Veterans, the hidden wounds of war, and soul repair

Introduction

Recent studies have shown that deployment in conflict zones such as Bosnia, Kosovo, Afghanistan, Mali, and Iraq had a significant impact on veterans (Rosenberg 1993; Bragin 2010; Beder 2012; Moore 2012; Grimell 2017). The physical, psychological, moral, and spiritual costs of deployment and combat in conflict zones may severely impact the health and wellbeing of veterans in many ways. While physical injuries are more obvious, the psychological impact is often more difficult to discover. In addition, the concepts of moral injury (Shay & Munroe 1998; Litz et al. 2009) and spiritual injury (Berg 2011) have quite recently been introduced and have generated intense discussion. This discussion has, among other things, led to attempts to conceptualize potential damages to the moral and spiritual integrity of the veterans’ “souls” or “spirits” (Stallinga 2013; Vargas et al. 2013; Harris et al. 2015).

Throughout the history of warfare, the emotional wounds of combat have been given many names, such as nostalgia, shell shock, battle or combat fatigue, and soldier’s heart (Tick 2005). The concepts of moral and spiritual injury have recently emerged as attempts to conceptualize different types of inner damages to the self because of deployment in war zones. Although these concepts are still under empirical and theoretical investigation and are continuously being refined, they have each become promising avenues of exploration for those who aspire to help veterans struggling with inner emotional turmoil resulting from deployment in war zones and combat (Berg 2011; Brémault-Phillips et al. 2017; Koenig et al. 2017; Wortmann et al. 2017). The conceptualizations of moral and spiritual injuries recognize the complexity of the “hidden wounds of war” (Rambo 2010) and “soul repair” (Brock & Lettini 2012), and suggest that there is an inner part of the self which may be transgressed and severely damaged in the line of duty.

However, while the concepts of moral and spiritual injuries help to improve therapies, they are rarely accompanied by a conceptualization of the inner part of the self. This inner part of the self could be described as a soul, as a spiritual domain of the self which both feels and is felt by. The aim of this article is to conceptualize the inner part of the self in the context of moral and spiritual injuries. Therefore, this article engages in a conversation with five important contributions from relevant scholars in the psychology of religion, theology, and clinical work since the end of the 19^th century: James (1890), Tillich (1952/2014), Tick (2005), Pargament and Sweeney (2011), Graham (2017). These scholars have been chosen to achieve some degree of disciplinary variety and to include a number of scholars who have explicitly developed their conceptualizations of the self in relation to veterans, trauma, and moral injury (Tick 2005; Pargament & Sweeney 2011; Graham 2017).

Even though this is a daunting theoretical arena to enter, such a conceptualization appears to be crucial to a holistic understanding of humans as intricate creatures who are constituted with a body, mind, and soul – that is, from the perspective of a bio-psychio-social-spiritual human behavior model. Such a conversation can broaden the interdisciplinary corridor between social sciences (psychology of religion), humanities (theology) and pastoral, spiritual and therapeutic care and counselling to advance the understandings of the inner part of a self which has suffered moral and/or spiritual injuries. Moreover, this can enhance potential methods of care.

Moral injury

Moral injury is a dimensional problem, i.e., there is no diagnostic threshold. The severity of moral injury varies significantly among veterans. In and of itself it can deeply affect the lives of veterans who have experienced trauma amid military service and deployment (Drescher & Foy 2008; Brock & Lettini 2012; Shay 2014). Although moral injury is often presented as a rather recent concept, it could be seen as a new term for an old phenomenon. Lindsay and colleagues (2016) suggest that Shay and Munroe (1998) have coined the term. Shay and Munroe’s definition of moral injury, which was based on veterans’ experiences of injustice in leadership malpractice, consists three components: (1) betrayal of what was considered morally right in the local culture (2) by someone who had been legitimately granted authority within the social system (3) in a high-stakes situation. This definition tends to emphasize authorized yet bad leadership and the implications thereof upon individuals. Other researchers have approached moral injury with a specific focus on the transgression of personal moral codes in the line of duty. For example, Litz and colleagues (2009) offer an understanding of potential morally injury experiences as implications of “[p]erpetuating, failing to prevent, or bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (Litz et al. 2009: 700). This formulation has become commonly accepted as a working definition of moral injury which spans from participation in or witnessing inhumane actions, to failure in preventing them from happening, to even relatively and/or seemingly subtle acts or experiences which later come to be perceived as violations of a personal moral code.

In an extensive literature review on moral injury, Lindsay and colleagues (2016) have found that other researchers in the field prefer not to speak of “injury” as it is often perceived as physiological damage. Instead, they use terms like moral affront, distress, conflict, pain, trauma, wounds and disruption.

In short, there is no consensus on the definition of moral injury and even the use of the word “injury” has been questioned. Nonetheless, this term has catalysed a growing exploration and conceptualization, and has become very common in the body of literature that has evolved around it. Therefore, this article continues to utilize the term moral injury. Returning to the conceptualization itself, moral injury cannot be fully encompassed under the diagnosis for posttraumatic stress disorder (PTSD) – instead, it is better to consider them as interrelated and/or partially overlapping (Drescher et al. 2011). Moral injury involves the transgression of a moral code on an individual level by malfunctioning authorized leadership. As the concept tends to emphasize cognitive dimensions of moral transgressions in varying forms, it tends to focus more on ethical foundations (i.e., right and wrong) and inner dissonances and/or conflicts.

Spiritual injury

The concept of spirituality has been object of serious debate for quite some time, which has resulted in a variety of definitions and applications within health research, psychology of religion, and theology. A higher degree of consensus about spirituality’s definition has arguably been attained within health research (Puchalski et al. 2009), whereas less consensus has been achieved in the realm of theology (Hermans 2014; Mordal Melvær 2015). A plausible explanation for the achievement of common sense within health research could be the need to find a complementary part of the bio-psycho-social model of human behaviour which can then better equip healthcare professional communities with a holistic approach which accounts for body, mind and soul/spirit.

A pioneer in the conceptualization of spiritual injury is Berg (1992), who has described spiritual injury as the effect of an event which has damaged the person’s relationship with God, self and/or others, and which has alienated that person from that which gives meaning in life. Berg (2011) has developed a scale of eight spiritual injuries (guilt, anger/resentment, sadness/grief, lack of meaning/purpose in life, despair/hopelessness, feeling that life or God has been unfair, worry over religious doubt or disbelief, fear of death). This model clearly intersects with moral injury, for example when it comes to guilt, anger, and sadness (Litz et al. 2009; Bryan et al. 2016; Wortmann et al. 2017). Yet, spiritual injury emphasizes the spiritual/religious dimensions of an inner injury inflicted upon the self and thus complements the aforementioned model as a part of a potential holistic bio-psycho-social-spiritual model for veterans (Berg 2016). Spiritual injury also closely relates to terms such as “soul wound,” “soul injury,” and “soul repair” (Tick 2005; Brock & Lettini 2012).

Berg’s (2011) spiritual injury scale has been complemented by the religious and spiritual struggles scale of Exline et al. (2014), which focuses on experiences of struggle in spiritual/religious (S/R) aspects of life. This scale provides a more comprehensive, reliable, and concise measurement tool covering six domains of S/R struggle: divine, demonic, interpersonal, moral, doubt, and ultimate meaning. All these domains can be utilized to investigate moral and spiritual injuries, but the moral domain, which focuses on wrestling with attempts to follow moral principles as well as on worry or guilt about one’s perceived offenses, is particularly promising for the investigation of spiritual and/or moral distress among veterans.

From a theological point of view, a spiritual injury can be understood as a violation of a sacred nexus within a person, which can damage a person’s sense of strong connectedness with the whole of creation, God and/or a transcendent dimension (Sippola et al. 2009). Such a spiritual injury does not heal easily and its potential recovery is more profound than merely psychological and/or cognitive adaptation. Experiencing God’s forgiveness may be a prerequisite to soul repair.

Conceptualizing an inner part of the self: the soul

William James, a pioneer in psychology – and in psychology of religion in particular – has written the first substantial psychological study of the self, which includes a discussion of the topic of the soul. In his first volume on the principles of psychology (James 1890) he presented a verifiable empirical psychology in which he described a mediator or agent in “the stream of thought” (consciousness), which he called, alternately, “the judging Thought,” “the Thinker” and “the I”. The purpose of this agent was to continually appropriate or reject various – and at times contradictory – thoughts in the stream of consciousness. Yet, James struggled with the concept of a soul, which could be understood as a concept synonymous with this agent in the river of thoughts. The problem for James, however, was that the soul was generally considered to belong to the realm of metaphysics. As James aimed to develop a verifiable psychology, this appears to have hindered him from integrating the concept of the soul as a crucial part of the self within the theoretical foundations of his first volume on the principles of psychology. Therefore, James instead spoke of “the spiritual self”, which he considered a crucial constituent of the empirical self. He conceptualized this empirical self by distinguishing three aspects: (a) the material self (e.g., body, clothes, physical things strongly belonging to a person), (b) the social self (a person having as many social selves as there are others who recognize and construct images of him/her), and (c) the spiritual self (a person’s inner being).

James went on to conceptualize the spiritual self as a person’s inner or subjective being, the whole of psychic faculties or dispositions that turn out to be the most enduring and intimate parts of the self. These include, for example, moral sensibility and conscience. The spiritual self was considered in two ways. James suggested that the spiritual self could be abstractly divided into sections or faculties, which in theory could be isolated from one another and utilized to identify various dispositions, even as they existed collectively and simultaneously as a plurality within the self. But he also proposed that the spiritual self could be concrete (like a single entity without any specific sections) and in such form act within us as an active and broader reflective process applied upon the entire stream of consciousness.

James described the spiritual self as a central part of the empirical, experienced self; its activity is experienced in the innermost centre of the self. The spiritual self is the citadel which is constituted by the subjective inner life. This is the active element in all consciousness, it is what welcomes or rejects, appropriates or disowns. This can be called “the self of selves”, “the innermost self”, “the innermost sanctuary”, “the pronoun I” or “an active soul-substance” (yet not in a metaphysical sense).

In James’ view, the spiritual self functions as an agent in the stream of consciousness which feels me and not me, and hence has the capacity to appropriate or reject ideas and acts. Moreover, the spiritual self strives for intellectual, moral, and religious aspirations and conscientiousness.

A similar view has been developed by theologian Paul Tillich (1952/2014). Yet, Tillich did not elaborate on the self in the same detailed psycho-spiritual fashion as James had done. Tillich’s main interest was to sketch the existential condition of the self – or, more generally, the existential human condition in his days. His was a theological and existential enterprise. In fleshing out the existential conditions of the self, Tillich also offered a deeper understanding of the constitution of the self. He suggested that there were three types of anxiety which threatened a person’s being: bodily, spiritual and moral anxiety. He argued that the individual must strive for ontic, spiritual and moral self-affirmation despite the constantly present threat of non-being. Non-being, he claimed, threatens man’s ontic self-affirmation in terms of fate (relatively) or death (absolutely); it threatens man’s spiritual self-affirmation in terms of emptiness (relatively) or meaninglessness (absolutely); and it threatens man’s moral self-affirmation in terms of guilt (relatively) or condemnation/ self-rejection (absolutely).

Spiritual self-affirmation is brought to life in every situation in which any individual lives creatively and spontaneously in various domains of meaning. By participating meaningfully in cultural life, a person establishes a spiritual centre in the self that tries to find the meaning of life. Moral self-affirmation implicates that a person is required to answer to what she or he has made of themselves. A person is responsible for their being in the world: “In every act of moral self-affirmation man contributes to the fulfilment of his destiny, to the actualization of what he potentially is” (Tillich 1952/2014: 49). This dimension of the self includes conscience, that part of the self that judges what a person has done or should have done but did not do. When one’s conscience evaluates one’s actions as failure, this results in a sense of guilt or, in the worst cases, in self-condemnation or self-rejection. In Tillich’s view, the self is dived into spiritual and moral faculties (or sections) that are responsible for the spiritual and moral life of an individual and, as such, are deeply involved in the (spiritual and moral) meanings of existence.

Another conceptualization of the inner part of the self has been provided by Edward Tick (2005), a clinician who has done research on “soul wounds” and healing among Vietnam and Gulf War veterans. He describes the soul as the centre of human consciousness and experience which cannot be seen or measured but only be felt or “feelingly” seen. He suggests that the soul provides humans with uniqueness and spiritual depth, and harbours creativity and intellectual powers. The soul is that which thinks, reasons, and understands. Moreover, the soul gives individuals their ethical sensibilities. Put differently, the soul is conscience, that inner voice that can speak to us. The soul harbours aesthetic sensibility in persons that love and seek intimacy.

An interesting reflection on pastoral theology, care, and counselling of “wounded souls” has recently been published by theologian Larry Graham (2017). He suggests that the soul is an integrating centre of awareness, meaning, and value that draws upon cumulative experiences of pain, joy, and pleasure in life. The soul is the location of a person’s most sacred aspirations and deepest pains. It is also the host of a person’s moral centre. The soul is contextually creative in that it is engaged in a dynamic integrative interplay between the individual, communities, and cultures. Graham also emphasizes the intimate dynamic relationship between the body and the soul. As the soul is an integrating centre, Graham argues that a personal trauma is not a contained and isolated element of a person’s life but rather grows into an ongoing permanent substructure of the soul. Because of the dynamic interconnection between the body and the soul, both will be deeply affected by a trauma.

The last conceptualization of the inner self to be discussed in this article has been introduced by Kenneth Pargament and Patrick Sweeney (2011). They speak of “the human spirit,” an “animating impulse” and “a motivating force” that is directed to realizing higher order goals, dreams, and aspirations which grow out of the essential self. The human spirit organizes an individual’s life and propels him or her forward. Moreover, the human spirit creates a mindset, defines values, determines actions, and predicts behaviour. Based upon these psycho-spiritual assumptions, the authors define spiritual fitness (for the U. S. Army)

in terms of the capacity to (a) identify one’s core self and what provides life a sense of purpose and direction; (b) access resources that facilitate the realization of the core self and strivings, especially in times of struggle; and (c) experience a sense of connectedness with diverse people and the world (Pargament & Sweeney 2011: 59).

From their perspective it is suggested that individuals can take many pathways in the pursuit of developing the human spirit and thus engaging in a spiritual quest. Nature, music, exercise, loving relationships, scientific exploration, religion, work, art, philosophy, and study are just a few examples of approaches individuals may follow in their efforts to grow spiritually as they search to discover and realize their essential selves.

To summarize: based on what these thinkers from the fields of psychology of religion, theology and clinical work have written, it seems plausible to recognize a faculty of the self, an inner part or a centre of the self, which “feels” in relation to the stream of consciousness. This part of the self harbours intellectual powers, creativeness, connectedness (to oneself, to others, and to the world), and conscience. This inner sanctuary of the self will be called “the soul” in this article. The conceptualization of what is ascribed here as the soul may be understood as an entity which harbours or includes several faculties (e.g., domain of conscience or a moral centre, spiritual domain, creative domain, aesthetic domain), which could be described as a number of internal voices or positions (e.g., the voice of my conscience, the voice of my creativity).

Moral and spiritual injuries result in sick souls

A transgression of a veteran’s conscience in the line of duty might in the end result in a moral injury because “[t]o violate your conscience is to commit moral suicide” (Brock & Lettini 2012: iii). Moreover, it is very likely that a soldier will face a violation or transgression of their conscience during deployment and combat in war zones. It has even been suggested that moral injuries already occur during basic military training, when they learn to break the civilian taboo of killing other humans (Verrips 2006; Brock & Lettini 2012). As has been suggested by Litz and colleagues (2009), moral injury does not necessarily require actions such as killing or hurting other soldiers or civilians to be considered as a violation of conscience. Moral injury can also result from witnessing inhumane actions and failing to prevent them from happening. In other words, moral injury may occur from engaging in, or witnessing, subtle acts or experiencing responses which at a later stage come to be perceived as having violated one’s conscience and moral code. The implications of a violation of conscience within the soul may eventually become a moral injury. One way in which this injury can be understood, following Tillich, as a real threat to an individual’s moral self-affirmation. It leads to anxiety of guilt and possibly to condemnation or self-rejection, an existential condition implied in the existence of a veteran’s alienation from self, others and the world.

A spiritual injury is understood here as another type of injury besides moral injury. As, for example, Litz and colleagues (2009) have shown, spiritual injury may be inflicted in similar situations, but a spiritual injury affects another part of the soul. Spiritual injury refers here to damage caused to that part of the soul which harbours creativeness, connectedness (to self, others and the Other), and the motivating and defining inner force of who I am (or was before the spiritual injury). A spiritual injury disturbs or even disconnects this part of the soul so that the drive for life declines or even disappears. This injury threatens an individual’s spiritual self-affirmation in cultural life (broadly understood as spanning from partner, marriage, family, hobbies, community, congregation, religious worship etc.) and thereby introduces anxiety of emptiness and meaninglessness in life. This can also mean the feeling of being disconnected from God, transcendent agents viz. angels, and/or the spiritual depths of life. A spiritual injury that damages a person’s spiritual self-affirmation is a threat to their life, as a never-ending experience of emptiness and meaninglessness may ultimately become too overwhelming to bear.

The two concepts of moral and spiritual injuries – and the different types of anxiety they may create – are interwoven yet still separated: guilt and condemnation are related to moral injury, while emptiness and meaninglessness are more indicative of spiritual injury. Spiritual and moral injuries may be related in such a way that if the spiritual contents have lost their power, the meaning of life could be rediscovered through moral self-affirmation. The moral call to duty, broadly understood, could save from emptiness by engaging in cultural activities. Military service and deployment is itself also a cultural activity, but from the perspective of moral and spiritual injuries among veterans this will not likely work well in the service of “soul repair” (Brock & Lettini 2012). An intact spiritual capacity may likewise support the process of repairing a moral injury as a kind of “driver” of life that remains in the soul.

Moral and spiritual injuries lead to varying degrees of soul sickness. The concept of a sick soul was first introduced by James (1902) as he presented the healthy mind and the sick soul as opposing personal dispositions and approaches to life. In James’ view, these two represent ideal types in his theoretical exploration of religious varieties. In this article, “sick soul” refers to the soul of an individual damaged in the line of duty, regardless of whether it is related to a violation of conscience or to damage inflicted upon the spiritual domain which, for example, could impair the capacity for creativity, love, and the drive for life. This soul has been sickened by participation in or witnessing inhumane actions, by a sense of failure to prevent them from happening, or by engagement in subtle acts or experiencing responses which were a posteriori perceived to have violated and damaged (moral and/or spiritual parts of) the soul. A sick soul feels and experiences sadness, melancholy, alienation, darkness and depression to such an extent that it becomes entrapped in the discords of life (Sippola et al. 2009; Berg 2011). It suffers from feelings of guilt/self-condemnation and emptiness/meaninglessness to such an extent that these afflict perceptions: one becomes cynical and withdraws from social life. It has great difficulties experiencing happiness, goodness and light in life.

Discussion

In response to the growing awareness of the phenomenon of moral injury, interest in the spiritual/religious (S/R) dimensions of the health and wellbeing of veterans has grown. This is partly the result of increasing evidence which associates S/R dimensions with improvements in the wellbeing and health of veterans. Yet, it also results from the growing recognition of the complexity of responding to adversities beyond psychological adaptation (Lindsay et al. 2016; Brémault-Phillips et al. 2017; Koenig et al. 2017). There is a growing awareness that insights from theology and the psychology of religion can broaden the spectrum of possible war traumas. In the end, this could even help veterans suffering from war traumas, such as moral and spiritual injuries, to live a meaningful life (Bryan et al. 2015; Kopacz & Connery 2015; Wortmann et al. 2017).

S/R traditions often have a long history and a strong capacity to forward and offer divine forgiveness and/or appropriate ritual forgiveness for transgressions made in the line of duty. This has been recognized in counselling and therapies, even to the point that they have tailored ongoing research (Currier et al. 2016; Koenig et al. 2017). In cultural contexts in which S/R traditions are a natural element of the lives of service members and veterans (e.g. where spiritual/pastoral caregivers are commonly employed), this may be particularly helpful, especially if soul repair can be facilitated by (re)integration into a spiritual community. Individuals within such contexts may embark on established routes into S/R traditions to traverse a path to reconciliation through forgiveness and atonement, regardless of the type of transgression (Weaver et al. 2003; Kinghorn 2012; Zippert 2014). As S/R traditions offer paths towards forgiveness for anyone who is committed to seek it, they also offer paths towards forgiveness for others who have harmed veterans, for example through malfunctioning leadership. Using a ritual as part of the act of forgiving military leaders (or soldiers or veterans) who have erred may release a person from the emotional burden of betrayal and help resolve anger, hate, and rumination (Meninger 1996). This, in turn, may set the stage for the process of atonement within oneself.

The case study of Vincent, a veteran of combat in the Falklands and Ireland, which has been discussed in detail elsewhere (Grimell 2016), illustrates a process of forgiveness and, finally, atonement. Vincent was born in London and was raised as a Catholic. Just having turned 18, he was enlisted in the British Royal Navy in the late 1970 s. He advanced in ranks to Lieutenant Commander, and his military proficiency led him into repeated close combat. During this service he began to feel increasingly immoral. This sense of “moral dirtiness” intensified to such a degree that in the end he could no longer stand to face his own image in a mirror. As Vincent lost himself in this process, he also lost his previously faithful relationship with God. After the Falklands he left active duty and drifted around Europe. Following some years of restlessness, he moved to Sweden, got married, and pursued a university career. He felt he needed to remain overly busy to escape his war memories, but after years of pushing himself so hard, he could no longer keep things together and was diagnosed with fatigue disorder. Shortly afterwards, he was additionally diagnosed with severe posttraumatic stress disorder. In the following years he attempted suicide several times and he came to be heavily medicated. At some point, his relationship with God came to the surface, but psychiatrists and psychologists failed to assist Vincent in this realm. He was wondering whether God was punishing him, but his greatest fear was that God could possibly even punish his child for the horrible things Vincent had committed in the line of service. In his struggle with God and his experiences of military service, he gradually began to shift his perception of it all. A new retrospective understanding began to evolve for him. The central idea was that he had actually been rescued by God and been granted a second chance. The love of Jesus as found in the Gospels absolved him from the ghastly things he had done while in service. He felt that God had decreed that it was time for him to move on with his life. Throughout the remainder of his life, Vincent continued to endure the burdens of PTSD, but with this new perspective on his life he testified that he could now be the father which he had never been before. Moreover, he began to interact with and integrate within his new-found local Christian community.

It is clear within this story of forgiveness and atonement that the capacity of S/R traditions to aid in the repair of moral injury is not necessarily easy and simple. It must be emphasized that mitigation and potential healing of a moral injury through confession, forgiveness, and reconciliation may require much patience and time. Stallinga (2013) warns that, although it may be tempting to lessen the suffering by rapidly assuring a veteran of his or her blamelessness given the demands of war, the chaplain must be careful. The veteran may not be asking to be judged; he or she may instead be asking to be allowed to hold themselves accountable. The spiritual caregiver must bear witness to the story, rather than offer a simple blanket solution. Furthermore, such dedicated listening may be difficult for chaplains and caregivers when it involves war and its (potentially unspeakable) horrors (Capps 2001).

Within the scope of (military) chaplaincy and pastoral care of veterans, biblical narratives have proven to be helpful tools for care receivers (Rambo 2010; Wortmann et al. 2017). One example that could be used when the relationship between a veteran and God is marked by spiritual injury can be found in Genesis 32. It tells the story about Jacob’s struggle with an unknown as he is travelling with his family to reconnect with his brother Esau after many years apart. As Jacob is about to ford a river at night as the last of a small entourage of his family he suddenly finds himself wrestling with an unknown man. This struggle continues through the remainder of the night. As dawn is breaking and the man realizes that he cannot overpower Jacob, he instead injures Jacob’s hip. When the unknown man asks to be released, Jacob responds that he will not release his contender without first receiving his blessing. The man then asks for Jacob’s name and then proclaims that Jacob is to be called Israel thereafter, for Jacob had struggled with God and with humans and had overcome. This had been an intense struggle, and Jacob limped away. He had endured and survived the fight; he was spared, blessed, and moving forward towards atonement.

This storied example about Jacob has profound layers. With some hermeneutical freedom, the fight between Jacob and a transcendent agent (maybe God) can be interpreted against the background of transgressions earlier in Jacob’s life, such as his betrayal of his brother with whom he now aspires to reconcile. But this transcendent agent with whom Jacob wrestles can also be taken as a symbol of persons, conscience or even life itself that a veteran is struggling with. This hermeneutical interpretation and application of the story of Jacob’s wrestle could help veterans in their soul-wrestling and even offer them some kind of reconciliation such as that which Jacob eventually found. The applicability of biblical narratives to pastoral care should be explored both amid spiritual injury (especially focusing on soul repair and reestablishing a relationship with God) as well as amid moral injury (particularly concerning guilt/forgiveness). Another important point here is that a veteran may never fully recover from moral or spiritual injuries – like Vincent, they may be scarred for life (Ganzevoort 2008). Moreover, a veteran is, to some extent, often alone in this struggle; even their closest family will be – to use a metaphor from the Jacob narrative – on the other side of the river. But if biblical stories generally play a role in a veteran’s life, they can offer comfort and hope when applied in the context of pastoral/spiritual care. Through such stories, a veteran tap into long S/R traditions of understandings of soul wounds and soul repair. These stories may instil hope that after a difficult struggle caused by hidden wounds of war – even amid daunting unknowns – one may endure and even, to some degree, be healed. The potentiality of sacred rituals of confession, forgiveness, and blessing within the process of pastoral care can allow healing to begin (Ramshaw 1987). These biblical narratives allow room for a care receiver, especially with encouragement from a pastoral or spiritual caregiver, to write what the story means to him or her as one step in the healing process and search for spiritual self-affirmation. In summary, biblical stories of struggles with self, others, God, and life as well as sacred rituals and prayers, can aid veterans and offer their soul injuries inflicted by the hidden wounds of war to tap into the spiritual healing of S/R traditions and communities. Jacob was left limping yet blessed at the same time.

Most research on moral and spiritual injuries – and on spiritual counselling and care for veterans in general – has been done in an American context. This also goes for a number of contemporary scholars discussed above (Tick 2005; Pargament & Sweeney 2011; Graham 2017). However, the author of the current article works as a researcher, minister, and reserve officer within a Scandinavian context (Grimell 2018). Scandinavia is more secularized than the U. S. and religiosity is expressed differently (Zwingmann & Hodapp 2018). Moreover, “lived religion” in secularized and deinstitutionalized contexts tends to be more private and less formal and official in character as people purse their search for existential bearing in life (Ganzevoort 2004, 2009; Ganzevoort & Roeland 2014). Caregivers must be aware of these contextual differences and their potential implications for the prerequisites for pastoral and spiritual care. A veteran suffering from moral and/or spiritual injuries may have no relationship to biblical stories yet still seek pastoral and/or spiritual support within an institutional religious context. They might seek contact with a pastoral or spiritual caregiver (a) because of the absolute confidentiality offered by a minister; (b) because going to a church or minister is perceived as less embarrassing than going to a therapist/psychiatrist; or (c) because secular therapists/counsellors might be less familiar with talking about existential, spiritual or religious experiences. A veteran with a sick soul might initially be better served by pastoral or spiritual care (while PTSD symptoms might still come to the surface and clinical treatment might be needed). The experience of a safe place and a sanctuary is important for the process to begin. Moreover, the caregiver must listen rather than talk (Herman 1992/2015; Stallinga 2013). Then the caregiver and the care receiver together need to identify what injuries trouble the soul (Berg 2016). They also need to decide how to continue. When a veteran has symptoms of PTSD, secular psychology might be needed in addition to, or instead of, spiritual counselling. If they decide to continue together, then elements outside of the caregiving sessions may also be invited into such a spiritual endeavour. A recent longitudinal study on existential and religious identity reconstruction among Swedes in the aftermath of military service displayed a type of lived and implicit religion among veterans (Grimell 2018). Many of the participants testified that nature instilled peace, serenity, and energy in their lives. Nature (i.e. mountains, forests, the sea etc.) was narrated as their escape and their sanctuary, in good as well as in bad times. Through outdoor activities – in solitude or with friends – many veterans experienced a type of spiritual depth in their lives. Therefore, it is suggested that nature can hold spiritual relevance for veterans in secularized contexts, and as such may provide a sanctuary where spiritual self-affirmation and soul healing can be assisted and explored under the guidance of a pastoral caregiver (Pargament 2011). Another tool which could be useful to address moral injury to the soul, is to write letters as a way of dealing with guilt. This may be beneficial to both religious and non-religious individuals. This suggests that a care receiver who deals with guilt (either or not towards God), may need forgiveness by other individuals for healing to continue. One goal of letter-writing is to engage in a written conversation with the deceased or with others who in other ways unreachable individual(s) whom this symbolic forgiveness is directed to. This serves as an alternative strategy for confession and forgiveness when travelling upon the path on atonement and soul healing (Keenan et al. 2014).

Concluding remarks

At the end of this article, some final remarks need to be made. First, this article has discussed avenues of care for veterans from a Christian perspective and within a Swedish context. Insights from other S/R traditions can help broadening the understanding of the potential needs of non-Christian veterans with moral and spiritual injuries (Wortmann 2017). Second, the conceptualization of the soul is an unverifiable enterprise. But, as James (1890) and Tick (2005) have suggested, many veterans can still “feelingly” see the soul as a distinct part of themselves. It can be violated and damaged, which can be conceptualized moral and spiritual injury. Third, further research is needed on the use of biblical narratives in the healing process of moral and spiritual injuries within secularized and deinstitutionalized contexts such as Scandinavia. Some biblical stories revolve around warriors/veterans with potential moral and spiritual injuries that should be further explored in pastoral care. This is a potential asset in S/R traditions that can be applied in pastoral and spiritual care among veterans (Rambo 2010; Graham 2017; McDonald 2017). Fourth, the estimated incidence of posttraumatic stress disorder (PTSD) among veterans in Scandinavia is low (c. 5 % in Sweden and Denmark) while in the U. S. it is much higher (c. 20 %). However, estimating the incidence of PTSD across nations is not necessarily the only way to measure the health and well-being of veterans. There is reason to believe that moral and spiritual injuries may actually be more common than PTSD since high numbers of service members have likely been exposed to potential moral and/or spiritual injuries during the recent decades’ campaigns via the war on terror in Afghanistan and elsewhere. As healthcare for veterans strongly focuses on possible psychiatric diagnoses such as PTSD, instances of moral and spiritual injuries run the risk of remaining under the radar of the healthcare system. However, as has been demonstrated in this article, moral and spiritual injuries can occur even from merely witnessing acts that are often considered essential to the vicissitudes war and conflict. Moral and spiritual injuries often arise several years after the events that triggered them, and they can have a significant damaging effect on veterans’ quality of life. Recent research on veterans suggests that S/R dimensions are more crucial than has long been assumed. This suggests that spiritual and religious caregivers may have a vital role in assisting veterans in the aftermath of military service (Nieuwsma et al. 2013; Vieten et al. 2016).