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BY: EDWARD TICK, Ph.D.

Human societies have known since ancient times that veterans need and deserve ministry as an essential component of their healing. This ministry is certainly ministry to the most wounded, underserved, needy and deserving among us, and it must include examining, wrestling with and providing guidance and relief for profound and complex wounds to heart and soul. How a caregiver relates to a veteran may be more important than any technique offered, and it requires a deeper understanding of the roots of what we know as post-traumatic stress disorder (PTSD).

Physical wounds caused by the recent wars in Iraq and Afghanistan are only the most visible damage to our returning troops. These wars also have caused three major invisible wounds to service people at epidemic levels. These so-called "signature wounds" of our modern high-tech wars are (PTSD), military sexual trauma (MST) and traumatic brain injury (TBI).¹

PTSD is not just a military wound. It can occur in anyone suffering severe, life-threatening trauma such as muggings, domestic or sexual violence or abuse, traffic or industrial accidents, environmental disasters. Because of many conditions of modern combat, including multiple deployments, prolonged exposure, moral ambiguity and the terrible realities of being placed in the kill-or-be-killed situation, military PTSD is especially wounding, prevalent and troublesome among our troops and veterans.

In 2008, a widely quoted study by the RAND Corporation, an independent nonprofit research institution based in Santa Monica, Calif., estimated that approximately 20 percent of returning active duty troops, that is, about 300,000 of the 1.64 million who served in the recent wars, suffer from PTSD accompanied by major depression; the PTSD rate alone was about 14 percent. Only about half reported seeking treatment, a rate similar to the civilian population.²

According to a Feb. 20, 2013, article in USA Today, 50,000 new veterans were diagnosed with PTSD during 2012, and in the last three months of that year, the national average of new military PTSD cases reached 184 per day.³

Because of the dominance of high explosives in modern combat zones, it is likely that many troops will suffer some degree of TBI. As of 2008, according to the RAND study, of the 1.65 million service members who had been deployed for OEF/OIF [Operation Enduring Freedom in Afghanistan, launched in 2001, and Operation Iraqi Freedom in Iraq, launched in 2003], as of October 2007, an "estimated 320,000 individuals probably experienced a TBI during deployment," a number slightly higher than for PTSD.⁴ Department of Defense statistics affirm that there have been over 265,000 diagnosed cases of TBI between 2000 and 2013 today.⁵

MST is similarly widespread among our troops, with at least 20 percent of women serving reporting some form of sexual abuse while in service, though the perpetrator may not necessarily have been in the military, and PTSD was the most common accompanying psychological distress.⁶ The U.S. Department of Veterans Affairs (VA) specifically says that this number is based on women who have had a general health screening at a VA facility; we cannot extrapolate the number of women suffering MST in the entire military force, as many do not report and there is no way to track them.

These three wounds, often with accompanying depression, often occur in combination in our veterans and create such a complex of transformed and troubled thinking, feeling, perceiving and behaving that the afflicted person can become lost for life with devastating personal, familial and social consequences. Too often both veteran and family despair over healing or homecoming, costs to society are high and far greater numbers of veterans die from suicide, "accidents" or stress-related diseases than were killed in combat. To date, more than twice the numbers of Vietnam veterans have killed themselves than were killed during the war.⁷ With more than 6,000 American military deaths in Iraq and Afghanistan, we presently have 18 veterans killing themselves every day and already more than 30,000 dead by suicide since the invasion of Iraq. In 2012, 6,500 veterans released from military service, or roughly one every 80 minutes, killed themselves.⁸ The latest VA statistics say we may lose as many as 22 veterans a day to suicide.⁹ Among active duty troops, 2012 was the worst year for military suicides.10 In all branches of our military combined, 349 service members took their own lives compared with 295 combat deaths, making troop suicide "now more lethal than combat."¹¹

PTSD first entered our diagnostic criteria in 1980. This diagnosis typically has four symptom sets: reliving the traumatic events, avoiding situations that remind you of the events, hyperarousal and psychic numbness.¹² These symptom sets can result in such behaviors as rebelliousness, violence, rage, hypervigilance, flashbacks and other forms of re-experiencing trauma, substance abuse, nightmares and sleep disorders, domestic, employment and legal troubles, intimacy and sexual difficulties, alienation, an inability to return home and to serve society and the possibility or tragedy of suicide.

PTSD is commonly treated with massive doses of pharmaceuticals to manage and reduce its complex symptomatology and cognitive behavioral therapies to teach the veteran to stay focused in the present, manage his or her life and avoid painful memories, feelings and stress triggers. This is consistent with the modern psychiatric interpretation that labeled PTSD a stress and anxiety disorder, though its classification category may change with the new edition of the American Psychiatric Association’s Diagnostic and Statistical Manual, expected to be released in May 2013. Modern approaches seek etiology and cure in brain chemistry and cognition, and a diagnosis of PTSD almost inevitably leads the sufferer, professionals and public to look for psychological and medical treatment as if the wound were primarily a medical condition.

However, PTSD has proven exceptionally resistant to successful treatment. In my 35 years of working with veterans, I have heard uncountable numbers of veterans complain that their care provider "doesn’t get it," that is, does not understand the military, war, or how to help. Veterans and VA hospital staff report from all over the country that our VA hospitals are so overtaxed that vets often have to wait months for an appointment.

While the conventional response to PTSD may be helpful, it does not take into account the massive frustration of veterans who have not achieved healing or homecoming and are asking their helpers and our nation for something more. Nor does it take into account the unique and complex moral, ethical and religio-spiritual dimensions of warfare that are inevitably troubling to the survivor and need to be addressed if healing is to occur.

Army veteran Tomas Young, paralyzed after an ambush during his service in Iraq, referred to the VA’s failings in an open letter published March 19, 2013, on the Internet. Young, 33, addressed his remarks to former President George W. Bush and former Vice President Dick Cheney: "I have, like many other disabled veterans, suffered from the inadequate and often inept care provided by the Veterans Administration. I have, like many other disabled veterans, come to realize that our mental and physical wounds are… perhaps of no interest to any politician. We were used. We were betrayed. And we have been abandoned."¹³

TRADITIONAL INTERPRETATIONS OF PTSD
What today we call PTSD has always accompanied war and violent trauma. It is not a new condition. Rather, our interpretations, treatments and responses differ from those of the past. We know of more than 80 names for the condition since ancient times. ¹⁴ From the Bible, consider, for example, Noah as a survivor of global trauma and Saul and David as traumatized warrior kings. Saul committed atrocities, flew into violent rages, turned against David and other friends, murdered priests and holy women. We are told, "The spirit of God left him, and an evil spirit sent by the Lord tormented him." (Samuel 16:14). Traditional cultures have always known of this wound. They understood that the wound was also spiritual, moral and holistic in its essence. For example, the Sioux people called the wound "the spirits leave him." The Xhosa of South Africa call it kanene, which is, according to paratroop veteran Roger Brooke, a Duquesne University professor of psychology, "the warrior’s insight into the depth and burden that follows him — like your shadow that always follows you and reminds you of what you have done."

Spiritually based cultures affirmed that once someone participates in destruction and killing, they become different forever, their souls are affected and afflicted and they need and deserve massive degrees of tending and caring by the community and its elder warriors and spiritual leaders. In traditional cultures, not only the health professionals but also the entire society took responsibility for their warriors’ safe returns.

This is not just ancient practice. Moral trauma and injury are now finally recognized as genuine psychological phenomena necessitating address in treatment and are being studied empirically.¹⁵ In contrast to our American experience, the Vietnamese experienced massive degrees of death and destruction during our war there. Though our veterans suffer PTSD in epidemic numbers, the story is different in Vietnam. As my research and the dozen healing journeys I have led to that country since 2000 confirm, the entire society shared the grief and wounding from war. Vietnam has a spiritual base that protects its people from long-term traumatic breakdown, and the entire society, from the village to the national level, took responsibility to help and support their afflicted before, during and since the war. Consequently there is almost no PTSD as we know it in Vietnam today.

Biblical wisdom, traditional and spiritually based cultures and veterans’ testimonies all affirm that PTSD is a holistic wound, affecting the survivor’s body, mind, heart and spirit, causing despair and loss of meaning and impacting the entire community. Because of this holistic and comprehensive nature of the wound, we can best understand it as a wound to the soul, to our spiritual and moral essence, to the core of who and what we are and to our communities. We could translate the acronym PTSD as both post-traumatic soul distress and post-traumatic social disorder.

Many treatment techniques have developed in recent years in response to the desperate need for non-pharmaceutical tools for reducing the suffering that PTSD can engender. For example, mindfulness meditation originating from Buddhism is being used effectively to help patients remain in the present rather than revert to traumatic memories. Other tools, such as Eye Movement Desensitization and Reprocessing, Trauma Resiliency Model and Emotional Freedom Technique, have been developed from recent advances in body-mind and energy medicines, neuro-linguistic programming and positive psychology. These approaches have helped many veterans to reduce symptoms and improve daily functioning.

However, these techniques are limited in holistic impact and do not address the moral or spiritual injuries of war. The approaches assume PTSD is a stress and anxiety disorder, that we can change our entire beings by changing the ways we think and that war and other trauma survivors should become like well-adapted civilians. They also assume that the discharge of war memories and emotions is not necessary or that they can be accomplished in a relatively brief time, that many stories can remain untold and that the facilitator never has to witness them. These techniques may protect the facilitator against exposure to traumatic stories, but it also means the facilitator does not fully share the healing journey, does not become educated to the realities of military experience and may inhibit the veteran from expressing an emotion or event needing witness and release.

A SOUL WOUND
We cannot cure PTSD; it does not go away. The condition is notoriously resistant to long-term healing and transformation. Part of the problem in developing effective therapeutic approaches is the difficulty many veterans have in trying to describe their war experiences and the resulting moral and spiritual anguish.

"My soul has fled," one Vietnam combat vet declared to me.

"It was all dark inside; the light had gone out," another said.

"PTSD is what results when your head tells you to do what your heart knows is wrong," an Iraq vet declared.

"War is sick, and everyone who participates in it catches the sickness," an Afghanistan vet stated.

"We are trained to be savage beasts, put into conditions that only beasts could survive, and kept there until the Beast takes over and owns our soul," said a Special Forces operative.

We clearly need new terms and concepts for combat experiences that differentiate them from civilian experiences. As a guide, we can study the principles and practices of spiritually based traditional cultures and adapt what we learn to contemporary needs and settings. We also must recognize that the experience of going to war constitutes a genuine descent into hell and undergoing a spiritual death. Thus PTSD is a soul wound.

From the perspective of the soul, a person with PTSD is stuck in hell and awash in destruction and death. Anyone in this condition needs rebirth. Healing occurs when the wounded soul is guided to that rebirth, and world spiritual traditions teach that there is a spiritual process of initiation involved in order to finally be able to declare, like the psalmist David, "Yea, though I walk through the valley of the shadow of death, I will fear no evil…"

That is not to say war’s changes to personhood can be reversed, even though many veterans and their families ache for a return to the pre-war self — often that’s their goal in therapy. But life and growth are one-way streets, and war changes who we are. A new self must be constructed that includes all the important stories, values, meanings and events of military and war experiences. We must normalize rather than pathologize the process.

PTSD is an identity crisis. We must help the survivor discover who he or she has become and enable the new self to thrive in ways that include the war experiences. We bring healing to an identity crisis through identity transformation and the creation of life-affirming meaning.

Combat transforms how we attach, relate to, love or connect with others. There are two intimacies in war, the brotherhood for which you kill and the foe you do kill. Combat survivors’ styles of relating are taken apart in war and re-forged from these twin dynamics of battle.

Psychiatry recognizes the diagnosis of attachment disorder — confusion about how we connect with others that is so old and deep, it is built into our psyches and can distort all our love relationships and social connections. War transforms the ways we love, connect and bond so profoundly that we may seem disordered, obsessed, terrified, abusive, distant, numb, neglectful, starved or disinterested when we connect.

In traditional cultures, hunters and warriors are taught that when they take a life, they are then connected to it and responsible for its soul forever. Though they didn’t call it PTSD, the condition is something traditional warrior cultures recognized as a danger, and they prepared and protected their warriors more effectively than we do. They recognized it when it occurred and responded to it holistically. Healing and homecoming were not left to specialists; the entire community was involved and did not isolate, alienate or blame its warriors, no matter the politics surrounding the war.

In our current wars and social environment, our military touts "soldier fitness," and the physical and mental training for soldiering is supreme, such that we create highly effective, trained killers. But, as soldiers, their chaplains and behavioral health specialists have attested, psychological and spiritual needs, both before and after deployment, are largely ignored. As Mary H. Paquette, Ph.D., RN, assistant professor of nursing at California State University Northridge, wrote, "The military is excellent at training and conditioning soldiers for war. … What the military does not do well, however, is to reverse the process and turn the ‘trained killer’ back into a well-adjusted civilian."¹⁶

In order for our veterans to heal, they must be properly and thoroughly prepared for combat before it occurs, fully and spiritually supported during service, and re-integrated into our communities, their experiences made public and responsibility for their actions transferred to all of us in whose names they served. "Treatment approaches," Paquette affirms, "must eventually include methodologies that address how to relieve psychological and spiritual distress…"¹⁷

Spiritual preparation, support during deployment and healing upon return are necessities that we do not practice in American society. The relationship between American citizens and veterans is in disorder. This disorder in our body politic can be healed through a reformulation of our social system so that we are truly veteran-supportive. This means that we are receptive to veterans, their stories and struggles. We are open to hearing and accepting responsibility for all war wounds, including damage done in our names. No matter what our own political beliefs, we tend our veterans until they have all they need to return. Only then will our veterans be able to spiritually return home and heal. Healing must include and happen in the community.

Also, changing what we call something changes how we respond to it. When we call it PTSD, we name an illness or syndrome. We evoke the medical and psychological models that locate the condition in the individual, out of his or her control, and in need of treatment and disability support. If it is an illness, syndrome or stress disorder, we are helpless victims and it has to be treated.

When we call PTSD a wound, we honor our veterans as warriors and recognize that they are reshaped forever by their service, that they willingly suffered for our benefit. In traditional cultures and in Vietnam today, wounds were not hidden while the warrior tried to appear "normal." Wounds to warriors were painted, decorated and displayed. In contrast, amid much controversy, in 2009 Defense Department officials decided that PTSD did not meet their criterion for awarding the Purple Heart, which is for wounds caused by "an outside force or agent."¹⁸

Combat veteran Brian Delate is an actor and writer. In 2008 he completed a movie about veterans’ struggles to heal and live well upon return to civilian life. His movie focuses on the relationships between a World War II father and his Vietnam War vet son, between two Vietnam vets who help each other through life’s daily difficulties, and between the vets and their women. When the vet son first hears that PTSD was once known as Soldier’s Heart, he says, "That’s poetic — makes me think of my dad." His girlfriend replies, "It made me think of you."¹⁹

Unlike most war movies, Delate’s is quiet. There are no explosions of violence. Rather, the movie shows that some veterans carry a pervasive sadness, hypersensitivity and an inability to find safety. Everyday life — organizing, paying attention, finding a job, paying bills, making relationships work — is just harder for them. Everything hurts. The name of Delate’s movie is Soldier’s Heart, a Civil War-era term that some veterans prefer.

We treat PTSD. We heal Soldier’s Heart. When we think of it as a medical or psychological condition needing expert repair or control, we do things to and give things for PTSD. When we think of it as a communal and spiritual wound that we all share and for which we are all responsible, we love and support, listen to, engage and guide survivors, and take a moral journey with them.

When we call PTSD Soldier’s Heart, it honors the weight and sorrow that permanently dwell in a veteran’s heart. It honors that they are wounded and must carry that heaviness their entire lives. It honors that life may be more difficult for them and they took these wounds for us. It calls for an empathic and generous response from our hearts.

We must redefine therapy for PTSD just as we must better comprehend PTSD and our veterans. Healing for PTSD requires a spiritual approach because PTSD is a sacred wound to both the soul and society. It requires a different psycho-spiritual approach because the identity must be recreated and meaning discovered. It requires a communal approach because it is a social disorder resulting from isolating the warrior from civilian classes. Healing PTSD requires moving beyond conventional therapeutic practices to restore the proper relationships between veterans and communities, to provide veterans with all they need in order to return from hell and to discover the personal and socially useful dimensions of PTSD.

We must think not only in terms of post-traumatic disorder but also in terms of post-traumatic growth.

EDWARD TICK is founding co-director of Soldier’s Heart, Inc. and the author of War and the Soul and three other books. He works with military and civilian chaplains and served as the 2012 U.S. Army Chaplaincy’s expert trainer in PTSD, training over 2,000 Army chaplains through their Chaplaincy Annual Sustainment Training. His next book, The Warrior’s Return, will be released in 2014.

NOTES

1. While major depression often co-occurs or is one symptom of these conditions, it is a common mental health issue not considered a "signature war wound." Further, these wounds are often misdiagnosed as depression. Depression may be related to factors other than military history, and veterans frequently protest or appeal this confusion.
2. Terri Tanielian and Lisa H. Jaycox, eds., Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery (Santa Monica, Calif.: RAND Corporation, 2008) www.rand.org/multi/military/veterans.html.
3. Gregg Zoroya, "Charities Take Up Mission to Help Vets," USA Today, Feb. 21, 2013. http://usatoday30.usatoday.com/NEWS/usaedition/2013-02-21-Military-Charity-CenterUSABrd2_ST_U.htm.
4. Invisible Wounds.
5. Defense and Veterans Brain Injury Center, "DOD Worldwide Numbers for TBI," www.dvbic.org/dod-worldwide-numbers-tbi.
6. National Center for PTSD, "Military Sexual Trauma," www.ptsd.va.gov/public/pages/military-sexual-trauma-general.asp.
7. By the late 1980s, the number had already taken as many lives as were killed during the war. See W. H. Capps, The Unfinished War: Vietnam and the American Conscience (Boston: Beacon Press, 1982). By 1998, the number had surpassed 100,000. See Daniel William Hallock, Hell, Healing and Resistance (Farmington, Pa.: Plough Publishing House, 1998).
8. Ed Pilkington, "For U.S. Soldiers, Suicide Now More Lethal than Combat," The Guardian, UK, Feb. 3, 2013, accessed at http://readersupportednews.org/news-section2/323-95/15849-for-us-soldiers-suicide-now-more-lethal-than-combat.
9. Janet Kemp and Robert Bossarte, Suicide Data Report 2012 (Washington, D.C.: Department of Veterans Affairs, 2013), www.va.gov/opa/docs/Suicide-Data-Report-2012-final.pdf.
10. Gregg Zoroya, "Suicides Rare Among Soldiers at Some Foreign Outposts," USA Today, Feb. 19, 2013, 3A.
11. Pilkington, "For U.S. Soldiers."
12. National Center for PTSD, "Symptoms of PTSD," www.ptsd.va.gov/public/pages/symptoms_of_ptsd.asp.
13. Tomas Young, "Dying Iraq War Vet’s Angry Message to Bush, Cheney," (letter first published on TruthDig, Mar. 19, 2013), www.salon.com/2013/03/19/dying_iraq_war_vets_angry_message_to_bush_cheney/.
14. Ilona Meagher, Moving a Nation to Care: PTSD and America’s Returning Troops (Brooklyn, NY: Ig Publishing, 2007): 20, 163-64.
15. See National Center for PTSD, "Moral Injury in Veterans of War," PTSD Research Quarterly 2, no. 1 (2012), and Rita Nakashima Brock and Gabriella Lettini, Soul Repair: Recovering from Moral Injury after War (Boston: Beacon Press, 2012).
16. Mary H. Paquette, "Spiritual Distress as a Component of PTSD: The Need for Spiritual Healing," in War Trauma in Veterans and Their Families, ed. J. Marvasti (Springfield, Ill.: Charles C. Thomas, 2012), 55-56.
17. War Trauma in Veterans, 66.
18. Jeff Schogol, "Pentagon: No Purple Heart for PTSD," Stars and Stripes, January 6, 2009, www.stripes.com/news/pentagon-no-purple-heart-for-ptsd-1.86761.
19. Brian Delate, Soldier’s Heart: The Movie (New York: Soldier’s Heart Productions in association with Liberty Studios, 2008), www.soldiersheartthemovie.com.

Copyright © 2013 by the Catholic Health Association of the United States
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