LAURA SCHWENT SHULTZ,
JESSE D. MALOTT,
AND ROBERT J. GREGORY
With over three million service members having deployed as a result of the lengthy conflicts in Iraq and Afghanistan and a shortage in available Veterans Administration (VA) services, there is an urgent need for community-based care for our veterans. The goals of this chapter are to provide Christian therapists with a brief overview of the wounds sustained by service members in the recent conflicts in the Middle East, to illustrate the psychological and spiritual consequences of the deployment cycle for service members and their families, to describe community-based approaches to care, and to provide guidance to Christian therapists caring for these veterans.
The Global War on Terror (GWOT) began as a response to the terrorist attacks on the United States on September 11, 2001. Operation Iraqi Freedom (OIF), Operation New Dawn (OND) in Iraq, Operation Enduring Freedom (OEF) in Afghanistan, and Operation Inherent Resolve (OIR) in Iraq and Syria have resulted in the deployment of almost three million US service members over the course of almost two decades of conflict.
Because of the extended nature of the conflicts in Iraq and Afghanistan and the smaller, volunteer force, troops frequently deploy more than once, have longer deployments than initially intended, and spend much less time stateside between deployments than in previous conflicts (Tanielian & Jaycox, 2008). According to a 2017 report, approximately 7,000 service members had died, and 53,000 had been wounded in action (Department of Defense, 2017). The number of long-term physical and psychological injuries is staggering. Improvements in medical technology and health care have resulted in much better survival rates than in previous conflicts, but frequently the survivors carry the psychological, moral, and spiritual wounds of war. In the first quarter of 2015, over 660,000 veterans who sought treatment were diagnosed with a mental illness, with countless others yet to seek help (Epidemiology Program, Post-Deployment Health Group, Office of Public Health, Veterans Health Administration, & Department of Veterans Affairs, 2015).
Deployment to a combat zone inevitably results in repeated and chronic exposure to many stressors and potentially traumatic experiences. Potentially traumatic experiences can include exposure to firing a weapon, being attacked by the enemy, witnessing injury or death, or proximity to explosions. The aftermath of direct combat (e.g., handling of bodies or remains, dealing with prisoners of war, or witnessing the destruction of homes and villages) can be potentially equally traumatic and may contribute more to spiritual/existential injuries (National Center for Post-Traumatic Stress Disorder & Department of Veterans Affairs, 2004).
Sammons and Batten (2008) assert that in addition to witnessing potentially traumatizing events, service members deployed to Iraq and Afghanistan experience significant psychological stress as a result of the unconventional nature of the recent conflicts. The enemies often are indistinguishable from civilians, and they commonly use improvised explosive devices (IEDs) that are difficult to detect and are highly lethal. La Bash, Vogt, King, and King (2009) report that US troops are, therefore, exposed to the atrocities of insurgency-style warfare where they may be forced to decide between killing potentially innocent civilians and risking the safety of themselves or their units. Because there is no distinct front line, troops are constantly at risk for personal injury. Deployment to the conflicts in Iraq and Afghanistan often means having to maintain a perpetual state of vigilance in order to survive (La Bash et al., 2009). The combination of the acute stressors of combat and the chronic stressors of deployment, such as sleep deprivation, heat, hunger, separation from family, and concerns about the home front, often result in psychological and spiritual injuries for those serving.
The psychological sequelae of combat stress appear to begin during deployment. Felker, Hawkins, Dobie, Gutierrez, and McFall (2008) screened service members who presented for initial mental health care between May and July of 2005 while they were still in theater1 at a US military hospital in Kuwait. The researchers found that 34% of their sample (N = 296) suffered from adjustment disorders, 32% from depressive disorders, 12% from posttraumatic stress disorder (PTSD), and another 13% suffered from other anxiety disorders including acute stress disorder. Additionally, 18% of the sample participants screened positive for two or more Axis I disorders as defined by the DSM-IV-TR (American Psychiatric Association, 2000).
Other studies have attempted to estimate the number of service members with diagnosable psychological injuries postdeployment. One large mental health screening (N = 88,235) conducted by the Department of Defense indicated that over 20% of active-duty soldiers and over 42% of reserve soldiers required mental health treatment on return from Iraq (Milliken, Auchterlonie, & Hoge, 2007). Specifically, the study found that service members were returning from combat with positive screens for PTSD, major depression, alcohol misuse, and other mental health problems. Lapierre, Schwegler, and LaBauve (2007) found that 44% of the soldiers who returned from the OIF and OEF conflicts reported clinically significant levels of posttraumatic stress symptoms, depressive symptoms, or both. McDevitt-Murphy et al. (2010) found that 39.1% of OIF/OEF veterans screened positive for PTSD and 26.5% screened positive for hazardous drinking. Another large study of OIF/OEF veterans who were seen at VA health care facilities found that 25% received mental health diagnoses with 56% of those patients being diagnosed with two or more distinct comorbid conditions (Seal, Bertenthal, Miner, Sen, & Marmar, 2007).
In addition to the location of the deployment, several other factors are likely to influence the extent and timing of the development of mental health symptoms—specifically, reservist/National Guard status, concerns about the home front during deployment, and relational stressors experienced during reintegration.
Reservist/National Guard status. National Guard and Reserve members have comprised approximately 40% of the US OIF/OEF troops (Shea, Vujanovic, Mansfield, Sevin, & Liu, 2010), and several studies have suggested that they are at higher risk than active-duty service members for developing mental health problems following deployment (Lane, Hourani, Bray, & Williams, 2012; Browne et al., 2007; Schwartz, Doebbeling, Merchant, & Barret, 1997; Stretch, Marlowe, Wright, & Bliese, 1996).
While the exact reason why reservists and National Guard members seem to return with greater psychological symptoms is speculative, Friedman (2005) asserts that the difference may be, in part, due to the many ways reservists and National Guard members are distinct from active-duty troops. Unlike active-duty troops, members of the National Guard and reservists are civilians and therefore are not immersed in military culture. They do not live on military bases and therefore often have less access to the support and family services than active-duty troops have (Friedman, 2006). Additionally, their expectations surrounding their terms of service differ from that of active-duty troops; they did not volunteer for full-time military service, and they may not have expected they would be deployed to a war zone. Their training is less intensive than that of their active-duty counterparts and may not equip them as well for the stressors of combat (La Bash et al., 2009). They also may be less equipped than active-duty personnel to deal with the stress of being separated from their families, because they typically experience fewer military commitments (Vogt, Samper, King, King, & Martin, 2008). Browne et al. (2007) also assert that the contexts in which reserve forces deploy are different from active-duty forces; they often deploy as individuals and have limited prior knowledge of or relationship to their comrades, resulting in decreased unit cohesion. Because of the limited amount of time they are given to prepare to deploy, reserve troops also may be more likely to be asked to serve in various capacities within theater for which they have not received specific training (Browne et al., 2007).
National Guard members and reservists also often report greater problems at home during deployment and greater difficulty with reintegration than do active-duty troops (Browne et al., 2007; Vogt et al., 2008). This may be due to the differing stressors that National Guardsmen and reservists face because of both demographic differences and differences that result from being civilians with occupational commitments other than the military. Demographically, guardsmen/reservists are often older (Browne et al., 2007; Kehle et al., 2010; Vasterling et al., 2010) and more likely to be married (Vasterling et al., 2010), resulting in the potential for greater disturbance within the family unit. Additionally, many may have lost their civilian jobs or may fear a pending job loss following return from deployment (Doyle & Peterson, 2005; La Bash et al., 2009). Because they often return home to communities that are not immersed in military culture, their family, friends, and coworkers may have little understanding of what the reservists/guardsmen may have faced while deployed (Browne et al., 2007), which can result in an increased sense of isolation for the service member (Doyle & Peterson, 2005).
Home front concerns. Concerns about finances, parenting issues, and other worries about loved ones back home have always been a priority for service members during deployments. During the recent conflicts, however, communication with families and friends has dramatically increased as a result of improved technology such as email and cellular phones. Although increased communication can be uplifting, this may also increase the service member’s concern and worry about home front issues while concurrently increasing their sense of helplessness because of the distance of deployment (La Bash et al., 2009).
Not only are home front issues a risk factor for stress during a deployment; they may also be a predictor of postdeployment adjustment issues. Vogt et al. (2008) found that concerns about family/relationship disruptions significantly predicted posttraumatic stress symptomatology in Gulf War I combat veterans (ES = .42, p < .05). Similarly, home front concerns also appear to be associated with negative outcomes in OIF/OEF veterans. Booth-Kewley, Larson, Highfill-McRoy, Garland, and Gaskin (2010) conducted a large (N = 1,569) study of Marines who deployed to Iraq or Afghanistan from 2002 to 2007 and found that deployment-related stressors such as family concerns resulted in a stronger association with screening positive for PTSD than did combat exposure. Vasterling et al. (2010) also showed a positive correlation between the home front concerns experienced during deployment and the severity of PTSD symptomatology. Additionally, postdeployment life stressors such as reintegration issues were correlated with the PTSD severity of National Guard soldiers in this sample (Vasterling et al., 2010).
Relational concerns. Upon return home, service members frequently encounter various reintegration problems. Sayer et al. (2010) surveyed 1,226 OIF/OEF veterans who were receiving VA medical services and found that an estimated 40% of combat veterans in their sample reported “some” to “extreme” difficulty in social functioning, productivity, community involvement, and self-care domains within the 30 days prior to completing the survey. Difficulties in social relationships, such as getting along with family members and friends, were particularly common. This finding is not surprising in light of other publications that have suggested that military deployment and exposure to combat trauma can have significant adverse consequences for family intimacy and nurturance of children (McFarlane, 2009) and marital relationships (Goff, Crow, Reisbig, & Hamilton, 2007; Solomon, Dekel, & Zerach, 2008).
Not only do the service members have difficulty in familial relationships during reintegration, but frequently their family members also experience similar challenges. During deployment, it is often necessary for family members to shift roles and take on new responsibilities, such as managing the household finances. Upon their return, the service members may expect familial duties to resume “as normal,” whereas their partners may or may not want to relinquish the roles they acquired during their loved ones’ deployments. This renegotiation of familial roles is necessary following a deployment and can cause relational discord if not managed well.
The moral and spiritual consequences of war have garnered increasing attention in recent years. Faith and spirituality can provide resilience to psychological distress in combat veterans (Bormann, Liu, Thorp, & Lang, 2012) and an interpretive framework with which to make meaning of suffering (Fontana & Rosenheck, 2005; Park, 2010). However, witnessing or perpetrating human suffering, injustice, death, and morally ambiguous scenarios can fracture service members’ moral and spiritual frameworks and hinder their abilities to make meaning following deployment (Drescher, Foy, Kelly, & Leshner, 2011; Litz et al., 2009). Moral injury has been explained as an array of possible symptoms, including anger, demoralization, poor self-care, shame, and guilt (Gray et al., 2012; Maguen et al., 2011), associated with activity or inactivity that violates a service member’s core values and beliefs (Litz et al., 2009). These experiences can include killing, atrocities, disproportionate violence, betrayal by leadership, harm to civilians, and the inability to prevent harm. These moral injuries have been shown to be better predictors of PTSD than more conventional life-threat stressors (Litz et al., 2009). Further, as many espouse faith in God as their primary source of meaning, one’s faith can also become a casualty of traumatic experiences of war (Fontana & Rosenheck, 2004).
Guilt and shame. As veterans struggle to make meaning of traumatic experiences, particularly those that violate their consciences, they may feel guilt and/or shame over their actual or perceived roles. In the psychological literature, guilt has often been associated with postdeployment psychopathology and therefore viewed as dysfunctional (Resick, Nishith, Weaver, Astin, & Feuer, 2002). Often guilt can be misplaced, such as feeling guilty for surviving an attack from enemy forces when other members of the unit were not so fortunate (termed “survivor guilt”). However, guilt also promotes prosocial behaviors, reparative actions, reintegration, and posttraumatic growth (Dekel, Mamon, Solomon, Lanman, & Dishy, 2016). Although guilt and shame are often used interchangeably, there seems to be a major distinction: with guilt the veteran feels remorse for the action, whereas with shame the veteran makes global and stable negative attributions about the self (e.g., “I am unworthy of love”; Nazarov et al., 2015). Often veterans return home from deployment feeling ashamed and isolate from the communities and people that once provided them with a pathway toward reintegration and self-worth.
Grief. Significant loss also often occurs during combat deployments, both for service members and for their families. Service members may experience intense grief over the loss of a comrade, as the relationships within a unit often become some of the closest social relationships in the service member’s life. Upon returning home, service members may experience grief over the many things they have missed while they were away, such as children growing up, significant events in the lives of their loved ones, loss of civilian employment, friends moving away, and transitions within familial roles and relationships. Family members also experience significant grief throughout the deployment cycle because they often feel abandoned by their military family member during difficult life circumstances. Reintegration presents additional sources of grief for family members as they adjust to the physical and emotional injuries that are now a part of their loved ones’ lives.
Implications for faith. An aphorism is that “faith is found or lost in a foxhole,” and it is true that combat presents many situations that frequently challenge a service member’s previously held beliefs or expose a lack of spiritual development. Whereas some service members may turn to religion for support, others may begin to doubt how a loving God could allow such atrocities. Significant trauma can also lead to negative consequences if veterans are unable to make sense of their experiences within the context of their spiritual beliefs and instead feel abandoned or punished by God. Combat trauma may thus result in a loss of core spiritual values, or veterans may feel a sense of estrangement from God (Underwood & Teresi, 2002). On the other hand, veterans may also describe that although they believe in a forgiving and loving God, the only way for them to atone for their wrongdoings is to reject forgiveness and to punish themselves.
In Sayer et al.’s (2010) large survey, which sought to assess the reintegration needs of Iraq and Afghanistan veterans, 42% of OIF/OEF veterans reported that they had lost touch with their spirituality or were experiencing difficulty in their religious life. This disruption in spirituality was common both in veterans who met the criteria for PTSD (67%) and in those with negative PTSD screens (25%). Existential difficulty, such as having trouble finding meaning or a sense of purpose in life, was also reported by 42% of this group. In the same study, Sayer et al. (2010) also sought to understand the treatment interests of OIF/OEF combat veterans, and 32% of those surveyed indicated that they would be interested in receiving spiritual counseling during reintegration. In addition, in a large study of Vietnam veterans, Fontana and Rosenheck (2004) concluded that many of the veterans seeking mental health services were doing so out of guilt and spiritual distress, not PTSD.
Currently, OIF/OEF veterans have two primary options through which they may receive care. First, the Department of Defense (DoD) operates a military health system that provides care for active-duty military and their family members, eligible military retirees, and some reserve-component members (Burnam, Meredith, Tanielian, & Jaycox, 2009). Primarily, these services are delivered on military bases and in clinics where active-duty members are given priority in receiving treatment. DoD services are supplemented through partnerships with civilian providers who accept TRICARE, the medical insurance plan offered by the military (Burnam et al., 2009). Additionally, the Veterans Health Administration (VHA) operates 1,233 hospitals and outpatient clinics nationwide to serve eligible veterans and some active-duty service members (U.S. Department of Veterans Affairs, 2017).
Although PTSD became an official diagnostic label in 1980, the VA began to emphasize its treatment during the Global War on Terror because of increasing rates of suicide. Two primary evidence-based therapies that have been strongly endorsed by the VA for PTSD treatment are prolonged exposure (PE) and cognitive processing therapy (CPT). PE (Foa, Hembree, & Rothbaum, 2007) is primarily a behavioral intervention that targets both the intrusive memories of the traumatic event through repeated imaginal exposures and the learned avoidant responses through in vivo exposure homework assignments. CPT (Resick & Schnicke, 1993) is a 12-week manualized treatment focused on the maladaptive beliefs experienced during and after traumatic experiences that affect emotions and behaviors. Although it was originally developed for sexual abuse survivors, it has been adapted for military trauma. Despite widespread dissemination and a mandate that veterans have access to these therapies, some VA researchers and clinicians have questioned whether this may be premature. They have criticized high dropout rates, limited research, doubts about real improvement in function, and limited flexibility to address the variability and complexity of posttraumatic responses (Steenkamp & Litz, 2014).
Eye movement desensitization and reprocessing (EMDR; Carlson, Chemtob, Rusnak, Hedlund, & Muraoka, 1998) has been strongly recommended and is being used by many providers within the VA (Department of Veterans Affairs & Department of Defense, 2010). It has demonstrated effectiveness for treatment of PTSD in soldiers (Carlson et al., 1998) and involves less focus on homework, often a deterrent for veterans seeking treatment. The VA continues to research new areas of treatment, including mindfulness and interpersonal interventions, and has placed increasing emphasis on using chaplains in PTSD treatment, signifying recognition of the spiritual injuries that often accompany PTSD.
With this increasing emphasis on the spiritual impact of war, new interventions and programs are being developed in an attempt to assess and treat moral injuries and build spiritual resilience. One step taken was the creation of a research and education center for Mental Health Integration for Chaplain Services. The purpose of this program was to fund research targeting best clinical practices for integrating faith and mental health for veterans and to provide training and certifications for chaplains to better embed them into mental health teams across the VA.
In addition, since the construct of moral injury surfaced, researchers and clinicians have been developing a variety of interventions, a few of which are gaining supportive data. Adaptive Disclosure (Litz, Lebowitz, Gray, & Nash, 2015), an eight-session manualized therapy for PTSD, was designed to target not only life-threat but also moral injury and traumatic loss. Combining imaginal exposure with a variety of cognitive and experiential interventions, the goal of the therapy is to identify unhelpful beliefs so that they may be examined, to accept emotional experience, and to reclaim one’s own sense of goodness. Another cognitive behavioral intervention, Impact of Killing in War (Maguen & Burkman, 2014), is a six-session module to be used after completing trauma-focused therapy and provides the veteran opportunity to identify his or her beliefs about killing others in combat, to work toward self-forgiveness, and to create an action plan for making amends.
These therapies emphasize changing cognitions about one’s personal wrongdoings. To promote further healing, self-forgiveness, restoration of a sense of community belonging and self-worth, and development of one’s faith are likely to be critical elements for many veterans with PTSD. Unfortunately, many of these goals fall outside the scope of typical targets of VA-sponsored interventions. Therefore, it is essential that community-based interventions seek to address these unmet needs.
In addition to targeting aspects of reintegration such as self-forgiveness, community-based interventions are optimal for addressing some of the barriers that often result in underutilization of DoD and VA mental health services by our veterans. One possible barrier is the concern of stigma associated with mental health diagnosis/treatment for military members. Many service members are hesitant to seek treatment through the traditional military venues because they fear consequences that may come as a result of having a mental-health-related problem on their military record. For example, they could fear that their ability to be promoted would be affected (Burnam et al., 2009). The military culture so greatly esteems strength that it may perpetuate the belief that any symptom is a sign of weakness; thus, service members may also fear judgment from their peers if they seek mental health treatment (Hoge et al., 2004).
Another significant barrier to veterans receiving mental health care is geographic distance from treatment facilities (Druss & Rosenheck, 1997; Seal et al., 2010). Many service members live too far from a VA hospital to be able to receive the necessary mental health care. Reservists and National Guard members are especially likely to reside in remote locations and to have difficulty accessing services (Doyle & Peterson, 2005).
Faith-based organizations (FBOs) are uniquely suited to address these barriers because they are distinct from the military system and they are ubiquitous in most communities, rural and urban. In 2004, by executive order, the VA Center for Faith-Based and Community Initiatives was established to minimize regulatory obstacles to those providing care for returning veterans. Understanding the need for community reintegration, especially in regard to communities of faith, 27% of religious congregations have reported hosting a group that supported veterans and their families within the last 12 months (Werber, Derose, Rudnick, Harrell, & Naranjo, 2015).
Hometown Support Program. One example of a program seeking to maximize community-based support for service members and their families throughout the deployment cycle is the Hometown Support Program through HEROES Care. Because it is outside the military system, the program has special relevance for those service members who are hesitant to pursue mental health care because of stigma. Additionally, because the Hometown Support Program is community-based, it is ideal for the National Guard and reserve service members who generally have less access to military resources and who may depend more heavily on community resources due to geographic proximity. Finally, because the program includes a faith-based component, any spiritual needs that may arise during the deployment cycle can be addressed.
The Hometown Support Program is the result of the combined efforts of several nonprofit civilian organizations committed to meeting the growing needs of service members and their families. They have sought to raise up “an army to serve an army”—hundreds of Hometown Support Volunteers who serve military families with the hopes of preventing, mitigating, and alleviating symptoms of psychological, moral, and spiritual injury.
In order to become a Hometown Support Volunteer, an individual must first become a Stephen Minister (www.stephenministries.org) by satisfactorily completing 50 hours of Stephen Ministry training for lay caregivers in areas such as the art of listening, relating gently and firmly, maintaining boundaries, confidentiality, making referrals, working with individuals who are suicidal, and ministering to those experiencing divorce, grief, or other family crises. The extensive network of Stephen Ministry congregations (over 10,000 congregations across all 50 states) provides the core volunteers who are eligible to become Hometown Support Volunteers.
In addition to the 50 hour Stephen Ministry training, a Hometown Support Volunteer must then complete eight hours of training offered by HEROES Care (http://heroescare.org/), which serves as the administrative agency for the Hometown Support Program. The goal of this secondary training is to provide the Stephen Minister with information regarding the unique nature of providing lay care to a military service member and his or her family. Topics covered include the structure and composition of US Forces, emotional consequences of the deployment cycle, how children may respond to the deployment cycle, posttraumatic stress disorder, traumatic grief, alcohol and drug abuse, sexual trauma, and secondary trauma to family members (Shultz, 2008).
Once a Stephen Minister has completed the required training to become a Hometown Support Volunteer (HSV), he or she is assigned a military family to serve. In compliance with the requirements of Stephen Ministries, the HSV is always matched by gender to the care receiver, who could be the service member or the service member’s spouse. The HSV will address the family’s physical, emotional, and spiritual needs by contacting the care receiver on a weekly, biweekly, or monthly basis, depending on the preference of the service member and family. HSVs are encouraged to provide face-to-face care or communicate with the care receiver electronically through telephone, email, or Skype based on the care receiver’s preference and geographic proximity.
The responsibilities and duties of an HSV are distinctly different from that of a Stephen Minister. In addition to demonstrating human compassion and understanding, which is a standard part of the Stephen Ministry training, the HSV serves as a conduit to resources that can assist the care receiver and family in various hardships that may be encountered throughout the deployment cycle. For example, through regular contact with the care receiver, the HSV may learn of financial needs, home repairs that need to be completed, issues with childcare, or other tangible needs that the family has as a result of the service member’s deployment. Through collaboration with the local church congregation that has commissioned the HSV and HEROES Care, these tangible needs often can be met. Additionally, because the HSV is supported by a local church congregation, if the care receiver is amenable, he or she can receive assistance from the HSV’s congregation in the form of friendship, letters of encouragement, prayer, or more tangible forms of support such as yard work, minor home repairs, or babysitting.
HSVs also clearly differ from Stephen Ministers in that they must agree to respect and promote the free exercise of whatever religious beliefs the military service member and his or her family members hold. HSVs are serving members of the US Armed Forces; therefore, they cannot proselytize. Specifically, HSVs cannot try to convert the person to the HSV’s own religion or try to induce the person to participate in or join the HSV’s faith congregation. If the military service member freely expresses interest in spiritual ministry from the HSV, then the HSV is free to provide prayer or coordinate transportation to worship services, but these requests must be fully initiated by the care receiver.
HSVs are trained to be aware of when their lay caregiving skills may need professional bolstering. Through a partnership with Give an Hour (www.giveanhour.org), the Hometown Support Program offers free, professional counseling to care receivers and their family members once a mental health need is identified. Give an Hour is a network of over 7,000 licensed mental health professionals located throughout the country—including psychologists, counselors, marriage and family therapists, psychiatrists, psychiatric nurse practitioners, and social workers—who have agreed to volunteer one hour each week to serve veterans and their families. Providers offer free care for individuals, couples, and families and treat a variety of presenting concerns, such as PTSD, depression, anxiety, substance abuse, traumatic brain injuries, bereavement, and relationship or intimacy concerns. Because these are private therapists who are not affiliated with the military in any way, service members and their families can receive services without any fear of negative effects on their military career.
With the wide-reaching presence of Stephen Ministry and Give an Hour, the Hometown Support Program was developed as a national strategy with the intention of the program being launched in every state. Currently, the Hometown Support Program has expanded to 25 states. A total of 2,843 HSVs have been trained in 579 “Outposts” or local congregations. To our knowledge, at least 115 family members or single soldiers have taken advantage of referrals through the Hometown Support Program to Give an Hour mental health providers, and 30 suicides have been averted.
The following are some examples of other programs that have been developed to support returning veterans and the unique spiritual and relational obstacles that face them today:
Coming Home Project. This California-based program with Zen Buddhist roots offers multi-day family retreats, workshops, and a network of psychotherapists and chaplains to provide psychological, relational, and spiritual support throughout deployment and reintegration. http://cominghomeproject.net/
Cru Military. Cru (formerly Campus Crusade for Christ) has developed a ministry to veterans and their families with particular emphasis on providing resources for military families and helping them to connect with Christian communities. As with Cru, much of the focus is on the development and resilience of one’s faith during and after deployment. http://crumilitary.org/
MilitaryBeliever.com. This connection-hub website offers service members, veterans, and families the ability to search for churches and ministries that have advertised a specific emphasis on ministry for veterans and families. The site also offers various social-networking options for connecting with other like-minded veterans. http://militarybeliever.com/
Military Outreach USA. This FBO has created a network of congregations and organizations that have committed to caring for the military community. It offers resources and training for these FBOs to offer assistance with particular concerns of moral injury and homelessness. http://militaryoutreachusa.org/
Soul Repair Center. Based out of Brite Divinity School, the Soul Repair Center is a formal research and educational center focused solely on assisting veterans with PTSD and moral injuries. They have produced their own publications, training conferences, and a full-length film, Honoring the Code, a documentary about the development and healing of moral injury. www.brite.edu/programs/soul-repair/
Samaritan’s Purse: Operation Heal Our Patriots. This FBO has narrowed its focus to primarily offering marital support for wounded veterans and their spouses in the form of a week-long marriage enrichment retreat. The retreat is biblically based, offers the services of chaplains, and provides opportunities for refreshment and reconnection for partners. www.samaritanspurse.org/what-we-do/about-operation-heal-our-patriots/
Soldier’s Heart. This unique organization offers clear spiritual perspective on PTSD and moral injury in training clinicians, clergy, and caregivers around the country. In addition, it provides domestic and international “healing retreats” and “reconciliation journeys” in attempts to heal participants from spiritually injurious military experiences. Emphasis is placed on storytelling, and civilians are invited to “witness” the stories of these veterans so that the community shares the burdens of one another with the ultimate goal of community forgiveness and restoration. www.soldiersheart.net/
For those who may be in situations where you are currently able to provide community support, spiritual counseling, and/or mental health services to service members or their family members throughout the deployment cycle, please consider the following key points:
Each service member and each deployment is unique. Although some experiences and emotions are common among combat veterans and their families, each service member is unique. Therefore, each one will respond to combat stress in different ways. Each family member also will respond differently depending on the nature of his or her relationship to the service member and developmental level. Additionally, the service member or family member likely will experience each deployment differently; what a person felt during the first deployment may not be indicative of his or her experience during a second deployment. Therefore, do not assume that you understand the service member’s experience or the experience of the family members. Instead, ask open-ended questions and seek understanding.
Encourage the family to seek social support. Community support from extended family members, neighbors, friends, and churches is crucial for family members during a deployment, especially for reservists and National Guard members who are not embedded in a military community. This will decrease isolation and will help foster the meeting of physical, emotional, and spiritual needs during the service member’s absence. Additionally, during reintegration, support from the Christian community is essential if service members are to heal from their moral and spiritual injuries.
It takes time to rebuild familial relationships following a deployment. During a deployment, both the service member and the family members left behind will change. Encourage military families to go slowly and intentionally spend time getting to know each other again and reconnect in ways that acknowledge the new roles established within the family system. Families should be open to service members talking about their combat experience; however, they should also understand if their loved one is not initially willing to do so. While most service members and their families are able to establish a new equilibrium eventually, others may have difficulty and need to seek professional help. Encourage the family to be patient; this process may take time.
Spend time establishing the relationship before encouraging the service member to share traumatic experiences. Deployments develop intensely close bonds within units that are difficult to replicate in the civilian world. Often upon discharge from military or end of deployment, service members can feel disconnected, isolated, and mistrustful of those who have not shared their experiences. Further, talking about traumatic experiences with others can feel particularly vulnerable and shaming. It is critical that the clinician honor this vulnerability by allowing the therapeutic relationship to develop and prioritizing it over any structure or particular intervention.
Assess for changes in faith. For any work with returning service members, it will be important to assess for their perceptions of God, place in their congregation, or changes in beliefs. Although these crises of faith may engender a growth and a deepening of faith, they may also lead to hopelessness, depression, loss of meaning, and even self-harming or handicapping. Allowing service members to explore these changes without correction or criticism may be an especially helpful service that the clinician can provide in lieu of home congregations, where they may be met with some perceived judgment.
An appropriate level of guilt can facilitate healing. Especially for Christian service members, guilt serves to make meaning of personal wrongdoing, to build empathy for others, and to move them toward redemption and their faith communities. It may be helpful to assist service members in determining whether they are shouldering an accurate level of responsibility. However, minimizing or challenging someone’s level of guilt will often serve to make it stronger and keep the person from naturally working through it.
Encourage service members to invite others into their stories. Sociologist Brené Brown (2012) defines shame as “the intensely painful feeling or experience of believing that we are flawed and therefore unworthy of love and belonging” (p. 69). This shame leads service members toward isolation and disconnection unless trusted others are there to witness their stories with honor and acceptance. However, being vulnerable and disclosing combat experiences is difficult for most service members. It may be easier for them to share these stories initially with a mental health professional, with clergy, or with another service member.
As Christian counselors and psychotherapists, we are uniquely suited to provide hope to families coping with the emotional and spiritual injuries that often result from combat stress and trauma. Veterans’ stories of suffering, violation, and shame are heavily defended because for them they represent weakness and failure. Yet as Paul encouraged in 2 Corinthians 12:9: “But he said to me, ‘My grace is sufficient for you, for my power is made perfect in weakness.’ Therefore, I will boast all the more gladly of my weaknesses, so that the power of Christ may rest upon me” (ESV). Sharing in these stories is an honor as we contribute to veterans’ pathways to healing and community.
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Booth-Kewley, S., Larson, G., Highfill-McRoy, R. M., Garland, C., & Gaskin, T. (2010). Correlates of posttraumatic stress disorder symptoms in Marines back from war. Journal of Traumatic Stress, 23(1), 69-77.
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