(The purpose of Soul Care Conversation is to create a place to generate dialogue, initiate thoughtful consideration for the challenges our veterans face each day, share ideas of veteran and family well-being and healing, and spark within all of us a call to be engaged with the veteran and caregiver community. Click here to visit the forum and join the conversation!)

We have been having a conversation for several weeks about the effects of trauma on the whole person. We have determined that the effects of trauma on our bodies, our minds, and our spirits, are profound. Last week, we looked at three distinctive and yet similar war injuries that have spiritual implications; PTSD, moral injury and soul wounds. This week we will focus specifically on PTSD.

PERCEPTIONS OF VETERANS?

It is important to note that there is much more to our veterans than PTSD.  The politicians, press, and advocacy groups tend to focus on our veterans who return from war wounded, having a difficult time adjusting to their new civilian life.  In fact, I have heard our combat veterans labeled by the press or others as either heroes or broken. Often Americans do not understand most of our veterans are not wounded and many have successfully navigated the transition to civilian life. Even those who have been diagnosed with PTSD make an enormous contribution in their communities.

However, many of our veterans have experienced deep physical, psychological and spiritual wounds. Since 9/11, the Department of Defense (DoD) and the Veterans Administration (VA) made progress in the traditional treatments for veterans who have been wounded. Recently, the Washington Post described alternative therapies for veteran well-being that the VA has explored as part of a treatment regimen to include;

• equine therapy
• alpha stimulation
• guided imagery
• yoga
• hypnosis
• aqua therapy
• Botox

War-related conditions simultaneously threaten the body, mind and spirit causing a full range of symptoms that effect the whole person. One of these symptoms is PTSD. David Wood in his article for the Huffington Post, “Iraq, Afghanistan War Wounded Pass 50,000”, 25 October 2012, states that there are over 4,000 new cases of PTSD each month. This is a significant statistic that demands our nation’s attention in providing long term care.

SO WHAT IS PTSD?

We have stated previously that trauma changes the person.  It is not that we are worse, but we are different.  Post-traumatic stress or deployment-related stress are normal reactions of normal people to extreme and life threatening events. It is part of the human survival response. Warriors often experience during a combat deployment intense fear, panic, confusion, helplessness and even horror.

During the American Civil War, soldiers experienced anxiety and depression. It was referred to as “soldier’s heart”. During World War I, veterans experienced “shell shock”. “Battle fatigue” or “war neurosis” were the terms used during World War II. It was not until after the Vietnam War that the American Psychiatric Association listed combat trauma as an official diagnosis. Additionally, after the studies on Vietnam veterans and now the in-depth studies on veterans of the Post 9/11 Wars; thousands of veterans who struggle with nightmares, insomnia, anger, isolation, and addictions, no longer are written off as failures, malingerers, or shirkers. Therefore, PTSD is an officially recognized mental illness.

For this conversation, we will not delve into the neuro-anatomy effects of PTSD on the brain except to say that when a person experiences trauma, there are three areas of the brain that are altered;

• prefrontal cortex
• amygdala
• hippocampus

These brain functions affect the fear response, memory, and emotions of a person.

Also, we will not take a deep dive into the Diagnostic and Statistical Manual of Mental Disorders to investigate all of the formal diagnoses. What is important to understand is that a formal diagnosis of PTSD requires a warrior to experience symptoms in five different categories (as per the US Department of Veteran Affairs National Center for PTSD);

• stressor (exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence)
• intrusion symptoms (recurrent, involuntary, intrusive memories; traumatic nightmares; dissociative reactions; intense or prolonged distress; marked physiological re-activity after exposure to related stimuli)
• avoidance (of trauma related thoughts or feelings, trauma related external reminders such as people, places, conversations, activities)
• negative alterations in cognitions and mood (inability to recall features of traumatic event, persistent negative beliefs and expectations of self, persistent distorted blame, markedly diminished interest in significant activities, feeling alienated from others, persistent ability to experience positive emotions)
• alterations in arousal and activity (irritable or aggressive behavior, self-destructive or reckless behavior, hyper-vigilance, exaggerated startle response, problems in concentration, sleep disturbance)

There are four additional criterion that further defines a diagnosis, but most important is the duration (persistence of symptoms longer than one month).

TREATMENTS

Many forms of psychotherapy have been used with our veterans diagnosed with PTSD. Those that have exhibited a track record of success include;

• cognitive behavior therapy (CBT)
• cognitive process therapy (CPT)
• eye movement desensitization and reprocessing
• exposure therapy

For one year, I was part of a trial program, PTSD Pathways, at Fort Belvoir. The program modules included psycho-education, CBT and CPT, relaxation techniques, relationships and coping, and post-traumatic growth. The program also included a weekly group process as well as one-on-one counseling with a therapist. The PTSD Pathways proved somewhat beneficial in my initial healing. More on this later.

The VA and DoD also have used additional therapies as reported by the Washington Post (see above). Also, our warriors have been treated with medication(s). Some of our veterans recover on their own. Some, even after therapy and medications, still linger in pain. Why?

SPIRITUAL COMPONENT 

From my personal observations and experiences a part of our veteran well-being that is under-served is the spiritual component. Why is this important? Our returning veterans face a deep spiritual crisis, not generally in public view.

The battlefield became a test of the soul for our warriors as they experienced life threatening events. After a near death experience, death haunts a veteran’s life. The ongoing realities of death linger deep in the soul. Trauma is suffering that will not go away. The aftermath of trauma challenges the veteran to overcome fear and to find meaning. These all have spiritual implications.

As trauma affects the body and mind, it also affects the spirit. Soul care should be an integral part of our veteran’s journey toward healing.

This concludes this week’s conversation on PTSD. Next week, we will discuss in some detail moral injury. Until next week, thank you for the conversation…

(The purpose of Soul Care Conversation is to create a place to generate dialogue, initiate thoughtful consideration for the challenges our veterans face each day, share ideas of veteran and family well-being and healing, and spark within all of us a call to be engaged with the veteran and caregiver community. Click here to visit the forum and join the conversation!)

We have been having a conversation for several weeks about the effects of trauma on the whole person. We have determined that the effects of trauma on our bodies, our minds, and our hearts, are profound. Additionally, last week we discussed that the impact of trauma on our spirits are as important. This week, we will look at three distinctive and yet similar war injuries that have spiritual implications; PTSD, moral injury and soul wounds.

PTSD OR MORAL INJURY OR SOUL WOUNDS?

Over these last several weeks we have discussed the impact and the symptoms of trauma on the warrior. You most likely began to see some similarities within the symptoms of the psychological, emotional, cognitive, behavioral, and the spiritual impacts of trauma. So, when a returning veteran exhibits anger, rage, moodiness, isolation, hyper-vigilance, depression…which injury does the veteran experience; PTSD, moral injury, or soul wounds? How can we differentiate between the three wounds? Why is it important to distinguish between the three?

Violence and killing are timeless descriptions of war. However, it is in the act of war that these three injuries can occur. An Army Special Operations Sergeant who beats an Afghan man in anger after he survived an Improvised Explosive Device but one of his team members did not survive. A Navy Corpsmen attempts valiantly to save the life of a comrade only to see her slip away in death. An Air Force Captain stands by frozen in shock unable to offer aid to a fellow Airmen whose legs were severed following a land mine explosion. Which injury may these warriors have experienced?

Each one of these warriors most likely will exhibit similar symptoms;

• inability to sleep
• confusion
• hyper-alertness
• depression
• anger
• isolation
• impaired memory
• lack of concentration
• panic attacks
• fatigue
• guilt

There is an overlap in symptoms with these three injuries. Why is this? While PTSD, moral injury and soul wounds are specific conditions, each produces similar symptoms that affect the whole person. As we have discussed previously, deep physical, psychological, and spiritual wounds are a result of war. Whether a warrior experiences depression, or had a traumatic brain injury, or has deep grief, these are all health problems that affect the whole person and often exhibit similar symptoms.

Personally, I experienced a mild traumatic brain injury during my Iraq deployment in 2004. It was almost 8 years later that I was diagnosed with PTSD. Now nearly 12 years after my return from Iraq, my therapist shared that he thinks that I may have experienced a moral injury. And on top of all of this, I know from my own spiritual assessment after my return from Iraq in 2004, I suffered from a soul wound. The interesting part, the symptoms of each malady are similar, but, now I know the treatments require different approaches.

HOW TO DIFFERENTIATE?

Because the symptoms are similar, how can we differentiate between the three? Let’s look at each of these separately.

1. PTSD – Most of the attention within the medical and behavioral health communities has been on the impact of life-threatening trauma that results in PTSD. PTSD is recognized as a mental disorder that can develop after a person is exposed to one or more traumatic events.  A formal diagnosis of PTSD requires that persons report symptoms in each of the following categories; disturbing recurring flashbacks, avoidance or numbing of memories of the event, and hyper-arousal. These symptoms continue for more than a month after the trauma. Important note, PTSD requires a diagnosis.
2. Moral Injury – The term moral injury is fairly new, however the concept goes back to the Iliad and Odyssey. There has been much recent attention given to this as a reality of most combat warriors. Some experts describe moral injury as a psychological scar of war. It has not been accepted as a diagnosis as yet; however, I believe as more research points to this as a valid wound, we will see the Veterans Administration and the Department of Defense coding veterans with this injury. Unlike PTSD, which is based on fear from feeling one’s life threatened, moral injury produces guilt and shame from something done or witnessed that goes against one’s values.
3. Soul Wounds – This term is largely used in the faith community. However, even warriors who are not persons of faith can also experience “soul wounds”. At the core of a person, is their soul, that which gives a person meaning. When the soul is in anguish, this can become a spiritual scar that can be identified as a “soul wound.” Similar to moral injury, soul wounds produce guilt and shame. However, a soul wound goes much deeper because the battlefield strips away the warrior’s belief system so that at the very core of the wound is the feeling of brokenness and hopelessness. In fact, the feeling to the warrior is that the spirit has left them. In addition, there is the lack of trust in the Holy to tend and transform their wounds.

WHY IS IT IMPORTANT TO DIFFERENTIATE?

As we have discussed previously, whether a warrior exhibits symptoms of depression, a traumatic brain injury, or deep grief, these are all health problems that affect the whole person. However, treatment of each requires different disciplines and diagnoses. Therefore, it is imperative that we can differentiate between the three injuries because the approach to healing and wholeness will be different. We do a disservice to our veterans if we fail to look at the whole person in treatment and if we do not treat the specifics for each injury.

While the idea of warriors feeling remorse over battlefield horrors is not new, moral injury has gained much attention since the Post 9/11 wars. After one year of intense mental health treatment for PTSD, I was not noticing improvement. In conversation with my therapist, we discussed that other mental health providers have seen veterans not improving with PTSD treatments.

Why? Wrong doing is not necessary for a PTSD diagnosis, nor does PTSD capture moral injury. And, PTSD and moral injury are not a soul wound. PTSD sufferers can find relief with medication and counseling that encourages reliving the trauma event to work through fear. But if the person considers what happened to be morally wrong, reliving it may only reaffirm that belief, and wound the soul further. Soul wounding is a very deep issue and I cannot say I have even grasped the depth of it myself. What I do understand is that whether it is PTSD, moral injury, or soul wound; healing takes time and will encompass a holistic approach.

Next week, we will begin to take a deep dive into these three spiritual issues, the first will be PTSD. Until next week, thank you for the conversation…

(The purpose of Soul Care Conversations is to create a place to generate dialogue, initiate thoughtful consideration for the challenges our veterans face each day, share ideas of veteran and family well-being and healing, and spark within all of us a call to be engaged with the veteran and caregiver community. Click here to visit the forum and join the conversation!)

We have been having a conversation for several weeks about the effects of trauma on the whole person. Last week we discussed the impact of trauma on the warrior’s behavior. This week, we will discuss the spiritual impacts of trauma.

Because warriors often experience intense fear, panic, confusion, helplessness and even horror during war, how can one return from war feeling anything but changed? Warriors can experience physical and psychological wounds that can incapacitate them and that can affect their behavior. Additionally, the combat veteran also can exhibit spiritual symptoms.

SPIRITUALITY AND TRAUMA

Each of us hold basic assumptions that give order to our world and can make stress bearable.  After one experiences trauma, these assumptions are shattered.   Trauma disrupts one’s view of the world, even their spiritual understanding, as suggested by Dr. Schiraldi in his book, The Post Traumatic Stress Disorder Sourcebook.

War’s violence press questions of faith into the lives of those who fight them.  When a warrior steps onto the battlefield he or she immediately is confronted by the kinds of horror and hardships that have moved humanity through the centuries to reach for the Holy.

A spiritual person can be characterized having;

• assurance
• confidence
• anticipation
• hope
• joy

Following trauma that same person experiences a loss of these qualities.  But the wounding of the soul goes much deeper. Soul wounded persons often exhibit;

• discouragement
• hopelessness
• despair

For some, the circumstances of the trauma may lead to the questioning of important and previously sustained beliefs. This can lead to a deep spiritual struggle. A key component in considering soul wounds is understanding how spirituality has been affected by trauma, and then, what role spirituality can now provide within the healing journey. For the warrior, these are difficult questions to answer.

EFFECTS OF TRAUMA

The effects of trauma on the person’s spirituality;

• can lead to confusion about God
• a shattered faith in God, others, and self

Spiritual symptoms can include;

• shattered self esteem
• finding it difficult to pray
• no spirit of thankfulness
• seeing no value in the Scripture

SOUL WOUNDS

Soul wound symptoms reflect something deeper. Soul wounds can result in a diminishment of everything meaningful to the warrior. What may a wounded soul feel like? Countless warriors describe the dark side of their war experience with the word – hell.  “War is hell.”  “I lived through hell.”  Soul wounds feel like hell at the very core of the warrior’s being.

Even people of great faith are changed by trauma.  There are numerous stories of chaplains who were so wounded by trauma of war that they lost their faith or adopted destructive behaviors as an escape of war.  Many have lingering fear and guilt from their experiences.

Many warriors struggle with ethical and moral challenges that they faced.  Transgressions can be from individual acts of perpetrating violence on another or by witnessing the behavior of others committing violence. The moral injuries exhibit similar symptoms as to soul wounds.

I did not understand soul wounds until I read the book, War and the Soul, by Dr. Edward Tick.  Dr. Tick revealed to me the importance of healing the wounded soul after combat.  This all became real to me when in Afghanistan during my first visit to the Marines, the Command Chaplain for Region South West told me about the Concussion Restoration Care Center (CRCC), where wounded warriors had an opportunity to begin their healing following a trauma event.  At the CRCC the psychologist, psychiatrist, and behavioral health specialist realized after months of counseling that there were three spiritual issues they were not able to help the wounded warrior; why, guilt, and fear.  They decided to bring a chaplain on-board as part of the team.  The whole person concept in treating trauma included the spiritual component.

SPIRITUALITY DEFINED?

But why has spirituality not been institutionalized as a part of the whole person concept in healing? Possibly because spirituality is a complex subject.  Spirituality challenges researchers when they attempt to frame it in scientific terms. One reason is that there’s no widely accepted definition of spirituality.

Definitions include;

• religious beliefs – a connection to that which transcends self
• nature, art, and meditation
• inner peace or harmony
• sense of the sacredness of life
• that which provides meaning and purpose

Yet, some researchers think that measuring spirituality with questions about peacefulness, harmony and well-being is meaningless since it results in spirituality being simply defined as good mental health, so they instead prefer to define spirituality in terms of religious practices and beliefs.

The spiritual domain is not a common field for the medical and mental health models for treating the symptoms of combat trauma.  The Department of Defense and the Veterans Administration have made progress in combat veteran care under the rubrics of the physical, emotional, behavioral, psychological, and mental.  The area that has been underserved is the spiritual.  All too often the spiritual and the soul are relegated to the purview of the religious counselors and religious leaders.  Combat trauma has not been treated traditionally as a spiritual or moral injury.

SPIRITUAL INJURIES

What do spiritual injuries look like? They may include;

• anger
• doubt
• grief
• fear
• hopelessness
• depression
• loneliness

These symptoms may change as time passes and a person moves further away from the trauma event. Trauma can be associated with loss of faith, diminished participation in religious or spiritual activities, changes in belief, feelings of being abandoned or punished by God, and loss of meaning and purpose for living. Suicide becomes a risk.

Next week we will discuss in more depth moral injury and the effects of wounding the soul. Until then, thanks for the conversation….

(The purpose of Soul Care Conversations is to create a place to generate dialogue, initiate thoughtful consideration for the challenges our veterans face each day, share ideas of veteran and family well-being and healing, and spark within all of us a call to be engaged with the veteran and caregiver community. Click here to visit the forum and join the conversation!)

Happy New Year! I pray that you experienced a joyous Christmas Day and New Year’s celebration. Last week we continued our conversation on the impact of trauma to the warrior. We focused on the psychological effects of trauma. This week we will discuss the effects of trauma on the warrior’s behavior.

Trauma is stress run amuck.  As we discussed during our last conversation, trauma changes the warrior.  It is not that we are worse, but we are different.  Post-traumatic stress or deployment-related stress are normal reactions of normal people to extreme and life threatening events. How a warrior reacts to a threat or stress is part of the human survival response. It is a defense mechanism.

Warriors often experience during a combat deployment intense fear, panic, confusion, helplessness and even horror. How can one return from war feeling anything but changed? Warriors can receive physical and psychological wounds that can incapacitate them. Events can also get past the normal defense mechanisms and severely disrupt our thought processes and our emotions. The changes experienced by the returning veteran are not only physical or psychological. The combat veteran also exhibits emotional and cognitive symptoms.

EMOTIONAL AND COGNITIVE SYMPTOMS OF TRAUMA

The emotional and cognitive symptoms of trauma can create lasting difficulties in the veteran’s life. The symptoms of anxiety are merely an exaggerated stress response.

Some of the emotional responses to trauma;

• irritation
• moodiness
• explosive anger
• withdrawal from normal routines and relationships
• spontaneous crying
• compulsiveness

All of these symptoms can be easily observed, most likely because you will be on the receiving end of the behavior. I exhibited many of these symptoms for years following my deployment to Iraq, 2003-2004. I just thought that it was because I was unusually exhausted. But, after my return from Afghanistan in 2012, I still exhibited these symptoms and I realized that there was more to my exaggerated response. On top of these symptoms I also kept several unobserved symptoms close hold.

The following are not so easily observed;

• fear
• loss of confidence
• emotional numbness
• depression

Each time following my return from war I was not myself, and those around me knew as much. It is important to remember, the returning warrior will not be him or herself, rather they will have very exaggerated emotions.

Some common cognitive responses might be;

• Getting lost or confused – often experience distortions of time and other spatial and temporal relationships (example, a small gun is remembered as being the size of a cannon)
• Cause and effect thinking – certain aspects of the trauma become universalized (example, all people with olive complexions are terrorists)
• Intrusive thoughts about the event – unwanted thoughts or memories of the traumatic event feeling as if the event is re-occurring in the present
• Memory loss – the simple things like names and places are difficult to recall, and the veteran often experiences forgetfulness
• Difficulty concentrating – a difficult time focusing and remaining on the task at hand, feeling distracted
• Difficulty in making decisions – the loss of ability to function well in daily life because the veteran either does not want to or does not know how to decide, or exhibits sluggish thinking

BEHAVIORAL EFFECTS OF TRAUMA

As we have just discussed the emotional and cognitive symptoms of trauma, you will see considerable overlap of symptoms with the emotional effects. There is a direct correlation between the emotional and cognitive effects and the behavioral symptoms.

The following by no means is an exhaustive list, but many are symptoms commonly experienced;

• Sleep disturbance – At night the warrior will have trouble sleeping and often will experience nightmares.  During the time when the warrior is awake, they may experience vivid flashbacks of the event.  At times these are triggered by something like a smell or sound.
• Hyper-vigilance – On constant alert to possible threats.
• Need to do certain things over and over – This reaction is in response to create order out of the chaos of the traumatic experience and create a sense of being in control.
• Doing strange or risky things – This reaction is usually an attempt to create the rush and excitement that are part of the survival reaction.
• Self-medication – A common way of avoiding painful memories of the horrors of combat is through alcohol or drug use.
• Eating problems – Loss of appetite is often associated with the down side of the trauma curve, but sharp increases in appetite can also occur as the body seeks to replenish its energy reserves.
• Depression – Reflective of the overwhelming power and shock of traumatic events leads the warrior down a path of depression.
• Isolation – Withdrawal is common as senses are overwhelmed and there may be fear and confusion associated with the traumatic stress reaction.
• Lack of motivation – Nothing excites the warrior, does not have the same sense of joy with self, family, job, friends, and activities.
• Agitation – Trauma victims often exhibit nervousness, irritability, and can be prone to bouts of anger.
• Always having to have things a certain way – A method to gain a sense of safety and control of one’s life after a traumatic experience.
• Over working – Burying oneself in one’s work is another way to avoid dealing with trauma by either creating a false sense of control or avoiding the effects of trauma through busyness.

All of these symptoms reflect a dysfunctional pattern that veterans use to deal with their trauma. Many of these symptoms become negative coping methods. Some veterans can recover by themselves. Others are at increased risk for;

• separation and divorce
• feelings of guilt and shame
• substance abuse
• low self-esteem
• panic attacks
• chronic anxiety
• unemployment and homelessness
• depression
• suicide

Some of us think that, “I would never do or experience these things.”  However, we can never predict how we will respond under the incredible stress and the threat of harm experienced in war. War brings out the worse in each of us.

What can the veteran do? First, we must be honest to recognize that in order to recover, we may not be able to accomplish this by ourselves. If this is so, then we can reach out for support, direction, coaching, or intervention. Lastly, we must understand that our recovery and healing may be a slow process.

Can the faith community be a part of the healing journey? Well informed and skilled faith community members can be a key partner in the compassion and care for our veterans and their families. This conversation is a part of that process. I look forward to our continued conversation next week…