Spirituality_and_Readjustment_Following_War-Zone_Experiences

14 Spirituality and Readjustment Following War-Zone Experiences KENT D. DRESCHER, MARK W. SMITH, AND DAVID W. FOY Religious beliefs and practices (spirituality)aid many people in devel oping personal values and beliefs about meaning and purpose in life. They can provide an avenue for coping with difficult lifeevents including trauma. Mental health professionals increasingly recognize spirituality as a primary human dimension, and a potentially robust area of research. The military has a long tradition of providing for the spiritual needs of its troops through chaplains representing many faith traditions. However, the direct spiritual consequence of participation in war has only recently begun to be studied, as has the potential role spirituality may play as a healing resource for those recovering from war-zone trauma. Researchers and theorists about the effects of trauma have suggested that traumatic events frequently call into question existential and spiri tual issues related to the meaning of life, self-worth, and the safety of life (Janoff-Bulman,1992). For those whose core values are theologically grounded, traumatic events often give rise to questions about the funda mental nature of the relationship between the creator and humankind. The question of how belief in a loving, all-powerfulGod can be sustained when the innocent are subjected to traumatic victimization has been labeled "theodicy" by philosophers. Frequently called "the problem of evil," theodicy poses the question: If God is all-powerful, and God is all good, how does God allow evil to exist in the world' Historically, varied solutionshave been proposed to the theodicy question, including solutions that diminish God (i.e., God is not all-powerful, God is not all-good, God does not exist), or that diminish evil (i.e., it is a punishment for sin, it may 295 296 Combat Stress Injury bring about some greater good), and perhaps individual solutions that diminish the self (e.g., self-blame, rage, loss of meaning, purpose, or hope). However, theodicy is not a philosophical question to trauma survivors - it is real, tangible, and can be an obstacle to fullrecovery. The purpose of this chapter is to provide an overview of the ways that war generally, and the current wars in Afghanistan and Iraq specifically, may affect the spirituality of returning troops. We hope to review the empirical literature related to trauma and spirituality among veterans of previous wars, share the anecdotal experiences of a chaplain who has directly debriefed many returning troops, and offer suggestions gleaned from clinical work among veterans with posttraumatic stress disor der (PTSD), of ways to help veterans utilize healthy spirituality in their trauma recovery. REFLECTIONS ON THE SPIRITUAL EFFECTS OF THE WAR ON RETURNING TROOPS: COMMANDER MARK W. SMITH (NAVY CHAPLAIN) Many Marines are reluctant to go to the chaplain after a dramatic or traumatic event such as war. They are afraid it might look as if they couldn't handle the pres sure and needed the chaplain. That is the advantage of requiring every returning Marine-gunnery sergeant through general in a particular force-to schedule a personal debrief with the chaplain. They can come into the outer officecomplain ing that they don't need this, then tell their whole story to the chaplain once the counseling office door is closed. I was that chaplain for the First Marine Expeditionary Force Command Ele ment when they returned from Iraq in the spring of 2005. As part of the "War rior Transition" program, I individually debriefed some 200 officers and senior enlisted personnel in a 45-day period. Their appointments ranged from 10 min utes to 1 hour and 15 minutes. Most were in the 30- to 45-minuterange. The longer appointments were usually the Marines who most boldly declared their lack of need of debriefing by the chaplain. These appointments were long not because I had to work so hard to get the Marines to admit they had emotions--the length was usually because I asked them how they were doing, and they had a lot more to say than they thought they did. Did some of what they talked about include spiritual issues' I haven't yet decided if it was surprising that so many gruff, tough Marines had sincere spiri tual issues. You might think they would feel obligated to talk spirituality since they were in the chaplain's office. But very few of these discussions had the sound of someone trying to make the chaplain feel needed. The Marines appeared to be grappling with the real meaning of life, and their own place in this world. Can't get much more spiritual than that. It seems to me that these Marines fell into two categories in relation to how they perceived they were responding to their experiences of trauma in war: the "Never-recovers" and the "Nothing-wrongs." Spirituality and Readjustment Following War-Zone Experiences 297 The Never-recovers: When the counseling office door closed, the fears and concerns began to pour out. Often Marines would say, "I'm not really having any problems, but I did see...." And the story would take them deep into the basic questions of life, and their own painful thoughts. They actually often seemed relieved to talk with someone other than a mental health clinician or an official member of the chain of command. They were glad to be able to talk honestly with no fear of their words ever getting out to the rest of the command. When these Marines talked about their fears, one of the chief concerns was that they would never be the same. Probably true. But they alsofeared that meant they would never get better. They would never recover from this. Veryfew Marines actually found themselves angry with God. Veryfewblamed God for what they had seen or for what was going on around them. In fact, many actually had some newfound appreciationfor the faith of others, but still retained the right to hate those who sought to destroy under misguided interpretations of valid religious expressions. And this appreciation of other religions caused a number of Marines to say that they planned to get more involved in their own faith group's practices. They might never be the same, but maybe they could live a better life anyway, despite the fact they feared the hate would never go away, or the compassion would never return. Another characteristic of some of the Never-recovers: they were tired of talk ing about their war experiences. They had done enough of that, they had pro cessed it, and wanted to be done with it. What they really wanted to talk about was the pain they were having right now. They didn't seem to want to consider that the two were still related. The Nothing-wrongs seemed to come in two variations: those in denial, and those who actually grew through their experiences. The Marines in denial continued to maintain nothing was wrong with them despite the painful stories and torturous symptoms they said they were living with. A number of them did say they appreciated that the military took their personhood seriously enough that they wanted everyone to see the chaplain. They appreciated that the focus was not just medical or cover-your-tail-in-case something-bad-happens when a Marine returns. They were hinting they wanted to go deeper. We usually did. Sometimes they left still maintaining they didn't need any help. But that was pretty rare. Many other Marines talked about not being traumatized because their faith sustained them. They had strong beliefs about their place in this world and their hope in an afterlife. They frequently believed that God would take care of them, but surprisingly that was not a naive belief that they would be safe, but that they would either be protected or God would comfort them even as they were called home (toheavenly places) or allowed to suffer. Their theology after war was bet ter than the average Marine often manages. They were spiritually stronger than they had been before. There were also a number who decided it was time to grow up and get more serious about their faith. They needed to decide what they believed and then get 298 Combat stress Injury more involved in the practiced that faith. Nearlyall were in agreement that their spiritual selves were important and had been affected by this deployment. I also debriefed several chaplains and a number of medical personnel. These debriefs were both one-on-one, and in two retreats aimed at helping caregivers deal with the extra burden of trauma they encountered while trying to take can' of others. Participants in these retreats completed an anonymous survey on spiri tuality. Here are some of my observations from that experience. The retreats included 31 recent returnees from Iraq, splitbetweenchaplainstall' and medical staff. They were surveyed on some of their reactions since returning. Some of the questions were specific toward ministry, others aimed at spirituality issues in general, and others directly targeted some of the human spirit connec tion points for spirituality. Whether we are looking at cognitive, behavioral, or relational definitions of spirituality, spiritual issues all seem to involve these human connection points. Nearly all participants, including the medical personnel, strongly agreed that spirituality is important. Additionally, a large majority of the respondents showed a high level of agreement that several spiritual aspects of their lives had been affected. Three were strongest: (1)their faith had been challenged, (2) they had found new purpose, and (3) their spiritual religious practices had changed. None of these changes are necessarily negative; in fact, they are probably another example of adversity providing the opportunity to grow in positive ways. Other responses may indicate when the changes were negative. There was nearly uni versal agreement that they were suffering spiritual burnout and were emotion ally drained. There were also a significant number who felt they had lost some of their "sense of call"-usually a term used by ministers to describe why they became ministers, but here used by medical personnel as well. A majority of these caregivers also reported damage to parts of their human ity that could arguably be the connection points for spirituality in the human makeup: (1)loss of their creativity, (2) having greater difficulty expressing and receiving love, and (3)having greater difficultyexpressing themselves or under standing others. Creativity, ability to love and be loved, and language are some of the quintessential aspects of being human-in other words, part of the spirit of being human. Other spiritual connection points were seen as damaged by a significant minority of respondents: (1)having troubleseeing themselves as others see them, (2) loss of their sense of place in this world, (3) loss of the ability to make choices for themselves, and (4) loss of their appreciation of beauty. These could be identi fied as the human distinctives of self-transcendence, autonomy, and aesthetics. These returning combatantsand caregiversshowed a high awareness of spiri tual needs, newfound theological understandings, and clear damage to elements of spirituality within themselves. Areas such as creativity, the ability to love and be loved, advanced language, self-transcendence, autonomy, and aesthetics were clearly affected. My impression of our times together lead me to think that a sig nificant number of these Marines were coming to see great potential for growth. SpiritualityandReadjustment Following War-Zone Experiences 299 Admittedly, these interviews and retreats were in close proximity to the partici pants' return from war. True damage caused by exposure to the trauma of war will undoubtedly not be fully realized or diagnosed until much later, but it does add credence to the common wisdom that there are no atheists in a foxhole. H O W SPIRITUALITY MAY PROMOTE TRAUMA RECOVERY Though not all these areas have been researched, there are several important clinical themes among trauma survivors that potentially involve religion and spirituality. For example, anger, rage and a desire for revenge may be tempered by forgiveness, spiritual beliefs, or spiritual practices. Feelings of isolation, loneliness, and depression related to grief and loss may be lessened by the social support of religious participation (McIntosh, Silver, & Wortman, 1993). Spirituality, as it is frequently experi enced in community settings, places survivors among caring individuals who may provide encouragement, emotional support, as well as possible instrumental support in the form of physical or even financial assistance in times of trouble. Recovery of meaning in life may be achieved through changed ways of thinking and involvement in meaningful caring activi ties or through religious rituals experienced as part of religious/spiritual involvement. In addition, traumatic experiences may become a starting point for discussion of the many ways in which survivors define what it is to have "faith." Finally, religion and spirituality may be associated with beliefs about healthy lifestyles and may keep people from engaging in unhealthy coping behaviors. This may, for instance, decrease survivors' risk for substance abuse and social isolation in the aftermath of trauma. It also may provide stress reduction through practices such as prayer and meditation. REVIEW O F RECENT RESEARCH ON THE SPIRITUALITY-TRAUMALINK A M O N G COM BAT VETERANS On the positive side, spirituality may help combat veterans achieve posttraumatic growth (Linley &Joseph, 2004) that could lead to benefits, such as increased resilience in the face of future life challenges, increased meaning or purpose, and strengthened capacity to utilize positive coping resources amid crises. However, surviving trauma may also be associated with a shift to more negative beliefs about the safety, goodness, and mean ingfulness of the world (Janoff-Bulman, 1992), negative views of one's relationship with God/deity (i.e., beliefs that God is punishing me, or has abandoned me) (Pargament, Koenig, & Perez, 2000), loss of core spiritual values, and estrangement from or questioning of one's spiritual identity (Decker, 1993; Drescher & Foy, 1995; Falsetti, Resick, & Davis, 2003; Wilson & Moran, 1998). Additionally, several authors (Gorsuch, 1995; Pargament 300 Combat Stess Injury et al., 2003) have suggested that unhealthy aspects of spirituality might actually lead to worse clinical outcomes. An early study (Green, Lindy, &Grace, 1988) found increased religious coping and attempts to assign meaning to war-zone events in military combat veterans. Additionally,a study from a residential PTSD treatment program found strong religious/spiritual distress (i.e.,abandoning faith in the war zone, difficulty reconciling war-zone events with faith) in a high percentage of military veterans (Drescher & Foy, 1995). To date, dimen sions of spirituality and their relationships to clinical outcomes among veterans treated for PTSD have not been examined. Several more recent studies have identified both positive and nega tive associations between spirituality and war-zone trauma or related PTSD. Witvliet and colleagues (2004) identified two dimensions of spiri tuality, i.e., lack of forgiveness and religious coping (both positive and negative) that were associated with PTSD and depression severity in an outpatient sample of veterans treated for PTSD. Further, another recent study (Fontana & Rosenheck, 2004) found a significant structural equa tion model pathway between war-zone trauma, change in religious faith, and increased utilization of VA mental health services for veterans being treated for war-zone-relatedPTSD. Specific types of war-zone experiences (killing others, failure to save the wounded, etc.) were directly and indi rectly (mediated by guilt) associated with reduction in comfort derived from religious faith. Both guilt and reduced comfort from religious faith were shown to be associatedwith increased use of VA services (Fontana & Rosenheck, 2004). In a recent study of women veterans, those who reported being sexu ally assaulted (23% of the sample) while in the military were found to have poorer overall mental health and higher levels of depression than veterans who did not report being assaulted (Chang,Skinner, & Boehmer, 2001). The study also found that more frequent religious participation among the sexually assaulted women was associated with lower depres sion, higher overall mental health scores, consistent with a buffering effect for religious participation on mental health, Taken together, these studies raise several key considerationsfor pro fessionals interacting with military service personnel returning from combat deployment. First is the potential that trauma exposure may lead to a loss of faith. Spiritual tensions that arise for many combat veterans attempting to come to terms with their war-zone experiencesmay reduce their use of spiritual resources as part of reentry, and may in turn lead to worse psychiatric symptoms and higher medical service utilization. Additionally, it is important to stay alert for signs of "negative religious coping" (e.g., God has abandoned me, God is persecuting me) or negative attributions about God, as these can be associated with more severe PTSD and depression in some veterans. Finally, difficulties with forgiveness and higher levels of hostility or guilt may be associated with more severe problems later on. It is notable that much of our current knowledge about Sprituality and Readjustment Following War-zone Experiences 301 relationships between trauma and spirituality comes from studies con ducted years after those traumatic experiencesoccurred. It will be impor tant to continue this line of research with individuals returning from the present conflict, soon after their actual combat experiences. REASONS WHY SOLDIER REACTIONSTO THIS WAR MAY EE MORE VARIED There are a number of reasons why' the current war might provoke more varied spiritual reactions than previous wars. First, the personal characteristics of the soldiers, and the context in which they serve, are different. This war is being conducted by an all-volunteer military with extensive use of National Guard and military reserve troops. Among per sonnel in the present war, greater variability in age, gender, and avenue of deployment (reserves or National Guard) exists than in previous wars. Because there is no military draft, experience levels of troops in the war zone may be somewhat higher as well. As has been true in previous wars, perception and impact of war-zone experiencesamong officers and senior enlisted soldiers may be different from those of more junior personnel. In the current conflict, repeated deployments of uncertain duration have cre ated significant stress. This is particularly true for reserves and National Guard troops, who left careers and businesses behind, and for whom sup portive resources may be lackingupon return home. Homecoming experi ences may be another source of differential spiritual impact for returnees from the current war. Though there is active and vocal opposition to the current war in some segments of the United States and even more largely abroad, there seems to be an awareness, even among those opposing the war, of mistakes made in previous wars. Even those in opposition seem to be making active attempts to express support and concern for returning personnel - something that was not always true for returning Vietnam veterans. Trauma expo sure is another area of difference from experiences in previ ous wars, which may contribute to differential spiritual impact. Aside from initial battles in the first weeks of the war and sporadic intensive battles within constrained geographic areas (e.g.,AlFallujah), a great number of the life-threatening experiences individuals are exposed to appear somewhat random. Many deaths have occurred from improvised explosive devices, rocket propelled grenades, and suicide bombers. As a result, those who, in previous wars, might have been considered noncombatants(e.g., truck driv ers) are now subject to high risk of traumaticexposure and injury. GUIDELINES FOR INCORPORATING SPIRITUALITY INTO TRAUMA RECOVERY Much of the clinicalwork that led to the developmentof the suggestions that follow has been done within a PTSD treatment program that utilizes 302 Combat Stress Injury a group therapy format. It is important to note that the principles dis cussed here are also appropriate for use with individuals. However, there are a number of potential advantages to using a group format. Groups provide the opportunity to learn from the experiences and thoughts of others. Discussing issues with other veterans who have similar experi ences helps veterans counter the idea that "I am the only one with prob lems like this." Groups also provide a wider range of feedback, which is often better received, because the feedback comes from peers rather than from staff. Finally, group interaction builds actual connections and friendships among group members, which carries with it both immediate and potential long-term benefit. The authors recognize that many of the clinical opportunities helpers will have with returnees from the war will occur one on one, and have tried wherever possible to tailor suggestions to be useful in both individual and group contexts. Another important question is who most appropriately should provide the services to address the interaction between spirituality and trauma. Traditionally, chaplaincy and mental health have operated somewhat independently, and not always collaboratively. Both disciplines have unique strengths and potentiallyserious limitations. Chaplains frequently receivelittle more than basic training inclinical skills and lack specialized knowledge of interventions for specificmental health disorders. Equally true is that mental health providers usually receive little or no training in how to address spiritual/religious issues. The clinical suggestions in this chapter were developed and originally implemented within a men tal health context. They, however, explicitly do not attempt to answer or resolve theological or religious questions which arise for veterans; rather, these interventions are conducted from a motivation enhancement per spective. We hope to increase veterans' openness to spiritual exploration and to remove barriers that have prevented them from seeking to utilize spirituality in their recovery from trauma. We encourage veterans to seek out additional support from chaplains to talk through specific issues or questions in greater individual detail. The ideal intervention might be collaborative in nature where both disciplines make contributions to the intervention process. To institute a spiritual component into efforts supporting recovery from trauma, one critical ground rule must be maintained: the experi ence must be experienced as safe. Safety in a clinical experience involving spirituality has two distinct components: () intentional awareness and acceptance of diverse spiritual experiences, and (2) mutual respect for the views of others and openness to new learning. It is very important for clinical staff to model these characteristics and to verbalize these ideals repeatedly. Safety is necessary for helpfuldiscussion of sensitive and deli cate issues and creates an environment that allows for honest, vulnerable self-disclosure on the part of participants. The tone and content of conversation needs to be fully inclusive so that participants can feel comfortable with, and benefit from, the experience. Spirituality and Readjustment Following War-Zone Experiences 303 To participate fully, participants need to experience the conversation as a place where feelings related to the existential impact of trauma can be expressed regardless of one's individual beliefs about religion or God. Intentional awareness of diversity means there can be no assumptions that individuals share common beliefs or religious traditions. Helpers need to be careful in their use of language to ensure that the way they speak about spiritual issues is not heard by clients as biased or advocating a particular spiritual perspective. If helpers choose to self-disclose infor mation about their own spiritual history, that choice should be both inten tional and directly based on the clinical needs of the client. Arising out of these core values flow "group rules" about using "I" statements when speaking about one's personal views and beliefs, and a proscription against "proselytizing" or speaking to persuade others that one's beliefs are correct or "true." Ultimately, this need for inclusive ness extends even to definition of terms. For example, we have selected a definition of spirituality that does not require belief in God or a "higher power" and can even accommodate active hostility toward religion in all its forms. Spirituality is defined for clinical purposes as "an individual's understanding of, experience with, and connection to that which tran scends the self' (Drescher, 2006, p. 337).The idea of spirituality as connec tion with something beyond self allows a given individual to define their personal spirituality as relationships with friends or family, or connection with nature, if connection with God or a higher power is not a personal option. When religion is discussed, emphasis should be placed on aspects that varied spiritual traditions share, rather than on those which separate. Acknowledgment of the varied contributions of each religious/spiritual tradition and culture represented should be made whenever possible and a tone of acceptance set by facilitators. As with all clinical activity, an environment should be established that allows for appropriate emotional expression and self-disclosure. It should be explicitly stated that helping conversations of the sort we are describing are not designed to teach spirituality; rather, they should be seen as providing a safe space in which to discuss the possibility that spirituality might be a recovery resource. One might view this as motiva tion enhancement toward reconsidering spirituality as a potential healing resource for veterans following war-zone experiences. The overarching goal of such conversations would be to allow individuals to reconsider the role that spirituality might play following trauma. Specific Suggestions for Topics/Activities Th Address Spiritual Needs Redefine Spirituality. Many people do not think very often about how they define spirituality. Engaging in a discussion of what an individual sees as core elements to a definition can be usefulin helping that person 304 Combat Injury Stress realize that he or she can actually reconsider views which may have been learned in childhood. Defining spirituality as "connecting to something outside the self' frees each individual to define that connection for him/ herself. We encourage individuals to engage in a journey of a new discov ery of what spirituality might now mean for their lives. Group Exercise to Encourage Self-Disclosure and Relationship Building. order to feel comfortable speaking about issues that can be very personal, it is very helpful for participants to get better acquainted. One exercise we have found useful, in helping facilitate both relationship and the real ization of how life experiences and spirituality have been related over time, is called a spiritual autobiography. Individuals are asked to describe their spiritual journey from childhood to the present using a timeline chart. This highlights key experiences and decisions which were made regarding their religious faith and illustrates the context in which they occurred. This exercise allows clients to clarify and see more objectively their current religious beliefs and practices and reflect on directions they would like to pursue. Autobiographies are presented in turn by group members during sessions and help to identify and begin discussion of relevant themes and issues. Encourage Involvement in Community. As humans, we are primarily social creatures. However, trauma and PTSDfrequently impair relationships and distance survivors from potential support systems. Defining spirituality as "connection" fosters a reconsideration of that distancing process. Our culture is highly individualistic, and one problem as society has begun to see spirituality as an individual endeavor is that the community aspect of spirituality, which is inherent in most religious traditions, sometimes gets lost. We encourage veterans to seek out healthy, supportive commu nities, whether religious or not. Examples of these communities obviously include churches or Alcoholics Anonymous meetings, but could also include nonprofit helping organizations, service clubs, meditation groups, and even sports teams. We also gently confront trauma victims who seem intent on pursuing spirituality in total isolation and solitude, and encour age them to consider the possible benefits of incorporating community and relationship as aspects of their spiritual experience. Incorporate Spiritual Practices. Spiritual activities should be described as being both inward and outward focused. A variety of inward expe riential exercises involving meditation, breathing, guided imagery, and silent prayer are appropriate. Exercises should include a relaxation com ponent which will build on existing stress management skills and which will contribute in a positive way to coping with war-zone-related stress. Activities should be drawn from a variety of religious traditions. In addi tion, outside "practice" of prayer and meditation exercises experienced during group sessions is encouraged. Spirituality and Readiustment Following War-Zone Experiences 305 From an outward perspective spiritual practice should include service and work on behalf of others. Nearly all religious traditions encourage service as a form of spiritual practice. One of the benefits of volunteeringis engagement in the lives of others, which for a person suffering from PTSD addresses the tendency toward withdrawal and social isolation. Service for others also is a way of creating personal meaning and living a life that matters to others. Trauma victims are sometimes quite self-focused because of the damage they perceive has been done to them. Engaging with others who also have significant needs helps to broaden a victim's focus of attention, and helps them recognize they are not alone and that they can actually provide benefit to others. This can have very positive effects on the self-esteemof both the helper and of those who are served. Examine Potentially HarmfulSpiritualAttributions. Severalstudies (Gorsuch, 1995; Pargament & Brandt, 1998; Witvliet et al., 2004) have indicated that negative religious coping (i.e., negative attributions about God), such as "God has abandoned me," "God is punishing me," or anger at God, is associated with a number of poor clinical outcomes. We find it useful to talk about these data with veterans and to share ways to alter these view points. Group interaction around these issues can be particularly helpful, as simply discussing the issue and hearing differing viewpoints voiced by other veterans can be helpful for those who are seemingly "stuck" in these negative ways of viewing their situation. Address Important Existential Topics. Each session can include discussion of important existential issues frequently neglected in day-to-day life. Though helpers need to be informed about how various faith traditions have wrestled with these issues, it should be left to individual clients to struggle with each topic, developing their own individual solutions. Theodicy--the Problem of Evil. This term comes from the Latin theos die, meaning justification of God. The term was coined by the philosopher Leibniz, who in 1710 wrote an essay attempting to show that the existence of evil in the world does not conflict with belief in the goodness of God (Leibniz, 1890). Simply stated, theodicy poses the question: If God is all powerful, and God is all-good, how does God allow evil to exist in the world' Historically, varied solutions have been proposed to the theodical problem, including philosophicalsolutions that diminish God (i.e., God is not all-powerful, God is not all-good, God does not exist), or that diminish evil (i.e., it is a punishment for sin, it may bring about some greater good), and perhaps personal nonphilosophical solutions that diminish the self (e.g., self-blame, rage, loss of meaning, purpose, or hope). From a psychological perspective, Festinger's (1957) cognitive disso nance theory posits that individuals tend to seek consistency among their cognitions and experiences. When inconsistency exists between cogni tions and experience, there is strong motivation for change, to eliminate the dissonance. In the case of a traumatic experience, the event itselfcannot 306 Combat Stress injury be changed, hence survivors must struggle to adapt their beliefs and atti tudes to accommodate their experience in order to resolve the dissonance. Many trauma survivors, along with their families and friends, thus begin a lifelong journey toward making sense of their experiences. Forgiveness. We have chosen to address the topic of forgiveness in two somewhat different ways. The first approach is to see forgivenessas some thing done in relation to a specific event. Thoresen, Harris, and Luskin (2000) define forgiveness as "the decision to reduce negative thoughts, affect, and behavior, such as blame and anger, toward an offenderor hurt ful situation, and to begin to gain better understanding of the offense and the offender"(p. 255). It has also been important to acknowledge that forgiveness does not include pardoning an offender, condoning or excus ing an offense, forgetting an offense, or denying that an offense occurred. Rather, forgiveness involves choosing to abandon one's right to resent ment and negative judgment, while nurturing undeserved qualities of compassion, generosity, and even love toward the offender (Enright & Coyle, 1998). Within a military war-zone context, forgiveness sometimes becomes an issue of tension, in that it may suggest to veterans a pressure toward forgiving an enemy that killed your friends; forgiving the government that sent you into harm's way; forgiving people who perhaps didn't do their jobs effectively or who made mistakes; forgiving God who allowed all this to happen; and forgiving the self for perceived errors, mistakes, or lack of action. Though not all these issues are relevant for any given vet eran, they are frequent areas of concern. Additionally, as veterans attempt to cope with the aftermath of war-zoneexperiences after returning home to families and friends, they frequently find the need for forgiveness or self-forgiveness in their relationships. One issue that arises with veterans with war-zone trauma experiences is that perceptions and memories of these experiences, which are colored by strong emotions such as fear, rage, grief, guilt, and shame, seem to be particularly subjectto cognitive distortion. The forgiveness process should not begin around distorted thinking. Rather, memories of things that hap pened around traumatic experiences should be examined carefully to look for distortions of belief, inappropriate assumptions or expectations, and illogical attributions about these traumatic events. After more reasoned, rational thoughts and attributions about the events have been attained, whatever remaining real blame or culpability that exists directed toward self or others can be addressed from the perspective of forgiveness. PTSD symptoms themselvescan sometimes become a barrier to forgive ness among veterans. In speakingwithnumerous veteransabout difficulties they were having with forgiveness,reexperiencingsymptomsare frequently cited as proof that forgivenessdoes not work. The authors have had to learn how to help disentangle the recognition that trauma experiences produce lasting intrusive memories from the actual forgiveness process. Spirituality and Readjustment Following War-Zone Experiences 307 The second way that forgivenessis addressed is by seeing it as a life style. We talk about forgivenessas an attitude which exists at the opposite end of a continuum from the attitude of hostility. Hostility is described as an attitude that is closed to new experiences, pushes people away, expects the worst, and is harshly critical and judgmental of people and experi ences. Forgiveness,on the other hand, hopes for the best, welcomes others, is open to new possibilities and new experiences, and is gently accepting and tolerant. Viktor Frankl, himself a trauma survivor, once said, "every thing can be taken from a man but one thing: the last of the human free doms-to choose one's attitude in any given set of circumstances, to choose one's own way" (Frankl, 1984/1946). In examining how one might move toward forgiveness,discussion centers are beginning to move away from an attitude of hostility and trying to take on some characteristics of an attitude of forgiveness. Ultimately, forgiveness is a choice. Forgive ness is presented as a positive choice, a choice for oneself, a choice that seeks health and wholeness, a choice that enhances supportive relation ship with self and others. Valuesfor Living. Values are the ideas and beliefs that we hold as good, as important, as worthy of our time and energy. When speaking with vet erans, the things they frequently mention as valuing the most include a sense of belonging; self-respect; inner harmony; freedom; family security; health; and enjoying life. A crucial question for all of us is to what degree our values are reflected in our day-to-daybehavior. In other words, do we walk our talk' It is important for each ofus to think about the degree to which our lives are authentic, such that how we spend our time accurately portrays what we hold to be important. Finding Meaning and Purpose. We have found two separate means of addressing meaning in the context of spirituality and trauma. The first is the sense of personal meaning that one derives from one's own internal view of self. First we talk about meaning as "the story we tell ourselves about our life experiences." In this way, meaning can be construed as being the sum of our perceptions (i.e., sensory experiences, sight, sounds, touch),and our interpretation of those events. We point out that the prob lem with this equation is that both perception and interpretation are subject to error and cognitive distortion during experiences of stress or trauma. Frequently, the clients we treat carry with them extremely nega tive and distorted beliefs such as guilt, shame, or self-blame related to the trauma, which affects their perceptions of personal worth and value and of their efficacy in successfully recovering from their experiences. Find ing ways to view their life experiences more accurately can be extremely important for those recovering from PTSD. In this context, recovery of meaning is a part of the cognitive restructuring process that trauma vic tims frequently do. The second way that we look at meaning has to do with the sense of meaning that one derives from outside the self (i.e., from one's personal support system). In this context, we talk about finding meaning by "being 308 Combatstress injur meaningful," or creating a life where one "matters" to other people. Rel evant to this discussion are the ways in which loss of a job or retirement, avoidance of social gatherings, and PTSD-related withdrawal and social isolation all serve to prevent one from making a significant positive impact in the lives of other people, and subsequently from receiving the posi tive regard and feedback that can allow a person to begin to feel better about themselves, and to see their lives as more meaningful and purpose filled. We encourage veterans to actively seek opportunities for service. Nonprofit service agencies as well as religious/spiritual communities are frequently looking for people with time on their hands, who can serve the community in significant ways. We point out that many spiritual tradi tions view service of others as a spiritual activity, where both the giver and receiver benefit greatly. utilize Rituals. We have found it useful to incorporate simple rit Simple uals as a part of our group process, something which could potentially be part of individual-helping conversations as well. These can include read ings of inclusive prayers or litanies from diverse spiritual traditions, or even poetry written by survivors. One challenge is that some religious perspectives can be inherently mutually exclusive. Selecting rituals based in specific religious traditions may be offensive for members of other tradi tions. To prevent this from being a problem, we carefully select resources with this in mind and often have crafted ritualized activities with no inherent religious connection. An example might be a closure exercise, such as holding hands and going around the circling with each mem ber saying one positive word reflecting his or her best hope for that day. Rituals can be developed which reflect important clinicalrecovery themes such as forgiveness or grief/loss. Something as simple as holding open an empty chair in recognition of someone who did not return home can be extremely powerful. Traditional therapy utilizes mostly verbal process ing. We have found that simple ritual seems to tap into a differenttype of processing, which is experiential in nature. These experiential exercises, though simple, can be experienced by members as both profound and emotional and seem to foster the experience of shared community. We said from the outset that we approach spirituality as a resource in the recovery from trauma. We believe that the guidelines and sugges tions addressed above specifically target a number of important PTSD symptoms. For example, the definition of spirituality as connection and the encouragement of group members to seek supportive healthy com munities directly address the PTSD symptoms of isolation and social withdrawal. Self-forgiveness and an emphasis on compassion toward self address both guilt and shame, which though not formally a part of the diagnostic criteria of PTSD are certainly recognized as important clini cal issues within certain PTSD populations. Forgiveness turned outward directly addresses anger and irritability which are PTSD symptoms, as well as chronic hostile attitudes that worsen social isolation and inhibit relationships with others. Inwardly directed spiritual practices such Spirituality and Readjustment Following War Zone Experiences 309 as mindfulness meditation can potentially have an effect on reducing hypervigilance and overall high levels of physiological arousal. Finally, rediscovery of meaning and purpose potentially enormously impacts at least two PTSD symptoms (i.e., foreshortened future and loss of interest in important activities). Taken together, we believe that finding ways to address spirituality in the context of trauma recovery can provide added benefit over treatment as usual. In a number of ways, addressing spirituality supports healthy readjust ment from war-zone trauma and recovery from PTSD. Defining spiritual ity as "connecting" confronts the tendency in PTSD toward isolation and withdrawal. Approaches addressing spirituality should emphasize the importance of building connections in creating for oneself a supportive healthy community. REFERENCES Chang, B.-H., Skinner, K. M., & Boehmer, U. 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