Spiritual Injury Assessment

I’m Gary Berg, developer of the spiritual injury scale or questionnaire. It is a software application or tool used for diagnosing spiritual injuries. Clinicians can also use it to name moral injuries, so this tool is useful in treating both spiritual and moral wounds.

When I have an appointment to visit my local medical clinic, my health provider asks me to fill out a form to find health and physical problems. Doctors use this questionnaire to screen for illness and medical conditions needing treatment. Questions are asked about pain, fatigue, sleep disturbance, falls, loss of appetite, and other conditions related to our health. Doctors and medical professionals are caretakers and take responsibility for the community’s physical health. These questionnaires screen for our physical health status and wellbeing.

Mental health professionals use similar surveys. They ask about feeling anxious or nervous, sad or depressed, absence of a support system, having no interest in doing what used to be enjoyable or needs to be done, feeling bad about oneself, or thoughts that one would be better off dead or hurting ourselves. These screens measure an individual’s mental health wellbeing and status, and counselors use them to treat mental illness. It is the mental health professionals who are the stewards of the community’s mental health and wellbeing.

Pastors, priests, chaplains, and religious leaders are the ones assigned responsibility for the spiritual health of the community and provide for the treatment of spiritual injuries and stress individuals and families are feeling. It is an area often ignored and overlooked. Like doctors and mental health providers, we too need tools to screen for and treat spiritual distress and problems that desperately need our attention and relief.

You can download this spiritual injury tool to treat what I consider to be a crisis in contemporary culture.

The spiritual injury questionnaire or screen includes 8 items. They are 1) Guilt, 2) Anger, 3) Grief or Sadness, 4) Lack of Meaning or Purpose, 5) Despair or Hopelessness, 6) Feeling God/Life Have Been Unfair, 7) Worry Over Doubts/Disbelief In God, 8) Frequent Thoughts About Death.

I define a spiritual injury as our response to an event caused by self, or an event beyond our control, that damages our relationship with God, self and other, and alienates us from that which gives meaning to our lives. Because spiritual injuries or accidents create an existential crisis or take meaning from our lives, they call for our response in providing spiritual care to those we serve.

The eight item Spiritual Injury questionnaire gives us entry points into what lays beneath the surface, and I would offer, into the depths of the human soul. The first injury I name is…

Guilt

The background for the development of the Spiritual Injury Inventory (SIS) originated in work done at the VA Medical Center in St. Cloud, Minnesota. More than 4,000 veterans who completed this inventory identified guilt as the number one spiritual injury they struggle with.

The literature on war is replete with mentioning guilt. Jonathon Shay, in his two books on war, Achilles in Vietnam, and Odysseus, references guilt 81 times. Robert Meagher and Douglas Pryer, in War and Moral Injury, the book they edited, mention guilt as the burden soldiers carry, 96 times; a second book Meagher wrote, Killing From the Inside Out, guilt is highlighted 28 times. The book, Soul Repair: Recovering from Moral Injury after War, written by Rita Nakashima Brock and Gabriella Lettini, name guilt as a primary symptom of moral injury 23 times; and Karl Marlantes in What It Is Like To Go To War, references guilt as the burden soldiers carry 27 times.

We may have difficulty identifying with the guilt suffered by combat soldiers, but if guilt can be addressed at the level experienced in the chaotic evilness of war, then lesser expressions of its existence we all suffer from can more easily be faced and treated.

The antidote for guilt is obviously forgiveness. Forgiveness is often the centerpiece for the rituals we practice in our worshipping communities. Worship services usually include public confession of sin followed by the assurance of forgiveness. If the confession of sin is not included in public worship, certainly it is included in reciting the Lords’ Prayer: Forgive us our trespasses or sin as we forgive those who trespass or sin against us.

In all four Gospels Jesus repeatedly says, “Your sins are forgiven.” It is at the heart of the Gospel story of the Prodigal Son. It is one of the last words Jesus says from the cross as he is dying, “Father, forgive them, for they know not what they do.”

A veteran of the Vietnam War attended the church where I served as pastor. He told me the reason he attended church was to hear words spoken following the confession of sins that his sins were forgiven.

Combat veteran Arthur Egendorf writes that “nothing in the repertoire of psychological techniques and philosophical arguments I knew came close to the power of forgiveness.”

A second spiritual injury is…

Anger

Our anger grows out of our insecurity. Its basis is fear where we fear the OTHER, the unknown and what we imagine. It is a short step from fear to anger, with a brief pause along the way. And it is anger in its exaggerated form that leads to violence and its most evil expression in war.

This anger has become endemic in our culture with fear of the other being used for political purposes to gain the highest office in our land. One of the roles religions needs to play is to lower the temperature. Unfortunately, religion has too often been captured to raise the temperature and heighten the fear of those we name as our enemy.

The antidote to the spiritual injury of anger and hate, is of course love. But it is not just any kind of love which can be transactional which is defined in the original Greek language as eros. The word the New Testament uses for love is agape. It is selfless love that does not demand anything in return. It is best illustrated in the story Jesus told of the Good Samaritan. In first-century Palestine, where the story takes place, Samaritans and Jews were enemies. It was in this context that Jesus says we are to love our neighbor as ourselves and do unto others as we would have them do unto us. Then, in his Sermon of the Mount, Jesus goes even further: “You have heard that it was said, you shall love your neighbor and hate your enemy. But I say to you, love your enemies and pray for those who persecute you.”

A protocol for responding to those who say that anger or resentment often or very often block their peace of mind is to listen to their stories that gave rise to the fear and anger that created an enemy. The purpose of worship is to fine tune our lives to give up animosity and hatred. We need, as Martin Luther King, Jr. taught us, a beloved community that loves us out of our hate. In the rituals of worship, we hear repeatedly, the words spoken by Jesus, “Be not afraid.” We must not let our fear lead us to hatred.

Next, we come to…

Sadness and Grief

In a study of 325 veterans, we conducted at the VA Medical Center in Saint Cloud, the second most cited spiritual injury after guilt was grief and sadness. Numerous research studies indicate a strong association between significant losses and mental and physical illness including heart attacks, onset of cancer, and depression, as well as PTSD. The protocol for treating sadness and loses due to the death of a loved one include grief therapy, individual spiritual and pastoral counselling, grief support groups, and the rituals of healing conducted by religious communities.

Protocols used by chaplains and spiritual counselors include the stages of grief identified by Elizabeht Kubler-Ross in her book, On Death and Dying. But before therapy for losses and sadness can be initiated, those losses must be identified. Screening for spiritual injuries allows this to happen.

The rituals conducted by religious communities include the act of remembrance with a strong emphasis on gratitude and thanksgiving. In the Christian tradition, All Saints Day is an opportunity for this when candles are lit remembering those who have died, names are spoken aloud and thankfulness is expressed for those who have crossed over the boundary of death. While the process of grieving includes denial, bargaining, anger, and depression, acceptance can be arrived at when gratitude and thanksgiving crowd out and overcome the negative and damaging attitudes that often accompany loss and death.

Meaninglessness

The loss of meaning or purpose is the next spiritual injury identified by the spiritual injury questionnaire. Theologian Douglas John Hall writes that the dominant anxiety of modernity is meaninglessness and despair and not guilt and condemnation. The denial of meaning is echoed in the familiar phrase of many veterans returning from combat that “it don’t mean nothin’." This sense of nothingness is captured in Al Santoli’s oral history of the Vietnam War, Everything We Had; there was nothing left including nothing left to give.

Victor Fraqnkl, writing out of his experience of the holocaust, states that what is driving us existentially is a search for meaning to lift us out of our despair, out of our self-indulgence and loneliness, to a higher calling that binds us together. It is what religious faith does at its best, introducing us to the transcendent values of goodness, beauty, truth, and love that make our lives meaningful and worthy. It is an answer to Richard Dawkins who asserts in his book, The God Delusion, that a materialistic cosmos gives us “no design, no purpose…nothing but blind, pitiless indifference.”

It is why in religious worship we pray “give us our daily bread, forgive us our sins, as we forgive others.” Robert Putnam, in his book Bowling Alone, and more recently, The Upswing: How America Came Together a Century Ago and How We Can Do It Again, analyzes how America has moved from a more egalitarian, more cooperative, more generous society to a highly individualistic, unequal, fiercely polarized culture. Putnam offers how we can again recapture meaning into our lives by once again becoming a “we” society rather than an “I” society. It is what the rituals of worship and religion at its bests do.

Despair and Hopelessness

Closely associated with the spiritual injury of meaninglessness is despair or hopelessness. Theologians John Douglas Hall and Paul Tillich seemingly use the terms interchangeably. In research we conducted at the VA Medical Center in Saint Cloud with combat veterans, the spiritual injury most highly correlated with both depression and PTSD was despair. In our study sixty-four percent of these veterans had considered suicide in the past two years. We know that more than 17 veterans commit suicide every day in our nation. In the United States, suicide is generally the second leading cause of death among young people ages 10–24. It is why Soren Kierkegaard considered despair the sickness unto death.

The antidote to despair is hope, and it is hard to be hopeful alone. It is why the heart of religion, especially Christianity, is not a fleeing from this world, nor is it the religiosity of the individual, private, inward, merely focusing on “personal salvation” or the “salvation of the soul.” We need to be a “we” community rather than an “I” society as Robert Putnam in his books Bowling Alone and Upswing, reminds us. It is why it is helpful to have a community of faith or people around us who are positive and hopeful themselves. We don’t overcome despair nor the nihilism of our age by ourselves.

There have been periods in American history where this was the case. Early in the 20th Century Walter Rauchenbusch peached and widely wrote about the Social Gospel. Its central thesis was that Christianity should address not only individual sin and personal salvation but also the social, economic, and political conditions that create suffering and injustice. It set the table for the follow-up which was FDR’s New Deal. And Martin Luther King, Jr’s March on Washington, I Have A Dream Speech, his protests, marches and sermons were the background for the Civil Rights Bill signed by LBJ in 1964 and Johnson’s Great Society legislation. King repeatedly referred to the faith community and church as the Beloved Community. We don’t bring about change alone; it is public transformation that is needed.

The antidote to the despair, individualism, and loneliness is our coming together as local communities, churches, and families in love and hope by aligning ourselves with the promises of God.

Unfairness of Life/God

Another spiritual injury is the feeling that Life or God has been unfair to us. A question that chaplains and pastoral counselors frequently face with the people they counsel or visit in hospital beds is: "Why me? What have I done to deserve this?" Clinical psychologist Paul Pruyser addresses this issue under the heading of Providence. He writes: "What one really wants to know about Divine Purpose is its intention toward oneself". Pruyser suggests that pastoral conversation and counseling situations are laced with direct or indirect references to Divine Purpose and Will. Is this a just or an unjust universe, do things happen randomly, fatalistically, intentionally or accidentally? Attitudes of cynicism, hope, despair, fatalism, and gratitude are all reflections of how this question gets answered and worked out in our daily lives.

Harold Kushner brought popular attention to this issue in his book When Bad Things Happen to Good People. Theologically, the problem of evil is known as theodicy, which wrestles with questions of God’s justice and love in the face of suffering and profound evil. Pastoral counselors and chaplains cannot avoid this struggle when caring for those who suffer.

What we want to know is what is God’s attitude towards me. We want to know, and what the people we minister to are asking, “Does God love me, does God care about me in my suffering?” Rather than causing our suffering, we want to know is God with me and present in my suffering? Does God suffer along with me?

Another spiritual injury focuses on…

Doubt and Disbelief in God

Alfred North Whitehead writes in Religion in the Making that “The modern world has lost God and is seeking him.” This loss of the Holy has been accentuated by the religion/science debate and the perceived conflict between them, or did humans create God rather than did God create the universe and all that is in it.

But for those who may be searching for God, there is hope. But this hope is coming from a surprising direction. Theoretical physicist Sir John Polkinghorne notes: “We are living in an age where there is a great revival of natural theology taking place. That revival of natural theology is taking place not on the whole among theologians, who have lost their nerve in that area, but among scientists.”

Michel-Yves Bollore and Olivier Bonnassies, in the book, God The Science The Evidence The Dawn of a Revolution, list 100 quotes by leading scholars in various scientific fields, highlighting the surprising and thought-provoking nature of God in the creation of the universe. This draws on the work of 62 Nobel laureates who believe God or a Higher Power created the universe. Bollore and Bonnassies write Nietzsche’s claim that God is dead, held by the scientists of the nineteenth and twentieth centuries, has itself suffered a mortal wound. In the science of today, God is more alive than ever.

Robert Jastrow, astrophysicist, professor at Columbia, and director of NASA, who was a religiously agnostic Jewish scientist, discussed the obvious theistic implications of the Big Bang theory in his book God and the Astronomers. He ends his book by writing, “For the scientist who has lived by his faith in the power of reason, the story ends like a bad dream. He has scaled the mountains of ignorance, he is about to conquer the highest peak; as he pulls himself over the final rock, he is greeted by a band of theologians who have been sitting there for centuries.”

The wounds suffered by both science and religion when a split took place are being healed, and both are the better for it.

Death

The final injury that the Spiritual Injury questionnaire addresses is our thoughts about death; are they obsessive, denied, feared, or accepted and even embraced where death can be considered a friend.

Modern ideologies that have replaced religion, whether they be materialism or science, are too thin to carry the burden of facing death. Otto Rank states that humans are “theological beings,” and not merely biological. Consciousness transcends our physical nature, and as such our ultimate destiny, our life and death, can only be realized from the perspective of that which is transcendent, from our theology or understanding of God. This includes the belief that there is no God. Religious traditions promise either literal immortality (life after death) or participation in an eternal reality or continuing to be connected to God after death.

The central argument of Ernest Becker’s book, The Denial of Death, is that the fear of death is the most fundamental source of human anxiety as well as human motivation. He states that, "The idea of death, the fear of it, haunts the human animal like nothing else." The antidote to this fear is the promise that nothing will ever separate us from the love of God including death itself.

Death and dying are areas which have traditionally been the domain of religion and the clergy. Historically, the faith of the religious community has been a resource and support system for individuals facing death. The rituals for the anointing of the sick, services of commendation for the dying, prayers at the bedside, the reading of Psalms and other scriptural passages, pastoral and religious conversations, as well as funeral services are all resources to support the person who is dying and their family. In the Christian tradition the worshipping or beloved community as Martin Luther King called the church, places the one who has died into the arms of a loving Savior or God. Death is not perceived as a period, but only as a comma, a stop over in life’s journey.

Conclusion

When I presented the Spiritual Injury Scale at a national chaplain’s meeting some years ago, I was told by the physician who headed up the psychiatric department of one of the leading medical schools in America, that it was merely a questionnaire for diagnosing depression. I will argue that medicalizing spiritual issues demeans religion and the needs of those we serve. The existential issues of guilt, meaning in life, despair, anger or hatred, and dying are not medical problems to be solved. They belong to the domain of spirituality and religious faith and are opportunities for spiritual healing and growth. Treating spiritual and moral injuries as medical problems rather than spiritual conditions is unfortunate and a mistake. Medication, no matter how good it is, will never soothe the soul or give us meaning that transcends the individual self.

The protocol for treating depression medically is prescribing medications and then perhaps referring them to a specialist in mental illness and talk therapy. The protocol for treating spiritual and moral injuries is philosophical, behavioral, life-changing, and religious by nature. The failure of developing adequate therapies for healing spiritual and moral injuries is not so much because of the overreach of medicine; it is the failure and hesitancy of religious leaders and caretakers to establish their rightful place at the table of the healing arts. It is our failure to develop the tools for diagnosing spiritual injuries that are quantifiable and lend themselves to both research and treatment. This is the purpose of the Spiritual Injury Scale I have created and the tools I am making available.

We have protocols and antidotes for treating these existential threats that are overwhelming our culture. They are faith, forgiveness, love, hope, providence, community, grace, gratitude, promise, justice or fairness, and peace. They are the essence of religion. Let us use them and make them available to others.