BACKGROUND
The impacts of war for humankind are enormous, particularly for those directly or indirectly involved in combat. War can affect an individual physically, psychologically, and spiritually. The physical impacts of war are usually more apparent and can often be treated with advanced medical care. The psychological impacts of war have been well recognized and extensively studied along with treatment protocols developed (Goodson et al., Reference Goodson, Helstrom and Halpern2011; Tanielian & Jaycox, Reference Tanielian and Jaycox2008; van Dam et al., Reference van Dam, Vedel and Ehring2012). Comparatively, the spiritual impacts of military experience are less well studied and are often overlooked by mental health professionals. Using violence to resolve conflicts contradicts human morality as well as the religious and spiritual doctrines of most, if not all, religions. It is therefore conceivable that participating in, witnessing or learning about military actions that violate the moral conscience or principles of an individual's religious/spiritual beliefs can cause profound damage.
Some psychologists have begun to study the devastating negative consequences of “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” (Litz et al., Reference Litz, Stein and Delaney2009). Studies have found that killing or committing atrocities in war and the inability to forgive oneself or others for these acts are associated with depression, anxiety, posttraumatic stress disorder (PTSD), and substance abuse (Maguen et al., Reference Maguen, Lucenko and Reger2010; Reference Maguen, Luxton and Skopp2011; Witvliet et al., Reference Witvliet, Phipps and Feldman2004). However, few studies have examined the religious and spiritual impacts of military experience.
We recently completed a study that we interviewed veterans, their family members, and chaplains about the spiritual needs and spiritual care received/provided to veterans at the end of their lives (Chang et al., Reference Chang, Stein and Trevino2012a ; Reference Chang, Stein and Trevino2012b ). In addition to the spiritual needs that are common among non-veteran populations, this study revealed the unique spiritual needs for veterans, including the need to receive forgiveness for war crimes or sins and the need to alleviate guilt. Building upon our previous study's findings, the goals of the present study are: (1) to gain an understanding of chaplains' perspectives on the spiritual impact of combat-related events that still affect veterans at the end of life, and (2) to describe how chaplains help these veterans in a Veterans Administration (VA) hospital. Our study will provide the basis for developing interventions to help veterans who are suffering from spiritual distress due to events that occurred while in military service.
METHODS
We conducted individual face-to-face interviews with five chaplains in the VA healthcare system to collect in-depth information regarding their experience in providing care to veterans who, at end of life, were still suffering from events that occurred during their military careers. These chaplains were members of the VA chaplain service. Two were on a palliative consult team, and all have provided care to patients at or near the end of life and their family members. All five chaplains (four Caucasian men and one Caucasian woman) were Christians (two Catholic and three Protestant). The length of VA service was between 1 and 4 years for four chaplains and nearly 20 years for the other one.
The chaplains signed an IRB-approved informed consent before they were interviewed by the study psychologist. They were asked six open-ended questions (see the Appendix) that covered the frequency of encountering veterans who were suffering from events in their military career, the events that caused the suffering, veterans' willingness and openness to discuss the events, techniques used to help the veterans, and additional aid that might be needed to resolve their conflicts. Based on their answers, the interviewer often asked followup questions. On average, the interviews lasted approximately 30 minutes.
The interviews were recorded and transcribed. Analyses were based on a grounded-theory method that involved reading the transcriptions line by line, initial coding of each interview, and reducing initial codes into categories (Strauss & Corbin, Reference Strauss and Corbin1990). Two authors (BC and NS) independently coded the interviews. They then discussed and resolved discrepancies to agree on final categories for each question, which are presented in the results section.
RESULTS
Frequency of Encountering Veterans with Spiritual Distress
All chaplains reported that they have encountered veterans still suffering from military events that occurred decades ago. Some chaplains reported that spiritual distress occurred more often among Vietnam veterans than with World War II (WWII) veterans. However, the issue of spiritual distress could reemerge for many WWII veterans when facing death:
There's a lot of World War II or Korean Vets who, especially, they tend to be kind of stoic, but then when they're (. . .) at the end of life, a lot of things come up where they will talk about images or it's triggering traumatic images which kind of haunt them.
One factor that might contribute to the greater occurrences of spiritual distress among Vietnam veterans is the time that it took servicemen to return home. Many WWII veterans spent a month or more on ships to come back, which gave them an opportunity to debrief with each other, while Vietnam veterans did not have the same opportunity to spend a long period of time with fellow servicemen because it took less than a day for them to fly home from the war zone. This sudden change made it more difficult for them to cope. One chaplain commented that veterans from recent wars (Iraq and Afghanistan) might face similar challenges.
Type of Events that Caused Spiritual Distress
The type of events that caused spiritual distress include what they did (e.g., killing in war), failed to do, or witnessed others do:
I would say about half say it's something I did—Will God forgive me, because I did such and such. About half of them are survivor's guilt things that “I should have done more,” “I could have done more,” but I didn't.
I mean, it really is quite traumatic for some of them to kind of just spill this, get it out, and get it over with. (. . .) I had one veteran that way, and he just carried that cross. Because he wasn't doing his stuff, the thirty men ahead of him got killed. And he had a real hard time getting that out.
Another chaplain reported that the guilt veterans experienced from killing on the battlefield was hard to overcome, especially for someone with a religious background:
The most traumatic was a good Catholic who was basically still wrestling with the fact that he was a very young man in Korea, and that was the first time he killed people, and just had to kind of continuously reassure him that he was okay with God.
Methods to Help Veterans Discuss Their Hidden Spiritual Distress
Chaplains reported various methods they have employed to help veterans become more comfortable in discussing the details of their experiences. These methods can be categorized into “establish rapport/a trusting relationship,” “approach gently/sensitively,” “start with general questions about military experience,” “encourage them to tell their story,” “express gratitude for their service,” “listen/reflect,” and “continuously make oneself available.”
One chaplain described how he used a general question about the memory of war to allow a veteran to talk about a traumatic event that happened 50 years earlier, which the veteran had not revealed to anyone:
I'll ask the question [their memory about the war or what was it like], (. . .) that kind of a question and (. . .) it gives them the sovereignty then to answer whether it's a traumatic thing or a more memorable kind of good memory, and so I get both. One guy answered me how he was in Korea, and it was like the end of the war, I mean, near the end of his deployment, and he was going to be going home the next day, and he was sitting around a campfire talking with his friends, his buddies, comrades, and as they're all talking about this they got shelled, and two or three guys that he was sitting around with died, and he survived. That was what he remembered, so that was what really haunted him, and he hadn't talked about that in fifty years, he said.
One chaplain expressed the importance of a trusting relationship and the value of having support from other veterans who shared the same experience:
Well, that kind of stuff really comes out of trust. You know, most people aren't building a bridge big enough to walk across. I've talked with a guy and they said, “I've never told this stuff to anybody, and I don't want you to tell my family about this stuff. I went through this stuff, and only people who've been through this stuff will understand who I am.” That's why you know the veteran's support groups are very important.
Methods Used to Help Veterans Resolve Spiritual Distress
The chaplains indicated the importance of being sensitive to the individual needs and faith background of veterans when providing care to help resolve issues related to spiritual distress.
All reported using religious approaches to help veterans address the spiritual distress from their military experience, particularly for those veterans who believed in religion and still had faith. The religious approaches included using religious scripts (e.g., from the Bible), encouraging them to give themselves over to a higher power, having them confess their sins, and responding to their questions about religion.
Chaplains also reported using approaches that were not necessarily tied to one specific religion, including helping them put their actions in context, making meaning of the events, and encouraging them to record their military experience. One chaplain described a project that helped veterans make meaning of their military experience and suggested that chaplains could help veterans to participate in that project and be there to assist when religious issues surfaced:
There's a project by the Library of Congress called Veteran's Voices. They have a set of prescribed questions that you ask the veteran, and you record, make a digital recording of their military experience. The program is designed to document the military history of veterans. I think the approach is to help them to think through that, as far as what meaning did I get out of that? Meaning making is an important thing in suffering.
Although chaplains reported success in helping veterans with spiritual distress, they recognized that some veterans need to be referred to other professionals for their psychiatric or psychological issues. However, if the distress was rooted in religion, it was possible that chaplains could be more helpful than psychologists.
Finally, the following statement from one chaplain clarifies that healing is a process, one that can take a long time and requires support from others:
It's a process. You just encourage them that (. . .) you have taken steps in the process. It's not an instant quick fix. It's a process and it's a decision because forgiveness is a decision. It's not (. . .) you do it and it's all done. It takes some work, hard work, so it's complicated, but it helps a person to know that somebody else understands that they're in that pain, and they feel so isolated in it. But once they get somebody else to join them in the battle, they feel like they have an ally.
Suggestions About Additional Help for Veterans
When asked about additional help for veterans who were still suffering from events that occurred during military service, chaplains responded with the following: support from family, help from other veterans, promotion of veterans engaging in present life to feel they are making a contribution, increased staffing, and matching the personality of patients and chaplains. The following comments from one chaplain indicate that personality and gender might be factors that contribute to building a good rapport between chaplains and veterans:
And what I find is that it all depends on the personality of the chaplain and of the individual. We have a guy who is dying now, and basically he won't talk to me, but he'll talk with the other chaplain (. . .) Plus, I mean, she [the chaplain] is also a woman.
DISCUSSION
The interviews with VA chaplains who provided care to veterans at a VA hospital indicate that many veterans at the end of life still grapple with the spiritual conflict that arises from participating in, witnessing, or learning about certain military events that transpired many decades ago. In order to help veterans discuss and cope with their spiritual conflicts, chaplains expressed the importance of establishing a trusting relationship and to be sensitive to their faith backgrounds. They reported using religious approaches such as referring veterans to scripture or religious figures associated with their religions. Such other approaches as making the events meaningful and storytelling of their experiences were also employed.
The strength of our study is provision of firsthand information about the effects of military-related traumatic events from the primary spiritual care providers in the VA healthcare system (i.e., chaplains). Because spiritual distress usually manifests itself in such psychological symptoms as PTSD, it is often overlooked by mental health professionals. To better serve veterans in the VA healthcare system, it is important to train health professionals to identify psychological symptoms that are rooted in religion or spirituality and to work with chaplains in helping veterans experiencing spiritual distress. Indeed, the VA National Center for PTSD recommends collaboration between pastoral care professionals and mental health professionals to help veterans in recovering from traumas (see http://www.ptsd.va.gov/PTSD/index.asp). The VA has a long history of chaplaincy and a well-established chaplain service that is under the Department of Medicine and Surgery (History of VA Chaplaincy, 2012). The VA is therefore well equipped to provide spiritual care to veterans who have a unique need to resolve spiritual distress from their military experience. A stronger collaboration between mental health services and the chaplain service will likely enhance the care of veterans.
Our study has some limitations, particularly in terms of generalizability. We based our results on a small sample from one VA medical center. Additionally, all of the chaplains were Caucasian and Christian, and all but one were male. Future studies involving chaplains with diverse religious backgrounds and demographics are needed to confirm our findings and to examine how these characteristics affect their provision of spiritual care to veterans who are in spiritual distress. Nevertheless, our study provides the foundation for further examination of the spiritual impact of military experience on veterans. Our study findings can also be useful in developing interventions to help veterans resolve spiritual distress. In addition, future studies are needed to examine the value of integrating the chaplain service and the mental health service for end-of-life care.
ACKNOWLEDGMENTS
Our study was funded by the VA Health Services Research and Development Services (PPO-10107). The institutional review board at the VA Boston Healthcare System reviewed and approved the study. We appreciate the time the chaplains spent in the interviews to provide the information for our study. We also thank the research assistant for recruitment and arrangement of interviews.
Appendix: Interview Questions
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1. How often have you encountered veterans who, at the end of life, are still suffering from events that happened during their military career?
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2. What types of events caused their distress? Was it mostly things that they did (e.g., they killed someone), failed to do (e.g., they failed to prevent someone from getting hurt), or witnessed others doing (e.g., they saw inhumane acts)?
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3. In general, how willing and open are these veterans to talking about their experiences in the military that affected their life, particularity their spirituality?
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4. What do you do/say to help the veterans become more comfortable with discussing the details of their experiences?
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5. How do you help the patients who are suffering?
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6. In general, how successful do you think that you have been in helping these veterans work through their distress from their military experiences? What else is needed to help these veterans?
