Chaplains in Mental Health: Healing the spiritual wounds of war
There may never have been a greater need for “skilled spiritual care” than the present time. The new millennium began with much of the world consumed in armed conflict. With each act of violence in war, even if a soldier is not physically wounded, new psychological and spiritual wounds are opened. In the war zones of Iraq and Afghanistan, the United States military is calling upon chaplains to render aide to soldiers hemorrhaging psychologically and spiritually. A chaplain may be a vital resource in assisting soldiers in reframing their war experience and may also strengthen a soldier’s ability to cope following a combat episode by lending psychological and spiritual support.
War and the Historic Chaplaincy
As long as human beings have engaged in war, the terror of the battlefield has caused psychological, biological, and spiritual wounds. Since ancient times, chiefs, rulers, and heads of state have appointed individuals to accompany armies into war zones to tend to their injuries. Those called upon to work with the psycho-spiritual wounds of warriors in tribal cultures were the shamans or “medicine men” (Walsh, 2007). Later, some European and Western cultures came to refer to their psycho-spiritual healers as “chaplains.”
The Bible recounts Levite priests accompanying the Israelites’ military and political expedition into Israel, carrying the Ark of the Covenant and playing a significant role in the care of military matters. Altough these priests cannot be considered “chaplains” according to present-day terms, their role as spiritual aides provides a model for modern chaplains. It also points to the idea that the ancient Israelites recognized the necessity of a warrior’s need for spiritual support during times of conflict.
The contemporary use of the word “chaplain” is not limited to any particular church or denomination. Clergy and ministers appointed to an assortment of institutions and corporate bodies such as the armed forces, prisons, hospitals, and universities are usually called chaplains. There are more than 3,800 military chaplains serving in the U.S. armed forces. The largest of the services, the Army, recognizes 120 endorsing bodies and faith organizations that sponsor chaplains (Lawrence, 2007).
Responding to Spiritual Alienation
There may never have been a greater need for “skilled spiritual care” than the present time. The new millennium began with much of the world consumed in armed conflict. As of mid-2005, there were eight major wars underway in the world and as many as two dozen ongoing “lesser” conflicts, all with varying degrees of intensity.
These are perilous times. The collective consciousness of humanity has been bombarded with images of war, greed, anger, hatred, and death, which leads to feelings of loss, lamentation, confusion, guilt, and fear. With the prolonged involvement of American soldiers in Iraq, Americans can expect more physical, psychological, and spiritual casualties to come. Statistics are kept and media attention is given to the physical casualties of war, but exposure to the trauma of war often leads to deep psychological wounds and a personal and spiritual search for meaning and purpose.
During times of war, faith that the Divine is readily available to act in response to one’s personal hopes, fears, and misfortunes can be destroyed. Individuals who are unable to or have difficulty resolving challenges to their moral and spiritual beliefs may begin to experience spiritual alienation. They may feel rejected or abandoned by the Divine or begin to believe that God is powerless to help. Soldiers may come to believe that the pain of war is punishment from God, and those experiencing the trauma of combat may be fearful that their behavior in war warrants eternal damnation. Many soldiers may find it extremely difficult to make sense of combat situations that don’t align with their moral or spiritual beliefs, and consequently experience isolation from the Divine. This kind of spiritual suffering, when coupled with the pure psychological horror of combat, can produce intense psycho-spiritual maladies (Pargament, 1997).
Military Personnel at Risk
According to the Department of Defense (Shudro, 2005), since October 2001, more than 1.1 million men and women have served in Iraq and Afghanistan. It is estimated that 140,000 U.S. troops are currently in Iraq, along with 30,000 to 100,000 private security employees. According to a New England Journal of Medicine study in 2004, almost 2 out of every 10 U.S. troops who have faced combat in Iraq may return with serious symptoms of depression, anxiety, or post-traumatic stress disorder (PTSD). Symptoms can include flashbacks and nightmares or frightening thoughts, especially when exposed to something reminiscent of the original trauma. Stress symptoms can also include emotional numbness, sleep disturbances, depression, anxiety, irritability, and outbursts of anger. Feelings of intense guilt are also common, according to the National Institute of Mental Health (Hodge et al., 2004).
A recent study published in the Archives of Internal Medicine estimates that one-third of all returning veterans suffer from serious mental health and psychosocial disorders. Of those, 56% were diagnosed with more than one disorder including post traumatic stress disorder (PTSD), depression, and substance abuse. The highest rate of mental health problems was among veterans in the 18–24 year-old range, often those most exposed to front line combat (Reinberg, 2007).
A Pentagon panel warned of an overburdened health system, indicating that the military is putting already strained troops at greater risk of mental health problems because of repeated deployments to Iraq and Afghanistan. Furthermore, the Defense Department’s Task Force on Mental Health, chaired by Navy Surgeon General Donald Arthur, said that more than one-third of troops and veterans currently suffer from problems such as traumatic brain injury and post-traumatic stress disorder. The system of care for psychological health that has evolved in recent decades is insufficient in meeting the needs of today’s forces and their beneficiaries, and it will be insufficient in meeting those needs in the future (Associated Press, 2007).
Suicide among Iraq veterans is also a growing concern. Preliminary research from the Veterans Affairs Department revealed that hundreds of American troops have come home from the Iraq war, left the military, and committed suicide. This research provides the first quantitative look at the suicide toll on today’s combat veterans. Continuing research reveals that between October of 2001 and December of 2005, at least 283 combat veterans who left the military committed suicide. Thousands of men and women return from war with disabling injuries and mental health disorders that put them at a higher risk for suicide. Suicides in Iraq have occurred since the early days of the war, but awareness was heightened when the Army revealed its suicide rate in 2006 rose to 17.3 per 100,000 troops—the highest in 26 years of record-keeping (“Iraq War,” 2007).
The trauma of war reverberates throughout the human organism. Researchers have now found that the trauma sustained in combat not only affects a soldier’s psychological health, but his or her biology as well. Yale endocrinologist John W. Mason, MD, now Professor Emeritus of Psychiatry, has found that the behavioral changes of PTSD have neurobiological correlates. Combat veterans with PTSD show elevated levels of stress hormones such as noradrenaline and adrenaline (Shudro, 2005). Yale researchers have found that veterans with PTSD not only undergo changes in stress hormone levels, but they may also have hyperreactive sympathetic nervous systems, exaggerated increases in heart rate and blood pressure, and reductions in the volume of the hippocampal region of the brain, which is critical for memory and learning (Shudro, 2005).
According to the Office of the Army Surgeon General, more than 60 percent of the soldiers wounded in Iraq have suffered injuries from blasts, often caused by improvised explosive devices. These hidden and often debilitating traumatic brain injuries have become the trademark of the Iraq war. Kevlar-armored soldiers who would have previously died in combat are surviving blasts only to walk away with injuries to the brain that might not be immediately apparent (Richter, 2007).
Nearly 1,900 of the more than 24,000 soldiers wounded in Iraq and Afghanistan have been treated for traumatic brain injuries. Eighty-eight percent suffered “closed head” injuries, those that are buried in the brain and are often missed by medics in the field. There are believed to be many others—at least 8,000 to 10,000 based on U.S. Army estimates—who have been discharged or are still in combat situations and are unaware of possible head injuries (Richter, 2007).
Even with the best of care, symptoms of brain injury might persist over time. In a 2006 study published in the Journal of Rehabilitation Research and Development, Henry Lew, MD, PhD, clinical associate professor of physical medicine and rehabilitation at Stanford, followed the progress of 168 brain-injured patients in his Virginia clinic. He found that, although their physical wounds usually healed, 94 percent still had cognitive difficulties and 84 percent had persistent emotional problems after two years. Lew says those with head injuries might continue to suffer social handicaps that impair their ability to relate to family and friends or to hold down a job. “This invisible wound is hurting them more than their visible wound because it affects them in so many ways—their jobs and their relationships,” Lew says. Fortunately, he says that with treatment these patients can still learn strategies to compensate for their residual cognitive and emotional problems (Richter, 2007).
Chaplains in Painful Predicaments
It is apparent that with each act of violence in Iraq, even if a soldier is not physically wounded, new psychological and spiritual wounds are opened. In the war zones of Iraq and Afghanistan, the military is calling upon chaplains to render aide to soldiers hemorrhaging psychologically and spiritually. There is currently a shortage of military chaplains, which explains why the Army National Guard is offering a $10,000 signing bonus for those willing to fill the role. Major Timothy L. Baer, the chaplain in charge of recruiting, says he has only 340 chaplains to fill 770 authorized positions. Lieutenant Colonel Ran Dolinger, spokesman for the Army Chief of Chaplains office, said there are about 452 vacancies among 3,000 chaplain slots in the National Guard, Army Reserve, and active duty positions. Barry reports, “They don’t have a lot of people who can and want to do this kind of work” (Zelson, 2007).
Chaplains in war zones often face gut-wrenching moral decisions where clear solutions and easy answers are not forthcoming. Situations may arise where a chaplain has to make a decision whether or not to protest the policies going on in a combat zone. That kind of decision may be difficult in its own right, but trying to determine where to direct the protest may be equally as challenging considering the allegiance a chaplain has as a staff officer and how that allegiance might conflict with his moral principles as a minister.
Considering that many American soldiers may have Christian roots, it is worth noting that the Christian tradition provides some measure of justification for war if it meets certain standards: 1) if there is no other way to protect oneself and society from an unjust aggressor, and 2) if the means used to achieve the military goals are commensurate with the ends. In Vietnam, the chaplains were often unable to provide the soldiers with practical religious options. A similar phenomenon may currently be playing out in Iraq. Chaplain William Mahedy (1986) recounts this phenomenon from his experience with soldiers in Vietnam:
Night closes in on the spirit and in this spiritual darkness religion became unavailable. God, they were convinced, was no longer with them, and efforts to prove otherwise only pushed them further from religious life. Soldiers talked about chaplains with great anger and resentment as having blessed the troops, their mission, their guns, and their killing: ‘whatever we were doing—murder, atrocities—God was always on our side’ (p. 117).
Times of war are frequently described in terms of their devastating physical, psychological, and social effects. Yet, war can also pose a great spiritual threat. War ignites questions about guilt, innocence, and a soldier’s religious frame of reference (Pargament, 1997). One function of a military chaplain is to be a calming presence as a soldier confronts distressing questions. Chaplains may invite soldiers to consider their experience from a perspective of non-judgment, acceptance, and forgiveness. They may even explore the possibility of their experience leading to personal growth and development through effective coping. However, at times, the psychospiritual suffering a soldier experiences might be so intense that it makes life seem meaningless. A soldier’s suffering may be experienced as an intense and complicated inner pain that includes fear, guilt, shame, confusion, grief, rage, and hopelessness. In William Triplett’s (2000) “Veterans of America” article, Chaplain William P. Mahedy, now a key member of San Diego VA Medical Center’s PTSD clinical team, says the following:
Having confronted real radical evil, the veteran is no longer able to accept the cultural assumptions which formed the basis of pre-combat life. Evil of this magnitude encompasses an almost total immorality into which the soldier is drawn. This creates moral pain on a scale incomprehensible to most noncombatants. The veteran’s entire belief system collapses into angry, often lifelong nihilism. This is the most enduring and intractable element of combat trauma.
Toward Post-Traumatic Recovery
Mahedy, a combat veteran himself, believes “spiritual recovery involves both a careful examination of one’s actions as well as deep soul searching.” He urges the veterans he works with to “take responsibility only for actions that were directly his and not the result of external pressure or intense stress, fear, or rage generated by combat” (Triplett, 2000). He then encourages soldiers to analyze those actions in terms of their effects on one’s spirit and their relationship to such concepts as grace, redemption, and forgiveness.
There is hope of healing, growth, and development for some combat veterans. Elder and Clipp (1989) conducted research on veterans from World War II and the Korean War. They introduce their study by describing two commonly acknowledged legacies of war for the veterans. The “No Legacy: The War is Over” involves a denial of any feelings or reactions to the wartime experience. The “Pathogenic Legacy” involves the experience of stress-related symptomology sometime after the return to civilian life when circumstances trigger unresolved, war-related conflicts. The researchers do not deny the power of these legacies, but they assert that a third possiblity has been overlooked, that of the “Developmental Legacy.” They write:
Combat exposed men to conditions that stretched survial skills to the limit, as in the control of emotions during excruciating pain or fear. Managerial skills were learned through the demands of leadership and combat experience. Among men who survived war’s traumatic experiences, this past and present can be tapped as a resource whenever life becomes exceedingly difficult (p. 317).
In Elder and Clipp’s study, veterans who had experienced heavy combat reported greater deprivation and trauma from war, including combat anxieties, misery, bad memories, death or destruction, and the loss of friends. Even though combat involvement was associated with greater pain and loss, it was also tied to greater gain. In comparison with those less involved in combat, the heavy combat veterans were more likely to say that they had learned to cope with adversity and had grown to value human life. These veterans were part of a longitudinal study that allowed researchers to confirm interview findings. The analyses revealed that the heavy combat veterans did indeed become more goal-oriented, less helpless, and considerably more resilient than veterans with less combat involvement (Pargament, 1997).
The study by Elder and Clipp (1989) has been strengthened by more recent studies showing that people facing intense stressors can find ways not only to avoid exhaustion, but to strengthen themselves psychologically, socially, and physically (Aldwin, Levenson, & Spiro, 1994; Dienstbier, 1989). Through coping, resources are not only used, they are developed; burdens are not only taken on, they can be transformed.
A chaplain may be a vital resource in assisting soldiers in reframing their war experience, and may also strengthen a soldier’s ability to cope following a combat episode by lending psychological and spiritual support. A chaplain may serve as a model of acceptance, compassion, and forgiveness. Religious soldiers that have not had their faith decimated by war experiences may be encouraged to persevere in their religious way of life and seek religious support from God, friends, family, and clergy. For soldiers who have had their tried and true way of life disrupted, a chaplain may offer survival skills that help break down barriers to religious resources and may explore new methods of coping with the soldier. By engaging with a chaplain following combat, a soldier may be unknowingly proceeding in a way that gives him or her the best chance to recover from the trauma of war.
Mental health professionals may assist a soldier in processing thoughts and feelings that can be potentially helpful in many circumstances. For soldiers experiencing the trauma of combat, chaplains may also offer a level of comfort, a means of grace, and a touch of the divine in the midst of the struggle to cope with incomprehensible tragedy (Timothy, 2007). In times of trauma, it has been found that people turn first to clergy for emotional support and only later, if at all, to mental health workers (Everly, 2003). This may be due in part to the fact that the field of counseling and psychotherapy has been slow to recognize the need to address spiritual and religious concerns (Corey, Corey, & Callan, 2003). Chaplains are certainly not the only caregivers that can be helpful to soldiers in crisis, but evidence points toward the importance many soldiers place on spirituality and the need for spiritually competent caregivers to be available to provide support in times of need.
Chaplains may assist soldiers in experiencing growth after major life stressors, such as severe trauma or combat. A chaplain may share research with a soldier indicating that it is possible to transform the evils and horrors of war into more meaningful interpersonal relationships, positive changes in life philosophy, and a sense of peace and optimism in the face of adversity. Chaplains may introduce the concept of “post-traumatic growth” to soldiers to instill hope, allowing them to see the possibility of recovering one’s normal state of functioning following combat trauma. This growth also allows soldiers to surpass their pre-trauma state of functioning, making them significantly better off for having suffered the traumatic event. This does not suggest that the trauma is therefore welcomed or trivialized, nor does it mean that there is no negative impact from the trauma. Rather, it suggests that it is possible for a survivor to go through periods of severe anxiety and grief on the way to post-traumatic growth and actually come out superior to where one started (Kelly, 2007; Ogden, Minton, & Pain, 2006).
Spirituality in Mental Health
In their work, chaplains draw on the near-universal human experience of faith, spirituality, and religion. These resources have been historically neglected by the field of psychology for various reasons, yet are now recognized as strongly related to mental health (Hill & Pargament, 2003; Kelly & Strupp, 1992; Miller & Thoresen, 2003). Due to the rediscovery of the role of spirituality in mental health, there is a growing amount of literature on the topic of spirituality and trauma, sometimes referred to as “religious coping.” Researchers have found that positive religious coping is associated with lower rates of depression and with fewer symptoms of psychological distress, such as those found in PTSD (e.g., Calhoun et al., 2000; Drescher & Foy, 1995; Everly, 2003; Harrison et al., 2001; & Meisenhelder, 2002).
Research points to the idea that there are two possible responses to trauma relevant to personal growth. One response focuses inward on self, holds rigidly to grievances, and increases the misery of post-traumatic stress. The other focuses outward on one’s understanding of God, is open to learning new things in the midst of suffering, and leads to post-traumatic growth. It is important to note that for some, the latter may be very difficult. Thus, it is never skillful to blame a person for the torment of his or her post-traumatic stress. The only wholesome response should be filled with love, kindness, and compassion. At the same time, it is important that trauma victims be made aware of the potential benefits of openness to religious growth. In that way, those who are so inclined will be encouraged to access this important resource and experience its benefits (Kelly, 2007).
Military chaplains may help soldiers turn toward the divine and open themselves to post-trauma growth. After experiencing combat, a soldier may have a series of questions that inevitably press on his or her mind. What should I conclude from this terrifying experience? How do I make sense of it? Why did it happen? Where was God? What must I do now to be safe? If such thinking leads to nothing but confusion, discouragement will follow and add to the weight of post-trauma distress. But if reflection leads to new realizations and conclusions that help explain not only the event but also deeper questions regarding life’s ultimate meanings, that is another matter. Productive, positive spiritual reflection may be a significant help for soldiers struggling to cope with the trauma of war.
Pargament and Park (1995) noted that although religious coping can serve simply to provide tension reduction, it is also motivated by a search for significance, intimacy, self, and spirituality. Religious coping can be expressed in a wide variety of ways. For example, Pargament et al. (1990) identified six different classes of religious coping consisting of 29 specific strategies. They found that spiritually-based coping activities were positively related to adaptive general outcomes, general health, and religious outcomes. Furthermore, religious coping strategies were found to predict outcome variance above and beyond that explained by non-religious coping strategies. The significance of religious-focused coping and chaplaincy is now acknowledged by most mental health clinicians as indicated by a recent survey by Shafranske & Malony (1990). Results of the survey showed that 74% of clinicians believed that religious and spiritual issues can be relevant to psychology, yet 67% of this sample believed that psychologists are incompetent in assisting clients with spiritual issues (Koenig, 2006).
Military chaplains are able to assist clients with spiritual issues, doing the work that other mental health professionals cannot or will not do. They nurture the living, care for the sick or wounded, minister to prisoners or prisoners of war, and honor the dead. They assist military personnel and family members in dealing with a variety of issues, and they do it from a spiritual and religious perspective.
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