans Administration (VA) has seen an increase in the number of veterans who are dealing with mental health issues (Department of Veterans Affairs, 2013). Scholars note that people who have mental illnesses receive relief from expressing their spirituality (Barber, 2013; Koenig, King, & Carson, 2012; Sulmasy, 2009). Numerous researchers have acknowledged the magnitude of spirituality in suicidal behavior (Colucci & Martin, 2008), as well as general mental health (Koenig, 2013). To summarize, spirituality provides life-sustaining meaning to many.
However, most veterans do not express a desire to meet with a chaplain during their initial assessment. Consequently, the majority of chaplain encounters with veterans are limited, occur by chance, and last only short periods. At-risk veterans in need of pastoral care are rarely first recognized by chaplains. Instead, clinical healthcare providers, such as nurses, usually make the initial identification of spiritual distress (Kopacz, 2013).
Evidence supports the utilization of mental health practitioners to help meet the spiritual needs of veterans. Hundreds of studies demonstrate a noteworthy positive association between religion and mental health (Bonelli & Koenig, 2013; Koenig et al., 2012). Studies have found that some patients with mental illness view spirituality as a significant part of healing (Koenig, 2013; O'Reilly, 2004; Wilding et al., 2006). In addition, spirituality influences positive coping abilities in those with mental illness (Wilding, May, & Muir-Cochrane, 2005). Because of findings that veterans with a desire to address spiritual needs actively seek the support of nurses (Koslander & Arvidsson, 2007), nurses with mental health expertise are ideal to help meet these requests.
INTEGRATING SPIRITUAL CARE
Several organizations recognize the significance of integrating spirituality into healthcare. The Joint Commission for accrediting healthcare organizations (1999) created a policy related to the need for hospital staff to provide pastoral care and other spiritual services in response to patient needs and requests. The American Nurses Association (ANA) Nursing'sSocial Policy Statement suggests that faith, religion, and spirituality are components of nursing practice (ANA, 2015). Other national nursing associations bring in spirituality as part of professional practice (i.e., Australian Nursing and Midwifery Council [ANMC], 2006). A national goal of Healthy People 2020 is to increase the percentage of people with disabilities who engage in spiritual activities to improve health (Healthypeople.gov, 2012). The incorporation of spiritual interventions by mental health practitioners is indispensable in enhancing the well-being of veterans.
Mental health practitioners are expected to establish a therapeutic relationship that empowers and respects patients' lifestyle choices (Stylianos & Kehyayan, 2012). The incorporation of spirituality in clinical work begins innately with the mental health practitioner's awareness of the patient's spiritual needs. Patients often express to mental health practitioners a need to find coherence in a tragedy, hope for the future, purpose and worth for living, as well as a reason to trust religious beliefs. As emotional expression is an opportunity for accessing and expressing one's spirituality (Taylor, 2007), mental health practitioners offer this avenue for patients. For that reason, mental health practitioners should review the veteran's spirituality history during psychiatric assessment.
The Faith, Importance and Influence, Community, and Address (FICA) Spiritual History Tool was designed for practitioners to efficiently integrate open-ended questions into any standard medical history (Borneman, Ferrell, & Puchalski, 2010; Puchalski & Romer, 2000). The tool can be used to assist mental health practitioners in determining if a veteran has spiritual unease or unresolved needs. The findings often create feelings of empathy by the mental health practitioner that are reflected in care. In addition, psychological coping may be problematic if the veteran is experiencing spiritual distress. Sufficiently addressing the veteran's spiritual concerns and needs can contribute to a quicker recovery and better prognosis. The prevention of suicide and the enhancement of psychological well-being provide mental health workers with convincing reasons to routinely implement spiritual care. A spiritual assessment also helps the mental health practitioner identify veterans whose spiritual distress warrants immediate referral to the clinical chaplain. For mental health practitioners and patients who believe that people can receive enlightenment and inspiration from God, a spiritual assessment may go beyond conceptualizing information collected in an intake evaluation (Richard, 2009); it is a means to obtain spiritual notions and insights about the veteran to bring God into his or her treatment and offer better care for him or her. For example, many veterans report trusting in this Scripture for protection during deployment: “Put on the full armor of God so that you can take your stand against the devil's schemes” (Ephesians 6:11, NIV).
A qualitative inquiry was conducted to explore the experiences of mental health practitioners caring for veterans. Interviews were conducted with providers and a clinical chaplain who had experience helping veterans with spiritual issues. Sidebars 1 and 2 offer case studies of how the inclusion of spiritual care interventions led to positive outcomes for two veterans.
OUT OF THE TRENCHES
All healthcare providers need to sensitively assess patients, encourage open communication, listen, and facilitate opportunities for patients to express emotions. Many veterans who enter facilities for psychological treatment exhibit spiritual distress. Because mental health practitioners are the primary contact for veterans being admitted for psychological issues, these clinicians are in prime positions to address spiritual needs. To provide meaningful and supportive care, it is essential to understand key concepts underpinning spiritual health, such as life purpose and meaning, forgiveness, relatedness, love and belonging, and hope (O'Brien, 2013; Taylor, 2007). Although mental health practitioners possess many of the skills needed to care for veterans spiritually, special training can enhance these abilities. Furthermore, mental health practitioners are essential to linking veterans in need of intensive spiritual care to chaplains. Considering that mental health practitioners are prepared to be empathetic and sensitive caregivers regardless of personal preference, they are model clinicians to address the spiritual care of veterans.
Through Scripture, God provides assurance of forgiveness, hope, love, and contentedness, all emotions expressed in our spirituality. Through spiritual care, mental health practitioners have the opportunity to remind veterans of the omnipotent God, who is the protector and rescuer. During the battle, God is always with us as he stated, “Have I not commanded you? Be strong and courageous. Do not be afraid, do not be discouraged, for the LORD your God will be with you wherever you go” (Joshua 1:9, NIV). God wants to be our liberator, whether we are in or out of the trenches. And he wants to use healthcare providers to spiritually assist those caught in the trenches to rediscover meaning and purpose in life.
Lieutenant Colonel (Lt. Col.) S., a 49-year-old female, visited a mental health practitioner in an outpatient clinic. Approximately six months ago, she returned from a deployment in the Middle East. She stated, “I just started feeling terrible. It feels like a heavy black cloud has settled around me, and I can't see through it. All I see is blackness. It feels like a lead weight is on my shoulder.” As the psychiatric evaluation continued, Lt. Col. S. stated, “My deployment was awful. I saw so many awful and upsetting things that I can't get out of my mind.” She had been given some time off but relayed that “things just worsened,” and she had feelings of loneliness and hopelessness. She stated, “I just stayed in bed and cried. I even thought about killing myself.” Things she used to enjoy seemed “stupid and pointless.” The mental health practitioner initiated a spiritual assessment, using the FICA tool. Lt. Col. S. reported that at one point she was spiritual, but now she has doubts about the existence of God. She said before she went to war, faith was influential in her life. When asked, “How would you like me, your healthcare provider, to address these issues in your care?” she replied, “Please pray with me.” The mental health practitioner engaged in this spiritual intervention with Lt. Col. S. In addition, Lt. Col. S. was started on an antidepressant.
A month later, Lt. Col. S. returned for a follow-up appointment. She reported an improved appetite and increased involvement in enjoyable activities. Reflecting on the time when she felt hopeless, Lt. Col. S. reported that her favorite Scripture was, “May the God of hope fill you with all joy and peace as you trust in him, so that you may overflow with hope by the power of the Holy Spirit” (Romans 15:13, NIV). Related to her past spirituality and as a part of continued treatment, the mental health practitioner incorporated Scripture into every visit. Eventually, Lt. Col. S. recovered and continued proudly serving her country.
Sergeant (Sgt.) W., a 28-year-old male, was brought to the emergency department by the police, after presenting with disruptive behavior in a homeless shelter. He was admitted to an inpatient mental health facility under the state's mental health involuntary commitment law, his third admission within the past year. During the initial psychiatric evaluation, he stated, “I am God of the world.” He expressed a belief that he possessed supernatural powers to heal himself and others. His speech was pressured, loud, rapid, and difficult to interrupt. He was prescribed an antipsychotic and a mood stabilizer to treat the exhibited symptoms.
Over the following two weeks, Sgt. W.'s mood and symptoms improved. He no longer stated a belief of being God or having supernatural powers. However, he stated he knew there were “issues” that he needed to work out with God. The mental health practitioner addressed these concerns by providing psychotherapy to Sgt. W. that included his spirituality. She asked open-ended questions that focused on what Sgt. W. was feeling, such as his concerns, needs, or hurts. The questions enabled the practitioner to gain an understanding of Sgt. W.'s worldview, especially in relation to his personal concept of spirituality. Sgt. W. believed he had a special relationship with God that no one else understood, but he recognized that at times his thinking about God was distorted. At this point, the practitioner asked Sgt. W., “What has helped you the most in the past when you have felt this way?”
Sgt. W. responded that while at war, his faith that God was going to protect him helped him survive. He found consolation by daily reciting Psalm 23:4 (KJV), “Yea, though I walk through the valley of the shadow of death, I will fear no evil; for Thou art with me; Thy rod and thy staff they comfort me.” At the end of the session, the mental health practitioner validated Sgt. W.'s spiritual concerns and referred him to the clinical chaplain.
During his meeting with the chaplain, Sgt. W. reported confusion with God. After several sessions of individual therapy, he stated, “I now understand that my experience with God is my own personal experience with him, and no one can take that away from me.” During this time, the mental health practitioner continued to provide appropriate spiritual care, listening to Sgt. W. talk about his spiritual beliefs and concerns. Sgt. W. stated an understanding that his mental disorder at times caused him to believe things that were untrue. Yet, through appropriate spiritual care, that in his case included discussions with the chaplain, mental health practitioner, and Scripture, he realized he could have a special, personal relationship with God.
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