Coming Home

1
Coming Home

• Developing a Theological Response for Returning
  Combat Veterans
• Rev. Dr. John P. Oliver, BCC
• Chief of Chaplain Service, Durham VA Medical
  Center

2
Sponsored by the
VISN 6 MIRECCVA Medical Center508 Fulton
StreetDurham, NC 27705919-286-0411 x5106
3
Objectives

• Identify re-adjustment challenges veterans and
  their families face post-deployment.
• Identify psychological and spiritual effects of
  war trauma on survivors.
• Develop theologically-grounded,
  patient-appropriate pastoral care responses.
• Plan a community response.

4
Scope of Issue

• 3,000 USA - Fatalities (OEF/OIF)
• 12,132 WIA Returned to duty
• 10,834 WIA Not returned to duty
• 869 Non-hostile deaths
• Over 1.4 Million soldiers are involved in the
  GWOT

5
Who are these folks?

• Highly trained men and women.
• Members of one of the elite fighting forces of
  the world
• Individuals with HUGE responsibilities while
  deployed
• Our family members, neighbors, friends,
  co-workers, patients

6
Re-adjustment Challenges

• Neither the returning soldier or the family
  members at home are the same as before deployment
  to war.
• Returning home is disorienting and can represent
  an absence of social community, structure, order
  and predictability.
• The enormity of the war experience shatters the
  individuals basic sense of safety and basic
  understanding of the meaning of life.
• Virtually all individuals returning from combat
  will face acute stress reactions and other
  re-integration issues.

7
Challenges in Returning Home . . . .

• Psychiatric trauma is essentially a normal
  response to an extreme event.
• Trauma reactions upon returning from war are
  NORMAL reactions to abnormal circumstances.
• Resetting - Difficulty of coming home and
  turning off combat skills.

8
Definitions

• Trauma Any injury whether emotionally or
  physically inflicted.
• An experience that is emotionally painful,
  distressful or shocking and which may result in
  lasting mental and physical effects.
• Greek word for a wound and damage or defeat.

9
Definitions (cont.)

• Acute stress reaction
• A psychological condition arising in response to
  a terrifying event.
• Combat Operational Stress (COS)
• Every participant in a war zone will manifest
  some symptoms of COS (Hyper-alertness, anxiety,
  frustration, anger, confusion, intolerance of
  stupid behavior, sleep disruption etc.) but
  this does not indicate that the person has PTSD.
• Post-traumatic Stress Disorder (PTSD)
• A specific psychiatric disorder in which a
  cluster of symptoms occurs beyond one month after
  someone experiences a traumatic event.

10
Typical Crisis Cycle
Crisis
A typical crisis has a beginning where stress
builds, a high point of stress and then a slow
tapering of anxiety and fear that leads to
recovery.
11
Re-setting for Civilian Life
Crisis
Individuals post-trauma are often at a constant
state of readiness. Hypervigilance
12
Battlemind Video Vignettes
13
Objectives

• Identify re-adjustment challenges veterans and
  their families face post-deployment.
• Identify effects of war trauma on survivors.
• Develop theologically-grounded,
  patient-appropriate pastoral care responses.
• Plan a community response.

14
Reactions to Traumatic Events

• Psychological
• Cognitive
• Behavioral

• Physical
• Emotional
• Interpersonal

Spiritual
15
Psychological Reactions to Trauma

• Traumatic events are often re-experienced in the
  following ways
• Recurrent and intrusive distressing recollections
  of the event, including images, thoughts, or
  perceptions.
• Recurrent distressing dreams of the event.
• Acting or feeling as if the traumatic event were
  recurring.
• Intense psychological distress at exposure to
  internal or external cues that symbolize or
  resemble an aspect of the traumatic event.

16
Psychological Reactions (cont.)

• Physiological reactivity on exposure to internal
  or external cues that symbolize or resemble an
  aspect of the traumatic event
• Hyper-vigilance, jumpiness, an extreme sense of
  being "on guard overreactions, including sudden
  unprovoked anger
• General anxiety
• Insomnia
• Obsessions with death

17
Physical Reactions to Trauma

• Eating disturbances (more or less than usual)
• Sleep disturbances (more or less than usual)
• Sexual dysfunction
• Low energy
• Chronic, unexplained pain
• By the way. . . . .
• Traumatic Brain Injury / Orthopedics
  Poly-Trauma

18
Cognitive Reactions to Trauma

• Memory lapses, especially about the trauma
• Difficulty making decisions
• Decreased ability to concentrate
• Feeling distracted

19
Emotional Reactions to Trauma

• Depression, spontaneous crying, despair and
  hopelessness
• Anxiety
• Panic attacks
• Fearfulness
• Compulsive and obsessive behaviors
• Feeling out of control
• Irritability, angry and resentment
• Withdrawal from normal routine and relationships
• Emotional numbness

20
Emotional Reactions (cont.)

• Avoidance of situations that resemble the initial
  event
• Detachment
• Amnesia
• Altered sense of time
• Depression
• Guilt feelings
• Grief reactions

21
Behavioral Reactions to Trauma

• Substance abuse
• Self-destructive and impulsive behavior
• Uncontrollable reactive thoughts
• Inability to make healthy professional or
  lifestyle choices
• Dissociative symptoms ("splitting off" parts of
  the self)
• Feelings of ineffectiveness, shame, despair,
  hopelessness
• Feeling permanently damaged
• Loss of previously sustained beliefs
• Compulsive behavior patterns

22
Traumas Effect on Interpersonal Life

• Common effects on interpersonal relationships
• Inability to maintain close relationships or
  choose appropriate friends and mates
• Sexual problems
• Hostility Impatience with the stupid stuff
• Arguments with family members, employers or
  co-workers
• Social withdrawal
• Feeling constantly threatened
• Feeling detached from life

23
Spiritual Reactions to Trauma

• Confusion about God
• Altered sense of meaning in/of life
• Grief and loss issues
• Questions of Theodicy
• Feelings of ineffectiveness, shame, despair,
  hopelessness
• Feeling permanently damaged
• Loss of previously sustained beliefs
• Feelings of guilt
• Confusion about core ethical beliefs.

24
Spirituality Rebuilding a Life

• Spirituality is that which gives a person meaning
  and purpose.
• It is found in relationships with self, others,
  ideas, nature, and, possibly, a higher power.
• These many relationships are prioritized
  according to an organizing principle and form an
  intra-, inter-, and trans-relational web that
  houses a person's sense of meaning and purpose.
• Spiritual distress arises when one of these
  relationships that provide meaning is threatened
  or broken. The more significant a particular
  relationship is, the greater the severity of
  spiritual distress if that relationship is
  threatened or broken.
• Spiritual wholeness is restored when that which
  threatens or breaks the patient's relational web
  of meaning is removed, transformed, integrated,
  or transcended.
• Mark LaRocca-Pitts, Ph.D. .

25
Spiritual Consequence of War
26
Weakened Faith

• Research showed that a Veterans' war zone
  experiences (killing, losing friend, etc.)
  weakened their religious faith, both directly and
  as mediated by feelings of guilt.
• Weakened religious faith and guilt each
  contributed independently to more extensive
  current use of VA mental health services.
• Fontana, A., Rosenheck, R. (2004). Trauma,
  change in strength of religious faith, and mental
  health service use among veterans treated for
  PTSD. J Nerv Ment Dis, 192(9), 579-584.

27
Objectives

• Identify re-adjustment challenges veterans and
  their families face post-deployment.
• Identify psychological and spiritual effects of
  war trauma on survivors.
• Develop theologically-grounded,
  patient-appropriate pastoral care responses.
• Plan a community response.

28
Veterans Use of Clergy

• Veterans feel more comfortable approaching their
  pastor than they do a mental health professional.
• Research shows that 4 of 10 individuals with
  mental health challenges seek counseling from
  clergy.
• Individuals seek council from ministers more than
  all other mental health providers combined.
• Often seeing a member of the clergy is less
  threatening and has less stigma attached. Is
  viewed as engaging a known community resource.
• Negative reasons. . . Magical thinking, avoiding
  truth of diagnosis, etc.

29
Pastoral Care Approaches

• Providing a Safe Haven
• Listening
• Grounding
• Accepting
• Referring

30
Pastor as a Safe Haven

• Offer a calm, safe and non-judgmental,
  non-anxious presence.
• Provide clear, reliable boundaries of communion
  and respect.
• Be present with veterans and families during the
  storms of reintegration.
• Provide a compassionate space wide enough to
  encompass the awfulness of war trauma.

31
Pastor as Listener

• Avoid advising or offering platitudes
• Listen without interruption or comment
• Hearing content and emotion with respect
• Convey warmth and acceptance of the person, their
  journey and their struggles
• Avoid asking questions
• Notice what is in a caring and genuine way.

32
Pastors Role in Grounding

• Provide roadmap for reintegration into church
  community and community at large.
• Provide roadmap of opportunities for appropriate
  outlets regarding frustration, pain, fear, guilt
  and trauma.
• Provide avenues of dialogue for spiritual and
  religious growth and engagement.
• Provide honest and realistic reflection of
  recovery process.
• Provide spiritual, religious and community
  resources for veterans and their families.

33
Pastors Role in Accepting

• Understand the both/and nature of good and
  evil. Then and now.
• Not trying to fix the unfixable.
• To offer deep reflection on what is goodness
  and how to help others find goodness within
  themselves.
• Understanding and accepting the dark side of
  human nature.

34
Referrals

• Pastors are keen observers of symptoms
• The more clinical education, the more likely they
  were able to provide appropriate interventions
• .08 of CPE students independently thought to
  refer parishioners with symptoms

35
Spiritual Approaches by Symptom
Developed by Kent D. Drescher, Ph.D
36
Theological Reflection

• Sacraments
• Sacred Narratives
• Hymns
• Theological Constructs
• Festival Days
• Stages of Faith
• Images of Ministry

37
Theological Approaches by Symptom

• Confusion about God
• Acceptance of humanity, confession of anger
• Altered sense of meaning in/of life
• Orientation, Disorientation, New Orientation
  Jacob wrestling with the Angel.
• Grief and loss issues
• Rituals, shepherding,
• Questions of Theodicy
• Us with God us rather than God For us
• Feelings of ineffectiveness, shame, despair,
  hopelessness
• Confession, forgiving self, faith, love

38
Theological Approaches by Symptom

• Feeling permanently damaged
• Soteriology, humanity, doctrine of sin etc.
• Loss of previously sustained beliefs
• Faith development, PTS Growth potential, prayer,
  community
• Feelings of guilt
• Forgiveness / Humanity / Limitations
• Confusion about core ethical beliefs
• Confession / Community

39
Objectives

• Identify re-adjustment challenges veterans, their
  families face post-deployment.
• Identify psychological and spiritual effects of
  war trauma on survivors.
• Discuss support pastors might provide.
• Develop theologically-grounded,
  patient-appropriate pastoral care responses.
• Plan a community response.

40
Community-based Support Teams

• A community-based support team is
• a group of volunteers
• organized to provide practical,
• emotional
• spiritual support to veterans and their families.

41
Types of Support Teams

• HIV/AIDS
• Aging
• Prisoner release and re-integration

42
Value of Teams for Clients

• Hope
• Decreased isolation
• Increased quality of life
• Decreased stigmatization
• Early intervention
• Adherence to treatment regimen
• Peer-to-Peer support

43
Value for Team Members

• Altruistic experiences
• Decreased social isolation
• Increased awareness of problems experienced
• Gratitude
• Mission and Purpose

44
Concentric Circles of Care
45
Concentric Circles of Care
Support at any level ripples back to veteran.
46
Support Team Philosophy

• Do what you can, when you can
• In a coordinated way
• With a built-in support system

47
Do What you can

• Everyone can do something.
• Do what you love to do when helping others.
• Do what energizes you when you offer it. Do what
  gives you joy.
• The team approach allows team members to do what
  they love to do in a practical way.

48
When you can

• Members decide
• how much time they have to give and
• how long they want to be involved in a
  "guilt-free" environment.
• Availability is unique to each team member.
• Flexibility is key.

49
In a Coordinated way

• Coordination
• maximizes efforts and skills of the team
• avoids duplication of activities.
• Team meetings to
• communicate, educate, and coordinate mission.
• Each team has a volunteer leader

50
With a built-in Support system

• Members support one another by
• setting personal and team boundaries,
• sharing the care,
• inviting new persons to join the team.
• The support system encourages
• mutual, respectful relationships
• appropriate educational and emotional support

51
Resources

• Project Compassion
• 180 PROVIDENCE RD STE 1-CCHAPEL HILL,
  NC 27514(919) 402-1844

www.project-compassion.org
52
Bibliographic Resources

• Kent D. Drescher, National Center for PTSD
  Menlo Park.
• Dictionary of Pastoral Care and Counseling
• Andrew Weaver, Laura Flannely John Preston
  Counseling Survivors of Traumatic Events (2003).
• Emily Paynter, Compassionate Care, Meditations
  and Insights
• Jaelline Jaffe, Jeanne Segal, Lisa Flores Dumke,
  Fontana, A., Rosenheck, R. (2004). Trauma,
  change in strength of religious faith, and mental
  health service use among veterans treated for
  PTSD. Journal of Nervous Mental Disorders.
• LaRocca-Pitts, Mark, Walking the Wards as a
  Spiritual Specialist. Harvard Divinity Bulletin.
• Hasty, Cathy and Mona Shattell, (2005) Putting
  Feet to What We Pray About The Experience of
  Caring by Faith-Based Care Team Members. Journal
  of Hospice Palliative Nursing.
• Cantrell, Bridget and Chuck Dean, Down Range to
  Iraq and Back, 2005.

53
Other Resources

• http//www.helpguide.org/mental/emotional_psycholo
  gical_trauma.htm
• http//www.hooah4health.com/mind/combatstress/defa
  ult.htm
• www.ncptsd.va.gov
• Rev. John P. Oliver, D.Min.
• Chief, Chaplain Service
• Durham, NC 27712
• [phone] john.oliver_at_va.gov