Thank you for asking me to share with you on the subject of PTSD. I am
not sure I have anything really new to bring to you today. But what I do
want to say is how important it is for us as chaplains in the VA system
to be ready and available to reach out to all veterans who suffer from
PTSD. A lot of literature has come out in the last several years on the
subject of PTSD. We tend to think of PTSD in terms of combat experience,
because we deal mostly with veterans who have experienced combat trauma,
or military sexual trauma. But trauma comes in many forms as we are well
aware of just since the turn of the 21^st^ century -- The world trade
Towers, Tsunamis, hurricanes like Katrina, childhood sexual abuse, adult
rape, tornados, fires. Any kind of trauma can leave a lasting mark.

The DSM-iv defines PTSD criteria as follows:

A.  The Veteran has experienced, witnessed or confronted an event
    involving actual threat or death, injury or serious harm, and that
    this serious harm involved intense fear, helplessness or horror.

B.  The traumatic event persistently is re-experienced through intrusive
    recollections, distressing dreams, flashbacks, intense physiological
    and psychological distress.

C.  Persistent avoidance of triggers associated with a traumatic
    experience and a general numbing or over responsiveness to these
    triggers.

D.  Persistent and chronic arousal noted in difficulty falling asleep or
    sleeping through the night, irritability, outbursts and anger,
    difficulty concentrating, hypervigilance, and exaggerated startle
    response.

E.  The disturbance is for greater than one month.

F.  This condition causes significant impairment in social, occupation,
    or other areas of functioning.

[Acute]{.underline} PTSD is diagnosed if the duration of symptoms is
less than 3 months.

[Chronic]{.underline} PTSD is diagnosed if symptoms have been present
for three months or more.

[Delayed Onset]{.underline} is diagnosed if the symptoms are at least
six months after the stressor.

[Complex PTSD]{.underline} involves the above criteria but also includes
dissociative experiences, and flashbacks so severe, that the person
cannot tell whether they are experiencing the world accurately or not.

Almost 70% of veterans diagnosed with combat related PTSD, have other
mental health diagnoses, the two most prevalent being an affective
disorder and substance abuse.

( An Operators Manual for Combat PTSD)

PTSD is not a phenomenon of the 20^th^ century. It has existed for ages,
and given some review of the Old Testament, I am sure that Biblical
survivors of trauma, suffered from PTSD as well. It just wasn't called
that. People just "weren't right" after the event. I wonder if a number
of folks locked away in the county asylums of 19^th^ century America
were victims of trauma, and were thought to be crazy and dangerous, when
it was what we now know as PTSD. And after the Civil War another
phenomena was documented. In the 1880s civil war veterans were
documented by medical staff as waking up in the morning to rapid and
pounding heartbeats. This was referred to as "Battle Heart". (Operator's
Manual).

With WWI and trench warfare and its horrors, along with constant
shelling, it was dubbed as Shell shock. One report stated that fully 40%
of British troops suffered from this malady. There was great stigma to
being labeled with this. Sufferers were seen as malingerers and
shirkers.

With WWII, there seems to be a more conscientious attempt to understand
and treat those who came down with what was now called Battle Fatigue.
It was felt that sufferers should be quickly pulled to the immediate
rear, treated for a brief period and then returned to their unit to
continue on with their comrades. In 1946 a study by two American
psychiatrists stated that 200-240 days in combat would break any
soldier. (Trauma and Recovery). And we now send them to 365 days "boots
on ground."

It was after the Vietnam War, in 1980, that this disorder was finally
given a clinical name, a real diagnosis and found its place in the
Diagnostic and Statistical Manual of Mental Disorders, or DSM-III.

Having been deployed in OIF I, I truly believe that everyone who has
served in a combat zone, whether or not they faced actual combat, will
come home with some symptoms of combat stress. If they deny any
symptoms, they are being dishonest with themselves and others. These
symptoms may dissipate fairly quickly, but when someone spends 365 days
doing strange things to stay alive, as simple as running red lights
rather than be a sitting duck, when they come home, their bodies do not
yet know they are home, and they are going to run the first red light
they come to if they get behind the wheel. Readjustment takes time and
patience.

If you want a listing of articles in newspapers and magazines, subscribe
to the deployment Health newsletter, which is compiled by folks at
Walter Reed Army Medical Center. It comes out almost every day. They
printed two articles from the April edition of the American Journal of
Psychiatry on PTSD studies. In a recent Army Times it was stated that 1
in 3 returning soldiers from OIF/OEF would seek mental health care.

With all the attention to newspaper articles and clinical studies, I am
sorry to say that I have seen almost nothing new on spiritual care in
the treatment of PTSD. It's up to you and me to do the ground breaking
there.

As Spiritual leaders, we chaplains tend to think in religious
categories. Thinking in separate categories of Spirituality and of
Religion, is a new way of thinking for many of us. Yet in the 21^st^
century in order to be fully present to our veterans, we may need to
make this shift. A significant number of individuals no longer identify
with traditional religious categories, but still feel they are spiritual
beings. This is happening in society overall, but is also increasingly
happening in the military. As military chaplains we are not there to
convert but to support the individual in his/her sense of spiritual
connection.

35 years ago, most Americans claimed at least nominal connections to a
traditional religious organization. Young people were reared and trained
in traditional religious beliefs. This included believing that God
rewarded you if you were good, and punished you sometimes if you were
not. But basically, God was loving and treated you fairly. Vietnam
killed all that. 19 year-olds who still had not grown up enough to know
who they were went to war, and part of them is still roaming around in
the jungles, trying to find themselves, and make sense of what happened
back then. They were disenfranchised when they came home, and in
response dissociated and separated from a world that didn't understand
them, anymore than they understood themselves.

The man or woman who witnesses or participates in combat, and killing,
can begin to question and challenge the beliefs they were raised in.
They feel rejected and betrayed by God, and they in turn reject the
beliefs that failed them. They reject the God who let this trauma
happen. And out of the combat experience a number of feelings remain,
shame, guilt, inability to forgive oneself and others, anger, distrust,
hopelessness. All those spiritual injuries we screen for in our
spiritual assessments.

All Trauma has an effect on a person's sense of spirituality. In
addition to the above named spiritual injuries we can add

-Loss of self-worth; feelings of being unlovable

-shame

-confusion

-Powerlessness; helplessness

-Self-doubt; self-critical and judgmental

-Depression

-Sense of being out of balance

-Negativity; nothing feels right

-Difficulty with boundaries; setting them/respecting them

-self-directed anger

-lack of meaning and purpose in life; feeling empty

-loss of intimacy; breakdown in relationships; with others and

With one's sense of the Divine presence

-Suffering without meaning

-Diminished ability to feel pleasure or love

( from Pastoral Care for Post-Traumatic Stress Disorder by Dalene Fuller
Rogers)

Basically the only feelings remaining, that the PTSD veteran finds
allowable, are anger and bitterness. Just this past Friday, one of the
soldiers from my unit came to my office as he does on a regular basis.
He was wounded in Iraq, and has had a number of issues in coming home.
He returned home spring of 2005, about half way through his tour. He was
very angry and bitter then. He still is today. On Friday without
prompting, in the middle of our conversation, he said, "I am still angry
and bitter. I am working on it, but it's so slow." He still feels
betrayed by the military/government that sent him there.

Perhaps the way to begin with the veteran suffering from PTSD, is to
simply offer friendship, without judgment. Offer a safe place for the
veteran to unload. It is when we have earned their trust that they will
open up to share the deep, dark places in their wounded souls. Their
pre-war God failed them. In their heart they are angry with God, but for
most people it's not okay to be angry with God. He is after-all...GOD.
The veteran may need permission to be angry with the God who betrayed
him or her, to have the freedom to shake their fist at God and spill out
all that has been bottled up. God is a big God, and can take it. The
veteran may share things that will shock us to our depths, but we cannot
stand in judgment. They have already judged themselves as not worthy of
the crumbs under the table. It is not helpful to rationalize that
although God loves, he sometimes punishes, or God allows bad things to
happen. The veteran still hears this as punishment and judgment. The
journey toward spiritual healing may involve in a sense a new God, or a
new understanding of the old one. Many veterans suffering from PTSD feel
they cannot be forgiven. They often feel they are bad people. It's been
my experience that God is far more willing to forgive than we are to
forgive ourselves. In his book, An Operators Manual For Combat PTSD,
Ashley Hart said something so simple, and yet it is so profound, I could
kick myself for not thinking of it before. He said "Only good people
feel guilt and shame." What a revelation! For the veteran who feels he
is unforgivable, this is an act of cleansing, that no matter what
happened in combat, he/she is still a good person. Perhaps if the
veteran, in their spiritual journey can come to a juncture where they
can forgive the God who failed them, perhaps then they can begin to
forgive themselves AND accept the forgiveness of God for what they
thought was unforgivable.

That brings me to the rituals of forgiveness and cleansing. Almost all
religions today and those of ancient times include rites for forgiveness
and cleansing. Some simple, some complicated. What they show, is
humankind's need to be right with God and right with their community.
Such rituals symbolize wholeness and renewal, positive concepts for all
who suffer. Such rituals, or even new rituals designed specifically for
PTSD sufferers can be helpful for veterans as they begin to discover
their reconnection with the Holy in their life. It may even be part of
the healing experience for the veteran to design his/her own ritual with
the help of the chaplain. The purpose is not for the veteran to forget
his or her past, but that the past no longer controls the present. It is
important to remember that the healing process is never over. The
rituals are symbols of victories along the way. Kind of like the road to
Emmaus. It was a painful, dark journey, but with the glimpse of Jesus,
those two followers were able to complete the journey back, not just to
Jerusalem, but to a healing or renewal of their broken spirits. As for
all of us in our own spiritual journeys, it is an ongoing process of
some steps backward but more steps forward.

I encourage veterans to practice meditation as a way to relax. This can
help with the hyper vigilance issues. If the individual can get to the
point where they can relax at some level without having to be on guard
duty constantly, it's a good thing for their sense of well-being. Reiki
could also be beneficial, mainly because it forces one to lie still for
30 to 60 minutes. With one's guard down, there is the possibility of
intrusive thoughts, or even flashbacks, but with time the individual can
see that although these may happen, he/she is in a safe place, and it's
okay. Guided imagery can help control the fear of intrusive thoughts. If
in the imagery you set up the picture of a very safe place where there
is no danger, the individual is more likely to enter into some bodily
relaxation, and learn to trust that indeed he/she is safe.

As I said before, there is not a whole lot in print on new perspectives
in spiritual programs and approaches in spiritual care in the treatment
of PTSD. We are going to start to see an influx of OIF and OEF veterans
seeking treatment for PTSD at our facilities. We as chaplains are on the
creative edge. And we need to share with each other our breakthroughs in
methods we have found to be affective in walking with veterans through
their valleys of the shadow of death, and into life renewed.

I'd like to share with you a part of the story with my unit that
returned from a year's deployment last fall. And their story did not end
with their return home. In some ways that's where the hard work begins
-- coming home.

There are a number of disparities between active duty and
reserve/national guard in terms of the return home, and services
available to them. Active Duty forces, when they redeploy home, return
to a military Post, where everyone lives, or they live just off-post.
All medical services, and social services, and organizations are right
on post to assist with the individual and family need. The family
support group system is very active on active duty posts.

When they return home part of the process is to be screened for combat
stress and PTSD symptoms. And then this screening will be repeated in
3-6 months. That's the plan. The accuracy of the screening is dependent
on the individual's honesty. Treatment is easily accessible on post.

It is not so simple for the Reserve and National Guard forces when they
return home. First of all, there is no centralized military Post where
everyone reports for duty, and the majority of families live in close
proximity. Their children do not go to school with each other, so that
they have friends who have the same military kid's experience who
understand what they are going through when Mom or Dad is off at war
somewhere. Soldiers may drive 2 hours normally just to get to their
weekend drill, which is the case for me. Elements of my unit, the 98^th^
Division (IT) , are found in New York, New Jersey, and every state in
New England. Individual companies and Battalions may have family support
groups, but they are seriously challenged because families are so spread
out geographically. They are not as strong as their active duty counter
parts.

When Reserve and Guard units redeploy home after a year or more in
theater, they first return to the mobilization station from which they
deployed. They will spend approximately 5 days in various types of
briefings designed to help them begin the readjustment process. They
complete a redeployment questionnaire that covers a lot of things. A
section of it is a PTSD screen. Now think about it. If you've been away
from your family for over 365 days, and you are back stateside, almost
but not quite home, are you going to be honest when filling out that
screening tool? Are you going to say anything that could hold you back
from going home in 5 days? I don't think so. So again we have to
question the validity of the responses in my estimation. It's a good
attempt, but I am not sure it is 100 % reliable. They finish their 5
days and go home. They are now on leave for anywhere from 15 to 30 days.
After that they do not need to show up for a drill for 90 days. If there
is an issue, a lot can happen in that 90 days that will slip through the
cracks. The soldier has been told he/she has 2 years of medical care at
the VA and is encouraged to get registered. Many do. A lot don't. There
is still a concern that DOD will somehow have access to their medical
records at the VA. On top of this, there is no organized method to
re-screen reservists for PTSD symptoms when they have been home 3-6
months. It is impossible to get them together in one place at one time.

The 98^th^ Division Command Chaplain and I got our heads together last
summer and decided that we needed to do something to address the
screening process. 750 of our troops deployed from two mobilization
sites. The commanding General felt that the Division needed to make a
special effort to welcome our guys and gals home. Two teams were created
to go to the mobilization sites and work with the returnees as they went
through their 5 days of briefings. We gave our own PTSD screen. I met
with soldiers individually and asked them to fill it out, and assured
them that no one would see it but the chaplain. Of the approx 400 troops
who returned through the mobilization site where I was located, approx
300 agreed to fill it out. ( this was in addition to the screen used by
the mobilization site in their questionnaire).

The mission of the 98^th^ Division, was to train the Iraqi Army. We were
the first unit to get this assignment. 750 troops were deployed in Sept
of 2004. They were split up into 10-12 men cells mostly and embedded
into the Iraqi forces all over Iraq. There were a lot of glitches in
their experiences in Iraq. Sometimes communications with higher
headquarters were all but non-existent. They felt very isolated and
unsupported by higher HQ. Sometimes they could not get water or food
through regular supply channels. Sometimes they could not get ammunition
and were forced to use Iraqi weapons. 5 of our soldiers were killed
during their 365 days "boots on ground". We heard the stories at home.
We knew we were going to be greeting some very angry soldiers. In the
Mobilization site questionnaire was a question that asked, "while
deployed, did you feel supported by your command?" A full 75% responded
that they did not feel supported. I knew the Mobilization site chaplain
personally, and he allowed me to actually go through his questionnaires
from my unit. There were some very colorful comments. A lot of anger.
Another question of interest in this questionnaire was "How did this
deployment affect your Spiritual beliefs?" 62% said it did not affect;
37% felt it had a positive effect; and 1% felt it had a negative effect.

The other question, "Do you want to discuss privately any concerns you
have at this time with the Chaplain?" 1% said yes, 99% said no. Fears of
being held up?????? Didn't want to talk about painful memories -- just
wanted to go home?

Other details from our PTSD screen:

If an individual checked at least 4 or more symptoms to any degree of
severity, we decided that would be an indicator for definite follow-up.

72.8% of returnees through the Atterbury MOB site completed the
Division's screening tool.

The largest groups pooled around 2 levels: those who claimed they did
not experience ANY of the symptoms at all -- 40 % of those who completed
the questionnaire; and

Those who marked at least 4 symptoms to any degree of severity -- 30.3%

The remaining 29.7% were divided among the 1, 2 and 3 symptoms to any
degree of severity.

This screen was administered the last week of September 2005 and the
1^st^ week of October 2005.

We began seeing an increase in adjustment issues in January 2006, which
is roughly 3 months after their return home. We expect this to continue
for awhile.

Issues are centering around marital problems, employment issues,
disability issues, and the combat experience itself.

We have conducted 2 marriage enrichment weekends for couples, focusing
on communication skill (using the PREP model out of Colorado). We plan
to offer more if we can get the funding.

We began the process, in late January, of our chaplains personally
contacting soldiers via telephone or at weekend drills to see how they
are doing in their readjustment to home life. We decided that we would
contact every deployed soldier, not just those who completed the
screening questionnaire.

[BIBLIOGRAPHY]{.underline}

[The Endless tour: Vietnam, PTSD and the Spiritual Void]{.underline}

Rev. Amy L Snow, M.A., Trafford Publishing, LTD

[Pastoral Care for Post-Traumatic Stress Disorder : Healing the
Shattered Soul]{.underline}

Dalene Fuller Rogers, The Haworth Pastoral Press

[The Spiritual Recovery Process of the PTSD Vietnam Veteran: a
Psychological Analysis]{.underline}

Michael Carr, Wyndham Hall Press

[The PTSD Workbook]{.underline}

Mary Beth Williams, Soili Poijula, New Harbinger Publications

[Out of the Night]{.underline}

William Mahedy, Stress Press (out of print??)

[Trauma and Recovery]{.underline}

Judith Herman, M.d., Basic Books

[Effective Treatments for PTSD]{.underline}

Edited by Edna B. Foa, Terence M. Keane, and Matthew J. Friedman, The

Guilford Press

[An Operators Manual For Combat PTSD: Essays for Coping]{.underline}

Ashley B. Hart II, Ph.D, Writer's Showcase

Deployment Health News

This is an almost daily publication, compiled by Walter Reed Army
Medical Center. It has a lot of articles from newspapers and magazines
that deal with military health issues. There are other items as well.
Self-subscribe (free) at the following website:

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