Healing After War

I’m a U.S. Army chaplain, serving in the Texas Army National Guard.  I was first commissioned as a Chaplain Candidate while in seminary back in March of 1986.  That fall, I did Clinical Pastoral Education at Walter Reed Army Medical Center.  I was twenty-four, and I was the chaplain for neurology and neurosurgery, orthopedics, and urology. That was my introduction to ministry in the clinical setting, to some of the leading injuries that soldiers suffer, and to working as part of an interdisciplinary team, caring for the whole person.  I served in the Reserve and Guard for about ten years, then got out. I didn’t deploy. The closest I got to war was serving at Fort Bragg for a couple of months during Operation Desert Shield.

When I reentered service in the Texas National Guard in 2009, things had changed. We had been at war eight years by then—fourteen years today.  And I reentered knowing that I would deploy; and I did so in 2013, going to Kuwait for nine months in support of Operation Enduring Freedom.

My ministry today is radically different than it was during those first ten years–I deal with many more behavioral health issues.  In one year, 2012, I did a dozen suicide interventions, and ministered to soldiers and family members after two soldiers died by suicide.  I am now a suicide intervention trainer (using the ASIST program from LivingWorks Education).  And I am regularly involved in working with soldiers dealing with issues we barely talked about thirty years ago:  PTSD, Moral Injury, and Military Sexual Trauma.

Fourteen years of war have taken their toll on service members, their families, and veterans.  Politicians assured us the wars in Afghanistan and Iraq would be over quickly.  But “Shock and Awe” and “Mission Accomplished” gave way to more than a decade of quagmire.  Over 6800 US service members have died.[1]  Over 1600 have had limb amputations.[2] 55,000 Purple Hearts have been awarded.[3] 280,000 have been diagnosed with PTSD or depression (without TBI); another 182,500 have been diagnosed with PTSD or depression and TBI; and 305,000 TBI without a diagnosed mental health condition.[4]

And these numbers don’t address the impact of war on the people of Iraq and Afghanistan.  It is estimated there have been 210,000 civilian casualties.[5]  There is no number attached to those who may have died from disease, from malnutrition, from the decade of sanctions before the invasion of Iraq, the number of refugees from the region.

In an episode of M*A*S*H, Hawkeye told Fr. Mulcahy, “War isn’t Hell. … War is a lot worse. … There are no innocent bystanders in Hell.  War is chock full of them—little kids, cripples, old ladies.  In fact, except for some of the brass, almost everybody involved is an innocent bystander.”

Besides PTSD, about which much has been written, these horrors can lead to another invisible wound of war—Moral Injury.  It’s a term that’s been growing in use over the past few years. As defined by Shira Maguen and Brett Litz, Moral Injury is “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”[6]  It’s distinct from PTSD in that PTSD is caused by things that have been done to a person, resulting in symptoms that include fear and anxiety, whereas Moral Injury is caused by the person doing things, or failing to do things, resulting in symptoms that include guilt and shame. Neither is restricted to the context of war.

The literature is growing quickly. The most recent book, by Brett Litz, et al., Adaptive Disclosure: A New Treatment for Military Trauma, Loss, and Moral Injury, is a practical guide for caregivers.  As he and others speak of Moral Injury, it could be said to be primarily a spiritual disorder.  And the solutions include spiritual themes:  confession, mercy, forgiveness, restitution.

The process of “adaptive disclosure” Litz outlines (in which the person tells their story to a sympathetic caregiver over several sessions) includes “Evocative imaginal ‘confession’ and dialogue with a compassionate and forgiving moral authority … to challenge and address the shame and self-handicapping.” He describes it as a “process of being exposed to goodness, repairing by giving back.”  The person is encouraged to “Reclaim goodness and humanity.”  It is a journey of  “self-forgiveness and accommodating the possibility of also living a moral and virtuous life requires life course changes.” [7]

In this book, however, he never discusses using an interdisciplinary care team of behavioral health professionals and chaplains—though this happens regularly in the military and in Veterans Administration hospitals. He acknowledges that the person’s religious background is relevant, and the person might want to be referred to the appropriate religious figures as homework or as aftercare.  But that seems very weak, given the power of the spiritual themes he has raised and the rich resources of our faith traditions and the experience and wisdom of chaplains in dealing with spiritual crises. In personal correspondence, he assures me that he is working on a paper that will explore this.

Litz recognizes that the journey of moral repair is one that does not end after either confession with a priest or a series of sessions with a therapist.

For many, this is a lifelong challenge that is dependent on personal resources, one’s family, the community, the culture, the health care systems, and government (e.g., financial compensation for service-connected problems).[8]

Healing occurs in community.  In our community.  One of the things I love about Houston is that we are not only diverse, but connected.  This is true of our support of veterans, from the City of Houston Office of Veterans Affairs, to the VA, to the many Veterans Service Organizations, to health care providers, to businesses–even to the Houston Grand Opera, which is telling the stories of veterans through its Veterans Songbook project.  Our spiritual, medical, and service organizations and institutions are equally necessary. Each of us can play a part in the healing journey of veterans. Each can offer an understanding ear, a forgiving embrace, or companionship along the way.

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[1] Iraq Coalition Casualty Count. Accessed December 14, 2015. http://icasualties.org/.

[2] Hannah Fischer, “A Guide to U.S. Military Casualty Statistics: Operation Freedom’s Sentinel, Operation Inherent Resolve, Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom,” Congressional Research Service (August 7, 2015).
https://www.fas.org/sgp/crs/natsec/RS22452.pdf

[3] “Military Order of the Purple Heart Today.” Military Order of the Purple Heart.  Accessed December 14, 2015. http://www.purpleheart.org/DownLoads/MOPHToday.pdf.

[4] Terri Tanielian, et al.  “Invisible Wounds: Mental Health and Cognitive Care Needs of America’s Returning Veterans.” Santa Monica, CA: RAND Corporation, 2008. http://www.rand.org/pubs/research_briefs/RB9336.html.

[5] “Civilians Killed and Wounded.”  Costs of War.  Watson Institute, Brown University.  Last modified March 2015.  Accessed December 14, 2015. http://watson.brown.edu/costsofwar/costs/human/civilians.

[6] Shira Maguen and Brett Litz, “Moral Injury in Veterans of Veterans of War,” PTSD Research Quarterly 23 (2012):1. http://www.ptsd.va.gov/professional/newsletters/research-quarterly/v23n1.pdf.
http://www.ptsd.va.gov/professional/co-occurring/moral_injury_at_war.asp

[7]Brett T. Litz, et al. Adaptive Disclosure: A New Treatment for Military Trauma, Loss, and Moral Injury (New York: Guilford Publications, 2015), p. 5.

[8]Ibid., p. 44.