AUTHOR: Chaplain Kristian Carlson, Th.M. (Duke Divinity School), M.Div. (Assemblies of God Theological Seminary), Lieutenant Commander, Navy Chaplain Corps, serving at Fort Sam Houston, TX.
This past year I got to study at Duke University through the Naval Postgraduate School’s advanced education program. There I learned directly with Dr. Warren Kinghorn, a Psychiatrist and Theologian, and with Dr. Margaret “Jan” Holton, a Pastoral Theologian. They allowed me to deep-dive into the issue of trauma and healing for active-duty service members and veterans. There’s no way I could have known when I started the program, of the pervasiveness of mild Traumatic Brain Injury (mTBI) as a signature wound of post-9/11 wars. Or to what degree, whether mild, or severe, that TBI complicates healing from moral injury and post-traumatic stress. Below, please see some of my research findings and some ideas toward healing. They are written from my vantage as a military chaplain, minister of the Gospel, and veteran with his own wounds from this exciting, stretching, operational life. Note: I get stoked to share scientific approaches to healing e.g. NICoE’s work, theological ideas which provide an overarching existential narrative, and simply relying on God’s Holy Spirit to do something we could never accomplish on our own: reaching the deep places of joy and pain with LIFE abundant.
Part One: The Relevance of Chaplain Care to Veterans with TBI and its Personal Significance
Military chaplains have the unique opportunity to provide pastoral care for servicemembers suffering Traumatic Brain Injury (TBI). The signature wounding weapon in America’s post 9/11 wars in Iraq and Afghanistan most often came from Improvised Explosive Devices (IED) which caused TBIs. Blasts from IEDs, rocket propelled grenades, and other munitions account for an estimated 78% of all injuries from these conflicts.[i] 45,000 post-9/11 servicemembers suffered “moderate to severe [blast TBIs] and penetrating TBIs.” [ii] Among units returning from Afghanistan and Iraq, TBIs were sustained by nearly one in five persons. [iii] While many Chaplains are aware of the commonness of TBI among troops, they may not be aware of the complex psycho-social-spiritual impacts. TBI affects physical health, but also one’s very self: spirit, personality, identity, memory and mood. Its effects are further complicated by the frequent intertwining of TBI survivors’ wounds with posttraumatic stress and moral injury.
When I began ministry to servicemembers in 2005, the surge in Iraq was in full swing. During this time I invited a Marine to my family’s home who was suffering from posttraumatic stress disorder (PTSD) and likely from TBI. I will not forget that night. As we relaxed in the family swimming pool “Thad” repeatedly smashed the water with his hands to simulate concussions from nearby explosions. It seemed to bring him an adrenaline rush, excitement and calm, as if he replayed the memories that haunted him. He opened up to me, an aspiring Chaplain, about the impacts of combat upon him, and revealed acts of violence he had committed against the enemy which looped inside his head and his heart. The complex interplay of close combat, the nearby potentially TBI-inducing explosions, and his grief, trauma and moral injury stand out to me.
The issue surfaced in Thad’s experience has not gone away. From 2000 to 2020, 430,000 service members sustained TBIs.[iv] Blast explosions in theater leading to 40% of deaths.[v] Service members for twenty years of war would be killed and wounded by IEDs and suffer TBIs. In my previous command at a SOCOM unit, TBI was exceedingly common among operators who routinely breached the doorways of homes with explosives during raids. They had to train to precision and many suffered TBIs in training, from overpressure and underpressure effects, long before settling into high operation tempo combat in the Middle East.
I well remember dear ministry mentors from 2005-2008, Chaplain (Colonel) Skip and Mrs. Dawn Lamertha, telling me about their “Recon Marine” son, Ernie, whose life and career were dramatically altered by TBI. In an off-duty motorcycle accident, Ernie struck a driver who had run a red light. His jaw was broken as his face impacted the side of the oncoming vehicle, his helmet fell off, and his head hit the ground fracturing the base of his skull. When he awoke he remembered two things: he was a U.S. Marine and a child of God. He lost all memory from his childhood on. He did not remember his wife Tiffany. He jokes today that the Marine Corps issued him his wife, as she was introduced to him at the hospital by his First Sergeant. He spent three and half years at Balboa Hospital before being medically retired. Ernie’s recovery was an extremely long journey. His is a story with a very happy ending. Now 25 years after his accident he is still married to Tiffany. They had a second wedding ceremony so that he could remember it. They have 3 children and Ernie serves in ministry as a chaplain in the Phoenix area. A supportive wife, supportive parents, and excellent medical, psychological and spiritual support were instrumental to his wellness. Many servicemembers with TBI do not have such support.
The Chaplain I am replacing at my new assignment at Fort Sam Houston (FSH), Texas, asked if my studies at Duke would include understanding TBI. At the command, 500 staff are annually responsible for the clinical phases of training for 5000 advanced medical corpsman and officers, in their four training campuses at FSH and the Naval Hospitals in Portsmouth, Camp LeJeune and San Diego. TBI is a relevant issue to this medical community which has borne a heavy burden of combat casualty care.[vi] Sometimes the greater medical community can embrace a model of care “veteran therapeutics” [vii] which can overemphasize cure, technology, prescriptions, and optimism. I hope what I share will be rooted in care which respects the strengths of medicine for those with TBI, but also understands the limitations, and the spiritual needs of survivors.
Navy chaplains, trained as ministers, do not enter institutional ministry trained in integrative care for Sailors, Marines and Coast Guard personnel. To become prepared to care for Sailors wholistically and effectively takes initiative. As veterans [viii] today come to terms with injuries and inner wounds sustained in their time of service, I think that chaplains can position themselves to help these warriors practically and spiritually. An integrative approach ensures that pastoral care is not provided in a vacuum. Chaplains are sometimes more trusted than psychologists, physicians and therapists by service members due to their protected confidential communications[ix] and pastoral role. Therefore the information shared by a servicemember can stop at the chaplain or, with knowledgeable support, it can embrace a wider community to advance others’ healing. Chaplains who practice such compassionate competency minister not only to the individual, but to the organization. This has a cumulative effect of trust-building which opens doors of ministry where Christ’s hope, through a Christian Chaplain, can become known.
As I headed off to Duke, multiple Chaplains told me to “go learn essential things of value and bring that knowledge back to us here on the frontlines of ministry.” They implied that they did not have the opportunity I was given: ten months of paid education leave from the Navy to learn. They admired the task I was heading out to do but their words implied that “strings” were attached: I must come back stronger, informed, and with relevant tools to share. I received similar encouragement from special warfare leaders and operators, “Go learn, and come back and help us, because…the needs are great.”
We are in a unique time within our military’s history. This September we will reach the twentieth anniversary of September 11th. Many of the young women and men who were inspired to serve after witnessing this devastating attack and loss of life will soon be eligible to retire. The issue of TBI-related physical, mental and spiritual problems is a crucial one to many of these veterans. While the wars in Iraq and Afghanistan are nearly ended, there are many for whom the war within is in full swing. There remain those “yet to be diagnosed for post-traumatic stress disorder…or a head injury…yet to be treated,” says Navy Captain Dr. Carlos Williams the director of the Department of Defense’s (DOD) premier TBI treatment hub, the National Intrepid Center of Excellence (NICoE) at Walter Reed. [x] As servicemembers prepare to retire they must complete numerous medical appointments to round out their record in preparation for transfer of care to the VA, and consideration of their disability rating. At this late part of their career, many will be more comfortable to disclose, and to seek to understand, their struggles with PTSD and TBIs received from deployment or training-related injuries.
A consistent area which concerns inner wounds but remains of limited understanding to many chaplains are complications which stem from mild Traumatic Brain Injury (mTBI).[xi] In the Special Warfare community there was great awareness of TBI’s impacts. Some of this came from suicides of its members like Ryan Larkin in 2017, who had sustained multiple TBIs. Larkin was discharged with PTSD and in two years’ time had been prescribed 40 different medications. After his death, his brain was studied at Walter Reed’s NICoE where it was found to have “microscopic level[s] of severe brain injury.” Ryan had told his father, “something is wrong with my head. I don’t know what it is. But they [the VA] keep telling me I’m nuts. I’m crazy.”[xii] In the SEAL community, operators must train and fight with explosives, heavy weaponry, and endure numerous physically dangerous parachute jumps, close quarters combat training, and underwater dives. Operators and trainers have come to understand the dangers from explosions. They have placed greater safety protocols around explosives training, and high-risk evolutions such as shooting shoulder mounted Carl Gustaf rockets and training with mortar rounds. Chaplains who work alongside operators are instantly in a unique position to learn about the personal and familial impacts of having gotten “rocked” one too many times. The process for getting help is a delicate one, as the gravest concern for these warriors is to lose credibility if “placed on the bench”[xiii] or to lose their leaders and peers’ confidence that they are ready to deploy at a moment’s notice. Chaplains can use their rapport to build a trusted network: a transdisciplinary team ready to offer full-round support. This kind of integrative approach builds high trust with service members, commanders, medical doctors and corpsman, with psychologists, clinical social workers, and military family life counselors. And, importantly, it protects chaplains from burning out by trying to solve tough problems which others are poised to join in and to assist with.
In my reading of a recent peer-reviewed article from one of NICoE’s lead centers out of Fort Hood, I was struck by their omission of chaplains as part of the integrated team. The authors spoke of nine medical care disciplines and numerous alternate therapies but did not mention chaplains or spirituality once in their full-orbed discussion of PTSD, TBI and combat deployments’ effects on veterans’ health.[xiv] A sister center was recently launched at Eglin Air Force Base. It will be the first NICoE Intrepid Spirit Center (ISC) built with a chapel and full-time chaplain assigned. This is a solid development, but it seems surprising that it took 13 years from when the surge of combat casualties began, to devote such space to spiritual needs. I share this to highlight the siloed nature of much care on both sides. The chaplain too easily can use the “confidentiality” of their work with Sailors to remain a spiritual counselor sundered from the wider network of support. Likewise, the medical community, which often doesn’t know how to use chaplains, struggles to grasp the spiritual impact of TBI and PTSD. In the following two sections I aim to close the gap by demonstrating knowledge about the risks posed by TBI, the interrelatedness of TBI with PTSD, to explain key resources available to struggling servicemembers to which chaplains can refer, and to offer an initial attempt at a pastoral theology approach to TBI.
Part Two: The Science of TBI Treatment and Effective Chaplaincy Care
By training and calling, chaplains are often difference makers in the realm of ministering to inner wounds but they are rarely trained to recognize TBI. Researcher Lydia Chevalier found that clergy “were not prepared to recognize mental health related gaps… [they had] problems identifying “relevant symptoms of disorders such as PTSD and TBI.” [xv] Better understanding in this area can help chaplains to advocate to servicemembers how they can get help. Grasping the science behind TBI, and learning current first line therapies, sets the stage for chaplains to appreciate the unique capabilities which they bring to address spiritual needs arising from it.
The neurological findings on the impacts of blast TBIs are ongoing, but the wealth of data underscore the insidious nature of these hidden wounds suffered in combat and in training, “Essentially, the blast produces stretching and shearing of synapses that disconnects neural circuitry and results in a temporary loss of neuronal communication.”[xvi] Retired Army Psychiatrist, Brigadier General Stephen Xenakis explains that TBI,
“most sensitively affects executive functioning, that part of the brain that we use for judgment and we use for decision making… when we are in situations of intense emotion…a person [doesn’t] have the controls that they had before. … They can’t think as clearly. …[and] are vulnerable to just reacting, overreacting, [perhaps] doing something that they had done when they’d been in combat.” [xvii]
TBI can be a serious injury whether the initial event is mild or severe. It may arise from blunt force trauma to the head, penetrating wounds, [xviii] or a closed TBI from blast waves.[xix] The severity of a TBI is judged by the length of time one’s consciousness is altered or lost from the event and by the extent of post traumatic amnesia—the time in which they cannot recall the events following the injury. In mild TBIs loss of consciousness lasts up to 30 minutes, in moderate TBI up to 24 hours, in severe TBI consciousness is lost for more than 24 hours.[xx] The symptoms from TBI include: “headache, dizziness, blurred vision, ringing in the ears, noise and light sensitivity, attention and memory deficits, insomnia, fatigue, irritability, and anxiety.” [xxi] For veterans with mTBI the most common symptoms are headache (58%), memory problems (48%) and sleep disturbance (44%).[xxii]
Much evidence demonstrates crucial connections between TBI and the onset of PTSD. [xxiii] [xxiv] [xxv] Dr. Jan Kennedy and her team of authors report that 40% of Soldiers with TBI reported PTSD.[xxvi] When chaplains encounter troubled service members they often seek to tend to the whole person by asking counselees about the physical, social, emotional and spiritual aspects of their lives. They ask questions like, “How is your sleeping, eating, physical exercise, spiritual welfare, and social connectedness?” But rarely do chaplains screen for TBI-related PTSD and depression.
It is hard to disentangle TBI symptoms from PTSD symptoms because there is much overlap. Dieter and Engel share common symptoms of both and helpful differences,
“Both conditions commonly include insomnia, fatigue, irritability, depression, anxiety, emotional numbing, avoidance, trouble concentrating, memory deficits, derealization [a sense that one’s surroundings are not real], depersonalization [feeling detached from one’s mind and/or body], and hyperarousal. Headache, dizziness, and light and sound sensitivity are more common following TBI. Re-experiencing and feelings of shame and guilt occur more frequently in PTSD”. [xxvii]
Those experiencing blast TBIs have significant re-experiencing issues. Dieter and Engel found that operational deployment stress exacerbates PTSD-linked effects of TBI by making the central and autonomic nervous systems more vulnerable.[xxviii]
It’s important to lay out the specific hallmark aspects of PTSD which TBIs can work to reinforce. Dieter and Engel describe the challenges which include re-experiencing of involuntary and intrusive thoughts; avoidant behaviors in physical, mental and social spheres; negative emotional states and negative thinking; and activated awareness that seems jumpy, irritable, and can be physically and verbally aggressive. [xxix] Exposure to combat and operational stress is a large determinant of the severity of PTSD. In the counseling setting chaplains should cue into the duration, proximity, and intensity of combat events experienced by the servicemember. These can signal the significance of injury and need for clinical help.
The mixing of TBI, PTSD and major depression within a person is a dangerous stew. Lisa Brenner, a psychologist with the VA, believes that the conditions are “mutually exacerbating” with negative impacts upon health, mental wellness, and can lead to harmful self-medicating behaviors. The problems also affect relationships, economic stability and can present a “cumulative disadvantage” and foster “negative feedback loops.” [xxx]
Chaplains ministering to veterans who have experienced combat and are emotionally and spiritually troubled will likely home in on the potential presence of PTSD and moral injury. In moral injury, the events in which one has participated, permitted, or witnessed shake one’s moral foundation and beliefs. Certainly the fear reactions of PTSD, and the shame experienced from moral injury, may be present, but a next step of competent care is to realize that simultaneous injuries from TBIs may also be at work. Such events, as we’ve seen in the research, attack cognitive functioning and emotional well-being. If this is so, the challenges will also affect the spiritual grounding on which the servicemember stands.
Chaplains have an important tool in their arsenal when they are met with Sailors with TBI related problems. They can minister to profound spiritual needs while connecting servicemembers to resources where unhealed physical and psychological wounds can be addressed. The DoD offers an intensive interdisciplinary clinic for service members who have sustained TBIs and who find themselves struggling in the aftermath. The main hub is the National Intrepid Center of Excellence at Walter Reed in Washington D.C. It has nine campus extensions called Intrepid Spirit Centers (ISC) located across the country.[xxxi] NICoE and its ISCs provide “comprehensive neurological, psychological, physical, and lifestyle programs to active duty service members with TBI and associated health conditions, including post-traumatic stress disorder (PTSD), anxiety, and depression.” [xxxii]
Chaplains working with their commands and healthcare teams may find a waiting list to get service members in to NICoE. At Walter Reed, NICoE admits about six new veterans a week into their intensive four-week program.[xxxiii] The Fort Hood, TX, ISC has about 300-350 active patients at any given time. Outpatient treatment there lasts six months. Their inpatient/outpatient track lasts six weeks and consists of 40 hours of intensive individual and group care work each week. Group work encompasses, “adaptive physical therapy, stress management, mindfulness, sleep therapy, cognitive rehabilitation, PTS treatment, pain management, art, music, yoga, health and leisure, and nutrition.[xxxiv] NICoE also conducts “family-centered” assessments [xxxv] and works to instruct families and patients in problem-solving and coping skills and through family counseling.[xxxvi]
The thinking undergirding NICoE is captured by Fort Hood’s ISC Director, Dr. Engel:
“We provide everything over six weeks to help the service member to build a skill set to manage their symptoms…We integrate a model called ‘The War Within’… to conceptualize the enemy within [which] attempts to isolate, marginalize, and stigmatize the soldier, and…drive them to take their own life.”
NICoE offers many treatment options. If servicemembers experience memory problems, they may be helped by various assistive technologies. There are assessments and treatments for hearing and balance issues. Computer-based programs at the Brain Fitness Center can help improve cognitive functioning. The aim is to match challenges and deficits with right-sized therapies: CAREN, a virtual reality tool, can help address movement and balance problems; there is creative arts, driving rehabilitation, a firearms training simulator, neuroimaging, neurology focused on headache problems, occupational therapy, optometry, physical therapy, psychiatric therapy, sleep medicine, speech-language skill building, spiritual counseling, and vocational rehab. [xxxviii]
While the opportunities for therapeutic help from TBI are many, it is key that chaplains understand that therapies must be tailored to veterans. In listening to numerous TBI survivors’ stories I found that different strategies worked for each person. Mindfulness, prayer, meditation or yoga were difference makers for some. [xxxix] For others, a service dog has been crucial to help with sleeping at night, guidance, and emotional support. [xl] [xli] [xlii] Art therapy has been shown to provide great break throughs. [xliii] Studies have shown strong links between sleep apnea and TBI.[xliv] The momentum of research which links sleep problems to compromised health is profound.[xlv] Tools and technology for improving sleep can be a game changer. In the office one of chaplain’s great tools is conversational. “Talk therapy” is effective for some, but not for others. [xlvi] One obvious therapeutic intervention is taking medication. For some this is lifesaving, for others it is an avalanche of medicine with undesirable outcomes, and uncertain benefit.[xlvii] A strong element in healing for many is telling their story, with a good listener or in community. Many are sharing their TBI story online at places like the Concussion Story Wall. [xlviii] Dr. Odette Harris of the Palo Alto VA explains, “There’s a lot of evidence in our peer reviewed literature that the phenomenological component of…the patient’s experience…the storytelling is significantly contributory to their recovery.” [xlix]
By placing their hands on the crucial issue of TBI, chaplains touch something that really matters to many commanders, doctors, therapists and veterans. Too often our spiritual care for servicemembers is siloed. Chaplains train together, mentor young chaplains, and frequently discuss effective ministry. But rarely do they integrate in their ministry research findings on vital issues like TBI and its corresponding relationship to PTSD, suicide and depression. It may be that we are “too busy”, or in our comfort zone with our respective spiritual care tool kits. Perhaps we feel that the theological, ethical, and whole person needs of Sailors are self-evident. But we have an opportunity to advise leaders, fellow care providers, and servicemembers of the risks of TBI and PTSD and show the sacred opportunity of caring well for these suffering persons who matter to God.
One of the four pillars of Naval Chaplaincy is advisement of leadership.[l] By grasping the nature, scope and impact of TBI, chaplains in austere field locations, and on smaller combatant warships, can address commander’s “so whats” and “whys” regarding Sailors’ needs for medical, spiritual and psychological attention. In such locations, there is often no other advisor who can answer such concerns and articulate needs. For unit commanders TBI treatment impacts personnel readiness to execute the mission. For military policy makers in Washington, TBI has long-term outcomes that affect retention. Treatment may lead to return to duty or to medical retirement for Marines and Sailors. Missed treatment may lead to suicides, behavior problems, and decreased morale across the military services.
The most exciting aspect of this challenge for spiritual shepherds is that while TBI sufferers have many resources for healing available, none will reach the inner person as deeply as one’s need for God. TBI can be the site of deep healing possibilities in Jesus Christ who reaches with power and compassion to the suffering. This suffering may come from physical pain, from emotions of fear from PTSD, or shame and guilt from moral injury.[li] The advantage of an integrated pastoral care approach is that the real-world problems of mobility deficit, insomnia, need for employment, headaches, depression, self-medicating, embarrassment from not recognizing friends, having a poor memory…all these things are also “spiritual”. The issues intersect with God’s care and the possibilities within the community of God. If a chaplain can be attentive to it, they can join sufferers in bearing witness, in lament, in celebrating victories, in encouragement and offering simple active presence alongside the sufferer.
Part 3 Application: Providing Pastoral Care to a Post 9/11 Veteran with Traumatic Brain Injury
Luz is a medically retired female Latinx Army veteran. 45,000 post 9/11 veterans, like her, suffer from moderate or severe TBI. Her story is a fictionalized account based off an actual veteran. I have designed her case study to engage a more functionally challenged TBI survivor who cannot benefit from the often close-knit community and top-shelf care given to those on active duty through the NICoE Intrepid Spirit Centers. [Please See Appendix 1 for Case Study.]
In Luz’s dynamic situation, I note concerns and I see strengths. There will be communication challenges. There is heavy caregiver burden and potential for burnout. There may be presence of moral injury and PTSD. Luz’s disability should shape an accessible pastoral approach. I will seek to hold the realism of great loss and unknown functional recovery with a strengths-based perspective grounded in God’s grace and positive aspects of Luz’s life. As I engage Luz, I will respect intersectional factors, other potential trauma and the issue of personal agency. The presence of grief calls for gentle “remaining” presence and lament, they also open the door to healing opportunities from ritual and life-giving koinonia relationships. There may be harmful embedded theologies, “crosses” which Luz was not meant to bear. I am sure that Luz and her mother’s visit offer an opportunity for the three of us to experience God’s powerful love.
As we begin to talk I want to attend to communication challenges. Luz struggles to speak by herself due to her brain injury. Because of this, she depends on her mother for aid in communication. I am concerned that the triangulation in the conversation may make it difficult for her to share her deep thoughts. Practical Theologian John Swinton says that God’s pace is about 3 miles per hour.[lii] He believes that by aligning our hearts with God’s comfortable “walking pace” at which God journeys with us, and works in our lives, we also can inhabit time in ways which more closely match the experience of time for those with disabilities. I will not be able to care for Luz well if I am in a hurry.
One of the places I have erred as a Chaplain is to zero in on problems. But Dr. Kimberly Kick, a clinical social worker, urges us to remember others’ strengths which flow from their spiritual life, “Spirituality…gives the service members and their families the foundational support to realize their strengths and resiliency. It is transformational.” [liii] In Luz’s case, her functional impairments and losses from war are extensive but I want to remain alert to her strengths, her family’s strength, and God’s ongoing grace in her life. Holding this awareness will keep my perspective clear as I care for her and her mother. It impresses me that Luz and her mother chose to stop at the chapel and to greet the chaplain. Their visit says something about their open-hearted posture to God and offers a ray of light amid challenging recovery, and amid Luz’s coming to terms with her new life and the future before her.
I am interested that Luz’s mother has asked such a personal spiritual question on her behalf, “What advice do you have for Luz to rebuild her relationship with God?” The word rebuild could imply that something was broken. Is this a judgment, or an accurate reflection of how Luz feels? Pastoral Theologian Carrie Doehring’s approach challenges me to consider intersections where Luz’s agency may have been compromised in the past. She believes that such analysis makes us “alert to…vulnerability to harm.” [liv] The theologian Nancy Ramsay offers Doehring’s insight in the context of moral injury, “Persons…bring varied histories, vulnerabilities, and strengths to military service…. emotional and physical trauma… simultaneous ways each of us is shaped by power laden, socially constructed, and sustained experiences of oppression and privilege.” [lv] Through further conversation I may learn from Luz, and her mother, of prior experiences of trauma and challenged agency, but even if they do not address them, I can recognize some risk factors. She is a Latinx retired woman Soldier. She is divorced and a mother. She has battled life threatening brain injury and is disabled. Considering these things pushes me to show great respect to her choices and perspective, both by safeguarding her privacy and taking time for her to communicate her desires. I would ask Luz, “your mother has asked a question about building your relationship with God, is this something that you would like to talk about?” Bethany Fox, a disabilities scholar and pastor, says that “Jesus asked those to be healed what they desired.”[lvi] I want to closely, and gently, observe Luz’s body posture if she seems eager and open, or uncomfortable and closed. [lvii]
I notice grief and loss in Luz’s story. The grief is clear in the descriptions of desiring her daughter closer, of wondering why she survived, and perhaps in the tears she cries when hearing worship music. The loss is clear in her longing for autonomy, in her loss from speech impairment, in the mobility impairment from her right arm, and in her apparent delayed cognitive processing and the “zoning” which may speak to problems with concentration and attention. The zoning may be from TBI amnesia, TBI synapse damage or PTS-related intrusive reexperiencing of thoughts. While it is remarkable that she has regained so much functioning, as a minister I also want to help Luz and her mother to be okay in the hard spaces that are “right now.” Perhaps, despite my doubt, God’s love may be seen somehow in these losses of independence, of not being able to care for her daughter or herself, and being required to depend on others.
Anthropologist Zoe Wool, who studied wounded warriors, has criticized “veteran therapeutics” for its penchant for novel medical therapies, constant optimism of improvement and for placing a heavy focus on interventions, surgeries and medication. Her concern highlights something to which trauma theologian Shelly Rambo speaks. Too often we seek to elide life’s challenges. In our Christian triumphalism,[lviii] we, metaphorically, want to skip Holy Saturday and get right to Easter. But Rambo advocates the middle, the “in between spaces” and a theology that “remains.” She says that “the rush to life can belie the realities of death in life.”[lix] It is her conviction that “the middle can easily be covered over and ignored…the good news of Christianity for [trauma victims] rests in the capacity to theologize the middle…to witness between death and life…[here] we are oriented to suffering in a different way—its dislocation, distance and fragmentation.”[lx] In my conversations with Luz and her mother, I’d like to talk about her losses, “the deaths” that Rambo alludes to, of real people, of dreams and of functioning, and lament them with her.
Such lament falls in line with the Biblical example from Lamentations of which theologian Kathleen O’ Connor speaks, that God would not be silent but would “see and hear” the “unspeakable”, “ungraspable”, events which have happened in our lives.[lxi] These events deny expression even if we could mouth the words. And while God seems absent, the writer can say, “the steadfast love of the Lord never ceases, God’s mercies never come to an end, they are new every morning.”[lxii] This is beautiful hope. But alongside it exist anger, fury, and sadness. These emotions are God-honoring too and distinctly present in Lamentations, the Psalms and throughout the Bible. One leader at NICoE described the “psychological ‘noise’ and pain” of TBI.[lxiii] This pain calls for lament as it stays with a person on good days and bad.
My former CPE advisor, Navy Chaplain, Dr. David Alexander, was deeply impacted by pastoral theologian Stephen Muse. Muse believed that in pastoral care we must “help people suffer for the right reasons and stop suffering for the wrong reasons” and that we can “help people lay down crosses that they are carrying by compulsion so that they can choose to pick up the cross of their own free will.” [lxiv] David’s insight from Dr. Muse prompts me to wonder what embedded theology may be driving Luz. For what reason does she cry when she hears worship music on Sundays? What opened her heart to ask her mother the reason that she survived her combat injury? It may be that she feels survivor guilt for having survived, a common feature of PTSD. Perhaps she feels unworthy for having lived or feels alone in her injuries apart from God. I would like to hear her share about this and also to hear about her battle buddy Donnie. It is possible that other forms of communication like song, drawing, painting, poetry, sculpture would be more conducive to Luz’s expression. In whatever form, sharing her story offers healing possibility.
Of survivor guilt, and self-recrimination, Ramsay urges ministers to help others externalize blame when appropriate. We should not hold ourselves accountable for evils in which we had no part, or in which others hold the greatest responsibility. Luz may need to hear this. But in her tears and in her “why” question, I hear her wondering about her personal worthiness. This “why” is the common ache of the suffering human soul. When it met by the One who calls us by name—as with Job, and as with His speaking, “Mary” at the tomb, the why fades. God’s intimate presence is a pronouncement of how worthy we are and how purposeful our life is in God’s hands. Perhaps when Luz hears worship music, she does not cry tears of sorrow, but feels an overflow of the Holy Spirit’s ministry in ways which confound cognition and speech. Perhaps she feels enabled to worship, grieve, and feel loved. I want to ask Luz, “could you describe what you feel when you hear worship music?” It may trigger negative emotions or be a gateway to expression and receiving of grace.
Similar to the way that NICoE offers multiple individually tailored therapies, Christians have numerous rituals and practices which, in the right context and time, can be healing to Luz. The most pivotal to me is the experience of receiving the redemptive grace and salvation of Jesus. It is possible to admire Jesus, but to not have known Christ as friend and Lord. I do not know the time, or context that such a question will be appropriate to Luz. But she and her mother have sought me out, for something unique, that in her two years of therapy, she has not found elsewhere. Knowing herself to be “in Christ” would be the greatest gift I could see develop in her life, if it is not already there.
Ramsay speaks of “embodied practices.” These flow from the experience of being in Christ. The cognitive relationality of faith in God, which could seem challenging to Luz, could be built up through rituals and practices experienced bodily. Some poignant Christian practices include the Lord’s Supper, baptism, lament, confession, musical worship, fasting, prayer, corporate worship of lament and praise, testimony, anointing with oil, Lectio Divina, solitude, personal retreat in a natural setting, and service to others.
In my heart, and from study, I believe that group therapy and the koinonia of fellowship will aid Luz’s healing and reintegration into society. Luz might find Christian fellowship and connection in a Reboot Recovery group. Dr. Jennie Owens was an occupational therapist who contributed to the founding ethos of the Intrepid Spirit Center at Fort Campbell, KY. As she and her husband, Evan, befriended veterans traumatized by war, they saw that many of the questions they asked were the same. They also saw how authentic relationships, meals shared together, and conversation about God, life, and the things that mattered most to the inner life, were profoundly healing to them. She and her husband founded REBOOT Recovery, a non-profit curricular small group program, which through 12 weeks of small group meetings, has led to significant trauma recovery for 10,000 persons. Jennie says that the program’s purpose is, “to help service members and their families heal from the spiritual wounds of combat and trauma…REBOOT exists to see the person transform.” [lxv] She found many Soldiers asking, “How do I bear the weight of living when my brothers and sisters have died?” [lxvi] To me, REBOOT could be a good entry point to lifegiving relationships for Luz and her mother. It would be complementary to the community I hope that their home church offers.[lxvii]
Judith Herman, a pioneer thinker in posttraumatic healing and recovery, believed that trauma was political. By political she referred to passion for activism and service which trauma wounds prompt many survivors to embrace. Service is also a Christian form of worship. Many servicemembers embraced the warrior identity and enlisted because of the value of service to others before self. I wonder if Luz, even in the midst of complicated recovery, might need an outlet of service to others as part of her healing. Evan Owens, cofounder of REBOOT, said, “don’t waste your pain” he encourages servicemembers to “recycle pain into purpose.” [lxviii] While Luz has many new limitations, she also has unique opportunities and a unique voice. If a passion for such service connected with her God-given gifts, God-given identity and vocation, it might be a powerful catalyst for healing.
It will be impossible to share these insights with Luz in one meeting.[lxix] The best use of time together will be attentive listening, words of gentle encouragement, and perhaps anointing with oil and prayer for the Lord’s healing in her life and throughout her person. But I hold out in my heart the hope that essential areas of need may be met in the future, both through interdisciplinary partners, fellow ministers, and supremely, by the Lord. My confidence is built on the reality that I am not the only one providing Luz pastoral care. She has a shepherd who walks beside her and who understands death and wounds. This Shepherd offers to be her host, her defender, her safehaven of nourishment and the One who gives life-refreshing water.
Appendix 1 Case Study: Luz Medically-Retired LatinX Army Veteran
Luz received a severe TBI while on deployment two years ago in Afghanistan. While in a vehicle convoy en route to a village to facilitate an NGO’s food distribution, her truck rolled over due to damage from an IED which had left a portion of the mountain road missing. The armored truck tumbled down a 30-foot ravine. As the front seat passenger, Luz struck her head repeatedly in the rollover and was medevacked to Germany and on to Walter Reed. She remained in a coma for a month. The truck’s driver, a fellow supply sergeant named Donnie, died from injuries he sustained.
Luz is a 32-year-old divorced parent, Latinx, (2nd generation Mexican American). She is now medically retired from the Army with a 100% disability rating. Although she wants to live independently, she cannot take care of herself. Because of this her 7-year-old daughter lives with her ex-husband. Luz would like to have custody.
In many ways Luz seems like a child herself. As her mother shares her story, Luz, with bright expressions and sweet attentiveness, mirrors her mother’s recounting, and mouths aloud a few relevant words from her story like “coma” or “communicating” (she pronounces it ‘munitating’) adding facial nuances showing her own feelings. She smiles often. She is able to talk, but often misunderstands words or can’t recall words. Sometimes her expression goes blank and she “zones.” She complains of headaches and problems sleeping.
Her recovery has been astounding as she relearned how to walk and speak. She cannot use her dominant right arm due to the brain injury. She walks with a brace. She regularly goes to physical therapy and speech therapy at the military hospital on base which is closer than the VA. Luz is trying to begin to function independently with daily tasks like washing dishes and cooking. But these can still be dangerous due to her cognitive and physical impairments. As her mother shares her challenges from cooking, Luz looks up with a mischievous pre-teen-like smile, as if to say, “yeah, why do you get so worried?” Luz is often sad and labors hard to voice her thoughts. She flourished in her independent, take-charge ways as a Soldier. Now as a dependent she struggles. She has asked her mother, “Why did God let me live?” When the family tunes into online Sunday services at their non-denominational church, she cries when she hears the worship songs. This week at the hospital after physical therapy, they visited the chapel and stopped to say hello to the chaplain. In her Army days she always felt a connection with chaplains. As Luz is introduced to you, her mother says, “What advice do you have for Luz to rebuild her relationship with God?”
[i] Dieter, John N.I., and Scott D. Engel. “Traumatic Brain Injury and Posttraumatic Stress Disorder:
Comorbid Consequences of War.” Neuroscience Insights 14, (2019). 5. The authors, Clinical Psychologist Scott Engel, and Neuropsychologist John Dieter, warn that these numbers do not account for the TBIs which were not reported, “It is likely that far more soldiers have been affected by them than those who were formally diagnosed with concussion.”
[ii] Armstrong, Michael, Julie Champagne and Diane Schretzman Mortimer. “Department of Veterans
Affairs Polytrauma Rehabilitation Centers” Physical Medicine and Rehabilitation Clinics of North
America 30, No. 1 (2019), 14.
[iii] Cook, Philip A., Thomas M. Johnson, Suzanne G. Martin, Philip R. Gehrman, Seema Bhatnagar, and James
C. Gee. “A Retrospective Study of Predictors of Return to Duty versus Medical Retirement in
an Active Duty Military Population with Blast-Related Mild Traumatic Brain Injury.” Journal of Neurotrauma 35, No. 8 (2018). 992. The authors explain, “In the war in Iraq and Afghanistan, blasts are the leading cause of TBI with incidence reported to be as high as 20% in some units returning from the Iraqi or Afghan theater of operations.”
[iv] Dieter and Engel. “Traumatic Brain Injury.”5.
[v] Ibid, 5.
[vi] Ramsay, N.J. “Moral Injury as Loss and Grief with Attention to Ritual Resources for Care.” Pastoral
Psychology 68, (2019). 2. Ramsay shares insight from Simmons and fellow authors from their 2018 article “The role of spirituality among military en route care nurses: Source of strength or moral injury?” that,“Combat support personnel such as nurses and physicians also may return from battle haunted by experiences of medical traumas to civilians of all ages and to combatants.”
[vii] Wool, Zoe H. “Veteran Therapeutics: The Promise of Military Medicine and the Possibilities of
Disability in the Post‐9/11 United States.” Medical Anthropology Quarterly, 34, (2020). 305.
[viii] Veteran refers to anyone who has served in the military. They may now be processed out, or retired. They may be active duty. I use “servicemember” to refer to someone actively in the military. In common public parlance, veteran often connotes someone whose service time has concluded. But in this paper, depending on context, I will use veteran with both shades of meanings: the person may be actively serving or now in civilian status.
[ix] Chaplains in the Navy share protected privileged communication with all servicemembers and families with whom they speak. There is no mandated reporting required or permitted. Everything disclosed is 100% confidential. Due to this chaplains stand at the gateway of help for many servicemembers who trust them alone to devise a path to healing from inner wounds that affect them psychologically, physically and spiritually.
Official Website. March 8, 2021.
[xi] Dieter and Engel. “Traumatic Brain Injury.” The authors explain that in mild TBI, the greatest harm may come from the psychological problems it presents rather than the structural issues. Mild TBI accounts for 82% of all service-related TBI.
[xii] Atlamazoglou, Stavros. “His Navy SEAL Son Committed Suicide, Now he Fights for his Name.” Sofrep.com. February 5, 2020. Accessed May 5, 2021. I first became aware of Ryan’s death through a letter circulated among NSW teams about the dangers of TBI written by his father, Frank Larkin, also a former Navy Seal, and the 40th Sergeant at Arms of the United States Senate, 2015-2018.
[xiii] Other common concerns from seeking help, and thus being willing to take a “time out”, include fear of being seen as weak, as a malingerer, or as complainer.
[xiv] Dieter and Engel. “Traumatic Brain Injury,” 1. The authors are strong proponents of their catch all term “consequences of war syndrome” which describes the intricate interplay of TBI, PTSD, Combat and Operational Stress upon returning veterans well-being.
[xv] Chevalier, Lydia, Elizabeth Goldfarb, Jessica Miller, Bettina Hoeppner, Tristan Gorrindo & Robert Birnbaum. “Gaps in Preparedness of Clergy and Healthcare Providers to Address Mental Health Needs of Returning Service Members.” Journal of Religion and Health 53, No. 4 (2014).
[xvi] Ibid., 6. The authors explain,“Blasts’ effects are likely magnified by inherent deployment stressors, the ensuring HPA over-reactivity, and its impact across multiple biological systems. Blasts themselves would further contribute to allostatic overload. In addition, and as will be discussed below, there is support that blast-TBI may precipitate PTSD in some soldiers and that it, and not head injury, accounts for the protraction of PCS and neuropsychological deficits.”
[xvii] Edge, Dan. “Three stories from Frontline’s ‘The Wounded Platoon’: Several Years After Their Tours in Iraq, these Soldiers Still Live with Debilitating Symptoms from their Brain Injuries.” PBS.org website. September 2010. General Xenakis was a former top military psychiatrist who ,the author notes, consulted the Joint Chiefs of Staff.
[xviii] Hernandez-Ontiveros, Diana G., Naoki Tajiri, Sandra Acosta, Brian Giunta, Jun Tan, and Cesar V
Borlongan. “Microglia Activation as a Biomarker for Traumatic Brain Injury.” Frontiers in Neurology 4, (2012). Authors write, “Traumatic brain injury (TBI) has become the signature wound of wars in Afghanistan and Iraq. Injury may result from a mechanical force, a rapid acceleration-deceleration movement, or a blast wave. A cascade of secondary cell death events ensues after the initial injury. In particular, multiple inflammatory responses accompany TBI prolonged state of inflammation after brain injury may linger for years and predispose patients to develop other neurological disorders, such as Alzheimer’s disease. TBI patients display progressive and long-lasting impairments in their physical, cognitive, behavioral, and social performance.”
[xix] Centers for Disease Control. “Dr. Nicole Eastman’s Story: Finding Hope Through Connecting with
Others.” National Center for Injury Prevention and Control PDF. Pages 1-2. The document explains closed-TBIs, as “ an injury to the brain caused by movement of the brain within the skull.”
[xx] Dieter and Engel. “Traumatic Brain Injury,” 4. The authors share specific details, “mTBI are concussions, and LOC lasts up to 30 minutes. Moderate TBI is distinguished 30 minutes to 24 hours of LOC and up to a week of PTA. Severe TBIs lead to AOC/LOC of more than 24 hours, and PTA of more than seven days.”
[xxi] Ibid, 5.
[xxii] Ibid. Authors write, “common associated features included headache (58%), memory problems (48%), sleep disturbance (44%), irritability (40%), balance problems or dizziness (29%), and light sensitivity (29%).”
[xxiii] Traumatic Brain Injury Center of Excellence. “TBI Hot Topics Bulletin.” Fourth Quarter 2020. Military Heath System, health.mil website. Accessed 1 May. Bulletin contains reviews of the latest TBI findings. Two studies, one from Oberman et al. in their 2020 article in the Journal of Head Trauma Rehabilitation about the “Use of Repetitive Transcranial Magnetic Stimulation in the Treatment of Neuropsychiatric and Neurocognitive Symptoms Associated with Concussion in Military Populations” the other article is from Stein et al., their article focused on how “Smaller Regional Brain Volumes Predict Posttraumatic Stress Disorder at 3 Months After Mild Traumatic Brain Injury in a journal on psychiatry and neuroimaging.
[xxiv] Tanielian, T. & L.H. Jaycox, Eds.. Invisible wounds of war: psychological and cognitive Injuries, their
consequences, and services to assist recovery. Santa Monica, CA: RAND, 2008.
[xxv] Cook et al. “Blast-Related Mild TBI,” 10. Authors explain that,“there is growing recognition in the literature that post-concussive and psychological symptoms frequently co-occur, presenting distinct challenges to both diagnosis and treatment.”
[xxvi] Ibid, 11.
[xxvii] Dieter and Engel. “Traumatic Brain Injury,” 10.
[xxviii] Ibid, 1. “The impact of specific deployment events such as TBI, other physical injuries, and psychological trauma may be far greater than if analog experiences occurred during a non-deployment period.” The authors go on to explain the causal relationship between head injury and the onset of PTSD, some of which remains a mystery.
[xxix] Ibid, 6.
[xxx] Walter, K.H., S.M. Barnes and K.M. Chard. “The Influence of Comorbid MDD on Outcome After
Residential Treatment for Veterans with PTSD and a History of TBI.” Journal of Traumatic Stress
25. (2012). 426.
[xxxi] NICoE’s Nine Locations are at Fort Belvoir, VA, Fort Bragg, NC, Camp Lejeune, NC, Eglin AFB, FL, Ft. Campbell, KY, Ft. Hood, TX, Ft. Bliss, TX, Camp Pendleton, CA and Joint Base Lewis-McChord, WA.
[xxxii] Aker, Janet. “Intrepid Spirit Centers Promote Healing from Traumatic Brain Injury.” Military Health
Systems Communications, Health.mil website. March 30, 2021.
[xxxiii] Walsh. “NICoE Director Sets an Ambitious Agenda.”
[xxxv] Walter Reed National Medical Center. “National Intrepid Center of Excellence: Clinical Offerings.” Tricare.mil. Accessed May 1, 2021.
[xxxvi] Walter Reed National Medical Center. “NICoE: Clinical Offerings.”
[xxxvii] Aker, “Intrepid Spirit Centers Promote Healing.”
[xxxviii] Walter Reed National Medical Center. “NICoE: Clinical Offerings.”
[xxxix] Traumatic Brain Injury Center of Excellence. “TBI Hot Topics Bulletin.” Research evidence backs up their effectiveness.
[xl] Healing Therapy: A New Role for Man’s Best Friend Citation. Bob Woodruff Foundation in Collaboration with NICoE. 2013
[xli] Yount, Rick, Elspeth Cameron Ritchie, Matthew St. Laurent, Perry Chumley, and Meg Daley Olmert. “The
Role of Service Dog Training in the Treatment of Combat-Related PTSD.” Psychiatric Annals 43, (2013).
[xlii] O’Haire, Marguerite E, and Kerri E Rodriguez. “Preliminary Efficacy of Service Dogs as a Complementary
Treatment for Posttraumatic Stress Disorder in Military Members and Veterans.” Journal of Consulting and Clinical Psychology 86, No. 2 (2018).
[xliii] Walker, Melissa S., Girija Kaimal, Adele M. L. Gonzaga, Katherine A. Myers-Coffman & Thomas J.
DeGraba. “Active-Duty Military Service Members’ Visual Representations of PTSD and TBI in
Masks.” International Journal of Qualitative Studies on Health and Well-Being 12, No.1 (2017).
[xliv] Dieter and Engel. “Traumatic Brain Injury,” The authors explain the high prevalence of sleep apnea at the Fort
Worth Intrepid Center: 40% with TBI also had sleep apnea.
[xlv] Yoo, Seung-Schik, Ninad Gujar, Peter Hu, Ferenc A. Jolesz, Matthew P. Walker. “The Human Emotional
Brain Without Sleep — A Prefrontal Amygdala Disconnect.” Current Biology 17. No. 20, (2007). 877-878. A good night’s rest helps regulate mood and help one cope with the next day’s emotional challenges, sleep deprivation does the opposite by excessively boosting the part of the brain most closely connected to depression, anxiety and other psychiatric disorders. “It’s almost as though, without sleep, the brain reverts back, unable to put emotional experiences into context and produce controlled, appropriate responses,” said Matt Walker, one of the writers of this article and director of UC Berkeley’s Sleep Lab.
[xlvi] Schuyler. Army Veteran with TBI. “Make the Connection Video Series: Recognizing Signs of PTSD and
TBI.” Department of Veterans Affairs. MakeTheConnection.net, January 23, 2013. Accessed May 1, 2021.
[xlvii] David, Army and Navy Veteran with TBI. “Make the Connection Video Series: Treatment for TBI improved David’s Life” Department of Veterans Affairs. MakeTheConnection.net, March 5, 2013. Accessed May 1, 2021.
[xlviii] Concussion Story Wall. A Collection of Online Video Interviews of TBI Survivors. Brain Injury Association
of America and TeachAids. Accessed MAY 3, 2021.
[xlix] Temin, Tom. “VA Develops a New Program for Helping Veterans Recover from Traumatic Brain Injury.” FederalNewsNetwork.Com. March 25, 2021. Accessed May 2, 2021. Interview with Dr. Odette Harris, professor of neurosurgery at the Palo Alto VA Health Care System.
[l] The four pillars and the latest guidance for “Religious Ministry within the Department of the Navy,” are detailed by the Navy’s Chief of Chaplains in the Secretary of the Navy’s Instruction, 1730.7E.
[li] There is overlap between PTSD and Moral Injury symptoms. Moral Injury is not yet a disorder recognized in the DSM V Manual. Dr. Kinghorn argues that a better term for moral injury, might be moral response. This recognizes the positive aspects that come from being troubled by the profound moral quality of events.
[lii] Swinton, John. “Becoming Friends of Time: Disability, Timefullness, and Gentle Discipleship.”
Waco, Texas: Baylor University Press, 2016. 68-69.
[liii] Kick, Kimberly A. and Myrna McNitt. “Trauma Spirituality, and Mindfulness: Finding Hope.” Social Work
and Christianity 43, No. 3, (2016) 105. The authors write, “Spirituality in all its forms of expression gives the service members and their families the foundational support to realize their strengths and resiliency. It is transformational.” She then cites Richard Rohr who describes “spiritual transformation as a process flowing from great love and great suffering.”
[liv] Ramsay, N.J. “Moral Injury as Loss and Grief with Attention to Ritual Resources for Care.” Pastoral
Psychology 68, (2019). 109.
[lv] Ramsay, “Moral Injury,” 109.
[lvi] Barton, Sarah. “Discipleship and Disability Class: Implications for Christian Ethics Mini Lecture.” PDF, Duke Divinity School, Durham, NC, March 15th, 2021. Barton cites Chapter 5 from Dr. Bethany Fox’s book, “Disability and the Way of Jesus.”
[lvii] McKinney Fox, Bethany. Disability and the way of Jesus: holistic healing in the Gospels and the Church. Downers Grove: InterVarsity Press, 2019. 146. Fox urges ministers to attend to the body when considering the matter of healing and transformation.
[lviii] Rambo, Shelly. Spirit and trauma: theology of remaining. Louisville, KY: Westminster John Knox
Press, 2010. 7. Rambo writes, “The rush to life can belie the realities of death in life.”
[lix] Rambo, Spirit and Trauma. 6-8.
[lx] Rambo, Spirit and Trauma. 8.
[lxi] Hansen, Christopher, O’ Connor, Kathleen and Nancy Ramsay. “Fostering Expressions of Lament and
Bearing Witness with those experiencing Military Moral Injury.” Webinar, Soul Repair Center, Brite Divinity School of Texas Christian University, Fort Worth, TX. April 19th, 2021.
[lxii] Lamentations 3:22-23. “The steadfast love of the Lord never ceases; his mercies never come to an end; they are new every morning; great is your faithfulness.” English Standard Version.
[lxiii] Aker, “Intrepid Spirit Centers Promote Healing.”
[lxiv] Alexander, David William. “He’s Home, but He’s Not the Same: A Pastoral Counseling Impression of
Family Care after Combat Related Traumatic Brain Injury.” Journal of Pastoral Care & Counseling 66, no. 4 (December 2012): 1–6.
[lxv] Newcomb, Amy. “REBOOT offers combat recovery.” Fort Campbell Courier.
[lxvi] Newcomb. “REBOOT offers combat recovery.”
[lxvii] Luz is attending church online. I would like to ask about how she connected to the church and her past involvement there. Pending COVID19 health restrictions I would hope she could experience in person encounters there when possible. I would also like to know about the church’s ministry philosophy, theology and overall organizational health.
[lxviii] Owens, Evan and Kevin Weaver. “The Warriors Journey Podcast: REBOOT Recovery.”
thewarriorsjourney.org. Episode 120.
[lxix] Luz and her mother will have to dictate the pace of our conversation. They may want to come again repeatedly for spiritual care and counsel.