The Impact of Worldviews on Behavioral Health Providers Descriptions of Moral Injury: A Qualitative Exploratory Multiple Case Study

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Lane, Jr. This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6033275/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND Humans are holistic beings. Moral Injury (MI) creates holistic distress. There is limited standardization in MI constructs, assessments, and treatments. Current care for MI often limits spiritual integration. AIMS- The purpose of this qualitative exploratory multiple case study was to explore how military behavioral health providers’ worldview influenced their description of the construct of MI, the morbidity of MI, and how these providers chose to treat clients they perceived to be suffering through the effects of MI. METHODS Eight Department of Defense or Veterans Affairs affiliated behavioral health providers completed a worldview assessment, prompted journal responses, and semi-structured interviews to understand how their worldview impacts their descriptions of MI constructs, morbidity, and treatment decisions. I analyzed the data through postpositivist beliefs utilizing Codebook Template Analysis. RESULTS Participants’ worldviews influenced how they described MI as a construct, what they assessed as MI morbidity, and how they chose to treat it. CONCLUSIONS More studies are needed to explore MI’s spiritual dimensions and effects. Assessment and treatment should include all stakeholders’ methodologies. Treatment for MI should include care from providers for the body (medical doctors), soul (chaplains), and mind (behavioral health providers). Moral Injury Worldview Behavioral Health Providers Holistic Care Introduction Moral Injury (MI) has gained increasing attention in psychological and spiritual domains, particularly in military contexts. Rooted in a holistic view of human nature—mind, body, and spirit—MI extends beyond traditional trauma models, affecting the soul in profound ways (Haynes, 2009). Jinkerson (2016) defines MI as a syndrome arising from a perceived violation of deeply held beliefs that create psychological, existential, behavioral, and interpersonal issues. MI often produces guilt, shame, moral conflict, self-perception issues, and loss of faith, leading to emotional numbness and relational difficulties. Though researchers have taken a keen interest in MI over the past twenty years, the National Center for PTSD acknowledges gaps in empirical assessment and treatment, with no standardized interventions available (Norman & Maguen, 2024). While spirituality is widely recognized as essential to trauma recovery (Canda, 1998; Canda & Furman, 1999; Crisp, 2016; Park, 2016), many behavioral health providers fail to integrate it due to lack of training, leaving patients feeling unseen (Borges, 2019; Borges et al., 2020). Veterans often turn to chaplains rather than psychologists, as chaplains address the spiritual injuries central to MI (Drescher et al., 2018; Boska et al., 2021; Kopacz et al., 2014). However, clinical approaches remain fragmented, with providers relying on personal religious backgrounds rather than formal training (Sheridan, 2009). This qualitative multiple-case study explored how military behavioral health providers’ worldviews shape their understanding of MI, its morbidity, and treatment decisions for Veterans suffering from its effects, bridging the gap between behavioral health and spiritual care by examining these influences and ensuring a holistic approach to treating MI. Methods This study employed a qualitative exploratory multiple case study guided by Yin’s (2018) perspective on an exploratory case study. Each participant was treated as a distinct “case.” The novelty of this research lies in its focus on the understanding of MI components among behavioral health providers and the influence of worldviews on them. This unexplored territory led to an exploratory design, which aims to unearth questions, variables, and hypotheses for future research. The research proposal was reviewed by Liberty University’s IRB and approved as an exempt study. Eight participants were recruited through snowball sampling and from two social media groups comprising Army and VA behavioral health professionals. Participants had to be licensed clinical psychologists or professional counselors working for the Department of Defense or with the VA. Participants gave written consent via email after receiving the study information sheet. This confirms that any participant has consented to the inclusion of material pertaining to themselves, that they acknowledge that they cannot be identified via the manuscript; and that the participant has been fully anonymized by the author. The recruitment process yielded eight participants, seven clinical psychologists, and one LPC. The data collection process was comprehensive, utilizing three distinct sources: the Worldview Assessment Instrument (Koltko-Rivera, 2000) to identify participants’ worldviews, four prompted journal entries, and a semi-structured interview. The Worldview Assessment Instrument, which tests six categories, was used to understand the participants’ worldviews. See Table One for an overview of the assessment and the definitions it utilizes (Koltko-Rivera, 2000). The interview questions and journal prompts were selected from studies that explored a chaplain’s understanding of MI (Drescher et al., 2018; Boska et al., 2021), ensuring the questions were relevant, insightful, and based on the literature. These questions allowed behavioral health providers to describe the construct of MI, its morbidity, and their intervention strategies, directly addressing all three research questions with previously established questions. Table One Definition of Key Terms relevant to the Worldview Assessment Instrument Key Terms Key Term Definitions Categories Categorical Definitions Worldview A set of interrelated beliefs about the nature of reality and human life, including beliefs about motivations, social behavior, and human capacities; within these topic areas, any given world view encompasses beliefs concerning what exists or is possible to occur in the universe, what experiences and entities are good or bad, and what behaviors and end states should be sought or eschewed. N/A N/A Mutability The possibility of changing human nature. Changeable Permanent Represents beliefs that an adult’s character, behavioral tendencies (e.g., habits), or personality characteristics may exhibit change over time, due to the effect of factors external to the individual (such as social learning). Represents beliefs that an adult’s character, behavioral tendencies, and personality are not susceptible to any but the most superficial and temporary change due to external factors. Agency The degree to which behavior is chosen or determined. Voluntarist Deterministic Represents beliefs that individuals possess what is termed in philosophy “free will” or “moral agency,” in terms of exercising true choice for at least some of their behaviors; thus, some behaviors cannot be accounted for by factors of genetics, social learning, or unconscious intrapsychic factors such as those hypothesized in psychoanalytic theory. Represents beliefs that all human behavior is determined; these determining factors may be genetic, intrapsychic (in the psychodynamic sense), Or social (including social learning). Relationship to Authority Beliefs about what is considered the natural, “right,” or appropriate way for people to relate to authority figures. Linear Lateral Represents beliefs that the best way to relate to authority figures is in the context of a clearly defined hierarchy, where those who hold superior statuses in the hierarchy make decisions for and issue instructions to those who hold subordinate statuses in the hierarchy. Represents beliefs that the best way to relate to authority figures is in the context of an egalitarian partnership, where authority is widely distributed throughout an organization, and decisions are made in a consensus fashion. Relationship to Group The priority that should be placed on one’s own agenda in life versus that of one’s reference group. Collectivist Individualist Represents beliefs that the reference group’s agenda and goals have priority over the individual’s goals and agendas. Represents beliefs that the individual’s agenda and goals have priority over the reference group’s agendas and goals. Locus of Responsibility Beliefs about perceived blame or responsibility for the position one occupies in life. External Internal Represents beliefs that view the sociocultural environment as more potent than the individual and that success or failure [in society] is generally dependent on the socioeconomic system and not necessarily on personal attributes. Represents beliefs that “success or failure [in life] is attributable to the individual’s skills or personal inadequacies, and ... that there is a strong relationship between ability, effort, and success in society. Metaphysics Beliefs concerning the reality or unreality of a spiritual dimension to life. Spiritualist Materialist Represents beliefs that spirit is a prime element of reality. Represents beliefs that “physical matter is the only or fundamental reality and that all being and processes and phenomena can be explained as manifestations or results of matter. Locus of Control Beliefs concerning the causes of certain events, experienced by the person as reward or punishment. External Internal The belief that reinforcements are the result of luck. Represents beliefs that rewards and punishments are contingent upon the person’s “own behavior or [one’s] own relatively permanent characteristics.” A researcher’s worldview influences their work (Creswell & Poth, 2018), so owning mine seems relevant. I viewed the data through a postpositivist lens, knowing truth is out there and can be known, though each person brings their own experiences and beliefs to the search and analysis. Post-positivism values structured approaches and multiple perspectives. To sort the data, I separated participants’ descriptions into three areas: descriptions speaking to MI construct, descriptions speaking to MI morbidity, and descriptions speaking to MI treatment. From there, I entered the data into MAXQDA as three separate projects to analyze each research question separately. I then coded data using Braun and Clark’s (2022) Codebook Thematic Analysis or Template Analysis. After coding, I sought to answer who said what and if there were differences in how they described the theme related to their worldview beliefs. First, I conducted crosstabs in MAXQDA to organize themes by participants’ worldview categories within each cluster. I then examined distribution patterns. If a theme appeared only in one belief cluster, I reviewed the participants’ descriptions for content aligning with Koltko-Rivera’s worldview definitions. When such alignment was present, I concluded that worldview beliefs might influence the observed distribution pattern. When themes were present across both worldview categories, I used a segment matrix in MAXQDA to compare descriptions. Differences in descriptions were analyzed against Koltko-Rivera’s (2000) definitions to assess whether worldview beliefs accounted for any thematic variations. Results This study produced more than 500 pages of data. Given space limitations, only a few examples from the data can be shared. See Lane (2025) for all the study’s data and complete analysis by theme. When analyzing the data for Research Question One, the following codes emerged: the holistic impact of MI, individual variation seen in clients with MI, MI distinct from PTSD, the need for collaborative care, assessment tools, more people seeking care, MI harder to treat than other trauma related disorders, cultural pressure, social expectations, psychological distress, spiritual distress, identity crisis, MI as a belief-behavior conflict, moral contextuality, and nuanced descriptions. Finding One: Metaphysical Influences on Behavioral Health Providers’ Description of the Construct of MI Metaphysical beliefs influenced behavioral health providers’ reporting of the need for interdisciplinary care, MI involving aspects of contextual morality, the individual variation often seen in clients with MI, and descriptions of the belief-behavior conflict that defined their understanding of MI when describing their conceptual understandings of MI. Thematic distributions across the metaphysical categories in Research Question One and Research Question Three suggest that spiritualists call for collaboration between behavioral health and spiritual care providers, whereas materialists do not mention this need. P4 noted, I do believe that to navigate through MI, which is pretty complex because it’s tapping into several aspects of someone’s life, you know. Not just the emotional or psychological but also the spiritual. Because it taps into multiple areas, it’s really important, I think, for there to be collegial effort for mental health field and those in spiritual care to work together and to hone one another’s understanding and experiences. Given that the literature review suggested MI creates spiritual issues and the lack of spiritual integration when treating MI, this finding has empirical implications. Behavioral health providers who lean more spiritual in belief recognize the spiritual implications of MI and the need for spiritual care providers to be present during treatment. The thematic distribution between the metaphysical categories shows that four of five spiritualists included descriptions of the context in which they made a decision that led to MI. In contrast, none of the three materialists included this distinction in their descriptions of their conceptual understanding of MI. Spiritualists find a need or value in justifying their behaviors to a higher moral power or authority, explaining the difference between distributions. On the other hand, materialists would see no need to make such a justification, as to them, material is all that exists in this world- there is no higher moral power. From an implication perspective, this belief could alter how the behavioral health provider hears what their clients are saying and if they perceive the spiritual implications of the contextual nature that is often a part of MI. Description comparisons of the individual variation of MI across the metaphysical categories suggest that materialists focus their understanding of MI on the tangible, reporting only observable symptoms. On the other hand, spiritualists reported more existential concerns. The implications of this finding suggest that materialists may fail to recognize the spiritual symptoms of MI or may not address them if they identify them because current trauma-focused protocols fail to address spiritual needs. This finding could explain why Soldiers often feel behavioral health providers fail to address their spiritual needs when completing current trauma-focused EBTs, though spiritual needs may not be the focus of the EBTs (Borges et al., 2020; Battles et al., 2018; Purcell et al., 2016). Description comparisons between the metaphysical categories on the nature of the belief-behavior conflict that defined MI by the participants of this study show differences connected to the metaphysical categories. Materialists focused their descriptions around the concrete and tangible psychological response to the behavior-belief conflict. P1 described, “When I think about MI, I think about behaviors that might contradict deeply held beliefs which ultimately leads to psychological distress.” He continued, “To me MI is essentially a conflict between a belief and a behavior. If we behave in a way that is at odds with what we believe, then that will create emotional conflict.” On the other hand, spiritualists focused their descriptions more holistically, often including existential elements. P7 described, “When someone commits an act that is against their personal moral code and struggles to reconcile the person they believe they should be with the person they were in the moment when the act occurred.” P4 stated, “I view MI as a byproduct to unresolved thoughts or feelings one incurs after they have experienced or witnessed an event(s) that go against his/her moral fiber or personal beliefs about how the world, how others, or how they individually think they should behave.” Finding Two: Locus of Responsibility Influences on Behavioral Health Providers’ Descriptions of the Construct of MI Locus of responsibility beliefs influenced participants’ descriptions around the individual variation of MI, the difficulty treating MI, the social expectations and cultural pressures found in MI, the psychological distress MI creates, the contextual morality found in MI, and the belief-behavior conflict that defined MI when describing their conceptual understanding of MI. P7 (external locus of responsibility) reported that MI is more challenging to treat than other trauma-related disorders. P7 believes this finding to be because the person suffering “committed the act that triggered the MI whereas most other traumas that lead to PTSD, the individual may have contributed to the situation which led to the trauma but is less responsible for the act than with MI.” No participants with an internal locus of responsibility reported increased difficulty treating MI compared to other trauma-related issues. I find that P7’s locus of responsibility explains why he included this in his description of MI. In his statement, he explicitly states that the reason for the increased difficulty in treatment lies in the level of responsibility given to the person who is experiencing the MI. People with an external locus of responsibility place more value on the influence of external factors on a person’s success than those with an internal locus of responsibility. In this context, providers with an external locus of responsibility will focus more on the context of the situation that led to MI than on the decisions a person made. This distinction is seen in P7’s description, showing the influence of their locus of responsibility beliefs in their description of MI. Given that outside factors are complex, placing blame is more complicated, increasing the difficulty of treating MI. When comparing participants’ descriptions of the above themes, I observed the same difference across all themes. Participants with an internal locus of responsibility included an element of control in their descriptions. Participants with an external locus of responsibility focused their descriptions on the contextual nature of MI. See the whole study for a detailed comparison of findings. For a quick comparison, “It’s my moral code, or the moral code of someone’s being challenged by decisions they’ve made, or having to be in situations that they may be in control of or not in control of and making decisions that kind of violate their belief systems and what they may do in a different circumstance if situations were different” versus “In short, it feels like applying garrison morality to a wartime decision. What may have been necessary in Baghdad is being evaluated based on Salt Lake City’s morality” (internal versus external locus of responsibility participants’ descriptions, respectively). Finding Three: Relationship to Group and Authority Influences on Behavioral Health Providers’ Descriptions of the Construct of MI Relationship to group and relationship to authority beliefs influenced participants’ descriptions of their construct of MI, with the idea of betrayal being the key difference observed across these categories. I found the same difference when comparing participants’ descriptions of their construct of MI between the relationship to group and the relationship to authority categories. In the relationship to group descriptions, participants with an external relationship to group described a sense of betrayal or turning against those that turned them “into a monster” in the person suffering with MI’s eyes. I observed the same pattern in the relationship to authority descriptions. Those with a linear relationship to authority describe issues with commanders or betrayals that participants with a linear relationship to authority did not report. P8 (linear relationship to authority) described MI as “distress stemming from witnessing, engaging, or being unable to prevent a traumatic event which violates the individuals moral or ethical beliefs. There is a feeling of shame or guilt or even betrayal from the organization for being ‘put’ in position to be exposed to the risks that violate their moral code.” Research Question Two When analyzing the data for Research Question Two, the following codes emerged: delayed onset of symptoms, longevity of symptoms, loss of control, spiritual, worth or value, meaning and purpose, changes in beliefs, issues of faith, intrusions, nightmares, turning against people, substance abuse, issues of trust, resentment, anxiety, remorse, anger, emotional, shame, fear, self-hate, depression, guilt, physical symptoms, cognitive issues, suicidality risk unchanged, suicidality risk increased, yes and no suicidality risk, isolating behaviors, and differentiating MI from other trauma related issues. Finding Four: Metaphysical Influences on Behavioral Health Providers’ Descriptions of the Effects of MI Metaphysical beliefs influenced behavioral health providers’ descriptions around the delayed onset, spiritual issues, issues of faith, remorse, self-hate, increased suicide risk, turning against people, and cognitive issues when describing the effects of MI. Thematic distribution comparisons show that spiritualists are more likely to report spiritual issues, issues of faith, remorse, self-hate, and an increased risk of suicide when describing the symptoms and presentation of MI. While other explanations are certainly possible, I find the underlying metaphysical beliefs of the behavioral health provider may influence these differences. For instance, P7 (spiritualist), when describing why he assesses a higher suicide risk, specifically addresses spiritual issues like community, faith, and general beliefs. I haven’t seen research to show that that bears out, but I know, as far as my own personal practice, I am more concerned about somebody who is struggling with a MI, and a lot of that has to do with just general risk factors. And so, like we discussed, they’re less connected to their community. They’re less connected to their families. They’re struggling with their faith. They’re struggling with what their values truly are. And so, all of those things that are kind of secondary to the MI in my work would place them at a higher risk of self-harm. Comparing participants’ descriptions between the metaphysical categories, spiritualists focused their descriptions of people turning against others on reconciliation, whereas materialists focused on retribution. Spiritualists generally believe in a spiritual world where other powers exist. In the context of Christianity, reconciliation after the commitment of sin is vitally important. Conversely, materialists generally believe in a sole material existence. They may be less likely to place reconciliation as high of a need. I also saw a difference in participants’ descriptions of the cognitive issues in MI. The spiritualists’ descriptions included a person’s need to understand or make meaning when describing the cognitive issues that come with MI. In contrast, the materialists’ descriptions solely focused on their “concentration is impacted.” Given that meaning and purpose lie in our spiritual capacity as humans, I conclude that metaphysical beliefs explain the difference in participants’ descriptions. Finding Five: Locus of Responsibility Influences on Behavioral Health Providers’ Descriptions of the Effects of MI Locus of responsibility beliefs influenced behavioral health providers’ descriptions around the longevity of MI symptoms, the delayed onset, the spiritual issues of MI, issues of worth and value, changes in beliefs, issues of faith, resentment, and suicide- risk increased and suicide- risk unchanged when describing the morbidity of MI. Thematic distribution comparisons suggest that participants with an external locus of responsibility described the systems around the person. In contrast, those with an internal locus of responsibility focused more on the individual’s ability to change. The difference in beliefs led participants with an external locus of responsibility to describe MI as a long-lasting issue, including spiritual concerns, issues of worth and value, and changes in beliefs in their description of MI morbidity. Given the systemic view found in the external locus of responsibility participants’ descriptions, I believe this difference may be explained by the participants’ locus of responsibility beliefs. The one mention of faith issues came from a participant with an internal locus of responsibility. I believe the distribution difference may be explained by locus of responsibility beliefs, though I recognize that metaphysical beliefs may also explain this difference. P6 (internal locus of responsibility) stated, I think that part of my consideration for how I think people recover from moral injuries is the lens in which they see their decisions in. I found people who have a more spiritual glance at it manage it through their belief. They see what they did as it was something they did it for their country and believe “God forgives me!” You deal with a lot of people who are dealing with forgiveness. From their description, the idea of personal accountability is clear. It highlights a person’s ability to contribute to their success or failure, the defining aspect of Koltko-Rivera’s (2000) locus of responsibility beliefs. When comparing participants’ descriptions across the locus of responsibility categories, the locus of responsibility beliefs influenced participants’ descriptions around resentment. P8’s description of resentment highlights individuation by describing much of the person’s resentment as secondary to their control. P8 highlights that Soldiers are often placed in situations they were not expecting and asked to do things they could not imagine, demonstrating their inability to control the situation and P8’s internal locus of responsibility beliefs. There were also differences in participants’ descriptions of suicide risk assessments. Participants with an external locus of responsibility focused their descriptions of suicide risk factors on external or environmental factors. Participants with an internal locus of responsibility focused their descriptions of risk factors on the client’s internal beliefs, not other external risk or protective factors. Locus of responsibility beliefs explain these differences in participants’ descriptions. Finding Six: Relationship to Group Influences on Behavioral Health Providers’ Descriptions of the Effects of MI Relationship to group beliefs influenced behavioral health providers’ descriptions around the spiritual symptoms, meaning and purpose, issues of faith, substance abuse, issues of trust, anxiety, remorse, self-hate, loss of control, and resentment when describing the morbidity of MI. Thematic distribution comparisons between the relationship to group categories suggest that providers with an individualist relationship to group identify clients’ self-assessment, as seen by their reporting issues of self-hate. Participants with a collectivist relationship to group identified the spiritual issues, meaning and purpose, issues of faith, substance abuse, issues of trust, anxiety, and remorse when describing the morbidity of MI. In contrast, those with individualist beliefs did not report these themes, highlighting MI’s communal impact on Soldiers and the communal focus of external relationship to group participants. Comparing participants’ descriptions of the morbidity of MI across the relationship to group categories suggests that behavioral health providers with individual relationships to group beliefs focused their descriptions on the impact on self when describing the loss of control that comes with MI. Conversely, participants with a collectivist relationship to group describe the loss of control in relational terms by mentioning the person’s feelings about their community. Similarly, when describing resentment, participants with a collectivist relationship to group included the idea of “just Army fallacy” and their expectations for the group to look out for the individual when describing resentment. Individualists reported resentment as a possible symptom with no reference to the direction of that resentment. Finding Seven: Relationship to Authority Influences on Behavioral Health Providers’ Descriptions of the Effects of MI Relationship to authority beliefs influenced behavioral health providers’ descriptions around the loss of control, issues of trust, suicide risk, meaning and purpose, turning against people, and resentment when describing the morbidity of MI. Thematic distribution comparisons between the relationship to authority categories suggest that behavioral health providers with a lateral relationship to authority are more likely to assess loss of control and suicide risk when describing the morbidity of MI. People with a lateral relationship to authority believe power should be distributed throughout the group and often value autonomy. As such, the relationship to authority beliefs may explain the observed distribution difference. In terms of suicide risk descriptions, those who assess a higher risk often do so because of isolation concerns. This reason fits well within the lateral relationship to authority beliefs as people holding them are more communal and group-oriented. When comparing participants’ descriptions of MI’s morbidity between the relationship to authority categories, data suggests behavioral health providers with a lateral relationship to authority focus their descriptions on meaning and purpose around the expectations of the group. P8 included a “just Army fallacy,” or the expectation that the Army should have the back of the Soldier when describing issues of meaning and purpose, potentially highlighting her lateral relationship to authority beliefs. When describing how people turn against others when dealing with MI, those with linear beliefs included a direct example of Soldiers not trusting their command, potentially highlighting their linear beliefs. I found the same pattern in participants’ descriptions of resentment. The linear participant highlighted issues with linear authorities, whereas the collectivists did not. Research Question Three When analyzing the data for Research Question Three, the following codes emerged: REAL Program, interdisciplinary collaboration, limitations of existing protocols, EFT, SFT, attachment-based interventions, client specific perspective, worldview therapy, normalizing MI, therapeutic dropout prevention, EMDR, PE, CBT, compartmentalization, timing of seeking help, ACT, CPT, and creating a safe space to process. Finding Eight: Metaphysical Influences on Behavioral Health Providers’ Descriptions of Treating MI Metaphysical beliefs influenced behavioral health providers’ descriptions of their treatment choices for MI when describing the use of the REAL Program, a need for interdisciplinary collaboration when treating MI, and the use of Worldview Therapy to address the challenges those suffering from MI face. Participants with spiritual, metaphysical beliefs report treatment options that directly address the spiritual implications of MI, whereas materialist participants did not report their use. Behavioral health providers collaborate with chaplains to conduct the REAL Program to “hone one another’s understanding and experiences” and ensure “both perspectives are being explored at the same time with the group.” When describing the need for interdisciplinary collaboration, P4 describes, I do believe that to navigate through MI, which is pretty complex because it’s tapping into several aspects of someone’s life, you know. Not just the emotional or psychological but also the spiritual. Because it taps into multiple areas, it’s really important, I think, for there to be collegial effort for mental health field and those in spiritual care to work together. When discussing using Worldview Therapy, P5 describes their approach to treating MI as starting with client education around MI, followed by some worldview work, establishing and challenging core existential beliefs. Materialists reported the use of current trauma-focused EBTs such as CBT, CPT, EMDR, and ACT. Finding Nine: Locus of Responsibility Influences on Behavioral Health Providers’ Descriptions of Treating MI Locus of responsibility beliefs influenced behavioral health providers’ descriptions of their treatment for MI when describing the current limitations of existing protocols, Worldview Therapy, Compartmentalization, and the use of ACT. Thematic distribution comparisons suggest that participants with an external locus of responsibility describe their treatments more systemically, considering environmental and existential implications. One sees this in the distribution differences between the limitations of existing protocols and Worldview Therapy themes. P1 (external locus of responsibility) described, I think those evidence-based protocols that we have, whether it be prolonged exposure, cognitive processing therapy, written exposure, might not target those specific concerns. Now, I think there’s a lot of really awesome work being done to adapt those protocols to moral injury, and a lot of those different difficulties that go along with it, but I think it’s still in the early stages. So that’s one thing that I hear when I’m delivering trauma focus protocols is well, we haven’t really talked about, you know, the guilt piece, or haven’t fully resolved this component. The participants’ descriptions focus on the guilt aspect not being addressed, which I connected to the provider’s holistic and systemic beliefs when assessing and treating MI. I found the same difference when comparing descriptions across the locus of responsibility categories. The external locus of responsibility beliefs places a higher weight on the environmental influences on a person. In contrast, internal locus of responsibility beliefs place a higher weight on individual attributes when considering success and failure. Applying that lens to the participants’ descriptions, I identified an emphasis on the environmental considerations in the external description of compartmentalization. The participant described walking the client through the impact of those around him in his decision-making. Conversely, the internal participant focused on factors that helped the individual cope, showing a more internal perspective when describing the compartmentalization of MI. Finding Ten: Relationship to Group Influences on Behavioral Health Providers’ Descriptions of Treating MI Relationship to group beliefs influenced behavioral health providers’ use of the REAL Program to treat MI, the need for collaboration when treating MI, and their use of client-specific strategies to address the concerns of MI. Thematic distribution comparisons suggest that the relationship to group beliefs may influence behavioral health providers’ treatment descriptions and decisions. Participants with a collectivist relationship to group included the use of group therapy as their primary choice, the REAL Program. They also included the need for collaborative treatment when treating MI. Given that both themes speak specifically to group and collaboration, this difference may be explicable by the relationship to group categories. Likewise, only participants with collectivist beliefs included using client-specific treatment approaches. This difference highlights the participant’s relationship to group beliefs, leading me to include it in this finding. The bottom line is that the data shows that behavioral health providers’ worldviews influence how they describe their construct of MI, how they describe MI morbidity, and how they treat people they perceive as struggling with a MI. Discussion Connections to Previous Research and Theory The findings of this study, which reflect Haynes’ (2009) argument, are of paramount importance. Focusing on only one aspect (e.g., physical or mental health) contributes to fragmentation, as evidenced by Veterans feeling that EBTs fail to address spiritual or existential aspects of MI (Borges et al., 2020; Battles et al., 2018; Purcell et al., 2016). Koltko-Rivera (2000) posits that worldview influences how individuals interpret stimuli. The study’s findings support this by showing that behavioral health providers’ worldviews affect how they describe and understand MI, as seen in RQ1. According to Koltko-Rivera (2000), worldview shapes the experiencing self, guiding how individuals assign meaning to their experiences. RQ2’s data demonstrates that providers’ worldviews influence how they assess and describe MI symptoms’ severity (morbidity), providing support for this part of the theory. Worldview also influences how individuals respond to experiences. RQ3’s data illustrates that providers’ worldviews shape their treatment decisions for MI, aligning with Koltko-Rivera’s theory on the acting self and how worldview guides responses to stimuli. Findings for Research Question One show that worldview beliefs influence how behavioral health providers describe and understand MI, highlighting variations in construct and morbidity interpretations. Findings for Research Question Two demonstrate that MI generates holistic distress involving psychological, existential, and behavioral dimensions, which is consistent with Jinkerson’s understanding of the multifaceted nature of MI. Implications These findings have significant implications. First, Koltko-Rivera’s worldview theory (2000) underscores that client and provider worldviews actively shape each patient encounter, creating complex dynamics that can either enhance or hinder care. Providers must be aware of how their worldviews influence what they perceive, assess, and prioritize when providing care. When it comes to treating MI, Veterans often express that current treatments fall short in addressing the existential and spiritual dimensions of MI. Their shared experiences suggest a potential gap in understanding the holistic nature of MI among some providers. However, the inclusion of diverse professional perspectives, such as those of mental health providers and chaplains, can bring complementary strengths in understanding and addressing MI. The joint approach underscores the value of collaboration in the field. It is crucial for providers to recognize when differences between their worldview and the client’s worldview hinder care, and to address these differences ethically to avoid harm. We all have an ethical responsibility to do right by the patient, even when that means admitting our limitations and referring to/integrating others into assessment and treatment. This collaborative approach is the only way Veterans and Soldiers can trust that they will receive the help they need when facing the impossible for our freedoms. Limitations In terms of limitations, transferability is the first to be discussed. I do not claim transferability of findings outside the population of this study. Qualitative research does not claim transferability. Transferability is on the reader to interpret the findings and establish how they impact their world and reality. However, I did remain open and honest throughout to allow replication and increase internal validity. Next, there were only eight participants. More is typically better and generally desired. However, Braun and Clark (2022) recommend six to ten participants for a small self-funded project. As a self-funded project, eight participants fall within the current recommendations. Third, my worldview is indeed present as well. I own this and openly report it. See the entire project for examples of reflexivity, which I openly discuss in several places. Fourth, participants for this study were limited to those who were VA or DoD affiliated. A civilian population would likely produce different results as the VA and DoD drive MI research and often provide more continuing education on this topic than their civilian counterparts. The last limitation I will present here is the participants’ geographical location. The REAL program was initially piloted in one VA location from my research. Providers from different parts of the country may not be familiar with this treatment option. Thus, there are likely other factors than just their worldview that influence the use or lack of use of this program. Recommendations Recommendations for future research come from the participants and the researcher. The fourth journal prompt asked participants how they would advise the research field to advance the MI conversation. They would like to see the following: standardized instrument of measure for MI; more qualitative studies to capture lived experience of MI; more studies on MI treatment modalities; explore the spiritual dimensions of MI; explore effects of comorbidities on MI treatment; and to integrate all stakeholder methodologies. Furthermore, I advocate exploring the feasibility and efficacy of including spiritual care providers in MI assessment and treatment. This approach could pave the way for establishing collaborative treatment approaches, thereby addressing some hesitations and limitations in treating MI. Conclusions In closing, a statement from P4 sums up this study for me: “It’s really important, I think, for there to be collegial effort for mental health field and those in spiritual care to work together and to hone one another’s understanding and experiences.” From my Christian perspective, there is safety in the presence of counselors (see Proverbs 11:14). In the context of MI, chaplains, behavioral health providers, and primary care providers need a seat at the treatment table. MI is complex and affects the soul, mind, and body. Each subject matter expert has something to offer. Lastly, my clinical pastoral educator shared a quote his grandmother often used to encourage him: “Hope isn’t the belief that things will change, but that they can change.” I hope this work can start a real conversation in both fields on how to cross-pollinate and work better together. We each bring different experiences and expertise. Those suffering the effects of MI need and deserve both perspectives. References Battles, A. R., P2, A. J., Kelley, M. L., White, T. D., Braitman, A. L., & Hamrick, H. C. (2018). MI and PTSD as mediators of the associations between morally injurious experiences and mental health and substance use. Traumatology, 24 (4), 246–254. https://doi.org/10.1037/TRM0000153 Borges, L. M. (2019). A service member’s experience of acceptance and commitment therapy for MI (ACT-MI) via telehealth: “Learning to accept my pain and injury by reconnecting with my values and starting to live a meaningful life.” Journal of Contextual Behavioral Science , 13 , 134–140. https://doi.org/10.1016/j.jcbs.2019.08.002 Borges, L. M., Bahraini, N. H., Holliman, B. D., Gissen, M. R., Lawson, W. C., & Barnes, S. M. (2020). Veterans’ perspectives on discussing MI in the context of evidence-based psychotherapies for PTSD and other VA treatment. Journal of Clinical Psychology, 76 (3), 377–391. https://doi.org/10.1002/JCLP.22887 Boska, R. L., Dunlap, S., Kopacz, M., Bishop, T. M., & Harris, J. I. (2021). Understanding MI morbidity: A qualitative study examining chaplain’s perspectives. Journal of Religion and Health , 60 (5), 3090–3099. https://doi.org/10.1007/s10943-021-01414-3 Braun, V., & Clarke, V. (2022). Conceptual and design thinking for thematic analysis. Qualitative Psychology (Washington, D.C.), 9 (1), 3-26. https://doi.org/10.1037/qup0000196 Canda, E. R. (1998). Afterword: Linking spirituality and social work: Five themes for innovation. Social Thought, 18 (2), 97–106. https://doi.org/10.1080/15426432.1998.9960229 Canda, E. R., & Furman, L. D. (1999). Spiritual diversity in social work practice: The heart of helping . Free Press. Creswell, J. & Poth, C. (2018). Qualitative inquiry & research design: Choosing among five approaches (4 th ed.). Sage. Crisp, B. R. (2010). Spirituality and social work. Ashgate. Drescher, K. D., Currier, J. M., Nieuwsma, J. A., McCormick, W., Carroll, T. D., Sims, B. M., & Cauterucio, C. (2018). A qualitative examination of VA chaplains’ understandings and interventions related to MI in military Veterans. Journal of Religion and Health , 57 (6), 2444–2460. https://doi.org/10.1007/s10943-018-0682-3 Haynes, C.J. (2009). Holistic Human Development. J Adult Dev 16 , 53–60. https://doi.org/10.1007/s10804-009-9052-4 Jinkerson, J. D. (2016). Defining and assessing MI: A syndrome perspective. Traumatology , 22 (2), 122–130. https://doi.org/10.1037/trm0000069 Koltko-Rivera, M. E. (2000). The Worldview Assessment Instrument (WAI): The development and preliminary validation of an instrument to assess world view components relevant to counseling and psychotherapy. Dissertation Abstracts International: Section B: The Sciences and Engineering, 61 (4-B), 2266. https://www.researchgate.net/profile/Mark-Koltko-Rivera/publication/34669560_ The_Worldview_Assessment_Instrument_WAI_the_development_and_preliminary_validation_of_an_instrument_to_assess_world_view_components_relevant_to_counseling_and_psychotherapy/links/591ca30845851540595a8ba8/The-Worldview-Assessment-Instrument-WAI-the-development-and-preliminary-validation-of-an-instrument-to-assess-world-view-components-relevant-to-counseling-and-psychotherapy.pdf Kopacz, M. S., McCarten, J. M., & Pollitt, M. J. (2014). VHA chaplaincy contact with Veterans at increased risk of suicide. Southern Medical Journal , 107 (10), 661–664. Lane, M. C. (Jr). (2025). Worldview and Moral Injury: An Exploratory Multiple Case Study on Behavioral Health Providers’ Descriptions of Moral Injury [Doctoral Dissertation, Liberty University]. https://digitalcommons.liberty.edu/doctoral/6471 Norman, S. B. & Maguen, S. (August 2, 2024). Moral Injury. Veterans Affairs. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp Park, C. J. (2016). Chronic shame: A perspective integrating religion and spirituality. Journal of Religion & Spirituality in Social Work: Social Thought , 35 (4), 354–376. https://doi.org/10.1080/15426432.2016.1227291 Purcell, N., Koenig, C. J., Bosch, J., & Maguen, S. (2016). Veterans’ perspectives on the psychosocial impact of killing in war. Counseling Psychologist , 44 (7), 1062–1099. https://doi.org/10.1177/0011000016666156 Sheridan, M. (2009). Ethical issues in the use of spiritually based interventions in social work practice: What are we doing and why. Journal of Religion & Spirituality in Social Work: Social Thought, 28 (1), 99–126. https://doi.org/10.1080/15426430802643687 Yin, R. (2018). Case study research and applications : design and methods (Sixth edition.). SAGE Publications, Inc. Additional Declarations The authors declare no competing interests. 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Lane, Jr.","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYDACdhBRYSPDJgETOUBICzOIOJPGA9ZygGgtjG2HeRiI1qLbzPzswYcz53n4pJuPff7YxiDHdyMBvxazw2zmhjMqbvOwyRxLnnGwjcFYkrAWBjNpnjNALRI5xgxALYkbCGth/yb9t+0cUEv+Z5CWeiK08JhJM7YdANnCDNKSYECEljLJnjPJIL8YM5w5J2E488wDAlqOt2+T+FFhJyc/u/kxQ0WZjTzfcQK2oAJGRBogGvwhWccoGAWjYBSMAAAAF6hDjnecc+4AAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0004-3920-5713","institution":"Liberty University","correspondingAuthor":true,"prefix":"","firstName":"Mark","middleName":"C.","lastName":"Lane","suffix":"Jr."}],"badges":[],"createdAt":"2025-02-14 21:31:33","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6033275/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6033275/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":76668442,"identity":"1667a355-842a-4e24-a68e-3df8e864d1ae","added_by":"auto","created_at":"2025-02-19 13:11:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":880534,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6033275/v1/9f6a6129-0abc-4076-99f7-743592ec85d7.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eThe Impact of Worldviews on Behavioral Health Providers Descriptions of Moral Injury: A Qualitative Exploratory Multiple Case Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMoral Injury (MI) has gained increasing attention in psychological and spiritual domains, particularly in military contexts. Rooted in a holistic view of human nature\u0026mdash;mind, body, and spirit\u0026mdash;MI extends beyond traditional trauma models, affecting the soul in profound ways (Haynes, 2009). Jinkerson (2016) defines MI as a syndrome arising from a perceived violation of deeply held beliefs that create psychological, existential, behavioral, and interpersonal issues. MI often produces guilt, shame, moral conflict, self-perception issues, and loss of faith, leading to emotional numbness and relational difficulties. Though researchers have taken a keen interest in MI over the past twenty years, the National Center for PTSD acknowledges gaps in empirical assessment and treatment, with no standardized interventions available (Norman \u0026amp; Maguen, 2024). While spirituality is widely recognized as essential to trauma recovery (Canda, 1998; Canda \u0026amp; Furman, 1999; Crisp, 2016; Park, 2016), many behavioral health providers fail to integrate it due to lack of training, leaving patients feeling unseen (Borges, 2019; Borges et al., 2020). Veterans often turn to chaplains rather than psychologists, as chaplains address the spiritual injuries central to MI (Drescher et al., 2018; Boska et al., 2021; Kopacz et al., 2014). However, clinical approaches remain fragmented, with providers relying on personal religious backgrounds rather than formal training (Sheridan, 2009). This qualitative multiple-case study explored how military behavioral health providers\u0026rsquo; worldviews shape their understanding of MI, its morbidity, and treatment decisions for Veterans suffering from its effects, bridging the gap between behavioral health and spiritual care by examining these influences and ensuring a holistic approach to treating MI.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study employed a qualitative exploratory multiple case study guided by Yin\u0026rsquo;s (2018) perspective on an exploratory case study. Each participant was treated as a distinct \u0026ldquo;case.\u0026rdquo; The novelty of this research lies in its focus on the understanding of MI components among behavioral health providers and the influence of worldviews on them. This unexplored territory led to an exploratory design, which aims to unearth questions, variables, and hypotheses for future research. The research proposal was reviewed by Liberty University\u0026rsquo;s IRB and approved as an exempt study. Eight participants were recruited through snowball sampling and from two social media groups comprising Army and VA behavioral health professionals. Participants had to be licensed clinical psychologists or professional counselors working for the Department of Defense or with the VA. Participants gave written consent via email after receiving the study information sheet. This confirms that any participant has consented to the inclusion of material pertaining to themselves, that they acknowledge that they cannot be identified via the manuscript; and that the participant has been fully anonymized by the author. The recruitment process yielded eight participants, seven clinical psychologists, and one LPC.\u003c/p\u003e\n\u003cp\u003eThe data collection process was comprehensive, utilizing three distinct sources: the Worldview Assessment Instrument (Koltko-Rivera, 2000) to identify participants\u0026rsquo; worldviews, four prompted journal entries, and a semi-structured interview. The Worldview Assessment Instrument, which tests six categories, was used to understand the participants\u0026rsquo; worldviews. See Table One for an overview of the assessment and the definitions it utilizes (Koltko-Rivera, 2000). The interview questions and journal prompts were selected from studies that explored a chaplain\u0026rsquo;s understanding of MI (Drescher et al., 2018; Boska et al., 2021), ensuring the questions were relevant, insightful, and based on the literature. These questions allowed behavioral health providers to describe the construct of MI, its morbidity, and their intervention strategies, directly addressing all three research questions with previously established questions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable One\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003cp\u003eDefinition of Key Terms relevant to the Worldview Assessment Instrument\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eKey Terms\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eKey Term Definitions\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategories\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategorical Definitions\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorldview\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA set of interrelated\u003c/p\u003e\n \u003cp\u003ebeliefs about the nature of reality and human life, including beliefs\u003c/p\u003e\n \u003cp\u003eabout motivations, social behavior, and human capacities; within these\u003c/p\u003e\n \u003cp\u003etopic areas, any given world view encompasses beliefs concerning what\u003c/p\u003e\n \u003cp\u003eexists or is possible to occur in the universe, what experiences and\u003c/p\u003e\n \u003cp\u003eentities are good or bad, and what behaviors and end states should be\u003c/p\u003e\n \u003cp\u003esought or eschewed.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMutability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe possibility of\u003c/p\u003e\n \u003cp\u003echanging human nature.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChangeable\u003c/p\u003e\n \u003cp\u003ePermanent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRepresents beliefs that an adult\u0026rsquo;s character, behavioral tendencies (e.g., habits), or personality\u003c/p\u003e\n \u003cp\u003echaracteristics may exhibit change over time, due to the effect of factors external to the individual (such as social learning).\u003c/p\u003e\n \u003cp\u003eRepresents beliefs that an adult\u0026rsquo;s character, behavioral tendencies, and personality are not susceptible to any but\u003c/p\u003e\n \u003cp\u003ethe most superficial and temporary change due to external factors.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAgency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe degree to which behavior is\u003c/p\u003e\n \u003cp\u003echosen or determined.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVoluntarist\u003c/p\u003e\n \u003cp\u003eDeterministic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRepresents beliefs that individuals\u003c/p\u003e\n \u003cp\u003epossess what is termed in philosophy \u0026ldquo;free will\u0026rdquo; or \u0026ldquo;moral agency,\u0026rdquo; in terms of exercising true choice for at least some of their behaviors; thus, some behaviors cannot be accounted for by factors of genetics, social learning, or unconscious intrapsychic factors such as those\u003c/p\u003e\n \u003cp\u003ehypothesized in psychoanalytic theory.\u003c/p\u003e\n \u003cp\u003eRepresents beliefs that all human behavior is determined; these\u003c/p\u003e\n \u003cp\u003edetermining factors may be genetic, intrapsychic (in the psychodynamic\u003c/p\u003e\n \u003cp\u003esense), Or social (including social learning).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelationship to Authority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeliefs about what is considered\u003c/p\u003e\n \u003cp\u003ethe natural, \u0026ldquo;right,\u0026rdquo; or appropriate way for people to relate to authority\u003c/p\u003e\n \u003cp\u003efigures.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLinear\u003c/p\u003e\n \u003cp\u003eLateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRepresents beliefs that the best way to relate to authority figures is in the context of a clearly\u003c/p\u003e\n \u003cp\u003edefined hierarchy, where those who hold superior statuses in the hierarchy make decisions for and issue instructions to those who hold\u003c/p\u003e\n \u003cp\u003esubordinate statuses in the hierarchy.\u003c/p\u003e\n \u003cp\u003eRepresents beliefs that the best way to relate to authority figures is in the context of an egalitarian partnership, where authority is widely distributed throughout an organization, and decisions are made in a consensus fashion.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelationship to Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe priority that should be placed on one\u0026rsquo;s own agenda in life versus that of one\u0026rsquo;s reference group.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCollectivist\u003c/p\u003e\n \u003cp\u003eIndividualist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRepresents beliefs that the reference group\u0026rsquo;s agenda and goals have priority over the individual\u0026rsquo;s goals and agendas.\u003c/p\u003e\n \u003cp\u003eRepresents beliefs that the individual\u0026rsquo;s agenda and goals have priority\u003c/p\u003e\n \u003cp\u003eover the reference group\u0026rsquo;s agendas and goals.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocus of Responsibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeliefs about perceived blame or responsibility for the position one occupies in life.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExternal\u003c/p\u003e\n \u003cp\u003eInternal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRepresents beliefs that view the\u003c/p\u003e\n \u003cp\u003esociocultural environment as more potent than the individual and that success or failure [in society] is\u003c/p\u003e\n \u003cp\u003egenerally dependent on the socioeconomic system and not necessarily\u003c/p\u003e\n \u003cp\u003eon personal attributes.\u003c/p\u003e\n \u003cp\u003eRepresents beliefs that \u0026ldquo;success or failure [in life] is\u003c/p\u003e\n \u003cp\u003eattributable to the individual\u0026rsquo;s skills or personal inadequacies, and ...\u003c/p\u003e\n \u003cp\u003ethat there is a strong relationship between ability, effort, and success in\u003c/p\u003e\n \u003cp\u003esociety.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMetaphysics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeliefs concerning the reality or unreality of a spiritual dimension to life.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpiritualist\u003c/p\u003e\n \u003cp\u003eMaterialist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRepresents\u003c/p\u003e\n \u003cp\u003ebeliefs that spirit is a prime element of reality.\u003c/p\u003e\n \u003cp\u003eRepresents beliefs that \u0026ldquo;physical matter is the only or fundamental reality and that all being and processes and phenomena can be explained as manifestations or results of matter.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocus of Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeliefs concerning the causes of certain events, experienced by the person as reward or punishment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExternal\u003c/p\u003e\n \u003cp\u003eInternal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe belief that reinforcements are the result of luck.\u003c/p\u003e\n \u003cp\u003eRepresents beliefs that rewards and\u003c/p\u003e\n \u003cp\u003epunishments are contingent upon the person\u0026rsquo;s \u0026ldquo;own behavior or\u003c/p\u003e\n \u003cp\u003e[one\u0026rsquo;s] own relatively permanent characteristics.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eA researcher\u0026rsquo;s worldview influences their work (Creswell \u0026amp; Poth, 2018), so owning mine seems relevant. I viewed the data through a postpositivist lens, knowing truth is out there and can be known, though each person brings their own experiences and beliefs to the search and analysis. Post-positivism values structured approaches and multiple perspectives. To sort the data, I separated participants\u0026rsquo; descriptions into three areas: descriptions speaking to MI construct, descriptions speaking to MI morbidity, and descriptions speaking to MI treatment. From there, I entered the data into MAXQDA as three separate projects to analyze each research question separately. I then coded data using Braun and Clark\u0026rsquo;s (2022) Codebook Thematic Analysis or Template Analysis.\u003c/p\u003e\n \u003cp\u003eAfter coding, I sought to answer who said what and if there were differences in how they described the theme related to their worldview beliefs. First, I conducted crosstabs in MAXQDA to organize themes by participants\u0026rsquo; worldview categories within each cluster. I then examined distribution patterns. If a theme appeared only in one belief cluster, I reviewed the participants\u0026rsquo; descriptions for content aligning with Koltko-Rivera\u0026rsquo;s worldview definitions. When such alignment was present, I concluded that worldview beliefs might influence the observed distribution pattern. When themes were present across both worldview categories, I used a segment matrix in MAXQDA to compare descriptions. Differences in descriptions were analyzed against Koltko-Rivera\u0026rsquo;s (2000) definitions to assess whether worldview beliefs accounted for any thematic variations.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study produced more than 500 pages of data. Given space limitations, only a few examples from the data can be shared. See Lane (2025) for all the study\u0026rsquo;s data and complete analysis by theme. When analyzing the data for Research Question One, the following codes emerged: the holistic impact of MI, individual variation seen in clients with MI, MI distinct from PTSD, the need for collaborative care, assessment tools, more people seeking care, MI harder to treat than other trauma related disorders, cultural pressure, social expectations, psychological distress, spiritual distress, identity crisis, MI as a belief-behavior conflict, moral contextuality, and nuanced descriptions.\u003c/p\u003e\n\u003ch3\u003eFinding One: Metaphysical Influences on Behavioral Health Providers’ Description of the Construct of MI\u003c/h3\u003e\n\u003cp\u003eMetaphysical beliefs influenced behavioral health providers\u0026rsquo; reporting of the need for interdisciplinary care, MI involving aspects of contextual morality, the individual variation often seen in clients with MI, and descriptions of the belief-behavior conflict that defined their understanding of MI when describing their conceptual understandings of MI.\u003c/p\u003e \u003cp\u003eThematic distributions across the metaphysical categories in Research Question One and Research Question Three suggest that spiritualists call for collaboration between behavioral health and spiritual care providers, whereas materialists do not mention this need. P4 noted,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI do believe that to navigate through MI, which is pretty complex because it\u0026rsquo;s tapping into several aspects of someone\u0026rsquo;s life, you know. Not just the emotional or psychological but also the spiritual. Because it taps into multiple areas, it\u0026rsquo;s really important, I think, for there to be collegial effort for mental health field and those in spiritual care to work together and to hone one another\u0026rsquo;s understanding and experiences.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eGiven that the literature review suggested MI creates spiritual issues and the lack of spiritual integration when treating MI, this finding has empirical implications. Behavioral health providers who lean more spiritual in belief recognize the spiritual implications of MI and the need for spiritual care providers to be present during treatment.\u003c/p\u003e \u003cp\u003eThe thematic distribution between the metaphysical categories shows that four of five spiritualists included descriptions of the context in which they made a decision that led to MI. In contrast, none of the three materialists included this distinction in their descriptions of their conceptual understanding of MI. Spiritualists find a need or value in justifying their behaviors to a higher moral power or authority, explaining the difference between distributions. On the other hand, materialists would see no need to make such a justification, as to them, material is all that exists in this world- there is no higher moral power. From an implication perspective, this belief could alter how the behavioral health provider hears what their clients are saying and if they perceive the spiritual implications of the contextual nature that is often a part of MI.\u003c/p\u003e \u003cp\u003eDescription comparisons of the individual variation of MI across the metaphysical categories suggest that materialists focus their understanding of MI on the tangible, reporting only observable symptoms. On the other hand, spiritualists reported more existential concerns. The implications of this finding suggest that materialists may fail to recognize the spiritual symptoms of MI or may not address them if they identify them because current trauma-focused protocols fail to address spiritual needs. This finding could explain why Soldiers often feel behavioral health providers fail to address their spiritual needs when completing current trauma-focused EBTs, though spiritual needs may not be the focus of the EBTs (Borges et al., 2020; Battles et al., 2018; Purcell et al., 2016). Description comparisons between the metaphysical categories on the nature of the belief-behavior conflict that defined MI by the participants of this study show differences connected to the metaphysical categories. Materialists focused their descriptions around the concrete and tangible psychological response to the behavior-belief conflict. P1 described, \u0026ldquo;When I think about MI, I think about behaviors that might contradict deeply held beliefs which ultimately leads to psychological distress.\u0026rdquo; He continued, \u0026ldquo;To me MI is essentially a conflict between a belief and a behavior. If we behave in a way that is at odds with what we believe, then that will create emotional conflict.\u0026rdquo; On the other hand, spiritualists focused their descriptions more holistically, often including existential elements. P7 described, \u0026ldquo;When someone commits an act that is against their personal moral code and struggles to reconcile the person they believe they should be with the person they were in the moment when the act occurred.\u0026rdquo; P4 stated, \u0026ldquo;I view MI as a byproduct to unresolved thoughts or feelings one incurs after they have experienced or witnessed an event(s) that go against his/her moral fiber or personal beliefs about how the world, how others, or how they individually think they should behave.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cb\u003eFinding Two: Locus of Responsibility Influences on Behavioral Health Providers\u0026rsquo; Descriptions of the Construct of MI\u003c/b\u003e \u003c/p\u003e \u003cp\u003e Locus of responsibility beliefs influenced participants\u0026rsquo; descriptions around the individual variation of MI, the difficulty treating MI, the social expectations and cultural pressures found in MI, the psychological distress MI creates, the contextual morality found in MI, and the belief-behavior conflict that defined MI when describing their conceptual understanding of MI.\u003c/p\u003e \u003cp\u003eP7 (external locus of responsibility) reported that MI is more challenging to treat than other trauma-related disorders. P7 believes this finding to be because the person suffering \u0026ldquo;committed the act that triggered the MI whereas most other traumas that lead to PTSD, the individual may have contributed to the situation which led to the trauma but is less responsible for the act than with MI.\u0026rdquo; No participants with an internal locus of responsibility reported increased difficulty treating MI compared to other trauma-related issues. I find that P7\u0026rsquo;s locus of responsibility explains why he included this in his description of MI. In his statement, he explicitly states that the reason for the increased difficulty in treatment lies in the level of responsibility given to the person who is experiencing the MI. People with an external locus of responsibility place more value on the influence of external factors on a person\u0026rsquo;s success than those with an internal locus of responsibility. In this context, providers with an external locus of responsibility will focus more on the context of the situation that led to MI than on the decisions a person made. This distinction is seen in P7\u0026rsquo;s description, showing the influence of their locus of responsibility beliefs in their description of MI. Given that outside factors are complex, placing blame is more complicated, increasing the difficulty of treating MI.\u003c/p\u003e \u003cp\u003eWhen comparing participants\u0026rsquo; descriptions of the above themes, I observed the same difference across all themes. Participants with an internal locus of responsibility included an element of control in their descriptions. Participants with an external locus of responsibility focused their descriptions on the contextual nature of MI. See the whole study for a detailed comparison of findings. For a quick comparison, \u0026ldquo;It\u0026rsquo;s my moral code, or the moral code of someone\u0026rsquo;s being challenged by decisions they\u0026rsquo;ve made, or having to be in situations that they may be in control of or not in control of and making decisions that kind of violate their belief systems and what they may do in a different circumstance if situations were different\u0026rdquo; versus \u0026ldquo;In short, it feels like applying garrison morality to a wartime decision. What may have been necessary in Baghdad is being evaluated based on Salt Lake City\u0026rsquo;s morality\u0026rdquo; (internal versus external locus of responsibility participants\u0026rsquo; descriptions, respectively).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFinding Three: Relationship to Group and Authority Influences on Behavioral Health Providers\u0026rsquo; Descriptions of the Construct of MI\u003c/b\u003e \u003c/p\u003e \u003cp\u003eRelationship to group and relationship to authority beliefs influenced participants\u0026rsquo; descriptions of their construct of MI, with the idea of betrayal being the key difference observed across these categories.\u003c/p\u003e \u003cp\u003eI found the same difference when comparing participants\u0026rsquo; descriptions of their construct of MI between the relationship to group and the relationship to authority categories. In the relationship to group descriptions, participants with an external relationship to group described a sense of betrayal or turning against those that turned them \u0026ldquo;into a monster\u0026rdquo; in the person suffering with MI\u0026rsquo;s eyes. I observed the same pattern in the relationship to authority descriptions. Those with a linear relationship to authority describe issues with commanders or betrayals that participants with a linear relationship to authority did not report. P8 (linear relationship to authority) described MI as \u0026ldquo;distress stemming from witnessing, engaging, or being unable to prevent a traumatic event which violates the individuals moral or ethical beliefs. There is a feeling of shame or guilt or even betrayal from the organization for being \u0026lsquo;put\u0026rsquo; in position to be exposed to the risks that violate their moral code.\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003eResearch Question Two\u003c/h3\u003e\n\u003cp\u003eWhen analyzing the data for Research Question Two, the following codes emerged: delayed onset of symptoms, longevity of symptoms, loss of control, spiritual, worth or value, meaning and purpose, changes in beliefs, issues of faith, intrusions, nightmares, turning against people, substance abuse, issues of trust, resentment, anxiety, remorse, anger, emotional, shame, fear, self-hate, depression, guilt, physical symptoms, cognitive issues, suicidality risk unchanged, suicidality risk increased, yes and no suicidality risk, isolating behaviors, and differentiating MI from other trauma related issues.\u003c/p\u003e\n\u003ch3\u003eFinding Four: Metaphysical Influences on Behavioral Health Providers’ Descriptions of the Effects of MI\u003c/h3\u003e\n\u003cp\u003eMetaphysical beliefs influenced behavioral health providers\u0026rsquo; descriptions around the delayed onset, spiritual issues, issues of faith, remorse, self-hate, increased suicide risk, turning against people, and cognitive issues when describing the effects of MI.\u003c/p\u003e \u003cp\u003eThematic distribution comparisons show that spiritualists are more likely to report spiritual issues, issues of faith, remorse, self-hate, and an increased risk of suicide when describing the symptoms and presentation of MI. While other explanations are certainly possible, I find the underlying metaphysical beliefs of the behavioral health provider may influence these differences. For instance, P7 (spiritualist), when describing why he assesses a higher suicide risk, specifically addresses spiritual issues like community, faith, and general beliefs.\u003c/p\u003e \u003cp\u003eI haven\u0026rsquo;t seen research to show that that bears out, but I know, as far as my own personal practice, I am more concerned about somebody who is struggling with a MI, and a lot of that has to do with just general risk factors. And so, like we discussed, they\u0026rsquo;re less connected to their community. They\u0026rsquo;re less connected to their families. They\u0026rsquo;re struggling with their faith. They\u0026rsquo;re struggling with what their values truly are. And so, all of those things that are kind of secondary to the MI in my work would place them at a higher risk of self-harm.\u003c/p\u003e \u003cp\u003eComparing participants\u0026rsquo; descriptions between the metaphysical categories, spiritualists focused their descriptions of people turning against others on reconciliation, whereas materialists focused on retribution. Spiritualists generally believe in a spiritual world where other powers exist. In the context of Christianity, reconciliation after the commitment of sin is vitally important. Conversely, materialists generally believe in a sole material existence. They may be less likely to place reconciliation as high of a need. I also saw a difference in participants\u0026rsquo; descriptions of the cognitive issues in MI. The spiritualists\u0026rsquo; descriptions included a person\u0026rsquo;s need to understand or make meaning when describing the cognitive issues that come with MI. In contrast, the materialists\u0026rsquo; descriptions solely focused on their \u0026ldquo;concentration is impacted.\u0026rdquo; Given that meaning and purpose lie in our spiritual capacity as humans, I conclude that metaphysical beliefs explain the difference in participants\u0026rsquo; descriptions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFinding Five: Locus of Responsibility Influences on Behavioral Health Providers\u0026rsquo; Descriptions of the Effects of MI\u003c/b\u003e \u003c/p\u003e \u003cp\u003eLocus of responsibility beliefs influenced behavioral health providers\u0026rsquo; descriptions around the longevity of MI symptoms, the delayed onset, the spiritual issues of MI, issues of worth and value, changes in beliefs, issues of faith, resentment, and suicide- risk increased and suicide- risk unchanged when describing the morbidity of MI.\u003c/p\u003e \u003cp\u003eThematic distribution comparisons suggest that participants with an external locus of responsibility described the systems around the person. In contrast, those with an internal locus of responsibility focused more on the individual\u0026rsquo;s ability to change. The difference in beliefs led participants with an external locus of responsibility to describe MI as a long-lasting issue, including spiritual concerns, issues of worth and value, and changes in beliefs in their description of MI morbidity. Given the systemic view found in the external locus of responsibility participants\u0026rsquo; descriptions, I believe this difference may be explained by the participants\u0026rsquo; locus of responsibility beliefs. The one mention of faith issues came from a participant with an internal locus of responsibility. I believe the distribution difference may be explained by locus of responsibility beliefs, though I recognize that metaphysical beliefs may also explain this difference. P6 (internal locus of responsibility) stated,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think that part of my consideration for how I think people recover from moral injuries is the lens in which they see their decisions in. I found people who have a more spiritual glance at it manage it through their belief. They see what they did as it was something they did it for their country and believe \u0026ldquo;God forgives me!\u0026rdquo; You deal with a lot of people who are dealing with forgiveness.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFrom their description, the idea of personal accountability is clear. It highlights a person\u0026rsquo;s ability to contribute to their success or failure, the defining aspect of Koltko-Rivera\u0026rsquo;s (2000) locus of responsibility beliefs.\u003c/p\u003e \u003cp\u003eWhen comparing participants\u0026rsquo; descriptions across the locus of responsibility categories, the locus of responsibility beliefs influenced participants\u0026rsquo; descriptions around resentment. P8\u0026rsquo;s description of resentment highlights individuation by describing much of the person\u0026rsquo;s resentment as secondary to their control. P8 highlights that Soldiers are often placed in situations they were not expecting and asked to do things they could not imagine, demonstrating their inability to control the situation and P8\u0026rsquo;s internal locus of responsibility beliefs. There were also differences in participants\u0026rsquo; descriptions of suicide risk assessments. Participants with an external locus of responsibility focused their descriptions of suicide risk factors on external or environmental factors. Participants with an internal locus of responsibility focused their descriptions of risk factors on the client\u0026rsquo;s internal beliefs, not other external risk or protective factors. Locus of responsibility beliefs explain these differences in participants\u0026rsquo; descriptions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFinding Six: Relationship to Group Influences on Behavioral Health Providers\u0026rsquo; Descriptions of the Effects of MI\u003c/b\u003e \u003c/p\u003e \u003cp\u003eRelationship to group beliefs influenced behavioral health providers\u0026rsquo; descriptions around the spiritual symptoms, meaning and purpose, issues of faith, substance abuse, issues of trust, anxiety, remorse, self-hate, loss of control, and resentment when describing the morbidity of MI.\u003c/p\u003e \u003cp\u003eThematic distribution comparisons between the relationship to group categories suggest that providers with an individualist relationship to group identify clients\u0026rsquo; self-assessment, as seen by their reporting issues of self-hate. Participants with a collectivist relationship to group identified the spiritual issues, meaning and purpose, issues of faith, substance abuse, issues of trust, anxiety, and remorse when describing the morbidity of MI. In contrast, those with individualist beliefs did not report these themes, highlighting MI\u0026rsquo;s communal impact on Soldiers and the communal focus of external relationship to group participants.\u003c/p\u003e \u003cp\u003e Comparing participants\u0026rsquo; descriptions of the morbidity of MI across the relationship to group categories suggests that behavioral health providers with individual relationships to group beliefs focused their descriptions on the impact on self when describing the loss of control that comes with MI. Conversely, participants with a collectivist relationship to group describe the loss of control in relational terms by mentioning the person\u0026rsquo;s feelings about their community. Similarly, when describing resentment, participants with a collectivist relationship to group included the idea of \u0026ldquo;just Army fallacy\u0026rdquo; and their expectations for the group to look out for the individual when describing resentment. Individualists reported resentment as a possible symptom with no reference to the direction of that resentment.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFinding Seven: Relationship to Authority Influences on Behavioral Health Providers\u0026rsquo; Descriptions of the Effects of MI\u003c/b\u003e \u003c/p\u003e \u003cp\u003eRelationship to authority beliefs influenced behavioral health providers\u0026rsquo; descriptions around the loss of control, issues of trust, suicide risk, meaning and purpose, turning against people, and resentment when describing the morbidity of MI.\u003c/p\u003e \u003cp\u003eThematic distribution comparisons between the relationship to authority categories suggest that behavioral health providers with a lateral relationship to authority are more likely to assess loss of control and suicide risk when describing the morbidity of MI. People with a lateral relationship to authority believe power should be distributed throughout the group and often value autonomy. As such, the relationship to authority beliefs may explain the observed distribution difference. In terms of suicide risk descriptions, those who assess a higher risk often do so because of isolation concerns. This reason fits well within the lateral relationship to authority beliefs as people holding them are more communal and group-oriented.\u003c/p\u003e \u003cp\u003eWhen comparing participants\u0026rsquo; descriptions of MI\u0026rsquo;s morbidity between the relationship to authority categories, data suggests behavioral health providers with a lateral relationship to authority focus their descriptions on meaning and purpose around the expectations of the group. P8 included a \u0026ldquo;just Army fallacy,\u0026rdquo; or the expectation that the Army should have the back of the Soldier when describing issues of meaning and purpose, potentially highlighting her lateral relationship to authority beliefs. When describing how people turn against others when dealing with MI, those with linear beliefs included a direct example of Soldiers not trusting their command, potentially highlighting their linear beliefs. I found the same pattern in participants\u0026rsquo; descriptions of resentment. The linear participant highlighted issues with linear authorities, whereas the collectivists did not.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eResearch Question Three\u003c/h2\u003e \u003cp\u003eWhen analyzing the data for Research Question Three, the following codes emerged: REAL Program, interdisciplinary collaboration, limitations of existing protocols, EFT, SFT, attachment-based interventions, client specific perspective, worldview therapy, normalizing MI, therapeutic dropout prevention, EMDR, PE, CBT, compartmentalization, timing of seeking help, ACT, CPT, and creating a safe space to process.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFinding Eight: Metaphysical Influences on Behavioral Health Providers’ Descriptions of Treating MI\u003c/h3\u003e\n\u003cp\u003eMetaphysical beliefs influenced behavioral health providers\u0026rsquo; descriptions of their treatment choices for MI when describing the use of the REAL Program, a need for interdisciplinary collaboration when treating MI, and the use of Worldview Therapy to address the challenges those suffering from MI face.\u003c/p\u003e \u003cp\u003e Participants with spiritual, metaphysical beliefs report treatment options that directly address the spiritual implications of MI, whereas materialist participants did not report their use. Behavioral health providers collaborate with chaplains to conduct the REAL Program to \u0026ldquo;hone one another\u0026rsquo;s understanding and experiences\u0026rdquo; and ensure \u0026ldquo;both perspectives are being explored at the same time with the group.\u0026rdquo; When describing the need for interdisciplinary collaboration, P4 describes,\u003c/p\u003e \u003cp\u003eI do believe that to navigate through MI, which is pretty complex because it\u0026rsquo;s tapping into several aspects of someone\u0026rsquo;s life, you know. Not just the emotional or psychological but also the spiritual. Because it taps into multiple areas, it\u0026rsquo;s really important, I think, for there to be collegial effort for mental health field and those in spiritual care to work together.\u003c/p\u003e \u003cp\u003eWhen discussing using Worldview Therapy, P5 describes their approach to treating MI as starting with client education around MI, followed by some worldview work, establishing and challenging core existential beliefs. Materialists reported the use of current trauma-focused EBTs such as CBT, CPT, EMDR, and ACT.\u003c/p\u003e\n\u003ch3\u003eFinding Nine: Locus of Responsibility Influences on Behavioral Health Providers’ Descriptions of Treating MI\u003c/h3\u003e\n\u003cp\u003eLocus of responsibility beliefs influenced behavioral health providers\u0026rsquo; descriptions of their treatment for MI when describing the current limitations of existing protocols, Worldview Therapy, Compartmentalization, and the use of ACT.\u003c/p\u003e \u003cp\u003eThematic distribution comparisons suggest that participants with an external locus of responsibility describe their treatments more systemically, considering environmental and existential implications. One sees this in the distribution differences between the limitations of existing protocols and Worldview Therapy themes. P1 (external locus of responsibility) described,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think those evidence-based protocols that we have, whether it be prolonged exposure, cognitive processing therapy, written exposure, might not target those specific concerns. Now, I think there\u0026rsquo;s a lot of really awesome work being done to adapt those protocols to moral injury, and a lot of those different difficulties that go along with it, but I think it\u0026rsquo;s still in the early stages. So that\u0026rsquo;s one thing that I hear when I\u0026rsquo;m delivering trauma focus protocols is well, we haven\u0026rsquo;t really talked about, you know, the guilt piece, or haven\u0026rsquo;t fully resolved this component.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe participants\u0026rsquo; descriptions focus on the guilt aspect not being addressed, which I connected to the provider\u0026rsquo;s holistic and systemic beliefs when assessing and treating MI.\u003c/p\u003e \u003cp\u003eI found the same difference when comparing descriptions across the locus of responsibility categories. The external locus of responsibility beliefs places a higher weight on the environmental influences on a person. In contrast, internal locus of responsibility beliefs place a higher weight on individual attributes when considering success and failure. Applying that lens to the participants\u0026rsquo; descriptions, I identified an emphasis on the environmental considerations in the external description of compartmentalization. The participant described walking the client through the impact of those around him in his decision-making. Conversely, the internal participant focused on factors that helped the individual cope, showing a more internal perspective when describing the compartmentalization of MI.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFinding Ten: Relationship to Group Influences on Behavioral Health Providers\u0026rsquo; Descriptions of Treating MI\u003c/h2\u003e \u003cp\u003eRelationship to group beliefs influenced behavioral health providers\u0026rsquo; use of the REAL Program to treat MI, the need for collaboration when treating MI, and their use of client-specific strategies to address the concerns of MI.\u003c/p\u003e \u003cp\u003eThematic distribution comparisons suggest that the relationship to group beliefs may influence behavioral health providers\u0026rsquo; treatment descriptions and decisions. Participants with a collectivist relationship to group included the use of group therapy as their primary choice, the REAL Program. They also included the need for collaborative treatment when treating MI. Given that both themes speak specifically to group and collaboration, this difference may be explicable by the relationship to group categories. Likewise, only participants with collectivist beliefs included using client-specific treatment approaches. This difference highlights the participant\u0026rsquo;s relationship to group beliefs, leading me to include it in this finding.\u003c/p\u003e \u003cp\u003eThe bottom line is that the data shows that behavioral health providers\u0026rsquo; worldviews influence how they describe their construct of MI, how they describe MI morbidity, and how they treat people they perceive as struggling with a MI.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eConnections to Previous Research and Theory\u003c/h2\u003e \u003cp\u003eThe findings of this study, which reflect Haynes\u0026rsquo; (2009) argument, are of paramount importance. Focusing on only one aspect (e.g., physical or mental health) contributes to fragmentation, as evidenced by Veterans feeling that EBTs fail to address spiritual or existential aspects of MI (Borges et al., 2020; Battles et al., 2018; Purcell et al., 2016). Koltko-Rivera (2000) posits that worldview influences how individuals interpret stimuli. The study\u0026rsquo;s findings support this by showing that behavioral health providers\u0026rsquo; worldviews affect how they describe and understand MI, as seen in RQ1.\u003c/p\u003e \u003cp\u003eAccording to Koltko-Rivera (2000), worldview shapes the experiencing self, guiding how individuals assign meaning to their experiences. RQ2\u0026rsquo;s data demonstrates that providers\u0026rsquo; worldviews influence how they assess and describe MI symptoms\u0026rsquo; severity (morbidity), providing support for this part of the theory. Worldview also influences how individuals respond to experiences. RQ3\u0026rsquo;s data illustrates that providers\u0026rsquo; worldviews shape their treatment decisions for MI, aligning with Koltko-Rivera\u0026rsquo;s theory on the acting self and how worldview guides responses to stimuli. Findings for Research Question One show that worldview beliefs influence how behavioral health providers describe and understand MI, highlighting variations in construct and morbidity interpretations. Findings for Research Question Two demonstrate that MI generates holistic distress involving psychological, existential, and behavioral dimensions, which is consistent with Jinkerson\u0026rsquo;s understanding of the multifaceted nature of MI.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eThese findings have significant implications. First, Koltko-Rivera\u0026rsquo;s worldview theory (2000) underscores that client and provider worldviews actively shape each patient encounter, creating complex dynamics that can either enhance or hinder care. Providers must be aware of how their worldviews influence what they perceive, assess, and prioritize when providing care.\u003c/p\u003e \u003cp\u003eWhen it comes to treating MI, Veterans often express that current treatments fall short in addressing the existential and spiritual dimensions of MI. Their shared experiences suggest a potential gap in understanding the holistic nature of MI among some providers. However, the inclusion of diverse professional perspectives, such as those of mental health providers and chaplains, can bring complementary strengths in understanding and addressing MI. The joint approach underscores the value of collaboration in the field. It is crucial for providers to recognize when differences between their worldview and the client\u0026rsquo;s worldview hinder care, and to address these differences ethically to avoid harm. We all have an ethical responsibility to do right by the patient, even when that means admitting our limitations and referring to/integrating others into assessment and treatment. This collaborative approach is the only way Veterans and Soldiers can trust that they will receive the help they need when facing the impossible for our freedoms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eIn terms of limitations, transferability is the first to be discussed. I do not claim transferability of findings outside the population of this study. Qualitative research does not claim transferability. Transferability is on the reader to interpret the findings and establish how they impact their world and reality. However, I did remain open and honest throughout to allow replication and increase internal validity. Next, there were only eight participants. More is typically better and generally desired. However, Braun and Clark (2022) recommend six to ten participants for a small self-funded project. As a self-funded project, eight participants fall within the current recommendations. Third, my worldview is indeed present as well. I own this and openly report it. See the entire project for examples of reflexivity, which I openly discuss in several places. Fourth, participants for this study were limited to those who were VA or DoD affiliated. A civilian population would likely produce different results as the VA and DoD drive MI research and often provide more continuing education on this topic than their civilian counterparts. The last limitation I will present here is the participants\u0026rsquo; geographical location. The REAL program was initially piloted in one VA location from my research. Providers from different parts of the country may not be familiar with this treatment option. Thus, there are likely other factors than just their worldview that influence the use or lack of use of this program.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003eRecommendations for future research come from the participants and the researcher. The fourth journal prompt asked participants how they would advise the research field to advance the MI conversation. They would like to see the following: standardized instrument of measure for MI; more qualitative studies to capture lived experience of MI; more studies on MI treatment modalities; explore the spiritual dimensions of MI; explore effects of comorbidities on MI treatment; and to integrate all stakeholder methodologies. Furthermore, I advocate exploring the feasibility and efficacy of including spiritual care providers in MI assessment and treatment. This approach could pave the way for establishing collaborative treatment approaches, thereby addressing some hesitations and limitations in treating MI.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn closing, a statement from P4 sums up this study for me: \u0026ldquo;It\u0026rsquo;s really important, I think, for there to be collegial effort for mental health field and those in spiritual care to work together and to hone one another\u0026rsquo;s understanding and experiences.\u0026rdquo; From my Christian perspective, there is safety in the presence of counselors (see Proverbs 11:14). In the context of MI, chaplains, behavioral health providers, and primary care providers need a seat at the treatment table. MI is complex and affects the soul, mind, and body. Each subject matter expert has something to offer. Lastly, my clinical pastoral educator shared a quote his grandmother often used to encourage him: \u0026ldquo;Hope isn\u0026rsquo;t the belief that things will change, but that they can change.\u0026rdquo; I hope this work can start a real conversation in both fields on how to cross-pollinate and work better together. We each bring different experiences and expertise. Those suffering the effects of MI need and deserve both perspectives.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBattles, A. R., P2, A. J., Kelley, M. L., White, T. D., Braitman, A. L., \u0026amp; Hamrick, H. C. (2018). MI and PTSD as mediators of the associations between morally injurious experiences and mental health and substance use. \u003cem\u003eTraumatology, 24\u003c/em\u003e(4), 246\u0026ndash;254. https://doi.org/10.1037/TRM0000153\u003c/li\u003e\n\u003cli\u003eBorges, L. M. (2019). A service member\u0026rsquo;s experience of acceptance and commitment therapy for MI (ACT-MI) via telehealth: \u0026ldquo;Learning to accept my pain and injury by reconnecting with my values and starting to live a meaningful life.\u0026rdquo; \u003cem\u003eJournal of Contextual Behavioral Science\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e, 134\u0026ndash;140. https://doi.org/10.1016/j.jcbs.2019.08.002\u003c/li\u003e\n\u003cli\u003eBorges, L. M., Bahraini, N. H., Holliman, B. D., Gissen, M. R., Lawson, W. C., \u0026amp; Barnes, S. M. (2020). Veterans\u0026rsquo; perspectives on discussing MI in the context of evidence-based psychotherapies for PTSD and other VA treatment. \u003cem\u003eJournal of Clinical Psychology, 76\u003c/em\u003e(3), 377\u0026ndash;391. https://doi.org/10.1002/JCLP.22887\u003c/li\u003e\n\u003cli\u003eBoska, R. L., Dunlap, S., Kopacz, M., Bishop, T. M., \u0026amp; Harris, J. I. (2021). Understanding MI morbidity: A qualitative study examining chaplain\u0026rsquo;s perspectives. \u003cem\u003eJournal of Religion and Health\u003c/em\u003e, \u003cem\u003e60\u003c/em\u003e(5), 3090\u0026ndash;3099. https://doi.org/10.1007/s10943-021-01414-3\u003c/li\u003e\n\u003cli\u003eBraun, V., \u0026amp; Clarke, V. (2022). Conceptual and design thinking for thematic analysis. \u003cem\u003eQualitative Psychology\u003c/em\u003e (Washington, D.C.), \u003cem\u003e9\u003c/em\u003e(1), 3-26. https://doi.org/10.1037/qup0000196\u003c/li\u003e\n\u003cli\u003eCanda, E. R. (1998). Afterword: Linking spirituality and social work: Five themes for innovation. \u003cem\u003eSocial Thought, 18\u003c/em\u003e(2), 97\u0026ndash;106. https://doi.org/10.1080/15426432.1998.9960229\u003c/li\u003e\n\u003cli\u003eCanda, E. R., \u0026amp; Furman, L. D. (1999). \u003cem\u003eSpiritual diversity in social work practice: The heart of helping\u003c/em\u003e. Free Press.\u003c/li\u003e\n\u003cli\u003eCreswell, J. \u0026amp; Poth, C. (2018). \u003cem\u003eQualitative inquiry \u0026amp; research design: Choosing among five approaches \u003c/em\u003e(4\u003csup\u003eth\u003c/sup\u003e ed.). Sage.\u003c/li\u003e\n\u003cli\u003eCrisp, B. R. (2010). Spirituality and social work. Ashgate.\u003c/li\u003e\n\u003cli\u003eDrescher, K. D., Currier, J. M., Nieuwsma, J. A., McCormick, W., Carroll, T. D., Sims, B. M., \u0026amp; Cauterucio, C. (2018). A qualitative examination of VA chaplains\u0026rsquo; understandings and interventions related to MI in military Veterans. \u003cem\u003eJournal of Religion and Health\u003c/em\u003e, \u003cem\u003e57\u003c/em\u003e(6), 2444\u0026ndash;2460. https://doi.org/10.1007/s10943-018-0682-3\u003c/li\u003e\n\u003cli\u003eHaynes, C.J. (2009). Holistic Human Development. \u003cem\u003eJ Adult Dev\u003c/em\u003e \u003cem\u003e16\u003c/em\u003e, 53\u0026ndash;60. https://doi.org/10.1007/s10804-009-9052-4\u003c/li\u003e\n\u003cli\u003eJinkerson, J. D. (2016). Defining and assessing MI: A syndrome perspective. \u003cem\u003eTraumatology\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(2), 122\u0026ndash;130. https://doi.org/10.1037/trm0000069\u003c/li\u003e\n\u003cli\u003eKoltko-Rivera, M. E. (2000). The Worldview Assessment Instrument (WAI): The development and preliminary validation of an instrument to assess world view components relevant to counseling and psychotherapy. \u003cem\u003eDissertation Abstracts International: Section B: The Sciences and Engineering, 61\u003c/em\u003e(4-B), 2266. https://www.researchgate.net/profile/Mark-Koltko-Rivera/publication/34669560_ The_Worldview_Assessment_Instrument_WAI_the_development_and_preliminary_validation_of_an_instrument_to_assess_world_view_components_relevant_to_counseling_and_psychotherapy/links/591ca30845851540595a8ba8/The-Worldview-Assessment-Instrument-WAI-the-development-and-preliminary-validation-of-an-instrument-to-assess-world-view-components-relevant-to-counseling-and-psychotherapy.pdf\u003c/li\u003e\n\u003cli\u003eKopacz, M. S., McCarten, J. M., \u0026amp; Pollitt, M. J. (2014). VHA chaplaincy contact with Veterans at increased risk of suicide. \u003cem\u003eSouthern Medical Journal\u003c/em\u003e, \u003cem\u003e107\u003c/em\u003e(10), 661\u0026ndash;664.\u003c/li\u003e\n\u003cli\u003eLane, M. C. (Jr). (2025). \u003cem\u003eWorldview and Moral Injury: An Exploratory Multiple Case Study on Behavioral Health Providers\u0026rsquo; Descriptions of Moral Injury\u003c/em\u003e [Doctoral Dissertation, Liberty University]. https://digitalcommons.liberty.edu/doctoral/6471\u003c/li\u003e\n\u003cli\u003eNorman, S. B. \u0026amp; Maguen, S. (August 2, 2024). \u003cem\u003eMoral Injury. \u003c/em\u003eVeterans Affairs. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp\u003c/li\u003e\n\u003cli\u003ePark, C. J. (2016). Chronic shame: A perspective integrating religion and spirituality.\u003cem\u003e Journal of Religion \u0026amp; Spirituality in Social Work: Social Thought\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(4), 354\u0026ndash;376. https://doi.org/10.1080/15426432.2016.1227291\u003c/li\u003e\n\u003cli\u003ePurcell, N., Koenig, C. J., Bosch, J., \u0026amp; Maguen, S. (2016). Veterans\u0026rsquo; perspectives on the psychosocial impact of killing in war. \u003cem\u003eCounseling Psychologist\u003c/em\u003e, \u003cem\u003e44\u003c/em\u003e(7), 1062\u0026ndash;1099. https://doi.org/10.1177/0011000016666156\u003c/li\u003e\n\u003cli\u003eSheridan, M. (2009). Ethical issues in the use of spiritually based interventions in social work practice: What are we doing and why. \u003cem\u003eJournal of Religion \u0026amp; Spirituality in Social Work: Social Thought, 28\u003c/em\u003e(1), 99\u0026ndash;126. https://doi.org/10.1080/15426430802643687\u003c/li\u003e\n\u003cli\u003eYin, R. (2018). \u003cem\u003eCase study research and applications : design and methods\u003c/em\u003e (Sixth edition.). SAGE Publications, Inc.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Liberty University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Moral Injury, Worldview, Behavioral Health Providers, Holistic Care","lastPublishedDoi":"10.21203/rs.3.rs-6033275/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6033275/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBACKGROUND\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHumans are holistic beings. Moral Injury (MI) creates holistic distress. There is limited standardization in MI constructs, assessments, and treatments. Current care for MI often limits spiritual integration. AIMS- The purpose of this qualitative exploratory multiple case study was to explore how military behavioral health providers’ worldview influenced their description of the construct of MI, the morbidity of MI, and how these providers chose to treat clients they perceived to be suffering through the effects of MI.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEight Department of Defense or Veterans Affairs affiliated behavioral health providers completed a worldview assessment, prompted journal responses, and semi-structured interviews to understand how their worldview impacts their descriptions of MI constructs, morbidity, and treatment decisions. I analyzed the data through postpositivist beliefs utilizing Codebook Template Analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants’ worldviews influenced how they described MI as a construct, what they assessed as MI morbidity, and how they chose to treat it.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMore studies are needed to explore MI’s spiritual dimensions and effects. Assessment and treatment should include all stakeholders’ methodologies. Treatment for MI should include care from providers for the body (medical doctors), soul (chaplains), and mind (behavioral health providers).\u003c/p\u003e","manuscriptTitle":"The Impact of Worldviews on Behavioral Health Providers Descriptions of Moral Injury: A Qualitative Exploratory Multiple Case Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-19 12:55:48","doi":"10.21203/rs.3.rs-6033275/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ad872570-4a04-4037-84bb-30cfc7dcf5b7","owner":[],"postedDate":"February 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-19T12:55:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-19 12:55:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6033275","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6033275","identity":"rs-6033275","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}