Our Veterans: Spiritual Issues at the End of life

1. Our Veterans: Spiritual Issues at the End of life Healthcare Chaplaincy Network New Orleans, April 23, 2018 Penny V. Phillips, MA, MDiv, BCC Palo Alto VA Hospice & Palliative Care Center Penny.Phillips2@va.gov; 650.493.5000 x65746

2. From Thich Nhat Hanh: Veterans are the light at the tip of the candle, illuminating the way for the whole nation. If Veterans can achieve awareness, transformation, understanding, and peace, they can share with the rest of society the realities of war. And they can teach us how to make peace with ourselves and each other, so we never have to use violence to resolve a conflict again.

3. Objectives • Identify three distinct US Military cultures • List 4 categories of Spiritual distress for Veterans • Define and contrast Post Traumatic Stress and Moral Injury

4. Military Culture • Military service is an acquired cultural experience that continues long after discharge. • The cultural context of Veterans can have positive and negative impacts on their end-of-life care. It can be a source of strength and a source of conflict. • ‘Culture’ refers to integrated patterns of human behavior that include the language, thoughts, communication, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups. • Most new recruits are young, fresh out of high school • Some search for adventure • Better economic circumstances • Search for community • Some to escape difficult circumstances

5. Basic Training • Turns soldiers into squads • Discipline, Privilege, duty, connectedness • Initiation into warrior class • Unique language, ‘battle mind’ training • One for all/all for one • Buddies = family/community • Stoicism promoted; ‘no pain, no gain’ • Admitting fear, pain seen as sign of weakness

6. Veterans’ Unique Characteristics >>Combat or non-combat experience >>War or era they served >>POW’s >>PTSD [Note: Most soldiers are able to integrate the experience into their lives as naturally resilient people. VA is studying this group in depth.] >>Branch of service and their rank; Special Forces (ie., Green Berets, Navy Seals >>Enlisted or drafted >>Family history of serving in military; current geographical (rural vs. urban)

7. Culture Comments Each era of service has its own unique culture which can influence the outcome of a soldier’s experience. WW2 Vets are more likely to have had areas of ‘safe haven’ than VN Vets who were often in immediate and constant physical danger. This resulted in a higher incidence of stress-related disorder. Korean Vets were often told not to discuss their military service and are sometimes overlooked in the discussion regarding the needs of Vets. A significant number of Korean Vets were POWs held by the Chinese, and subjected to torture and other mistreatment. So asking and understanding the military history of Vets is important

8. World War II • Almost all WW2 Vets >80 years of age • Many died or were wounded • Pride in American victory over fascism • No TV coverage so public shielded from brutality • Entire country supported war; came home as heroes; definite end to the war; “glories” of war • Segregation • Many have injuries from combat or environmental exposure --Radiation, mustard gas

9. Cold War 1950’s • Arms race • Radiation exposure to above ground nuclear testing • Anger/mistrust of gov’t, including VA • Every VA has a registry physician for • Agent Orange, Gulf War Syndrome, and Ionizing radiation

10. Korean Conflict • Unfamiliar to most Americans, never declared a war • No clear victory • Some feel service unappreciated; Korean trauma largely forgotten • Environmental exposure • Injuries from extreme heat and cold • Cold sensitivity • Vets may minimize experiences • Many relive experiences

11. Viet Nam War….. • Source of much angst for USA • Extensive television coverage; war was “in our living rooms” • Draft forced many into war they opposed • Soldiers required to on only one-year tours • Controversial • Distrust of political leadership • First guerilla war • Had to separate combatants and civilians, soldiers could never let guard down • Hard to have sense of completion, sense of accomplishment

12. …Viet Nam • Great physical, emotional, existential trauma • Severely wounded more likely to survive • Reintegration difficult • Alcohol/substance abuse • Many mental health issues, PTSD • Agent Orange • Hepatitis C • Traumatic Brain Injury, Polytrauma Injuries

13. Gulf War (early 1990’s) Many exposed to environmental toxins • burning oil fields • Depleted uranium, etc. • Multiple vaccinations Gulf War Syndrome • Memory loss • Fibromyalgia symptoms Two conditions correlate with service • ALS • Respiratory problems • Asthma, exposure to high levels of smoke Young age means few need palliative care now • Will change as population/Veterans get older! [8,000 people turning 65 EVERY DAY.]

14. OEF/OIF/OND • Early evidence suggests psychological toll will be worse than physical toll • Prolonged exposure to combat stress over multiple rotations • Several (inside and outside VA) groups already reviewing care • Increasing incidence of suicide/attempts, SI • Depression • PTSD • Traumatic Brain Injury

15. Culture Clashes Veterans generational cultural clashes have occurred and will continue to occur due to the very nature of military service at this time in history. Some WW2 Vets have a difficult time comprehending the Vietnam experience. Some saw these soldiers as ‘wimps’ who lost the war. The Veterans of Foreign Wars use to not allow Korean or Vietnam Veterans to join because neither of those wars were officially declared ‘war’. This is no longer the case. Despite best efforts, clashes will occur. The key is to continue attempts to understand each perspective and take time to understand your own reactions. Failure to take the culture seriously means we choose to place our own values over those of differing backgrounds. Stereotyping, disregarding personal rights, etc, are examples of not respecting another’s culture.

16. Women Veterans • 10% of all Veterans • 15% of all active duty military • 18% of all National Guard and REserve • 240,000 sought care at VA facilities (2006) • 6% of Department of Veterans Affairs (VA) health care users. • Top three diagnoses: Post Traumatic Stress Hypertension Depression • Higher rate of minority women serving in the military than minority men

17. What do you think might be spiritual issues that a Veteran deals with or will deal with?

18. Categories of Spiritual Distress • Spiritual Pain • Why is this happening to me? • What does all of this mean? • God doesn’t seem to be listening. • Spiritual Alienation • God just seems so far away. • Where is God when I need Him most? • I don’t need any help from God, I can it myself! • Spiritual Anxiety • I think God is punishing me. Why else would I have this cancer? • I’ve been so far from God; I don’t think he’s going to help me now. • I’m afraid of dying. • Spiritual Guilt – Moral Injury Moral Distress, Soul Injury • I don’t think God is very pleased with me. I haven’t exactly led a ‘good’ life. • I should have lived my life better. • Spiritual Anger • I want nothing to do with God. He has nothing to offer. • If God is good and loving, why is he allowing this to happen? • Spiritual Loss • I don’t think God loves me . • I don’t feel God’s love anymore. • Spiritual Despair/Hopelessness • What hope do I have? God doesn’t care. • I stopped praying. God is not listening.

19. Moral Injury • “Moral injury is present when (1) there has been a betrayal of what is morally correct; (2) by someone who holds legitimate authority; and (3) in a high-stakes situation.” (Shay, 2013) • “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” (Litz et al., 2009) • “the key precondition of moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or other culture-based organizational, and group based rules about fairness, the value of life, and so forth.” (Maguen, 2011) • Moral Injury is disruption in an individual’s confidence and expectations about her or her own moral behavior or others’ capacity to behave in a just and ethical manner.

20. Post Traumatic Stress History of exposure to a traumatic event that meets two criteria: 1. experienced, witnessed or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others 2. Response involved intense fear, helplessness or horror. AND Symptoms from each of these symptom clusters >> intrusive recollections >> avoidant/numbing symptoms hyper-arousal symptoms DSM IV criteria http://www.ptsd.va.gov/professional PTS disrupts relationship to world when it becomes unreliable.

21. What is the #1 question from Vets in hospice at the end of life? • What are other questions from Vets in hospice at the end of life?

22. Special challenges (with possible spiritual connections) serving Vets and their families: • PTSD, TBI, Polytrauma injuries • Military sexual trauma • Agent Orange (making claim) • Grief at all levels and stages • Guilt; Moral Injury • Distance from/in church after serving (people change but sometimes churches cannot change) • Financial distress; family dynamics • Loneliness and isolation

23. Do Vets have different end-of-life spiritual issues?

24. Interventions for all Vets • Create safety to build trust, rapport, relationship. • Thank Vet for his/her service! This may invite dialogue (or not). Some are quite shy about it; others will stand up taller and prouder. Many are still healing from their experience, regardless of how long ago their service was. • Affirm the difficult feelings aspect of your dialogue. • Remember that stoicism might interfere with acknowledging emotional or spiritual or physical pain. Some Vets have varied drug use history. • Go slow, and listen for what is not being said. • Get to know your local VA Hospital, and local VA programs. [CBOCs, Vet Centers] • On line resources for Veteran programs and assistance.

25. Invitation Invitation to do a self-assessment: How do your own values/beliefs influence your attitudes toward WW2 Vets vs. Iraq/Afghanistan Vets? We must become aware of our own cultural beliefs and attitudes in order to be culturally competent for our Veterans. Seek to understand; never assume.

26. A few resources…. Chang, et al. “Spiritual Needs and Spiritual Care for Veterans at End of Life”. American Journal of Hospice & Palliative Medicine. 29 (8) 610-617. Deborah Grassman. Peace at last: Stories of Hope and Healing for Veterans and their Families. 2009, Vandamere Press. Sebastian Junger. Tribe: On Homecoming and Belonging. 2016, 4th Estate, London. Joshua Phillips. None of Us Were Like This Before: American Soldiers and Torture. 2010, Verso Press, London. Justine Sharrock. Torture: When Good Soldiers do Bad Things. 2010, Wiley & Sons, Inc., New Jersey.

27. President Obama, Veterans Day, 2016 “Whenever the world makes you cynical, whenever you doubt that courage and goodness and selflessness is possible, then stop and look to a Veteran. On Veterans Day, we acknowledge humbly that we can never serve our Veterans in quite the same way that they served us, but we can try. We can practice kindness, we can pay it forward, we can volunteer, we can respect one another, we can always get each other’s backs.”