PTSD is a whole-body tragedy, an integral human event of enormous proportions with massive repercussions. —Susan Pease Banitt, LCSW
Wartime trauma produces profound psychological, physiological, and spiritual effects. While not everyone who goes to war returns damaged, all are affected, and many veterans are suffering today with the symptoms of post-traumatic stress (PTS) or post-traumatic stress disorder (PTSD). The differences between PTS and PTSD have to do with the extent and duration of the symptoms and whether the symptomology meets the clinical criteria for a diagnosis of PTSD. For my purposes, references to PTSD will include PTS symptoms unless otherwise stated.
In this chapter, we consider the wide range of effects of combat-related trauma, laying a foundation for understanding the spiritual aspects of trauma and the necessity for spiritual intervention. When we focus on spiritual aspects, many of the associated effects—whether mental, emotional, or physical—diminish and become manageable.
There is hope, and healing is possible. No one suffering from PTSD has to suffer with it forever. This may seem quite radical, but recovery is possible. Veterans can get their lives back and find healing through the use of spiritual interventions. But before I get to all of that, we need to understand the nature of trauma and how it affects our service members returning from combat.
Trauma and PTSD
Amazingly, nearly half of all Americans will experience or witness a symptom-producing traumatic event in their lifetime, such as a violent death, sexual assault, or natural disaster.1 While many Americans adjust quickly to their traumatic experiences, some do not. Most people who are traumatized experience some impairment immediately following the event; they may experience insomnia, nightmares, or disturbing thoughts and memories. In most cases, depending upon the trauma and how the particular person views the trauma, symptoms eventually go away within a few months.
However, in cases where people find impairment of their everyday functioning lasting for at least a month, there is the likelihood they are suffering from the effects associated with the onset of PTSD.2
Combat-related trauma is just one type of trauma that may lead to PTSD. While hundreds of thousands of veterans suffer from PTSD, many more do not exhibit any debilitating symptoms as a result of their wartime experiences. Nevertheless, PTSD is a significant issue in our veteran community, and many veterans suffer with its symptoms.
The combat environment is hostile, unpredictable, and emotionally traumatic because of the fear of the unknown. Service members are subject to multiple scenarios, from the possibility of being wounded or killed to engaging the enemy or witnessing a horrific incident. Whether a soldier experiences one traumatic episode or is exposed to a series of traumas over time, the effects can be devastating.
In 2007, researchers from the Walter Reed Army Institute of Research (WRAIR) reported 10–15 percent of soldiers developed PTSD after deployment to Iraq, while 11 percent developed PTSD after service in Afghanistan.3 It is estimated that somewhere between 13 and 20 percent of service members are suffering with PTSD.4 But the actual percentage of service members suffering with PTSD may be much higher.5
According to records of the Defense Manpower Data Center, as of May 2012, 1,515,707 veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) have separated from the military.6 This number includes service members who died in-theater. If 15 percent of these service members have PTSD, then well over 200,000 veterans from these wars may be suffering from PTSD.
According to a Veterans Affairs (VA) report that assessed veterans who served in OEF, OIF, and OND from the first quarter of fiscal year 2002 through the third quarter of fiscal year 2012, nearly 30 percent of its patients from Iraq and Afghanistan have PTSD.7 As of 2012, the VA had in total treated over 830,000 veterans from these wars. This means at least 249,000 veterans treated at VA hospitals and clinics have been diagnosed with PTSD. The figure is astounding, given the likelihood that there are many more veterans who suffer with PTSD from other wars or have never been seen by the VA.8
There are many problems associated with PTSD, particularly anxiety, depression, and suicide. Of the 13 to 20 percent of veterans overall who suffer with PTSD, 10 percent also suffer from an anxiety disorder, which highlights the challenges of those diagnosed with PTSD. Additionally, some studies further report that 35–75 percent of those suffering with PTSD suffer with depression.
There is no doubt that anxiety and depression contribute to the high number of marital difficulties among veterans diagnosed with PTSD. These difficulties manifest in terms of self-disclosure, intimacy, expressiveness, and aggression.9
Nearly 20 percent of those who suffer with PTSD, unfortunately, will also attempt suicide.10 Suicide has steadily increased in all the military services since 2002. There was a marked increase in the occurrence of suicides among combat troops after 2005. This increase correlates with the surge of troops in Iraq that began in 2005. Additionally, some standards for enlistment in the army were waived around 2005, and this resulted in the recruitment of individuals with a wide range of preexisting conditions that may have contributed to the increase in suicides.
In 2012, 349 service members took their own lives. Indeed, there were more service members who died by their own hands in 2012 than those who died in combat—and more than one-third of those who took their lives in 2012 had never been deployed.11 But while the number of suicides in the military increases, its documented connection to combat-related PTSD is less clear. Nevertheless, there is a connection between PTSD and suicide, and veterans who suffer from the chronic effects of PTSD are at risk for suicide.
What is trauma? Trauma involves a significant crisis; it is connected to a deeply disturbing and disruptive event that causes great distress, often attended by shock and fear. It frequently involves physical, moral, spiritual, or psychological injury. The term trauma originates from ancient Greek and means to wound or to hurt.12 Trauma, then, is a wounding, and in many instances a wounding of the heart and soul.
Post-trauma stress is typically negative stress or distress, which causes dysfunction. However, while trauma is hurtful and stressful, not all stress is bad, and not all trauma is completely negative or results in dysfunction.
while trauma is hurtful and stressful, not all stress is bad, and not all trauma is completely negative or results in dysfunction
The experience of trauma may challenge someone’s worldview and assumptions about life, i.e., how he or she assumes the world operates or expects things to turn out. The occurrence of trauma is often a life-changing event that rocks a person’s world; it taxes and overwhelms one’s capability to adapt or resume normal functioning. This latter aspect is always associated with a disorder, and PTSD is evident when there is a disruption of normal functioning that results in overall dysfunction and distress.
Violent events that threaten well-being, such as what one might expect in combat or from natural disasters, confront individuals at the limits of their capabilities. These events can sometimes evoke a catastrophic response.13 That response often contributes to PTSD.
Besides the emotional, mental, or spiritual effects, trauma produces many physiological effects. Trauma affects the body’s “flight or fight” response, which impacts the nervous system and engages the cardiovascular, respiratory, and gastrointestinal systems. It is common for a warrior to lose bladder and bowel control, hyperventilate, or physically freeze due to fear while engaged in intense combat operations. In a government study that evaluated the performance of soldiers in World War II, cited by Lieutenant Colonel Dave Grossman in his book On Combat: The Psychology and Physiology of Deadly Conflict in War and Peace, researchers concluded that one-quarter of all US troops admitted they had lost control of their bladder, and an eighth of them also admitted to loss of bowel control.14
Traumatic stress impacts the nervous system, particularly the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). Both are part of the autonomic nervous system (ANS), which is hard-wired to an area of the brain called the limbic system.15 This part of the brain stores memories of life-threatening events. A brief discussion of the ANS is helpful here because it will not only explain the effects of stress on the body but also help us understand how PTSD can develop later.
The ANS comprises three parts: the SNS and PNS mentioned above, and the enteric nervous system (ENS). The ANS regulates the functions of the body’s internal organs and is always “on duty” to maintain normal equilibrium—what is called homeostasis.16 The ANS controls smooth muscles such as those in the eye and around blood vessels, hair follicles, the bladder, and intestines. It regulates glandular secretions, heart rate, respiration, and the stomach. It accounts for why hair stands on end when one is frightened or nervous, why a person experiences dry mouth, and why some people sweat profusely under duress. The ANS is not something that we consciously think about because it functions involuntarily.
The SNS activates the “flight or fight” response during emergency situations. When stimulated, the SNS is responsible for releasing two primary chemicals, noradrenaline and adrenaline, resulting in physiological changes that include pupil dilation, increased heart rate, rise in blood pressure, and increased sweating. The focus of the SNS is survival. The primary emotion associated with this response is anger.
The PNS activates the rest mode during nonemergencies. The PNS and SNS work in opposition to each other in order to contribute to homeostasis. Generally, when the body is in a rest mode, the PNS allows it to recover and relax.
The ENS consists of a complex network of nerves that primarily monitors the digestive system. Sometimes it is referred to as the “gut brain.” When stimulated in connection with the other parts of the ANS, the ENS accounts for an array of responses, including diarrhea when a person is frightened and stomach cramping when the body is stressed.
Each system performs its role. For example, suppose Sergeant Smith, a member of a team, is conducting routine operations in what has been a quiet sector of the Helmand Province in Afghanistan. He is now returning to his base. His PNS has moved into a “rest and recoup” mode, conserving energy by lowering his heart rate and aiding digestion.
Suddenly there is an explosion, and then another explosion and the clatter of small arms fire. His vehicle has been attacked. Sergeant Smith’s PNS system reacts to his SNS, which is increasing his blood pressure, raising his heart rate, and reducing his digestion. All of this is occurring without any conscious thought on the part of Sergeant Smith.
It is the interaction between these systems that take a toll on the warrior. The attack on Sergeant Smith’s vehicle results in profound physiological changes and a massive expenditure of emotional and physical energy. Then the attack is over and he is back at his base, in relative safety. His team has survived the attack and repelled the enemy. What happens next? His PNS activates to compensate for the massive energy release. The system lowers the heart rate, reduces respiration and blood pressure, and opens the bowels. This is sometimes referred to as “parasympathetic backlash.” His body goes into maintenance mode.
Sergeant Smith and his team are exhausted and need sleep. They have burned a lot of adrenaline and must get rest. But suppose they cannot rest? Perhaps there is another mission? Continued operations will tax them, winding them tightly like a coiled spring. Erratic or continued tension will induce a temporary hormonal high but eventually result in a combat stress reaction that could lead to PTSD later.
Without the necessary downtime, the team is unable to physically recover. The body cannot remain in a constant state of vigilance without an effect—usually problems with sleep and anger later on, two very common symptoms of PTSD. The experience of the hormonal high, that adrenaline kick, is like the high of an addictive drug. It may explain why some soldiers returning from combat are unable to adjust to the boredom of noncombat operations and civilian life.
Without the necessary downtime, the team is unable to physically recover
These physiological effects are factors in the development of fatigue, detachment, isolation, and apathy. They explain why some soldiers have problems with sleep or irritability and, in worse cases, anger and rage. They account for poor concentration and memory loss after soldiers return home. Constant vigilance coupled with persistent sleep deprivation affects the neurological system. It is a physiological reason for the persistence of these problems when a soldier returns home. Clergy can help soldiers by making them aware of this problem. Understanding it may help them realize that there are physical and fairly normal reasons why they are responding in this way.
The inevitability of these effects is one reason the military pulls soldiers periodically out of the fight for a brief time-out. Periodic rest and recuperation from combat not only sustains the warrior, but lessens the likelihood of long-term effects from these physiological realities.17
Emotional and Psychological Reactions
Trauma also produces profound emotional and psychological reactions. A traumatic event may trigger painful experiences from the past. Often, soldiers suffering with PTSD succumb to reexperiencing the originating trauma through trigger events such as a sight, a smell, or a sound. These events provoke vivid memories and result in retraumatization.
Several soldiers have related to me how a pile of trash on the side of a road triggered emotional reactions in them. In Iraq or Afghanistan, it was common for the enemy to hide improvised explosive devices in piles of trash. The sight of civilians in Muslim dress may elicit reactions because the enemy sometimes concealed explosives under their garments. I recall flinching while passing under bridges that were occupied, because the enemy was known to throw grenades from overpasses at passing vehicles. Sometimes you see a veteran duck or flinch at the sound of a siren. That’s because sirens were used to alert soldiers of impending attacks in the combat zone. Such reactions in combat were a matter of survival, but back home they might seem strange or foolish.
A traumatic event may be attended by feelings of disgust, shame, and wrongness—feelings typical among victims of sexual assault. The sense of wrongness may stem from a personal violation or error. Incidences of rape occur in the combat zone, and some soldiers are traumatized not because of combat but because of such personal violations.18 I have counseled some soldiers and am aware of others whose traumatic experiences were the result of dysfunction in units, poor treatment by others, inferior leadership, or betrayal. These types of incidents and their effects are sometimes characterized as moral injuries.
Some soldiers suffer from a sudden realization of the unfairness of life as it affects other soldiers. The arbitrary loss of life, in which one soldier dies and another lives, perhaps as the result of a rocket that just happens to strike a living area, seems unjust and senseless. This perception of meaninglessness contributes to PTSD and is often a symptom of it.
Radical and Positive Transformation
Trauma may result in radical and positive transformation.19 Later I will consider some of these positive reactions. Although numerous studies and anecdotal evidence point to positive outcomes, how a person responds to trauma always depends upon that person’s appraisal of the event. What might be traumatic and negative for one person might not be traumatic to someone else. A third person might even construe that experience as something positive.
Spiritual Aspects of Trauma
There are many spiritual aspects to trauma. Trauma sometimes profoundly disrupts a person’s ability to understand, predict, or control her or his life. There can be a disruption of a person’s spiritual values, which may include beliefs, practices, and relationships among other aspects.20 This kind of disruption has devastating effects, resulting in the inability to cope with the normal requirements of living. In these instances, the traumatic event not only affects a person’s core beliefs or values but assumptions about the world and how he or she thinks it should work. All of these aspects may be described as spiritual trauma.
Spiritual trauma is an assault on a person’s sense of security, self-image, and the way he or she usually derives meaning in life. It is not difficult to comprehend, then, how combat trauma or personal violation might contribute to a breakdown in normal expectations and assumptions. This aspect of trauma is significant and requires our examination. In the next chapter, we’ll look at the spiritual dimension of trauma in greater detail, and in subsequent chapters consider specific examples of spiritual trauma. Then we’ll consider how appropriate spiritual interventions can effectively address these issues.
PTSD is fairly common in the United States, with approximately 6–8 percent of the adult population meeting the strict criteria for a diagnosis.21 Likely, there are many more who suffer from a range of PTS symptoms but do not meet the clinical criteria for PTSD. PTSD is the fifth most common mental illness and currently afflicts as many as 5.2 million Americans between the ages of eighteen and fifty-four.22
PTSD in the United States is often the result of sexual assault or domestic violence. Human-induced trauma is the most troubling form of trauma, whether it is assault- or combat-related. Interpersonal human aggression is the universal fear. This is because it is more difficult to assign meaning to human aggression than to other forms of trauma, such as natural disasters. This fact contributes most to the problem of PTSD.23
Interpersonal human aggression is the universal fear
But what exactly is PTSD and how does it manifest? PTSD is a delayed reaction to a traumatic event or a series of traumatic events, in which an array of symptoms persists for at least a month.24 PTSD is evident in people when it disrupts normal functioning. Symptoms may show up several months or even years after a traumatic event. It is important to remember that PTSD is a normal reaction to an abnormal situation or extraordinary event(s).
The hallmark feature of PTSD is the intrusive re-experiencing of an originating trauma. Like an irritating tune that keeps playing in your head, the originating trauma—often triggered by a sight, sound, or smell—is replayed over and over again. Sufferers become stuck in the pain of the original trauma. Often deprived of sleep, they feel trapped, held captive by the power of the trauma.
The Spanish referred to PTSD as estar roto, which means, “to be broken.”25 This is quite appropriate because many people who suffer with PTSD experience significant impairment of personal, social, and occupational functions. They feel their lives are broken; indeed, many of them are broken souls. They often experience anguish accompanied by deep anxiety because they cannot seem to return to being the people they were before.
Not all trauma leads to the development of PTSD. But PTSD is always the result of trauma. The development of combat-related PTSD correlates with several factors: the degree of trauma in war (intensity), proximity to the trauma (range), extent of exposure (duration), and frequency of traumatic experiences.
In truth, no one is immune from PTSD. Statistics from three wars confirm this observation. There were more PTS-related casualties from World War I, World War II, and the Korean War combined than casualties who were killed or physically wounded.26
Not all stress casualties resulted in PTSD, but significant numbers of soldiers did exhibit post-traumatic stress. Others developed PTSD and some eventually learned to manage their symptoms and recovered. Soldiers may lessen their risk of developing PTSD through training, resiliency-building measures, and other factors such as faith. Soldiers properly trained and positively oriented are less likely to develop PTSD or chronically suffer from the long-term effects of PTSD.
PTSD and Other Combat Stress Reactions
Combat-related PTSD usually results from losses (such as the deaths of fellow soldiers) or from guilt associated with perceived or actual failure. It can be the result of witnessing the horrors of war, such as killings, mutilations, civilian deaths, atrocities, or betrayal. Other circumstances also contribute to the development of PTSD in soldiers, and many of these will be explored in the chapters that follow.
Because every person is different, the response to a traumatic event depends on the individual. The different kinds of responses people may have to a trauma range from combat stress or “battle fatigue” to chronic PTSD. Chronic PTSD is a severe and lasting reaction to a traumatic event. Chronic PTSD may manifest initially as acute stress disorder or acute PTSD. The difference between the two has to do with the duration of the symptoms, their extent, and when they manifest. It is the chronic form that is most debilitating.27
Combat operational stress reactions (COSRs) are common and may include sleeplessness, eating problems, intrusive thoughts, hyperalertness, and other, similar reactions, which usually go away within three months.28
In contrast to typical COSRs, PTSD is the most severe of all stress reactions and includes the reexperiencing or chronic intrusiveness of a traumatic event. The sufferer may act or feel like the event is happening again, experience nightmares, or react with acute sensory alertness, such as jumping at the sound of a siren or a car backfiring. Soldiers who report PTSD symptoms may also indicate numbness—an inability to attach to someone emotionally or relationally—and avoidance of places, people, activities, or events because of their association with the traumatic experience.29
Symptoms of PTSD
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM—5) describes PTSD as a trauma and stressor-related disorder.30 In the earlier edition of the DSM, PTSD was listed as an anxiety disorder.31 The DSM—5 identifies six criteria for a diagnosis of PTSD and includes several significant changes from the previous edition.
The clinical definition of PTSD is complex, suggesting it is not particularly easy to be diagnosed with PTSD. But many service members and veterans manifest various symptoms of post-traumatic stress, and while they may not be clinically eligible for a diagnosis of PTSD, they have symptoms that warrant intervention. While it is not the clergy’s task to diagnose symptoms, they can intervene. Learning how to intervene on a spiritual basis is what this book is all about.
The Clinical Criteria for PTSD32
- Criterion A: Exposure to Trauma or a Major Stressor. According to the DSM—5, the criteria for determining a clinical diagnosis of PTSD presuppose an exposure to trauma, defined as a violent or accidental event occurring outside the person, either witnessed or experienced through repeated or extreme exposure to negative details.
- Criterion B: Presence of Intrusion Symptoms. (Only one of the following is required.) There must be the presence of recurring intrusion symptoms after the event(s) that manifest as (1) distressing memories; (2) intrusive dreams or nightmares (in severe cases, flashbacks in which the person feels or acts as if the traumatic event was actually happening again); and (3) intense or prolonged distress.
- Criterion C: Persistent Avoidance of Stimuli. These stimuli are associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following (only one of the following is required): (1) avoidance of distressing memories, thoughts, or feelings about the trauma and (2) avoidance of external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic events(s).
- Criterion D: Negative Alterations in Thoughts and Mood. The alterations begin or worsen after the event(s) (two of the following are required): (1) An inability to remember key features of the event; (2) persistent negative or exaggerated beliefs or expectations about oneself or the world; (3) persistent distorted thoughts about the cause or consequences of the event(s), such as blaming self or others; (4) persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame); (5) markedly diminished interest or participation in pretraumatic significant activities; (6) feelings of detachment or estrangement from others; and (7) persistent inability to experience positive emotions (e.g., happiness, satisfaction, or loving feelings).
- Criterion E: Marked Alterations in Arousal and Reactivity. The alterations are associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred (at least two of the following are required): (1) irritable behavior, angry outbursts, aggressive behavior; (2) reckless or self-destructive behavior; (3) hypervigilance; (4) exaggerated startle response; (5) problems with concentration; or (6) sleep disturbance.
- Criterion F: Duration. The duration of the disturbances listed in criteria B, C, D, and E persists longer than one month. The disturbance caused by the trauma must result in significant distress or impairment in social, occupational, or other important areas of functioning. In special cases, a diagnosis must specify when dissociative symptoms are present (numbing, depersonalization, or derealization, in which the person feels numb, feels outside of himself, or has a sense that things are not real), or when the disturbance is not due to drugs or other illness. Preliminary diagnosis may be given as early as one month after the event, but a full diagnosis is not met until at least six months after the traumatic experience(s).
Regardless of the type of traumatic event, a traumatic event does not necessarily result in PTSD nor does it result exclusively in PTSD. It is normal to be affected by trauma.
Guiding Principles for Treatment
There is no one preferred treatment for PTSD or evidence that any treatment is vastly superior to another. However, there are treatment principles that apply regardless of the methodology employed.
In this book, you will learn how to intervene through a methodology called cognitive restructuring. Two aspects of cognitive restructuring are narrative reconstruction and narrative reframing. I thoroughly explain them later on and then illustrate them using biblical examples. My approach uses principles found in cognitive-behavioral therapy (CBT).33 CBT involves working with the victim’s cognitions in order to change the way the victim thinks, feels, and acts in relation to the traumatic experience. The use of corrective feedback, new information, and counterargument are several ways cognitive restructuring occurs. CBT is particularly effective in attribution retraining and changing feelings of shame and guilt by teaching the sufferer how to reframe perceptions of the trauma, leading to a new perspective and healing.
So what are some of the principles we should use in treatment? Below are five significant guiding principles that I feel are essential for treatment.
Use a Client-Centered Approach
A client-centered approach focuses on the needs of the veteran and begins where the client is; nothing is forced and no demands are placed on the client. The veteran participates in the development and application of the treatment. This approach to treatment grants some personal control to the client and gives discretion to him or her over what is shared, how it is shared, and when it is shared. Voluntary involvement is critical. No one should be coerced, especially when spiritual protocols are being used. In the program I use, soldiers must begin together; no one may be added to the group after group treatment begins. But members may leave the group during treatment if they choose. Should they decide later to seek treatment, they need to join a newly formed group.
Lead Them to Meaning
Encourage self-discovery. Let the victim “connect the dots” that lead to the discovery of meaning. People who find meaning in their suffering find healing. Treatment requires sufferers to sever their connections to the past traumatic event and replace painful memories or emotions associated with that event with newly conditioned emotional responses and/or new cognitive constructs that provide relief.34 Healing begins when victims learn to separate the memory of the experience from the pain. Successful treatment enables the veteran/victim to live constructively in the present.
Conduct a Full Assessment
It is essential for those who provide treatment to conduct a full assessment of those who come into their care, taking into consideration associated problems and presenting issues, especially if these issues might present obstacles in exploring the trauma itself. Client-centered approaches emphasize the need for practitioners to allow clients to open the doors into their own souls. Prying at someone’s trauma, especially if there are layers of protective coping, may completely shut the person down, or worse, retraumatize the person unnecessarily.
Effective treatment plans also address multiple factors, including medical, relational, psychological, vocational, and spiritual factors. The practitioner must help separate the victim from the trauma and educate him or her about the nature of PTSD. As much as possible, caregivers should try to normalize the traumatic effect by contextualizing it or helping the sufferer to see the problem objectively.
Finally, since most pastoral caregivers are not qualified to make a diagnosis of PTSD, don’t diagnose. Deal with the presenting symptoms. If referral to a clinician is necessary, then do so. Keep in mind that there are clinical issues as well as spiritual issues. Only clinicians are qualified to address the clinical symptoms of PTSD.
Create a Safe Environment
Providing treatment in a safe environment where relationships are based on trust and compassion is essential. This is achieved when the practitioner establishes client-counselor rapport, identifies and adheres to ground rules, and honors the client’s needs. Many pastoral caregivers, especially military chaplains, have the experience, skills, and rapport to conduct group sessions that provide for a soldier’s safety and expression of painful experiences. Just the expression of pain often reduces it. Establishing rapport in a safe and secure setting is absolutely essential and contributes to a healing alliance.
Employ Group Methodology
Group treatment is an ideal methodology and widely regarded as essential in any kind of treatment plan. It must be conducted in a safe environment. Conducted properly, it promotes cohesion and mutual support among empathetic members.35 The use of group methodology facilitates sharing, promotes understanding, exercises patience, expresses empathy, and affirms all members in the group.36 In a group setting, veterans are comfortable sharing their pain, so long as they feel secure and are confident that trust has been established. This methodology is self-empowering and conducive to healing.
 Matthew J. Friedman, Post-traumatic and Acute Stress Disorders 4th ed. (Kansas City: Compact Clinicals, 2006).
 Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (Washington, DC: American Psychiatric Association, 2013).
 Charles W. Hoge, Carl A. Castro, Stephen C. Messer, Dennis McGurk, Dave I. Cotting, and Robert L. Koffman, “Combat Duty in Iraq and Afghanistan: Mental Health Problems, and Barriers to Care,” New England Journal of Medicine 351 (2004): 13–22.
 National Research Council, Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment (Washington, DC: The National Academies Press, 2012).
 Jamie Reno, “Nearly 30% of Vets Treated by V.A. Have PTSD,” The Daily Beast, October 21, 2012, accessed December 23, 2015, www.thedailybeast.com/articles/2012/10/21/nearly-30-of-vets-treated-by-v-a-have-ptsd.html.
 Epidemiology Program, Post Deployment Health Group, Office of Public Health, Veterans Health Administration, Department of Veterans Affairs. Report on VA Facility Specific Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans Coded with Potential PTSD, from 1st Qtr FY 2002 through 3rd Qtr FY 2012 Washington, DC: Author. Accessed on December 23, 2015. http://www.publichealth.va.gov/epidemiology.
 Carl Castro and Jeff Thomas, “The Battlemind Training System” (Arlington, VA: Walter Reed Army Institute of Research, 2007); National Quality Management Program Special Study, Post-Deployment Post-traumatic Stress Disorder (PTSD) Screening (Washington, DC: NQMP, January 2006); Michael Lyles, Tim Clinton, and Anthony J. Centore, “Trauma and PTSD: A Clinical Overview,” in Caring for People God’s Way: Personal and Emotional Issues, Addictions, Grief, and Trauma, eds. T. Clinton et al. (Nashville: Thomas Nelson, 2005), 387–408; see www.ptsd.va.gov for articles on the effects of traumatic experiences.
 Charles W. Hoge, A. Terhakopian, Carl A. Castro, Stephen Messer, and C. C. Engel, “Association of Posttraumatic Stress Disorder with Somatic Symptoms, Health Care Visits, and Absenteeism Among Iraq War Veterans,” The American Journal of Psychiatry 164 (2007): 150–153; P. Bliese, K. Wright, A. Adler, and J. Thomas, “Validation of the 90 to 120 Day Post-deployment Psychological Short Screen,” Walter Reed Army Institute of Research Report #2004-002 (Washington, DC: Author, 2004): 1–11; Matthew J. Friedman, “Acknowledging the Psychiatric Cost of War,” New England Journal of Medicine 351 (2004): 75–77.
 J. K. Trotter, “18% More U.S. Troops Committed Suicide Than Died in Combat Last Year,” The Wire, January 14, 2013, accessed December 23, 2015, www.thewire.com/national/2013/01/us-military-suicides-2012/60985/; see also Bill Chappell, “US Military Suicide Rate Surpassed Combat Deaths in 2012, “ The Two-Way, January 14, 2013, accessed December 23, 2015, http://www.npr.org/blogs/thetwo-way/2013/01/14/169364733/u-s-militarys-suicide-rate-surpassed-combat-deaths-in-2012.
 American Heritage Dictionary of the English Language, 4th ed., ed. J.P. Pickett (New York: Houghton Mifflin, 2000), 1836, 2051.
 Judith Herman, Trauma and Recovery (New York: Basic Books, 1992).
 Grossman and Christensen, On Combat, 9; Herman, Trauma; Charles W. Hoge, Once a Warrior Always a Warrior (Guilford, CT: Lyons Press, 2010).
 Hoge, Once a Warrior.
 Grossman and Christensen, On Combat; Hoge, Once a Warrior.
 Hoge, Once a Warrior.
 Lawrence G. Calhoun and Richard G. Tedeschi, “The Foundations of Posttraumatic Growth: An Expanded Framework,” in Handbook of Posttraumatic Growth, eds. L. G. Calhoun and R. G. Tedeschi (Mahwah, NJ: Lawrence Erlbaum Associates, 2006), 1–23; Annette Mahoney, Elizabeth Krumrei, and Kenneth Pargament, “Broken Vows: Divorce as a Spiritual Trauma and its Implications for Growth and Decline,” in Trauma, Recovery, and Growth: Positive Psychological Perspectives on Posttraumatic Stress, eds. Stephen Joseph and P. Alex Linley (Hoboken, NJ: Wiley, 2008), 105–123.
 Mahoney et al., “Broken Vows.” See also Robert Grant, “Spirituality and Trauma: An Essay,” Traumatology 5, no. 1 (1999): 8-10, accessed December 23, 2015, DOI: 10.1177/153476569900500103; M. J. Friedman, Post-traumatic; A. Matsakis, Post-traumatic Stress Disorder: A Complete Treatment Guide (Oakland: New Harbinger, 1994).
 P. Massad and T. Hulsey, “Causal Attributions in Posttraumatic Stress Disorder: Implications for Clinical Research and Practice,” Psychotherapy: Theory, Research, Practice, Training 43, no. 2 (2006): 201; Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder, Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment (Washington, DC: National Academies Press, 2014), accessed December 23, 2015, http://www.ncbi.nlm.nih.gov/pubmed/25077185.
 Lyles et al., “Trauma and PTSD.”
 Grossman and Christensen, On Combat; Meichenbaum, A Clinical Handbook. See Glenn R. Schiraldi, The Post Traumatic Stress Disorder Source Book (Los Angeles: Lowell House, 2000), 4, 404. Schiraldi cites Schopenhauer who observed, “Suffering which falls to our lot in the course of nature, or by chance, or fate, does not seem so painful as suffering which is inflicted on us by the arbitrary will of another.”
 Aphrodite Matsakis, Post-traumatic Stress Disorder: A Complete Treatment Guide; National Center for PTSD Fact Sheet (3) (2007); “Who is Most Likely to Develop PTSD?” US Department of Veterans Affairs, accessed January 21, 2008, http://www.ncptsd.va.gov/.
 Edward Tick, War and the Soul (Wheaton, IL: Quest Books, 2005).
 Grossman and Christensen, On Combat.
 Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
 US Army, Combat and Operational Stress Control for Leaders and Soldiers, Field Manual (FM) 6-22.5 (Washington, DC: Department of the Army, 2009).
 Friedman, Post-traumatic; see also A. Matsakis, Post-traumatic; VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress (2004), US Department of Veterans Affairs, accessed December 23, 2015, http://www.healthquality.va.gov/ptsd/ptsd_full.pdf.
 Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
 Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington, DC: American Psychiatric Association, 2000).
 Information provided here on the criteria for PTSD is a summary of what is available at