(Author, Department, University,
Corresponding Address and email)
Abstract
Post-traumatic stress disorder (PTSD) is an anxiety disorder that is associated with serious kind of traumatic events and can result in the development of suicidal thoughts. The problem of PTSD can develop in any person, but veterans have more chances of getting this disorder. Moreover, veterans may require more effective ways of treating the disorder as cognitive behavioral therapy, Prolonged Exposure, and Mindfulness-Based Stress Reduction are unable to give required results. Therefore, spiritual and religious ways of living a life are considered for treating the patients of PTSD, who have developed the problem as a result of war. In this study, veterans having war-related PTSD will be selected from a hospital. They will be provided several questionnaires to collect data. Those questionnaires will be about PTSD, suicidal thoughts and attempts, spiritual and religious beliefs, and demographic variables. Appropriate statistical techniques such as analysis of variance (ANOVA) and chi-squared (χ2) tests will be used to reach a conclusion.
Introduction
Post-traumatic stress disorder (PTSD) is an anxiety disorder that is associated with serious kind of traumatic events and characterized by the symptoms such as survivor guilt, numbness, lack of involvement with reality, reliving the traumatic events in imagination or dreams, and/or recurrent images and thoughts. PTSD can also lead to suicidal thoughts and can increase the risk of suicide. It can result in decreased quality-of-life in several domains such as physical, social, psychological, and environmental domains (Currier, Drescher, Holland, Lisman, & Foy, 2016). As a result of PTSD, patient may develop significant impairments in occupational functioning, interpersonal relationships, and physical health (Vujanovic, Niles, Pietrefesa, Schmertz, & Potter, 2013). The problem of PTSD can develop in any person, but veterans have more chances of getting this disorder as, for example, it has been found that the lifetime prevalence of PTSD is about 8% in the general population, but it can be increased to about 15% in veteran population (Kopacz, Currier, Dresher, & Pigeon, 2015).
Research shows that veterans with the problem of PTSD have more chances of attempting suicide. In the recent times, suicidal thoughts and behaviour has been found increasing in military personnel. It has been reported that 18 to 22 Veterans die every day as a result of suicide, and a high percentage, i.e. 18%, of suicidal deaths are attributed to military personnel (Kopacz et al., 2015).
In addition to PTSD, research shows that moral injury can also increase the chances of suicidality. Moral injury is found to be related to sense of guilt, shame, and inner conflict. It can develop from committing and/or witnessing the acts of extreme violence that is related to human suffering and death of other veterans. Spiritual distress and self-depreciation are among the most important warning signs of a moral injury. It can increase the severity of PTSD, thereby increasing the suicidal thoughts and chances of attempting suicide (Currier, Drescher, & Harris, 2014).
Standard methods of treatment for PTSD in general population may include the use of medication, eye movement desensitization and reprocessing (EMDR), cognitive-behavioral and exposure-based therapies, and/or relaxation (Bormann, Thorp, Wetherell, & Golshan, 2008). In veterans, studies have been done on several therapeutic strategies in dealing with the problem of PTSD. In a study, researchers worked on the use of cognitive behavioral therapy (CBT) for PTSD symptomatology. However, CBT was not able to fully deal with the problem of PTSD in veterans, and researchers reported that further improvements in CBT could be done while considering the patients’ relationship with people in their surroundings (Monson, Rodriguez, & Warner, 2005). There is another kind of empirically supported therapeutic strategy, i.e. Prolonged Exposure. Clients are exposed to trauma-related to feelings, thoughts, and memories. In these treatments, the clients are asked to recall the traumatic events in a well-controlled manner. However, many trauma-exposed veterans refuse these treatments, drop out from the therapeutic session, do not ask for help, and/or unable to get substantial help (Vujanovic et al., 2013). In another study, researchers have tried to explore the potential of Mindfulness-Based Stress Reduction (MBSR) in the treatment of PTSD of veterans, but they found that MBSR had no reliable effects on the depression or PTSD (Kearney, McDermott, Malte, Martinez, & Simpson, 2013).
In these situations, it is important to consider that health care in the modern age has become a complex issue due to cultural and religious barriers. For example, the western medicine came with its history, expectations, technologies, and methods that are related to science supporting it. With improvements in research and development of science, scientists started developing more focus on material reality and accepting the physical laws. Also, scientists have separated the religious perspectives from biomedicine and science, and this has further widened the gap between the western medicine and Christianity. The prosecution of Galileo between 1564 and 1642 for supporting the universe view by Copernican is a historical event that widened the gap between science and organized religion (Wink & Scott, 2005). Moreover, improved technology in the 21st century and increased number of chronic diseases caused the believers, especially those who have an in-depth knowledge of the Bible, develop the notion that healing should be done through creating an interconnection between spirit, mind, and body.
While considering this alarming situation of increasing suicidal behavior as a result of PTSD in veterans and inefficacy of modern therapeutic strategies, further research is required on optimal therapeutic strategies. With the wars faced by the world, demand for more holistic and complementary therapies has increased to help veterans in living a normal life. Veterans have also reported that they would like to use more complementary approaches to achieve good health, if such approaches are easily available (Bormann et al., 2008). An often unnoticed dimension of treating the problem of PTSD and dealing with suicidal thoughts is the help of religion and spirituality. Spirituality is related to many aspects of life, and it is also an important part of people’s coping skills as well as treatment strategies (Sherman, Harris, & Erbes, 2015). Studies show that increased attraction for religion can help in decreasing the depression. Increased level of spirituality can also help in decreasing the symptoms of anxiety in patients having advanced illness (Hourani et al., 2012). Spiritual well-being has also been found to be associated with improved quality of life in patients of cancer and HIV. Spiritually based therapeutic interventions have also helped in reducing pain in patients of migraine and controlling distress in students of colleges (Bormann et al., 2008).
Researchers have proposed various mechanisms that are involved in improving the condition in mental disorders with the help of spirituality. During the last years of the 19th century, it was reported that spirituality or religiosity helps in providing more social support that facilitates the body against psychopathology as well as suicidal behaviors. Studies in the present times also show almost same results. Another proposed mechanism is that enhanced level of spirituality increases the ability of the body to deal with stressors, decreases the sense of hopelessness, and/or enhances the sense of purpose, thereby protecting against different kinds of mental disorders (Hourani et al., 2012).Therefore, spiritual and religious well-being could be considered as a coping strategy for veterans. This can be of great help as it can also reduce the impact of moral injury, which is usually caused by spiritual distress.
The primary goal of performing this research is to provide empirical evidence that religion and spirituality can help veterans in coping with military-related PTSD, and lower the risk of suicide. Depending on the previous studies, we have two hypotheses:
The war may result in declining the spiritual power of the veterans, thereby affecting their inner strength to deal with mental issues that may often lead to inappropriate thoughts such as suicidal thoughts.
Every person has a different level of spiritual and religious mind, and working on that mind according to the level of the person can help in reducing many negative thoughts without generating more negative thoughts.
Methods
Participants and Procedure of the study
First study will be done on the effect of religion and spirituality on veterans dealing with military-related PTSD, and who were admitted to the hospital for the treatment of PTSD. This study will target the veteran population who will be stable for at least three months, with and without a history of suicidal ideations. Veterans will be selected on the basis of clinician referrals along with the recommendation of research study personnel. Moreover, veterans, who would not show response to less intensive therapeutic strategies, will be considered for the research. Inclusion criteria for the participants of this study will include the age of 18 years or older, diagnosis with a combat-related PTSD, English-literate, and self-rated score of 50 or more on Posttraumatic Stress Disorder Checklist –Military version (PCL-M). Veteran patients having any kind of psychotic symptoms or medical conditions that would disturb the treatment procedures, and/or drug/alcohol misuse within the previous two weeks will be excluded from the study. After meeting the inclusion and exclusion criteria, at least 30 veterans including males and females will be considered for the study, who would be able to give responses to the instruments discussed in the paper.
Second study will include two groups of participants, who will be analyzed on their understanding of the use of Christianity to develop natural healing. Moreover, they will be tested for their need of Western medications. The 8 participants with strong Christianity backgrounds will first be approached at different churches within the local area as well as at the school of theology. The second group of participants will comprise of 8 health compromised patients, who will be contacted as they attend a local clinic for treatment. The inclusion criteria for this study will be strong Christianity background. Data will be gathered by providing the identified participants with a pilot survey, which will comprise of relevant questions to the research and which will be provided with a scale. For example, the participants’ preference of religion over western medication will be given a scale of 1 to 10 and vice versa. If the participants consider western medicine over religion, then they will be given a scale of 10.
PTSD will be assessed through the diagnosis and clinical interviews. Diagnosis of PTSD will be supported by the commonly used assessment instruments. All kinds of evaluations and research procedures will be done after an appropriate consent process. The consent form will be approved by the University. The collected data and screening information will be assigned a specific study ID number that will remain confidential within the supervision of project coordinator. All the personal health information will be kept locked.
In order to carry out the research, we will perform a survey of veterans, who have gone through the symptoms of PTSD and faced suicidal thoughts. This survey will be done with the help of instruments including the questionnaires for PTSD, suicidal thoughts and attempts, spirituality and religiosity, and their affects on feeling good and against suicidal thoughts. With the help of survey research, many people would be easily studied at a relatively lower cost. These surveys could also help in reducing the bias as they are mostly confidential, and participants know that they can tell more about themselves without any worry of the leak of information to other people. With the help of more detailed and illustrated questions, biasness can further be reduced. Due to high representativeness, survey methods can also provide statistically significant results as compared to other types of data collection methods. Moreover, multiple variables can also be effectively assessed with the help of surveys and questionnaires.
Instruments used in the study
PCL-M will be used to assess the severity of PTSD symptomatology associated with military experiences (Bryan, Rudd, Wertenberger, Young-McCaughon, & Peterson, 2015). This instrument is helpful in evaluating the distress related to the 17 symptoms of the problem over the past 30 days. Items in this instrument have a five-point scale rating ranging from 1 (i.e. “not at all”) to 5 (i.e. “extremely”). It can help in assessing the three symptom domains according to DSM-IV: avoidance (7 items), re-experiencing (5 items), and hyperarousal (5 items) (Currier et al., 2016). Total score on the PCL-M vary from 17 to 85 (Kopacz et al., 2015).
In order to assess the spirituality and religiosity in patients of PTSD, the Brief Multidimensional Measure of Religiousness and Spirituality (BMMRS) will be used which is a 40-item instrument to evaluate the twelve aspects of spirituality in relation to behavioural health research (Kopacz et al., 2015). It was designed by Fetzer Institute and National Institute on Aging (NIA) (Currier et al., 2014).
For the assessment of organizational religiousness, two items instrument will be used to check the involvement in a church or certain other formal religious groups.
In order to establish spirituality in patients of PTSD, a modified version of the Daily Spiritual Experiences Scale will be considered (Kopacz et al., 2015). It will have five items for evaluating commonly encountered, daily experiences of spirituality such as feelings of harmony or peace, feeling the presence of higher power, and/or feelings of the beauty of the nature and universe. Those items will have five points ranging from 1 (showing “no experiences of spirituality”) to 5 (showing “high level of experiences of spirituality”). The scores on the instrument will range from 5 to 25.
In addition to the instrument for assessing the experiences of spirituality, private spiritual practices will also be considered. Those practices will be assessed with the help of an instrument having 5 items for the assessment of engagement in prayers, reading and feeling religious materials, meditation, and listening to religious programs. Those items will have five points ranging from 1 (showing “never”) to 5 (showing “more than once a day”). The scores on the instrument will range from 5 to 25.
Two questions for the assessment of suicidal thoughts and suicidal attempts will be considered in the clinical interviews. For suicidal thoughts, a question will be asked, “Have you ever faced any suicidal thoughts?”, and for suicidal attempts, a questions will be asked, “Have you ever attempted suicide?” Responses to the questions will be considered in a “yes” or “no” format. On the basis of these questions, three categories would be considered: One category will consist of veterans, who have never faced any suicidal thoughts and have never attempted suicide; second category will consist of veterans, who have developed thoughts only; and third category will consist of veterans, who have faced not only suicidal thoughts but also have attempted suicide.
Demographic variables will also be analysed including age group, race or ethnicity, marital status, gender (male and female), highest level of education, and religious affiliation. These tests would also help in giving an understanding of spiritual and religious beliefs at an individual level.
Statistical Analysis
For the first study, differences in the mean (standard deviation) scores for the PCL-M will be analysed for the three suicide risk groups (who were categorized after two questions for the assessment of suicidal thoughts and suicidal attempts) with the help of analysis of variance (ANOVA). Differences in the frequency distribution of the other demographic variables will be analysed with the help of chi-squared (χ2) tests. With the help of χ2 tests, we will be able to know whether there is any association between the different variables or not. In order to assess the relationship between spirituality and suicide risk Multivariate analysis of covariance (MANCOVA) will be used. With the help of MANCOVA, errors associated with independent variable (covariate) can be reduced, thereby increasing the authenticity of results.
In the second study, once the data will be gathered, data analysis will follow, and this paper proposes three different types of analysis.
The first data analysis method is the description of the data using different statistics such as range, mode, the mean and standard deviation for the religious consideration scores and western medicine consideration scores.
The second method proposed is the determination of the relationship between Christianity and Western medicines in promoting the health of the patient using Pearson product correlation coefficient.
The third proposed method of data analysis is the t-tests and chi-square to determine any differences in use of Christianity belief and western medicine scores.
Limitation or Potential Bias
The major limitation of the study could be its biased nature. This is because the study is subject to pre-trial bias that may come from the study design. Since this is a quantitative study design that is aimed at measuring the study’s important parameters, the researcher may be tempted to develop the plot of the study and score criteria that target his or her interest, and this may affect the study outcome.
The study is also subject to selection bias. This is because the identified population is clearly defined and this increases the risks of providing information, which is based on the researchers’ interest. Since the participants are not educated or informed on how to fill the pilot study, then there are increased chances that the obtained results will be subjected to bias and may not reflect the real information on ground.
In order to avoid any bias during the study, a pilot study will first be carried out to classify the participants. The participants will also be identified and confirmed for their committed Christianity. Their Biblical understanding will be important criteria which will measure their level of understanding.
Conclusion
Spiritual/Religious practices can enhance or diminish the suicidal thoughts and attempts in Veterans with PTSD. Studying a much larger and diverse population, and using intervention aimed at applying spiritual/religious practices to reduce the risks of suicide would help make more conclusive that spiritual coping can contribute to reducing the number of suicides in people with PTSD.
References
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Bryan, C. J., Rudd, M. D., Wertenberger, E., Young-McCaughon, S., & Peterson, A. (2015). Nonsuicidal self-injury as a prospective predictor of suicide attempts in a clinical sample of military personnel. Comprehensive psychiatry, 59, 1-7.
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