For veterans returning from Iraq and Afghanistan, the transition back to life in their communities is often a struggle. While some face physical challenges, others deal with emotional scars from combat as evidenced by the increased reporting of post-traumatic stress disorder (PTSD) compared with past conflicts. The Department of Veterans Affairs (VA) is responding with a multi-layered approach – one that often views the role of chaplains as a key element in a comprehensive team effort.
“Whether they function as Roman Catholic, Protestant, Jewish, Muslim, or Buddhist representatives, chaplains care for the whole person,” said chaplain Michael McCoy, director of the National Chaplain Center (NCC) of VA. “The chaplain is there to provide spiritual care in any way they can.”
In VA medical centers, chaplains typically serve as part of a patient care team as they make regular rounds to meet with individuals and participate in patient-care conferences alongside nurses and social workers. In other settings, they may provide one-on-one counseling – even by videoconference – to serve veterans where they live. In addition, they increasingly work with community clergy to learn about key symptoms of PTSD or depression, focusing on issues from substance abuse to suicide prevention.
“Even though I’m a rabbi, I’m there to take care of a human being, regardless of religion,” said Lowell Kronick, associate director for chaplaincy education at the NCC. “It’s one human being taking care of another human being. We are there to work with all patients.”
CHAPLAIN ROLES AND ASSIGNMENTS
More than 800 spiritual leaders are part of the VA’s chaplain service, and they work in VA medical centers and outpatient clinics. Most VA centers have multiple staff, including clinical chaplains and a lead chaplain, McCoy said. Often assigned to a certain floor or wing, chaplains typically participate in medical rounds – getting to know patients – and attend patient care conferences. At these conferences, chaplains are part of a team that includes a care manager and social worker, where they discuss individual patients and how best to serve them.
Chaplains typically also do a spiritual assessment of a VA patient. “A patient may not be religious but may require the use of a chaplain,” McCoy said, and one key ingredient is that chaplains emphasize spiritual care but not necessarily religion. “A chaplain does not force religion on anyone,” he noted. But chaplains also will conduct services in their religion at a VA chapel, with service times varied during the week.
Inside a VA hospital, the typical chaplain may see 20 patients per day, according to Kronick. “It’s not a pulpit, it’s a medical setting,” he noted. Even if veterans have not been typically religious in the past, “They may feel more of a link with chaplains.”
Most chaplains are full time, though there are some part-time staff in some communities. Contract or fee-based chaplains may serve as extra support to full-time chaplains or provide religious ministry to veterans belonging to small faith groups. At any time, there also are about 150 resident student chaplains training at VA medical facilities and participating in clinical pastoral education.
The chaplain program is open to U.S. citizens with a Master of Divinity degree and an ecclesiastical endorsement. Candidates also should have multiple units of clinical pastoral education and three years of pastoral experience.
“As VA chaplains, we are different from community clergy,” Kronick noted. “We’re not there to proselytize and we’re not there to push religion. It’s not a pulpit – it’s a medical setting. Whatever is going on, we are there to work with the patient.”
To lead this effort, the VA relies on the NCC in Hampton, Virginia. Led by McCoy, the center works to empower VA chaplains and sets policies and procedures for the spiritual and pastoral care of veterans. The center also:
■ Advises on all levels of chaplain staffing and management throughout the VA;
■ Provides comprehensive orientation and training for chaplains;
■ Manages award and recognition events, including twice-a-year ceremonies to recognize outstanding chaplains; and
■ Helps integrate spiritual care into the “whole-person care” philosophy of the Veterans Health Administration.
“We represent as many religions as we have veterans,” McCoy said. “Chaplains are a secret weapon in the VA because they can reach across all aspects of our veteran population.”
But the job of chaplain also is undergoing subtle changes, and one high priority is to provide more options to veterans who live in remote areas far from VA hospitals. According to the VA’s Office of Rural Health, there are 2.9 million rural veterans who account for 33 percent of all those served by the VA health system. Given this trend, the VA has bolstered its telehealth program, which includes the designation of “tele-chaplains” who can provide long-distance support. To initiate this remote contact, a chaplain and veteran typically communicate via both audio and video in real time to discuss issues and challenges.
“It’s a way for the veteran to be at home and talk to a chaplain,” McCoy said. Instead of a veteran – or a chaplain – driving many miles for a counseling session, technology brings the two individuals together remotely. “Veterans can receive counseling while they’re sitting at their kitchen table. It can be a really valuable tool.”
Of the approximately 800 chaplains in the VA, more than 150 are women as the VA seeks to better serve the needs of female veterans. “The VA has a relatively short history of caring for women veterans,” McCoy said. “That’s why it’s important to have chaplains who are skilled in dealing with women’s issues, from health care needs to successful return to the community or the workforce.”
GREATER ROLE IN MENTAL HEALTH
Another major trend is for chaplains to gain special certifications beyond their religious training. For example, some are gaining certification in areas such as mental health, where they can work alongside psychologists and social workers in the treatment of veterans with PTSD, depression, and other conditions.
Two factors help to drive this development, Kronick said. First, some rural areas have few mental health professionals; in addition, veterans may believe there is a stigma associated with reaching out to mental health professionals. He said VA chaplains can serve a valuable role by reaching out and listening to veterans and, where needed, encouraging them to seek additional counseling.
Aside from physical problems, veterans also may experience what Kronick describes as “moral injury.” Looking back on his or her service, a veteran may regret actions taken in tense situations in an environment where it can be hard to distinguish the enemy. “They may feel guilty about something they did in combat,” he said. “When they return home, they say, ‘I’m not the person I used to be.’”
In these situations, chaplains may counsel veterans to deal with these moral injuries by giving back and volunteering in their communities. In some cases, the goal is to “get reintegrated into the community where you can do good works,” Kronick said. However, the guilt may be so severe that a veteran would benefit from additional counseling from mental health professionals.
Chaplains also interact with the VA’s Office of Suicide Prevention, which seeks to address a national trend in which the number of suicides among veterans exceeds the rate in the U.S. population. All of these factors figure into the growth of chaplains with certification in mental health issues. Kronick said the goal is not for chaplains to diagnose PTSD and depression but to recognize the symptoms and encourage referrals.
“We are creating bonds between chaplains and mental health professionals,” Kronick said. While in the past the two groups may have had little communication, the goals now are for both groups to work collaboratively when possible. “We want to break down barriers,” he said, so that veterans can turn to a variety of individuals if they want counseling.
This new approach also has spurred the NCC to develop an outreach program to work with community clergy not affiliated with the VA. These clergy may have informal contact with veterans in their communities. “We’ve found that veterans return to their original communities and are much more likely to seek out clergy – including community clergy – more than any other professional,” McCoy said.
In response, the center established the Community Clergy Training Program (CCTP), which consists of short-term training sessions to educate local, non-VA clergy about the challenges facing returning veterans. These sessions are a mix of face-to-face training, online or video presentations, and other resources. As with VA chaplains, the goal is not for these clergy to diagnose veterans but to help recognize symptoms that may warrant follow-up.
“The goal is to provide community clergy with the tools they need to help veteran families when they are facing struggles emotionally and mentally,” McCoy said. So far, 18,000 community clergy nationwide have participated in workshops.
“Veterans may feel safe coming to a house of worship or a community of faith to talk about these things because they feel a sense that it’s confidential and that no one will know they are going to a mental health provider,” Kronick added. Yet there is also the potential for community clergy to encourage veterans to receive treatment. With a small amount of training, these clergy can “provide a warm handoff” to the VA so a veteran can get additional help.
In fiscal year 2017 alone, the CCTP added 28 VA chaplains to its training team to deliver workshops to community clergy – primarily in rural areas. The interactive training covers four major topics: military culture and the wounds of war; pastoral care with veterans and their families; mental health services and referrals; and building community partnerships.
“Our rural veterans don’t come to a VA facility. They’ll come first to clergy in the community,” according to Kronick. “We’re trying to train all chaplains to be able to identify signs and work with community chaplains.” The VA has identified this program as a rural promising practice, and more information on the program is online at www.patientcare.va.gov/chaplain/clergytraining/.
OTHER FOCUS AREAS
In addition to mental health, the NCC has increased its work in supporting the families of veterans. Such families often face undue stress: A study from Brigham Young University states first marriages of military veterans are 62 percent more likely to end in divorce compared with the national average.
One key initiative in response is a marriage enrichment program called “Warrior to Soul Mate” in which chaplains work with couples to support and restore their relationships. “There can be problems in sustaining marriages when veterans return from service. We’re concerned about that and designed this program,” McCoy noted.
Based on discussions that began in 2008, the Warrior to Soul Mate program relies on a curriculum for couples that deals with key issues such as emotional literacy, conflict, communication, stressful relationships, and intimacy in stressful relationships. At some point in the program, couples are strongly encouraged to attend a weekend workshop at a remote location.
“We’ve had people say they were on their way to divorce court but decided to try the weekend and were able to put their marriage back together,” McCoy said. “We believe we’re getting good outcomes from this program.” More information on this initiative is at training.pairs.com/docs/VA_Support.pdf.
Other innovations cited by chaplain leaders include home visits where feasible as well as chaplains gaining certifications in areas such as palliative care and hospice care for those with significant health issues, according to Kronick. Certification in substance abuse prevention is also growing as chaplains seek to provide comprehensive support. “We want our chaplains to have specialized training and stay current. Wherever the patient is, that’s where we go,” he said. “Our goal is to provide care for the whole person.”
This story originally appeared in Veterans Affairs & Military Medicine Outlook. Click here to view to read Outlook.