APA spiritual care chaplains

INTRODUCTION Who Owns Spiritual Care, and Why Does It Matter? J. Irene Harris 1, 2 and Anne Klee 3, 4 1 Veterans Affairs Maine Healthcare System - Togus, Augusta, Maine, United States 2 Department of Psychiatry, University of Minnesota Medical School 3 Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, United States 4 Department of Psychiatry, Yale University School of Medicine At our unique juncture in history, challenged by a global pandemic, the impact of climate change, and a polarized political landscape, more and more people are seeking mental health assistance ( Mochari- Greenberger & Pande, 2021 ), and a larger proportion of those who seek help are describing existential or spiritual concerns ( Chirico, 2021 ; Kondrath, 2022 ). Many psychologists may be experiencing themselves as insuf fi ciently prepared to help with spiritual concerns ( Vogel et al., 2013 ); the mission of this special section is to facilitate discourse and dissemination of resources among chaplains and psychologists to explore the interdisciplinary dynamics of spiritual care and to establish a foundation for the expansion of ethically appropriate, spiritually integrated care where needed. All of the articles presented in this special section were reviewed by both chaplains and psychologists, and often by professionals cross-trained in both fi elds. Our hope is that this special section will serve to increase interdisciplinary collaboration so that both chaplains and psychologists can provide appropriate services to rise to the present constellation of crises. Impact Statement Within the American Psychological Association, there is increasing recognition of religion and spirituality as a relevant aspect of psychological services; in the context of the pandemic and increasing experience of moral injury in health care and other social sectors, integration of spiritual and mental health care is becoming increasingly important. This article serves to describe the function of a Psychological Services special section on the integration of spiritual and psychological care, including societal needs, ethical considerations and boundaries, and emerging research in the area. Keywords: spiritually integrated care, organized care settings, chaplains, COVID-19, moral injury Several recent studies of psychology training programs indicate that spirituality and religion are underrepresented aspects of diver- sity in most graduate psychology training programs ( Hage, 2006 ; Hage et al., 2006 ; Vogel et al., 2013 ). Not only are spirituality and religion frequently neglected aspects of diversity, but graduate students in psychology are rarely taught to consult with clergy and chaplains or to learn about world religions ( Vogel et al., 2013 ). The fact that psychologists receive little training in spirituality and religion is compounded by the fact that psychologists are religious at far lower rates than the general public, are less likely to have ever attended events at any faith community, and are far less likely to believe in a Higher Power than the general public ( Delaney et al., 2007 ). Essen- tially, when it comes to spirituality and religion, there is a signi fi cant cultural divide between psychologists and the American public, and psychologists are not trained to consult or collaborate with experts such as clergy and chaplains to learn about aspects of spiritual and religious culture that are critically important in mental health, especially during this juncture of cultural crises. One important resource that most psychologists can access when spiritual concerns are relevant to mental health care is chaplains. Most organized health care settings have chaplains on staff ( Cadge, Lawton, et al., 2023 ; Cadge, Win fi eld, et al., 2022 ) who can act as expert consultants on beliefs and practices across spiritual and religious groups. Chaplains can not only help to assist psychologists with knowledge about spiritually integrated care; chaplains are required to have training in counseling skills ( Jacobs, 2008 ) and are therefore prepared to provide collaborative counseling interven- tions. Furthermore, several cultural subgroups trust chaplains more than mental health providers, including Veterans, African Americans, and Latinx Americans ( Kaltman et al., 2014 ; Kazman et al., 2022 ; Thompson et al., 2004 ); for these groups, chaplains can be effective in referring individuals to mental health services, helping them stay Editor ’ s Note. This is an introduction to the special section “ Spiritually Integrated Care and Chaplain Collaboration in Organized Care Settings. ” Please see the Table of Contents here: http://psycnet.apa.org/journals/ser/ 20/1/ . — LKK Anne Klee https://orcid.org/0000-0002-8838-3514 The views presented are of the authors alone and do not represent any state or federal agency. The authors do not have any fi nancial con fl icts of interest. Correspondence concerning this article should be addressed to J. Irene Harris, Veterans Affairs Maine Healthcare System - Togus, Augusta, ME 04330, United States. Email: Jeanette.harris2@va.gov Psychological Services In the public domain 2023, Vol. 20, No. 1, 1 – 5 ISSN: 1541-1559 https://doi.org/10.1037/ser0000739 1

engaged, and collaborating with mental health providers to assure that spiritually sensitive mental health care is provided. Spiritual concerns are inherent in many common clinical pre- sentations, especially in federal health care settings. For example, moral injury, fi rst identi fi ed in Veterans ( Litz et al., 2009 ), has now been identi fi ed in fi rst responders, health care providers, and teachers ( Koenig & Al Zaben, 2021 ; Riedel et al., 2022 ; Sugrue, 2020 ; Weber et al., 2023 ). Many of the evidence-based interventions for moral injury include a measure of spiritually integrated care ( Grif fi n et al., 2015 ; Harris et al., 2011; Harris, Usset, Voecks, et al., 2018 ; Litz et al., 2021 ; Maguen et al., 2017 ) and collaboration between mental health providers and chaplains is very appropriate in addressing moral injury. There is a growing body of evidence that spiritual distress impacts treatment outcomes for posttraumatic stress disorder (PTSD) and thus, consideration of spiritual concerns is an important part of PTSD treatment ( Currier et al., 2019 ; Harris et al., 2012 ; Wortmann et al., 2011 ). Evidence that spiritual distress is an important risk factor for suicide is also mounting ( Bryan et al., 2015 ; Currier et al., 2015 ; Raines et al., 2017 ; Trevino et al., 2014 ) and there is increasing advocacy to involve chaplains and clergy in the care of individuals who are at elevated risk for suicide ( Kopacz et al., 2014 ). Spiritual distress has been associated with outcomes in chronic pain ( Harris, Usset, Krause, et al., 2018 ; Peng-Keller et al., 2021 ), cancer ( Martins & Caldeira, 2018 ), heart disease ( Gillilan et al., 2017 ), and end of life/palliative care ( Velosa et al., 2017 ). Because of the increasing and compelling research on the need for spiritually integrated care, as well as research showing that as a discipline, psychologists are underprepared to meet this need, the mission of this special section has been to expand the foundation of published research on spiritually integrated care and collaboration with chaplaincy, especially in federal and state settings. One of the major concerns limiting the practice of spiritually integrated care are concerns about the scope of practice and church/state ethics observations, especially among psychologists in federal service, so we especially sought out contributions clarifying ethics concerns related to spiritually integrated care among psychologists. Ethics of Spiritually Integrated Care Psychologists in organized health care settings are appropriately concerned about separation of church and state and often avoid spiritual issues. This is understandable for a psychologist who has little or no training in spirituality, seeking to “ do no harm. ” However, there are other ethical principles that are important to consider as well. Our ethics code requires us to consider religion as an individual difference ( APA, 2017 ) and the Joint Commission requires us to provide spiritually sensitive care ( Joint Commission on Accreditation of Healthcare Organizations, 2007 ). Saunders et al. (2010) have published insightful work on the levels of involvement of spirituality in care, ranging from the spiritually avoidant to the spiritually conscious, through to spiritually integrated care. This body of work makes it clear that it is more ethically worrisome to fail to provide spiritual aspects of care than to avoid them. Currier et al. (2023) , make a detailed, empirically based case for the necessity of competency in spirituality and religion as an aspect of cultural diversity. This article also outlines the steps psychologists and trainees in our fi eld need to consider in attaining competency in this area of diversity, including awareness of religion and spirituality as aspects of diversity, awareness of personal biases in this area, accessing available resources, and appropriate consultation. The case studies in this article are valuable examples of biases about religion, imposing one ’ s own values on clients, awareness of religious and scienti fi c authority, awareness of boundaries in one ’ s scope of practice, multiple relationships involving communities of faith, and accessing relevant consultation with religious professionals, and level of consent needed for spiritually integrated care. The article thoroughly outlines options for assessing relevant aspects of spiritu- ality and religion in psychotherapy, as well as barriers to ethically implemented spiritually integrated care. Finally, the article outlines resources we have in the fi eld to develop appropriate training and standards to provide ethically appropriate spiritually integrated care. COVID-19 Pandemic and Needs for Spiritually Integrated Care The advent of the COVID-19 pandemic has changed many aspects of the landscape in health care, and the spiritual domain is one of the most prominent areas of change. While often health care providers think that “ we, ” the providers, are healthy, and “ they ” the patients, are ill, in the pandemic context that line between groups has largely disappeared ( Rosa et al., 2020 ). In the early pandemic, with high death rates, patients, families, and providers suffered, not only physically but also mentally and spiritually ( Rosa et al., 2020 ). Health care providers, in particular, were faced with ethical dilemmas related to equitable use of health care resources, duties to patients con fl icting with duties to families, and both personal and professional struggles with existential issues ( Chaturvedi, 2020 ; Rosa et al., 2020 ). For many health care providers, including us as psychologists, this has gone beyond the realm of struggle with spiritual and existential boundaries and falls within the description of moral injury syndrome ( Litam & Balkin, 2021 ; Weber et al., 2023 ). There are relationships between the COVID-19 pandemic and the need for spiritually integrated care. Weber et al. (2023) studied health care providers ’ exposure to potentially morally injurious events, as well as the extent to which health care providers ’ reported symptoms of moral injury syndrome. Findings indicated that a sizable proportion of our health care workforce is managing moral injury syndrome and that this is causing impaired functioning among those so affected. This study uses a sophisticated approach, de fi ning different types of moral injury syndrome in a large sample. The authors make the important point that at this time, most interventions being used for moral injury syndrome are spiritually integrated ( Grif fi n et al., 2015 ; Harris et al., 2011; Harris, Usset, Voecks, et al., 2018 ; Litz et al., 2017 ; Maguen et al., 2017 ), and options in this fi eld are important to consider as we ask the healers to heal themselves. Captari et al. (2023) make clear that our chaplain corps is not immune to spiritual distress associated with providing care in the context of the COVID-19 pandemic. As a pilot study, results are preliminary, how- ever, the study outlines a new model of care for our health care workforce; online group support by and for the discipline involved. Extension of these types of models of care may be useful in addressing COVID-19-related moral injury in other health care disciplines. Examples of Effective Collaborations Between Chaplains and Psychologists The African proverb “ It takes a village to raise a child ” is also applicable to the intersection of mental and spiritual care. As the need and demand for spiritually integrated mental health care 2 HARRIS AND KLEE

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Vogel, M. J., McMinn, M. R., Peterson, M. A., & Gathercoal, K. A. (2013). Examining religion and spirituality as diversity training: A multidimen- sional look at training in the American Psychological Association. Pro- fessional Psychology, Research and Practice , 44 (3), 158 – 167. https:// doi.org/10.1037/a0032472 Weber, M. C., Smith, A. J., Jones, R. T., Holmes, G. A., Johnson, A. L., Patrick, R. N. C., Alexander, M. D., Miyazaki, Y., Wright, H., Ehman, A. C., Langenecker, S. A., Benight, C. C., Pyne, J. M., Harris, J. I., Usset, T. J., Maguen, S., & Grif fi n, B. J. (2023). Moral injury and psychosocial functioning in health care workers during the COVID-19 pandemic. Psychological Services , 20 (1), 19 – 29. https://doi.org/10.1037/ser0000718 Wortmann, J. H., Park, C. L., & Edmondson, D. (2011). Trauma and PTSD symptoms: Does spiritual struggle mediate the link? Psychological Trauma: Theory, Research, Practice, and Policy , 3 (4), 442 – 452. https:// doi.org/10.1037/a0021413 Received November 21, 2022 Accepted November 21, 2022 ▪ Members of Underrepresented Groups: Reviewers for Journal Manuscripts Wanted If you are interested in reviewing manuscripts for APA journals, the APA Publications and Communications Board would like to invite your participation. Manuscript reviewers are vital to the publications process. As a reviewer, you would gain valuable experience in publishing. The P&C Board is particularly interested in encouraging members of underrepresented groups to participate more in this process. If you are interested in reviewing manuscripts, please write APA Journals at Reviewers@apa.org. Please note the following important points: To be selected as a reviewer, you must have published articles in peer-reviewed journals. The experience of publishing provides a reviewer with the basis for preparing a thorough, objective review. To be selected, it is critical to be a regular reader of the five to six empirical journals that are most central to the area or journal for which you would like to review. Current knowledge of recently published research provides a reviewer with the knowledge base to evaluate a new submission within the context of existing research. To select the appropriate reviewers for each manuscript, the editor needs detailed information. Please include with your letter your vita. In the letter, please identify which APA journal(s) you are interested in, and describe your area of expertise. Be as specific as possible. For example, “social psychology” is not sufficient—you would need to specify “social cognition” or “attitude change” as well. Reviewing a manuscript takes time (1–4 hours per manuscript reviewed). If you are selected to review a manuscript, be prepared to invest the necessary time to evaluate the manuscript thoroughly. APA now has an online video course that provides guidance in reviewing manuscripts. To learn more about the course and to access the video, visit http://www.apa.org/pubs/journals/resources/ review-manuscript-ce-video.aspx. WHO OWNS SPIRITUAL CARE, AND WHY DOES IT MATTER? 5