By Rev. Alejandro De Jesus
While there are around 19.6 million veterans in the country today, only 9.15 million are currently enrolled in the VA healthcare system. A little over 10 percent of the total veteran population are women. The women veteran population is more racially diverse than the men’s, with higher educational levels but lower median incomes, and higher poverty incidence with lower rates of health insurance coverage. This brings us to our story.
Jane joined the Marine Corps in her early twenties in 2003, just as the nation was preparing for Operation Iraqi Freedom. She recalled that it was the best time of her life, as she could prove that women can achieve anything, given the chance. As a staff sergeant, she saw action in ground combat where she participated in various assaults on civilian villages suspected of hiding armed insurgents.
In one of those assaults, her squad leader ordered them “to shoot and eliminate all moving things.” In the midst of the shooting in darkness, she heard screams of women and children. After seeing bodies of men, the elderly, women and children strewn on the ground, she later said to herself, “I’m sure I killed some of them!” This happened more than once in her six months of deployment.
Back in a base in Texas, Jane began having nightmares, loss of appetite, agitation, excessive guilt and decreased energy. She could not escape the memories of those bodies, especially unarmed civilians and children. She was also diagnosed with partial loss of hearing due to bomb blasts.
Similar to the psychological trauma of post-traumatic stress disorder but deeper in terms of moral expectations and spiritual distress, moral injury has been identified as a mental health concern that requires special attention. Jonathan Shay, the pioneer researcher on the topic, noted that the experience of feeling betrayed, transgressed or violated in one’s moral and even religious world by a person in authority in a “high stakes situation” cuts a very deep spiritual wound. The theologian Martin E. Marty portrays it as an “assault on the soul.”
Among the many instances that eventually lead to moral injury, the following experiences were more prevalent: (a) harm, especially unintended harm, to women, children and the elderly; (b) disproportionate violence to combat enemies but especially to unarmed civilians; (c) violence within the ranks, such as military sexual violence; and (d) issues of betrayal by officers or leaders to subordinates.
Rita Nakashima Brock, co-author of Soul Repair: Recovering from Moral Injury after War, expressly noted that “moral injury is not a disorder” but rather a “normal response to extremity.” That is the reason, she added, why treatment or therapy may not be a sufficient help. Instead, patients need a process to experience forgiveness and spiritual reconnection. So, what must chaplains do to help veterans in the end-of-life stage, while at the same time suffering from PTSD and moral injury?
In Jane’s case, she was eventually diagnosed officially with PTSD, and later with moral injury. Throughout this period, she never married, had three bad relationships, and never had children. She claimed no religious preferences but acknowledged growing up in her mother’s Baptist tradition. At age 33, she was diagnosed with advanced colon cancer, which had also metastasized to the liver and kidneys. When she first heard the sad news, Jane remarked to the team that she rightfully deserved to die as punishment for her sins.
Members of the palliative care and hospice teams made sure that the transition to hospice was smooth. Providers tried to medically respond to her recurring PTSD symptoms, especially her discomfort at night and sleep disturbance. The psychologist and the chaplain worked together to address her other emotional and spiritual anxieties.
The room had to be free from loud noises, while aromatherapy and music were made available, as she requested. Restraints were disallowed. Devastation and despair are twin consequences of moral injury, and chaplaincy intervention must take these into consideration. The female chaplain on a number of visits applied the listening technique not only to validate traumatic events but to allow for healing and forgiveness to surface. The chaplain guided Jane through a series of prayers for forgiveness, using the language of confession as a means.
In one of the prayer rituals, Jane invited the nurses and staff to join them. On a table covered in white cloth, Jane and the chaplain made paper flowers of blue and pink, representing the lives lost in the battle, especially the children. On top of each paper flower was a small votive candle. Quoting Scripture passages of forgiveness and pleas for mercy¹, the chaplain helped Jane through intermittent prayers for those who suffered and died at her hands. As she evoked each prayer intention, Jane dipped the bottom of the lighted candle at the bowl of water at the center of the table, then lit the votive candles, one at a time. The lighting of the votive candles was interrupted with Jane’s weeping. At the end of the ritual, everyone joined in an appropriate song.
In many similar rituals and prayer sessions, Jane was able to express remorse, regret and self-forgiveness. While not consistently religious, Jane had moral expectations and standards that formed part of her character. Dr. Harold Koenig, one of the top proponents of using religion in patient treatment, notes that when these expectations and standards are transgressed, the person experiences deep feelings of shame and guilt, which later connect with feelings of unforgiveness or being punished by a Supreme Being. Chaplaincy, therefore, must integrate this into its spiritual care, especially at end of life, to accompany the veteran through the journey towards forgiveness and peace.
¹ Psalm 51.9: Hide your face from my sins and blot out all my iniquities.
Isaiah 55.6-7: Seek the LORD while he may be found; call upon him while he is near; let the wicked forsake his way, and the unrighteous man his thoughts; let him return to the LORD, that he may have compassion on him, and to our God, for he will abundantly pardon.
Matthew 11.28-30: Come to me, all who labor and are heavy laden, and I will give you rest. Take my yoke upon you, and learn from me, for I am gentle and lowly in heart, and you will find rest for your souls. For my yoke is easy, and my burden is light.
Alejandro De Jesus, PhD, BCC, is certified in the NACC, NCVACC, and NAVAC and has specialty certification in hospice and palliative care and in mental health. This article is adapted from a talk at the Fourth Annual Integrative Medicine and Mental Health Conference at UCLA on March 9, 2019.