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Spirituality and PTSD
in Vietnam Combat Veterans

Margaret Nelson-Pechota, Ph.D.

Part I, Introduction and Overview




This is the first in a series of articles that will address various topics I investigated in my research with Vietnam combat veterans. The study was my dissertation requirement to complete my PhD in Clinical Psychology at the Illinois Institute of Technology. I wanted to find out how spiritual and moral issues are related to symptoms of Posttraumatic Stress Disorder1 (PTSD) in Vietnam combat veterans. Specifically, I wanted to know which aspects of an individual's spirituality might prevent a soldier from developing PTSD, and which aspects of his spirituality might result in prolonged suffering from symptoms of PTSD.


Prior to presenting information about my research I would like to extend my heartfelt appreciation to all those who valiantly fought the war in Vietnam, especially those of you who volunteered to participate in this study. My inspiration for this research came from my patients at V.A. Hospitals in Chicago and New York, whose names will not be mentioned to protect their privacy. Through their painful stories and courageous journeys through the healing process, I learned what my academic training did not and could not teach me about spirituality and trauma. I also extend my thanks to organizations and individuals who recruited participants for my study, especially the National Conference of Viet Nam Veteran Ministers, Point Man International Ministries, and Vietnam Veterans of America.

Please note that this material is copyrighted. Contact the author for permission to reprint or distribute information presented here, in whole or in part.

How is Spirituality Related to Combat?

Virtually every war that has ever been fought has been supported by at least one religion2. Faith in divine approval has helped soldiers go into battle confident their own cause was righteous and faith has strengthened their courage and convictions. Religious influences have also created moral confusion, however, because the same act of violence might be considered a sacred duty in one situation, or a violation of religious teachings in another situation. Victorious warriors usually believe they have pleased a God or gods, while defeat might be interpreted as divine punishment or displeasure.



Exposure to traumatic combat experiences often leads to a search for meaning and purpose within a personal and collective sense -- seeking the answers to myriad questions about the painful realities of warfare, the value of personal existence, and the value of the human race3,4,5,6,7,8. Faith that God is constantly available to respond to one's hopes, fears, anxieties, and tragedies can be shattered9. Individuals who are unable to resolve challenges to their moral and spiritual beliefs might find themselves in a state of spiritual alienation, which can take many forms: Feeling abandoned by God, rejecting God, feeling that God was powerless to help and therefore unavailable, feeling wartime pain was punishment from God, or at its most extreme, believing that God's ultimate punishment will be eternal damnation.



Why Is Spirituality an Important Issue for Vietnam Combat Veterans?



Most American soldiers who fought in Vietnam believed at first that their cause was just. Some held firm in their belief while others became disillusioned. Some soldiers used their faith as a source of strength to help them endure their pain and suffering, while the faith of others was shattered when they came to believe that a loving God was not present to provide concern, protection, and divine assistance. Mahedy6, a combat chaplain who became a team leader in the Vietnam Veterans Outreach Program in 1979, counseled soldiers in the field and after the war. He found that many of the veterans seeking treatment had difficulty making sense of combat situations that did not fit with their moral or spiritual beliefs. Many of these veterans felt spiritually alienated, or isolated from their God.



Soldiers adhering to monotheistic beliefs generally may have a greater struggle with spiritual isolation than pagan warriors. Shay compared Achilles of Troy with Vietnam combatants7. Achilles, who worshiped many gods, could be out of favor with one god while receiving support from another. Most American soldiers fighting in Vietnam came from a monotheistic Christian background. Those who believed they were out of favor with, or who rejected the one God in whom they believed, were likely to feel spiritually isolated.

On the other hand, some Vietnam veterans have experienced spiritual and/or psychological growth as a result of their combat experiences. The National Conference of Vietnam Veteran Ministers has members who have used the wisdom they gained through their own suffering, as well as their ability to overcome personal struggles with faith issues, to develop spiritual retreats for veterans and their wives. Point Man International Ministries is a Christian organization that provides outreach to veterans as well as non-veteran disadvantaged individuals.



What is Traumatic Distress?



In this series of articles I will be using a variety of terms relating to the topic of trauma, and I would like readers to have a clear understanding of their meaning. First, it is very important to separate a traumatic event from an individual's reaction to that event. A traumatic experience is a potentially terrifying situation in which an individual fears severe personal injury to him/herself or witnesses a threat to another individual. The key word is "potentially." Two individuals can be in the exact same frightening situation and one will react with little or no discomfort while others might experience high levels of distress. Likewise, some situations are more likely to be traumatizing than others. For example, soldiers who experience severe combat or exposure to atrocities are more likely to react with fear and horror than soldiers who never see combat or who participate in minor skirmishes.



Traumatic distress refers to the emotional and psychological symptoms, or reactions, a traumatized individual experiences as a result of exposure to a traumatic event. Phrases such as "traumatic distress" and "symptoms of PTSD" are general terms referring to some level of distress that might vary from mild to severe. Some of these symptoms are nightmares, unwanted thoughts , and relationship problems. When symptoms are severe and last for a long time, an individual is likely to be diagnosed with PTSD. Many survivors initially suffer traumatic distress, but symptoms usually subside within a few months. About 30% of Vietnam veterans have met the criteria for a diagnosis of PTSD at some point in their lives, with another 20% reporting some symptoms10,11.



What is the Relationship Between Spirituality and PTSD?



We know very little about the relationship between spirituality and symptoms of PTSD. Unfortunately, spirituality has long been a taboo subject in Western healthcare practices, a situation that has started to improve during the past 20 years. Spiritual alienation and loss of meaning have been identified by clinicians as issues that are distressing to veterans seeking treatment for symptoms of PTSD3,5,6,7.



Spiritual alienation means separation from the transcendent, the divine, or God. Regardless of the cause of spiritual isolation, it is likely to be associated with traumatic distress. Difficulty with interpersonal relationships, including estrangement from others, is a core feature of PTSD. Likewise, a problematic relationship with God, or separation from God, might also contribute to traumatic distress. It is well known among mental health providers that feeling supported by others is crucial to a trauma survivor's recovery process. In contrast, researchers have found that unsupportive behaviors may have a greater influence, delaying recovery or even contributing to symptoms of PTSD12,13,14. Veterans who desire the support of their Divine Creator might experience greater ongoing distress if they feel their needs have not been met.



Some aspects of spirituality might protect an individual from traumatic distress. The ability to make sense of a traumatic event in a way that "fits" with one's previous beliefs not only reduces the likelihood of PTSD, it may even lead to psychological or spiritual growth8,15,16,17. Limited research has found that combat veterans who were able to find meaning and purpose in their traumatic experiences were less likely to develop PTSD3,4.



Who Participated in the Study?



154 male Vietnam veterans who experienced combat during their tour of duty volunteered to participate. This nationwide community sample was recruited through several organizations, primarily Vietnam Veterans of America, Point Man International Ministries, and the National Conference of Viet Nam Veteran Ministers. Their ages ranged from 49 to 69 years, with an average of 56 years. Age at the time they arrived in Vietnam ranged from 17 to 36 years, and most (70.1%) were 21 or younger.



The vast majority of participants identified themselves as Christians: 60% Protestant, 21% Catholic, and 1% Latter Day Saints. Some (14%) said they had no current religious affiliation, and 3% did not clearly specify their current religious orientation. You might notice that an unusually high number of Protestant veterans participated in this study in comparison to Catholics (based on the most complete data available on U.S. religious affiliation18). This might be related to my recruitment sources. Since all Christians share core values and beliefs that form the theoretical basis for this study, and morality in the United States is based upon Judeo-Christian beliefs, the overrepresentation of Protestants is not a concern. Future research would be useful to examine possible differences between various denominations of Christianity.



Belief in God was lower among these veterans (84%) than the national average (95%; Gallup Poll, 200119.) However, the percentage of veterans in this community sample who believe in God was almost identical to that reported in a previous study of Vietnam veterans seeking inpatient treatment for PTSD20. Keep in mind that these are two small studies, and broad statements that Vietnam veterans in general are less likely to believe in God than non-veterans cannot be made. Interestingly, even though belief in God was similar in the two veteran groups, this community sample attended church worship services more often than the inpatient veterans. We don't know if the inpatient group had more severe PTSD symptoms than this community sample, although it is quite likely. Other interesting comparisons can be made between the current study of veterans in the community and the inpatient PTSD veterans:

  • Veterans in the community sample were more likely to be religious during childhood and at the present time than the PTSD inpatients.
  • Community veterans were more likely to believe that their experiences in Vietnam strengthened their faith, although about one-fourth of inpatients also reported that their faith increased.
  • Inpatient veterans had more difficulty reconciling their religious beliefs with their Vietnam experiences, although more than half the community veterans also struggled with this issue.

  • Inpatient veterans were more likely to have abandoned their religious faith in Vietnam (51% vs. 37%) than the community sample.




Which Components of Spirituality Did I Include in My Study?



Specific elements of spirituality that I considered to be important were: Spiritual alienation, religious practices (such as worship, prayer, meditation, reading scripture,) having a collaborative relationship with God, life purpose, and overall spirituality. I also included guilt, forgiveness, and combat severity. The latter will be discussed in subsequent articles.





Very Brief Summary of Results



When reading these results it is important to keep in mind that this is a small study. Therefore, we cannot say that the information presented here applies to Vietnam combat veterans in general.



Components of Spirituality



Information was gathered from participants on many different aspects of spirituality, and the most relevant were used in statistical analyses reported in the section below. However, some other interesting relationships were found:

  • Frequency of prayer and frequency of meditation were not strongly related, meaning some of these veterans who pray also meditate, but not a high number.

  • Having a collaborative relationship with God (e.g., seeking God's help through stressful life situations, trying to find a lesson from God in crises, thinking about one's life as part of a larger spiritual force, and confessing one's sins and asking for God's forgiveness) was associated with more frequent religious practices (e.g., prayer, church worship, meditation, and reading scriptures). With this sample of veterans, those who had a collaborative relationship with God were also more likely to participate more often in religious practices. However, only worship was included in the analyses, as explained below.



    Spirituality and PTSD



    The relationships between various aspects of spirituality and PTSD are reported here. Guilt and forgiveness will be discussed in future articles. For the purpose of this study spirituality was divided into two general types: Positive and negative. Three positive spiritual variables could be included in the study in keeping with rigorous standards that would make the results meaningful: Life purpose, current worship attendance, and overall spirituality. These were chosen because they appeared to provide the most unique information in comparison with the other components of positive spirituality. Collaborative relationship with God, prayer, and other religious behaviors were not included. Two components of negative spirituality were included: Spiritual alienation and difficulty reconciling faith with Vietnam experiences.



    Veterans who reported: Were also likely to report:
    Fewer and less severe PTSD symptoms or no PTSD symptoms Finding satisfaction and purpose in

    their lives

    More frequent church worship

    Higher number of PTSD symptoms and/or more severe symptoms

    Difficulty reconciling their faith with

    their Vietnam experiences

    Alienation from God







    What Do These Results Mean to Vietnam Combat Veterans?



    Overall, in this sample of veterans positive aspects of spirituality were associated with better long term adjustment to combat trauma, while negative components of spirituality were associated with greater long term distress. Two of the three hypothesized positive spirituality variables were related to better adjustment: (1) satisfaction with one's life, including a sense of meaning and purpose (2) attendance at church worship services. Meaning and purpose will be discussed in a subsequent article.



    Why is frequent church worship important? A possible explanation is that worship involves connection with the Divine as well as members of the community, even if these connections are minimal. This notion is supported by the wide body of literature documenting the significant positive impact of social support on recovery from trauma, as well as the emerging literature on God as a source of support21. While mere attendance at church services may not presuppose active engagement with God, it is likely that this variable assessed active involvement within this sample of combat veterans, because more than half the participants (60%) reported praying "almost daily" or "more than once a day." This high frequency of prayer indicates some level of involvement in a relationship with God.

    Negative dimensions of spirituality were associated with more severe PTSD symptomatology. Therefore, veterans who felt alienated from God, or who had difficulty reconciling their faith with their Vietnam experiences, also reported more severe levels of distress. Throughout his book Out of the Night, Mahedy6 talks about the experience of war and subsequent spiritual crisis of Vietnam veteran as a night of spiritual darkness. The journey out of the night is a lifetime process involving unconditional openness to God's will and an ongoing willingness to act as God's agents and instruments of peace and justice in a world of evil. Mahedy suggests there is:



    a certain irony in the question soldiers asked God 'Where were you in Vietnam?' The question comes full circle when one allows God to ask in return, 'Where were you in Vietnam?' When this kind of dialogue with God becomes possible, one is already underway in the journey out of the night (p. 218).



    Hopefully the results of this study emphasize the need to learn more about spirituality and trauma, particularly the need to provide spiritually-based treatment for veterans struggling with these issues.





    Who Can Provide Spiritually-Based Help?



    The author, Margaret Nelson-Pechota, Ph.D., completed her doctorate in Clinical Psychology at the Illinois Institute of Technology. Dr. Pechota provides spiritually-based trauma psychotherapy for residents of Chicago, IL and suburbs. She can be reached via email at mnpechota AT msn DOT com. (Email address modified to prevent harvesting for spam. Convert back to normal email before using).



    The National Conference of Viet Nam Veteran Ministers (NCVNVM) conducts weekend spiritual retreats for veterans and their wives. Non-veteran trauma survivors are also welcome. You can obtain further information at: www.vietnamveteranministers.org or call 617-278-4576.



    Point Man International Ministries (PMIM) is a Christian ministry "run BY vets FOR vets that provides individual and group counseling, literature, seminars, and conferences, to help bring aid and comfort to their brothers in arms." They can be reached at www.pointmanintl.org or call (800) 877-VETS

    For more information about PTSD contact the National Center for PTSD at www.ncptsd.org or the
    National Institutes of Mental Health at www.nimh.nih.gov/healthinformation/ptsdmenu.cfm

    References



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    2 War, Encyclopedia of Politics and Religion, ed. Robert Wuthnow. 2 vols. (Washington, D.C.: Congressional Quarterly, Inc., 1998), 783-789, www.cqpress.com

    3 Brende, J. & McDonald, E. (1989). Post-traumatic spiritual alienation and recovery in Vietnam combat veterans. Spirituality Today, 41(4), 319-340.

    4 Casella, L. & Motta, R. W. (1990). Comparison of characteristics of Vietnam veterans with and without Posttraumatic Stress Disorder. Psychological Reports, 67(2) 595-605.

    5 Lifton, R. J. (1973/1992). Home from the war: Learning from Vietnam veterans. Boston, MA, US: Beacon Press, Inc.

    6 Mahedy, W. P. (1986). Out of the Night: The Spiritual Journey of Vietnam Vets. New York, NY: Ballantine Books.

    7 Shay, J. (1994). Achilles in Vietnam. New York, NY: Touchstone Books.

    8 Wilson, J. P. (1989). Trauma, Transformation, and Healing. New York, NY: Brunner/Mazel Inc

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    10 Keane, T. M. (1990). The Empidemiology of Post-Traumatic Stress Disorder: Some Comments and Concerns, PTSD Research Quarterly, 1(3).

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    18 Jones, D. E., Doty, S., Grammich, C., Horsch, J. E., Houseal, J., Lynn, M., Marcum, J.P., Sanchagrin, K. M. & Taylor, R. H. (Eds.) (2002). Religious Congregations and Membership in the United States: 2000, An Enumeration by Region, State, and Country Based on Data Reported for 149 Religious Bodies. Nashville, TN: Glenmary Research Center.

    19 Gallup Index of Leading Religious Indicators (the Princeton Religion Research Index). Based upon data collected during the year 2000. www.gallup.com/poll/releases/pr010329.asp

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