Jack, a seventy-six-year-old hospice patient and veteran of the Vietnam War, had time on his hands. Stuck in a hospital bed, looking back on his life, he was increasingly focused on his time as a young infantryman caught up in the “catastrophe of war.”
Looking back and taking stock in one’s life is common as patients approach the end of their lives. In 1963, Robert Butler, MD, called this process life review, noting that it can bring insight, highlight meaning and purpose, improve mood, and enhance appreciation for one’s legacy and relationships.
But when memories include the violence of war, this life review process can be complex, even emotionally painful. Though combat veterans may have positive memories of their time in the military, such as close friendships, shared purpose, and teamwork, many look back on lives marked by war-related adversity such as post-traumatic stress disorder (PTSD), or moral injury.
For Jack, life review had uncovered layers of grief for two close friends whose deaths in battle he had never fully mourned. Instead, he’d hidden his grief behind a wall of stoicism hoping it would diminish over time but, as he neared the end of his life, it grew stronger.
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“I never really talked about my buddies who died,” Jack reflected. “At the time, I had to survive. When I got home, I didn’t think anyone would understand or care. I figured I was supposed to suck it up, put it behind me and go on with my life.”
“Suck it up”: You can’t grieve in a combat zone
Attempts to suppress or avoid grief are common in veterans who have lost friends in combat. Military culture and training inculcate the tight control of emotions, mental discipline, stoicism, and the ability to subordinate one’s needs to those of the group to ensure unit cohesion and the ability to respond to threats.
According to Perry-Crawford, LSW, M.Ed., a readjustment counselor with the Department of Veterans Affairs, “grief often gets deferred, where soldiers, medics, chaplains, and support staff must suppress emotional reactions to loss in order to stay focused, protect others, or maintain operational readiness.”
In a combat zone, suppressing emotions is necessary. Soldiers who get distracted by grief are apt to be viewed as weak and potential liabilities whose lack of focus might get themselves and their buddies killed.
As battle losses accumulate, many veterans become hardened or emotionally numbed to death. With dangers all around, soldiers are denied a period of bereavement during which grief can be expressed and processed through rituals, storytelling, counseling, and social support. Many do what Jack did. “Those two guys were the best friends I ever had. But when they died, I stuffed my feelings down into my guts, shut the vault, and moved on.”
High-risk losses
Complicating matters, the kind of deaths soldiers must stuff into this internal vault often carry elevated risks for complicated or prolonged bereavement. Consider some of the risk factors typical of those who are grieving friends killed in combat: The person who dies is young; the death occurs under violent, potentially traumatic circumstances and may have been witnessed by those left to grieve; multiple deaths may accumulate; ongoing dangers and mission focus are barriers to psychological and emotional support.
Moreover, it’s not just grief over the deaths of friends, and sometimes civilians, even “enemies,” that gets suppressed. Young men and women thrust into the savagery of war may endure less visible losses such as the shattering of assumptions about one’s sense of identity, betrayal by institutions or those in positions of authority, the loss of a future they had hoped for which they will never have, or grief over actions committed or witnessed which violate one’s moral beliefs.
Amidst the high-stake realities of war, veterans stuff increasing amounts of emotional and psychological pain into the vault. By the time a combat deployment ends, the vault is often full but the military code of stoicism and idealized notions of strength which discourage asking for psychological support remains strong.
As the Veterans Administration puts it, “Soldiers are taught to handle anything and how to live in survival mode; they learn to disconnect from their emotions. Stoicism contributes to survival and military success but can cause problems after returning home. It may later make grieving more difficult, hindering the process.”
Unfortunately, when combat-related grief is associated with events that have caused PTSD, moral injury, or survival guilt, the barriers for accessing support for one’s grief may be even more formidable due to perceived mental health stigma, fear of psychological distress, or patterns of avoidance.
Veterans who are discharged or reach the end of their terms of military service may face challenges such as finding jobs, relocation, or adjusting to war-related injuries, as well as additional losses including the loss of important roles and relationships, sense of shared purpose and belonging, and the familiar routines of military culture.
Given the tendency to deny or suppress troubling feelings and thoughts, veterans are often isolated in their grief. They may return to communities unfamiliar with those who were killed and which do not understand the intensity of bonds forged under fire. Some civilians assume that since death is one of the known risks of combat, veterans must not be affected by these losses. Many veterans are hesitant to share details of combat losses which might upset loved ones, stir up underlying pain, or because of fear of being misunderstood or judged.
Health care and counseling professionals working with veterans may focus on perceived mental health challenges like PTSD, elevated suicide risk, or depression, not realizing that beneath these issues is often a substrate of unexpressed grief. Differentiating between grief and PTSD or survivor guilt, for example, can be tricky. In my experience, grief is inseparable with PTSD, but a tendency exists to focus only on the PTSD, setting aside or remaining unaware of the way it masks and entangles with grief. This focus on psychopathology can add further stigma to veterans looking for a safe place to process combat-related losses.
Combat grief is often disenfranchised
This combination of internal and external pressures to remain silent or focus on other concerns can result in what Ken Doka calls disenfranchised grief in which a veteran’s grief is not recognized or supported by others. Grief is disenfranchised when the significance of the friendship, or the loss itself, is dismissed or not recognized, or where the veteran’s grief is not recognized or understood.
Given their military training and the general lack of community awareness and understanding for the hidden grief veterans often endure, many with whom I’ve worked locked their grief away only to find that it began to manifest in things like chronic physical complaints, anxiety, depression, or behavioral patterns such as being overprotective, withdrawal, catastrophizing about the future, or dependency on alcohol.
Delayed or deferred grief can emerge years later, perhaps triggered by life events like the loss of a loved one or a personal health crisis. A study involving Vietnam-era combat veterans with PTSD, for example, found that subjects reported levels of grief for friends lost in combat decades earlier that were comparable to grief for spouses who had died more recently. Researchers concluded that unresolved grief was an “important component of combat-related stress” and often entangles with PTSD and depression.
It is important for health care and mental health professionals who serve veterans to be aware that many harbor undisclosed grief for friends who did not survive. As men and women like Jack find themselves facing age-related losses and stressors such as the deaths of spouses, physical debility, or navigating dehumanizing health care systems, or as they look back on their lives and take stock, delayed grief may emerge. When it does, helping professionals must be prepared to respond with skill and compassion, creating safe environments and trusting relationships for stories that have been locked in the vault to finally be told if a veteran chooses to do so.
For professionals working with younger veterans there’s no reason to wait decades for delayed grief to emerge. We can support patients and clients who wish to mourn these hidden losses rather than spending precious time and energy, even their lives, trying to keep the vault shut.
Scott Janssen is a social worker.
