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Wars end and soldiers return.

Homecoming can be a bittersweet experience. There is the thrill of coming home; the enthusiastic welcome from families and friends. However, it does not take long for veterans to realize that life back home has continued without them. Parents have aged; spouses have learned to cope alone; children are older and bigger; a good friend is seriously ill; the old job may have vanished. The neighborhood seems different and there is no one to talk to, no one like buddies from the unit who understood daily combat life.

For the veteran, is the expectation of a return to normal even realistic?

Evidence is mounting that today’s veterans and their families are far from unscathed by their combat-related experiences. The transition back to civilian life means the end of Department of Defense-supplied health care. Though many veterans qualify for care from the Department of Veterans Affairs, up to half of all veterans don’t receive it — they don’t know about or don’t take advantage of it, they live too far from a facility, they belong to an employer’s health insurance plan, etc.

Catholic health care systems can be sure they will see former members of the military services and their families in the communities they serve. How can we, as Catholic health providers, welcome these veterans, be mindful and sensitive to what they may have endured and provide holistic healing for their bodies and spirits?

It starts with awareness. Many returning soldiers have seen their comrades being injured or killed. Many have been wounded themselves but, thanks to protective body armor and helmets, advances in medical care, more portable and efficient medical equipment and a rapid system of evacuation to the United States — usually within three days of the original injury — they have survived injuries that would have killed them in earlier times.¹

Roadside blasts and hand-held explosive devices have caused Iraq and Afghanistan veterans to lose limbs, hearing and vision. Soldiers injured by vehicle-borne improvised explosive devices have suffered severe chemical burns. High-velocity bombs full of nails and other bits of metal to pierce tissues and fragment bones have left survivors with complex, painful and serious injuries. Such wounds are prone to secondary infection, delaying healing and recovery.² Some survivors show respiratory symptoms associated with diminished lung function, a result of war injuries.³ Their health is compromised, and some of these veterans have developed chronic pulmonary disease.

Some returning military face multiple surgeries, rehabilitative care and long periods of hospitalization to recover from major physical injuries. Others bear wounds that are hidden, the residual effect of what they experienced: fear, loss, betrayal, conflict, injury and death. Some veterans have endured subtle injuries to their brains, diffuse, poorly understood trauma that affects problem solving, concentration and memory; creates slow and altered thought processes; and results in limited emotional expression.

While each coming-home experience is unique, each returning soldier has changed and can experience a wide range of feelings. Older and more mature, they are tired from frequent deployments. Some miss the exhilaration of combat, the security and purpose of a mission-driven life; others miss the military experience and their buddies. Home seems not quite real.

Brain-injured veterans experience anxiety attacks and depression. They have insomnia and loss of appetite. Recurring dreams and flashbacks about the experiences of war run like a tape in their minds, crowding out sensory experiences, blocking concentration and blunting or aggravating emotional responses. Loud sounds can trigger exaggerated and inappropriate responses. Smells of diesel fuel bring back vivid, painful memories.

Many returning combat veterans wonder why they survived when their buddies did not. They feel guilt and loss. It is hard to enjoy life when so many others are dead or injured. Suicide seems to make sense. Unlike missing arms and legs, emotional and spiritual injuries can be hidden or minimized by veterans and their families. They can also be ignored or passed over by health care providers.

What we know about the incidence of emotional and spiritual responses from the Iraq/Afghanistan wars is disturbing. Usually epidemiological studies are conducted when war ends; this has not been the case with troops deployed in Iraq or Afghanistan.⁴ The earliest studies of these wars were cross-sectional assessments of multiple convenience samples of three Army and one Marine Corps combat units pre- and post- deployment.⁵ Charles W. Hoge’s team found major depression, generalized anxiety and post-traumatic stress disorder (PTSD); exposure to more combat and increased evidence of PTSD were greater for soldiers who were deployed to Iraq. What is interesting is the lack of follow-up of soldiers and veterans with these symptoms. Hoge and his colleagues found that only 23 percent to 40 percent of those who reported symptoms sought mental health care.

The RAND Corporation’s 2008 report about the invisible wounds of war among the 1.6 million U.S. troops deployed to Iraq and Afghanistan suggests that those who were deployed frequently paid a higher price because of prolonged exposure to stress. The study also suggests that hidden war injuries may be disproportionately higher than the significant physical injuries.

The RAND study estimated that about 18.5 percent of soldiers deployed to Iraq and Afghanistan had symptoms of PTSD and depression; an estimated 31 percent of returning troops had mental health conditions or reported traumatic brain injuries.⁶ Based on the work of researchers such as Hoge, the RAND team estimated that about one-half of the symptomatic group will seek treatment. More surprisingly, they found that only about half of those who sought treatment received minimally adequate care.

The Substance Abuse and Mental Health Services Administration acknowledged that about two-fifths of the Iraq and Afghanistan veterans received health care and social support from the Veterans Health Administration.⁷ Researchers reporting in the Archives of Internal Medicine found that one-third of the veterans who received treatment at the Veterans Affairs Health Systems from 2001-2005 were diagnosed with mental illnesses.⁸ However, most veterans and their family members seek health care in the private sector or in public clinics.

The mental and spiritual anguish experienced by many returning veterans is often unreported. Perhaps the only witnesses to these losses are family members and intimate friends of the veterans. Often the veteran feels alone, unable to talk about his or her pain, ashamed of his or her feelings and fearful of losing control.

War-related psychological and spiritual injuries are not new; Homer described them around 800 BC. After World War I, this phenomenon was called shell shock; after the Vietnam War, it was called Post-Vietnam Syndrome; more recently it has been labeled PTSD. Regardless of the name that has been given to the phenomenon, war injures more than the body; it affects the mind and the soul.

Soldiers and their families can conceal their hidden wounds, hoping that they disappear or diminish when the reality of being home sinks in. This wish may be unrealistic as these hidden injuries become more problematic. Some veterans try self- treatment, seeking to lose themselves in drugs or alcohol. Outbursts and domestic violence increase. The veteran finds that he/she has little in common with friends or family members. Some veterans mourn a buddy who died in combat and wonder if he or she did enough to help. Some are haunted because they lived while their buddies died. The home and world they yearned for and dreamed about during their periods of service seem foreign and almost alien. Veterans become impatient with people complaining about little things.

Feelings of sadness or alienation are common responses to coming home from college, relocating to another city, enrolling in a different school, starting a new job or experiencing the death or diminishment of a friend or family member. People who struggle with adjustments to new realities or experience reactions to death or disability usually find others who have "been there." There are role models and mentors to share stories and feelings. Most importantly, as time passes, painful memories and feelings become less intense; people adapt, adjust and move forward.

Combat trauma is different. It may become worse as time passes, and normal adjustment does not take place. Most of the literature about PTSD conceptualizes responses to loss and recurring memories of combat trauma within a medical model. Post-traumatic stress is explained as a significant behavioral health problem, a disease process to be diagnosed and treated. Some psychologists suggest immediate and delayed reactions to combat are part of a larger phenomenon of developmental maturation that has been recognized and addressed in many cultures.⁹ Within this context, Jonathan Shay describes human responses to combat in both ancient and modern wars.^{10, 11}

There is little disagreement that war, combat experience and frequent and long deployments increase post-traumatic stress.¹² In 2013, as veterans are returning to their families and communities from Iraq and Afghanistan, many bear the spiritual scars of war and will need support, understanding and counseling. Most of these service men and women will seek health care in local hospitals and visit civilian primary care providers in their communities.

Providers in Catholic health systems will rely on their spiritual traditions as they care for veterans and their families. Catholic health care is a ministry as well as a science and an art. It integrates faith, prayer and the sacraments to reconcile and restore the human spirit as it simultaneously employs scientific evidence to treat the mind and body. Because comprehensive, holistic care of the sick is a work of mercy, healing of the spirit as well as the body is a goal of Catholic health care. Hospital-based chaplains and leaders of religious groups in the community join doctors, nurses and other health professionals as members of the health care team.

The Catholic social justice tradition that drives Catholic health care also offers inspiration and guidance to health care providers as they care for vulnerable patients and their families.¹³ The Catholic principles of social justice, respect for human dignity, participation, the preferential option for the poor and the common good enhance and personalize care of veterans and their families.

The dignity of military service is acknowledged when providers ask patients during routine health assessments if they served in the military. A follow-up question would inquire if patients think that their present symptoms or concerns are related to their service experiences. These questions provide important information about the patients’ sense of well-being, show respect for all veterans and encourage veterans to talk about their combat experiences and memories. Talking about deployment and combat is an important step in helping soldiers to integrate military experience into civilian life. The role of the provider is easy: attentive listening.

The Catholic social justice tradition actively engages patients in their care decisions and possible lifestyle alterations. During their periods of service, men and women veterans were responsible for their own lives, the lives of their combat buddies and the distribution of important resources. They are very capable of managing their health care and engaging in health-promoting behaviors, working as partners and collaborators with doctors, nurses and clergy members.

Perhaps the most useful of the social justice principles is the preferential option, a principle that invites health care workers to stand with veterans; enter nonjudgmentally into their worlds; and understand the impact of combat on them, their families and upon the communities that welcome them home. Because work on behalf of veterans and their families is an expression of the common good, the ministry of Catholic health care extends into the community. Because of their mission, Catholic health care administrators and clinicians can lead and participate in activities that improve community safety and health. They can join with veterans’ organizations in sponsoring programs and health fairs, and they can advocate for an informed public policy on veterans’ health.

Special outreach to veterans in finding employment reflects action on behalf of justice. Health care offers attractive job opportunities for returning veterans and their spouses, and Catholic health care institutions and systems can actively recruit and support veterans as they relocate, apply the skills learned in the military to civilian life and re-enter the job market. Meaningful work enhances self-esteem and improves the social and economic welfare of veterans’ families and the communities where they live.

When our veterans come home, justice demands that we welcome them, appreciate their sacrifice and help them to reunite with families and communities.

SR. ROSEMARY DONLEY, SC, holds the Jacques Laval Endowed Chair in Justice for Vulnerable Populations at the Duquesne University School of Nursing, Pittsburgh.

NOTES

1. Richard Hyer, "Iraq and Afghanistan Producing New Pattern of Extremity War Injuries," Medscape Medical News (March 27, 2006).
2. Dan Bieler et al., Current Strategies for the Treatment of Blast Injuries to the Extremities, (NATO/OTAN Report, 2008).
3. Anthony M. Szema et al., "Respiratory Symptoms Necessitating Spirometry among Soldiers with Iraq/Afghanistan War Lung Injury," Journal of Occupational & Environmental Medicine 53, no. 9 (September, 2011): 961-65.
4. Brett T. Litz and William E. Schlenger, "PTSD in Service Members and New Veterans of the Iraq and Afghanistan Wars: A Bibliography and Critique," PTSD Research Quarterly 20, no. 1 (Winter 2009), www.ptsd.va.gov/professional/newsletters/research-quarterly/V20N1.pdf.
5. Charles W. Hoge et al., "Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care," New England Journal of Medicine, 351 (July 1, 2004): 13-22.
6. 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.
7. Substance Abuse and Mental Health Services Administration, "Behavioral Health Issues among Afghanistan and Iraq U.S. War Veterans," In Brief 7, no. 1 (Summer 2012) http://store.samhsa.gov/shin/content/SMA12-4670/SMA12- 4670.pdf.
8. Karen H. Seal et al., "Bringing the War Back Home: Mental Health Disorders among 103,788 U.S. Veterans Returning from Iraq and Afghanistan Seen at Department of Veterans Affairs Facilities," Archives of Internal Medicine, 167, no. 5 (2007): 476-82, http://archinte.jamanetwork.com/article.aspx?articleid=769661.
9. Roger Brooke, "An Archetypal Perspective for Combat Trauma," Bulletin of the American Academy of Clinical Psychology 13, no. 1 (Fall 2012): 2-7 www.aacpsy.org/userfiles/file/Volume%2013,%20Number%201.pdf.
10. Jonathan Shay, Odysseus in America: Combat Trauma and the Trials of Homecoming (New York: Scribner, 2003).
11. Jonathan Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character (New York: Scribner, 1995).
12. Kathryn M. Gaylord, "The Psychosocial Effects of Combat: The Frequently Unseen Injury," Critical Care Nursing Clinics of North America 18, no. 3 (September 2006): 349-57.
13. William J. Byron, "Ten Building Blocks of Catholic Social Teaching," America, Oct. 31, 1998, http://americamagazine.org/issue/100/ten-building-blocks-catholic-social-teaching.