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BY: SR. THEA KRAUSE, CSFN, Ph.D., ACNP-BC

Foreign travel can be an exhilarating experience. Exposure to new cultures, foods and social structures expands an individual's world view. When that travel is couched within a military operation, though, the experience may change not only one's world view, but the very essence of one's self.¹ It can also open one to deep, devastating physical and psychic wounds.

Service men and women deployed to Iraq or Afghanistan have served in smaller numbers than in previous conflicts, such as Korea or Vietnam, and rates of killed or wounded have been lower, thanks to improved body armor and medical technology.² However, wounds commonly referred to as the invisible wounds plague veterans of Iraq and Afghanistan and are now recognized as a serious and growing problem. These include post-traumatic stress disorder (PTSD), depression, moral injury and traumatic brain injury (TBI).³

This does not imply that psychological reactions to combat experience and head injuries are new realities. Studies conducted on World War I veterans showed as early as 1919, veterans were experiencing fatigue, anxiety and irritability, symptoms associated with what was described as "shell shock."⁴ Understanding more about invisible wounds might help as we consider how compassionate care within a Catholic tradition might benefit these men and women returning from Iraq and Afghanistan.

THE INVISIBLE WOUNDS
The psychological injuries that many veterans face and that are being discussed in many venues are post-traumatic stress disorder and major depression. PTSD is a condition that follows an extremely traumatic event or one in which one's life or the life of another has been threatened. Symptoms include overwhelming and intrusive recall of the traumatic event, irritability, sleep disturbances, nightmares and hypervigilance. Major depression involves persistent sadness, hopelessness, lack of interest, social isolation, guilt and changes in sleep and appetite.

Further, the spiritual response to combat can be what is termed moral injury: "an act of transgression which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about fairness, the value of life, and so forth."⁵ Like psychological trauma, moral injury is often related to extreme and unprecedented life experiences, such as those of war. Serving in combat causes moral injury when actions occur that violate one's own moral beliefs and standards. Moral injuries may stem from direct participation in acts of combat, such as killing or harming others, although such indirect acts as witnessing death or dying, failing to prevent immoral acts of others, or giving or receiving orders that are perceived as inconsistent with rules of engagement can cause just as much moral trauma.⁶

Symptoms of moral injuries include shame, guilt, anxiety and anger over actions perceived as wrong. Studies show that symptoms of moral injury are similar to those of depression and PTSD and also include social isolation, suicidal ideation, substance abuse and instability in relationships.⁷

Psychological and spiritual injuries are complicated by head injuries. Battlefield conditions in Iraq and Afghanistan put military personnel constantly at risk from car bombs, suicide bombs and improvised explosive devices, according to the 2007 President's Commission on Care for America's Returning Wounded Warriors.⁸

TBI can be caused by bullets or other projectiles hitting the head, penetrating the skull and causing severe trauma. However, it also can be caused by closed head injuries resulting from improvised explosive devices, mortars and other types of blasts common in modern combat. Soldiers experience the blast, may have a momentary loss of consciousness, feel confused and disoriented for a period of time, do not remember exactly what happened but tend to shake it off and continue the mission. A single such TBI can be bad enough, but when soldiers experience multiple blasts, the cumulative effect is most concerning. Symptoms of TBI are memory loss, speech problems, hearing loss, visual disturbances and emotional problems.⁹

PTSD, depression, moral injury and TBIs have a compounding effect on one another. Two or three of these invisible wounds in a single individual potentiates long-term sequelae of symptoms that have significant impact on veterans, families, communities and caregivers. Long tours of duty and multiple deployments can exacerbate these injuries even further.¹⁰

As with any untreated illness, complications emerge when wounds are inadequately addressed. Family problems, drug and alcohol abuse, homelessness, suicide, joblessness and alterations in moral reasoning are consequences witnessed in veterans whose invisible wounds have gone untreated.¹¹ The Department of Defense (DoD) and Department of Veterans Affairs (VA) partner to address these and the more obvious traumas inflicted on veterans. However, reports estimate that only 54 percent of veterans returning from combat are seeking care through the VA health system.¹²

The need to engage other individuals and services beyond the DoD and VA is essential if seamless, high-quality care is to be provided to those who served. Catholic health care and those working outside Catholic health care but influenced by the values inherent in Catholic mission have a responsibility to care for those in need. The newest generation of veterans is indeed in need, and the compassionate care of Jesus is our mission and ours to offer these veterans and their families.

CATHOLIC MISSION — TO CARE AS JESUS DID
What is it that Catholic tradition has to offer men and women who serve and return home from the most recent combat zones? While one can never imply that compassionate care is realized only through Catholic mission, one can proclaim with confidence that Catholic mission motivates one to embody the compassion and love of Jesus Christ and to reflect these values when providing services to those in need.

As a church, we have a special concern for the most needy in our community. While the veteran population has a system of government committed to them and their particular needs, they come home to a much broader community. The transition from military life to civilian life is difficult under the best of circumstances. Soldiers leave the camaraderie of their "battle buddies" and return to a life where "nobody knows the trouble I've seen."¹³ As a community of faith, we are wise to understand that each veteran's story is unique, and our first call is to listen and provide a safe place where psychological and moral injuries might heal.

Listening to one another is an integral responsibility of any community of persons. Within our Catholic faith tradition, listening is a concrete demonstration of God's presence and as such is a holy encounter — it raises an echo in our hearts.¹⁴ Through our listening we have the potential to make God's presence known. Our concern, our compassion, our acceptance, our support allow God to become real and incarnate to the other. Therefore, it is critical that we listen to the suffering of these men and women with the compassion of Christ while checking our own prejudices, politics and naiveties at the door. Otherwise we will not be able, as Fr. Jon Sobrino, SJ, suggests is the responsibility of the church, "…to take the crucified down from the cross" and create an opportunity for their injuries to heal.¹⁵ Listening is not easy, for the wounds these men and women bring to the conversation are deep and raw and often unimaginable even to the most informed listener.

A unique experience you may hear as you listen is that in modern combat there is no way to tell the "good guys" from the "bad guys." Children and pregnant women are objects of suspicion because of their role as human carriers of improvised explosive devices. Veterans have had to decide in a split second to kill such civilians to avoid being killed or allowing harm to come to someone in their unit.

You may also hear the residual fear in the voices of veterans whose mission it was to train Iraqi and Afghani soldiers, and how they could not sleep for weeks out of fear that their students were embedded as part of an insurgency with the intent to do harm to American forces.

You may hear soul stories spoken in word but told best through the blank stares of those who utter the words. Our tradition leads us to listen without judgment, without scorn, without condemnation. It is in the telling of the stories that healing begins to take place, and while counseling is needed, that is best left to professionals. Our role as members of a faith community is to listen, to provide that sacred space where stories of life are honored, personal and communal reconciliation takes place and the dignity of the person is never at risk. The redemptive healing that takes place in our homes, our schools and our faith communities is the work of Catholic mission.

The human person's moral authority is that inner dimension where one knows oneself intimately in relation to God, others and the whole of God's creation. Redemptive healing emerges when forgiveness and reconciliation are realized. As a church we exercise sympathetic acceptance of the weaknesses of our world: those we see, those we contribute to and those we hear through the stories of others. When weakness violates our personal or communal moral authority, we recognize it as sin in ourselves and in our world. In other words, when we do something or participate in something that we or others might judge as wrong, we are restless until we reconcile with ourselves and at times, where appropriate or possible, with others.

Moving beyond one's sinfulness — that wrong which one has done and that which one has allowed to be done — takes maturity, takes time and takes a community. Compassion and understanding on the part of the church allow veterans who have transgressed their own or society's moral code to feel welcomed and accepted. It is in the faith community's acceptance that healing begins to take place and personal forgiveness and reconciliation are enabled.

In addition to listening and forgiveness, we are called to build right relationships. We do that by connecting veterans to support systems within our church and in the larger community of providers. The U.S. Conference of Catholic Bishops reminds us and Catholic tradition teaches that human dignity can be protected and a healthy community can be achieved only if human rights are protected and responsibilities are met. "Responsibility trumps rights, and we are never free from the duty to serve others, particularly those in need," according to Cardinal Timothy Dolan of the Archdiocese of New York.¹⁶

While we cannot be all things to all people, our efforts at common good are best realized when subsidiarity is actualized and support is provided by agencies and institutions closest to the veteran. Our institutions and those within our network of referral centers have an obligation to sensitize themselves to the particulars of veterans and the invisible wounds they carry. We need to know our limitations, refer accordingly and at the same time build our own competencies in serving this population within our faith tradition.

We profess a oneness of the human family whatever ideological differences exist among us. This is especially true when caring for today's veterans. They, like countless soldiers before them, return home from wars where political and religious opinions ridicule their efforts and question the very concept of a "just war," according to Catholic tradition: jus ad bellum or jus in bello.

As veterans struggle with their recovery from wounds, both visible and invisible, we are a community that embraces our ideological differences and honors the contributions of these men and women. They, with their experiences and woundedness, add to the multifaceted fabric of our society. What veterans seek is to be companioned through the questions and doubts of who they themselves have become. As they redefine themselves in light of those experiences, they need a faith community where they can return from war, transition from soldier to civilian and find new opportunities to again contribute to the common good.

The neediness of the veteran population varies. One thing for certain is their wounds may not be readily visible. However, for a faith community rooted in Catholic tradition, the obvious is not a measure of vulnerability. When one takes time to reflect on the experience of the veteran, need can be present in the silence of the invisible wounds of combat.

For a Christian, faith in action involves allowing oneself to be open to the mystery of God in and through life's experiences and being inspired to act. Our challenge is to hear the cries of the poor wherever and whenever they surface. The cries we hear from men and women who have served inspire us to listen, to open our communities with love and hope and thus allow common good to be realized.

SR. THEA KRAUSE, CSFN, serves as ethicist and nurse practitioner at the VA Medical Center in Altoona, Pa., and teaches health care ethics at Mount Aloysius College and Saint Francis University in Central Pennsylvania.

NOTES

1. Vanessa Williamson and Erin Mulhall, Invisible Wounds: Psychological and Neurological Injuries
   Confront a New Generation of Veterans. Issue Report (Washington D.C.: Iraq and Afghanistan Veterans of America, 2009).
2. Terri Tanielian and Lisa H. Jaycox, eds., Invisible Wounds of War: Psychological and Cognitive Injuries, their Consequences, and Services to Assist Recovery (Washington, D.C.: RAND Center for Military Health Policy Research, 2008). www.rand.org/content/dam/rand/pubs/monographs/2008/RAND_MG720.pdf (accessed Jan. 20, 2013).
3. Tanielian and Jaycox; Williamson and Mulhall.
4. Robert H. Stretch, "Follow-Up Studies of Veterans," in War Psychiatry, ed. Franklin Jones et al. (Washington, D.C.: Department of the Army, 1995), 457-76.
5. Shira Maguen and Brett Litz, "Moral Injury in the Context of War," Department of Veterans Affairs, www.ptsd.va.gov/professional/pages/moral_injury_at_war.asp (accessed Jan. 13, 2013).
6. Kent Drescher et al., "An Exploration of the Viability and Usefulness of the Construct of Moral Injury in War Veterans," Traumatology 17, no. 1 (2011): 8-13.
7. Shira Maguen et al., "The Impact of Killing in War on Mental Health Symptoms and Related Functioning," Journal of Traumatic Stress, 22 (2009): 435-443; Manueala Fumagalli and Alberto Priori, "Functional and Clinical Neuroanatomy of Morality," Brain 135, no. 7 (2012): 2006-21.
8. The President's Commission on Care for America's Returning Wounded Warriors, Final Report (Washington, D.C., 2007).
9. Tanielian and Jaycox.
10. Vanessa Williamson and Erin Mulhall.
11. U.S. Department of Veterans Affairs, Returning from the War Zone: A Guide for Families of Military Members, www.ptsd.va.gov/public/reintegration/guide-pdf/FamilyGuide.pdf.
12. U.S. Department of Veterans Affairs, Analysis of VA Health Care Utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans, A Report, www.publichealth.va.gov/docs/epidemiology/healthcare-utilization-report-fy2012-qtr1.pdf (accessed Jan. 13, 2013).
13. Kristen Hannum, "Returning Vets: Nobody Knows the Trouble I've Seen," U.S. Catholic, Oct. 11, 2012, www.uscatholic.org/culture/war-and-peace/2012/10/returning-vets-nobody-knows-trouble-ive-seen.
14. Second Vatican Council, Gaudiam et Spes, para. 1.
15. Jon Sobrino, The Principle of Mercy: Taking the Crucified People from the Cross (Maryknoll, N.Y.: Orbis Books, 1994).
16. Beth Griffin, "Catholic Laity Urged to Bring Faith-Based Convictions to Public Square," Saint Louis Review, March 7, 2012, http://stlouisreview.com/print/23505 (accessed Jan. 20, 2013).