Spiritual Injuries—An Australian Defence Force Experience

cause than PTSD, which is thought to occur after direct contact with a traumatic event (Matthews, 2018). It is instructive to note that Maguen’s and Litz’s (n.d.) definition of MI includes the term spirituality. Both MI and SI both share some basic commonalities. Factors such as shame, guilt, sorrow, remorse, redemption, and the need for punishment and/or forgiveness (see Figure 1) are common. The fundamental difference is that a MI is some form of breakdown between the individual and their society whereas a SI is a breakdown in the one-toone relationship between an individual and their concept

The ADF has recently completed a two-decade long period of intense engagements in a range of operations including Bougainville, East Timor, Afghanistan, and Iraq. In Afghanistan alone, nearly 300 ADF were either wounded or killed (Australian War Memorial n.d.). The wounded have already or will eventually transition from the ADF back into broader Australian society where they will join the 84,385 existing veterans receiving some form of disability payment related to their war service from the Department of Veterans Affairs (DVA) (2019). Preliminary evidence also indicates that approximately 8-13% of ADF personnel who deployed to Iraq and Afghanistan will suffer from some form of servicerelated mental illness (Centre for Veterans Mental Health [CMVH], 2019). Such is the scope of potential mental health problem, that the former commander of Australian forces in Afghanistan, Major General John Cantwell, has warned of a "tidal wave" of psychological issues (ABC News, 2013).
There is, however, a third category of wound that is not being currently addressed and yet, based upon international research, is a major issue in the general well-being and metal health of returning personnel. This category relates to the spiritual wounds or spiritual injuries (SI) that personnel undergo as a result of their Defence service.
At some stage, if not already, all of the research subjects mentioned in this paper will join the veteran community. The vast majority will go on to lead healthy and productive lives. Some will suffer from a range of physical, moral, psychological, and spiritual injuries at various points or throughout the rest of their lives. In the case of physical and psychological injuries in Australia the Department of Veteran's Affairs (DVA) takes the lead. Whilst inevitably veterans have mixed feelings and attitudes about the level of service and support offered by DVA it generally provides an appropriate level support. Care for Moral Injuries (MI) is also starting to be recognised as a part of this care spectrum. What is not being discussed, is not widely understood, or has any form of treatment regime are SI. Traditionally, SI have been considered as a subset of the broader MI area although there are significant areas of difference in the nature of the injury, the way it presents and its effects and treatment that needs to be discussed. Current ADF personnel are well supported by a large network of Chaplains and spiritual advisors. Once personnel transition to the civilian community Defence, DVA, the broader national faith community and academia in Australia offer no support to veterans suffering a SI. As a consequence, veterans effectively enter a "spiritual grey zone" or an area in which there is little to no guidance and specific help in spiritual or faith issues is available. This is not to suggest that this help is denied from them but rather, that the veteran is unsure how to approach or access the help and that faith practioners are unsure and unaware of veteran needs and how best to work with this particular community. Such is the case for Research Subject 208-200419 (negligent discharge). Now a veteran, this individual is suffering from a SI.
In short, a SI can be initially defined as an injury that occurs when personnel are involved in some way in an incident that causes them to question their belief or faith in the existence, purpose and benevolence of some form of higher being or entity. Not every veteran possesses, let alone practices the tenants of such a concept but for those that do, challenges and threats to issues of faith can be significant and play a major role in their lives. Whilst an SI may present with similar symptoms and behaviour to many mental health and moral injury conditions, the causes and consequently treatment and care approaches of an SI are fundamentally different.
Much of the research in this area is currently drawn from international and largely US sources. This is very useful for understanding overall concepts and behaviours, especially given the close cooperation of Australian and US forces in areas such as Afghanistan and Iraq. At the same time, US and indeed Canadian, New Zealand, and British approaches to issues of faith and spirituality are very different and specific research developed for Australian circumstances does need to be developed.
Understanding the causes, symptoms, and treatment of SI suffered by ADF veterans will become an increasingly important issue if Australia is to prepare for the "tidal wave" of mental health issues that General Cantwell suggests. As spiritual life is not a concern for all veterans and there is no evidence or suggestion that SI will plays the leading role in this range of conditions but rather, a role, one that has yet to be fully understood. It is more likely that SI will be one of a number of injuries that veterans will carry throughout their lives.
In order to understand the causes, symptoms and treatment of SI suffered by veterans there are a number of definitional and diagnostic issues that need to be discussed. These issues must be discussed as a part of a treatment continuum as in most cases veteran's SIs occur when they are still in uniform and continue through an individual's transition into civilian life. The nature of veteran's SIs will need to start from the perspective of serving ADF personnel. As a part of this, it will be important to understand the practical definition of terms such as spirituality and in turn fully describe the essential conceptual basis of a SI. This will include the causes and manifestations of a SI's and the subtle but important overlap it has with Moral Injuries (MI).
The ultimate goal of this paper is to introduce a SI Treatment Protocol (Provisional) (SITP-P) which will be the necessary fulcrum which tips the discussion of SI towards shining a light into the spiritual grey zone of veteran's spiritual health.

Definitions
There is an obvious and inherent contradiction between a spiritual life and war. This contradiction has puzzled some of history's greatest theologians, philosophers, and thinkers such as Aristotle, Saint Augustine, Thomas Aquinas, and Hugo Grotius, each of whom tried to determine how war could be just and meet God's will. During the Vietnam War a young Australian soldier approached an Anglican priest in the aftermath of a battle and asked, "Padre, where was God in all of this" (Gladwin, 2013, p. 237)? This type of comment is representative of many others that can be found in even a cursory search of primary sources such as those in the letters and diaries of service personnel in the archives of the Australian War Memorial. Before seeking how to approach SI it is critical to understand three important definitions regarding religion, spirituality, and morality.
In the epic work, The Broken Years, Bill Gammage makes the broad statement about soldiers in the Great War that "apparently the average Australian was not religious" (1970, p. xv). This is probably largely true. In the last Australian Census 30% of Australians claimed a "no affiliation" or membership of any religious group or body (ABS, 2019). The downward trend in religious affiliation in Australia is due to a range of factors, not least of which has been a number of significant cases of abuse in church-based institutions and groups. This national profile is matched within Defence. Despite the oft quoted aphorism that "there are no atheists in foxholes," not every member of the ADF has a religious faith or belief. It is likely that the general Australian figures regarding religious affiliation would be similar for members of the ADF. The important points of differentiation here is between the terms religion, spirituality, and morality.
The ADF's Joint Health Command (JHC) defines religion as "Religion is an organised system of beliefs, practices, rituals and symbols designed to: a) facilitate closeness to the sacred or transcendent (God, higher power, or ultimate truth/reality), and b) foster an understanding of one's relationship and responsibility to others in living together in a community" (Department of Defence, Personal Communication, 2018.). In other words, religion is the outward, public demonstration of particular set of spiritual or faith beliefs. It is the rituals, symbols, dogma, and branding that people choose to follow in order to demonstrate their membership of a specific faith community.
Spirituality is the belief in the relationship between the human spirit and the divine spirit. The search for understanding this relationship is one of humankind's longest standing and possibly least conclusive pursuits. In contemporary society spirituality has, as one commentator cautiously notes, "a bewildering array of meanings" that encompass a variety of religions, cultures, philosophies, and approaches (Dreyer & Burrows, 2005, p. xv.). The United States Department of Veterans Affairs provides a useful simple definition of spirituality as "an inner belief system providing an individual with meaning and purpose in life, a sense of the sacredness of life, and a vision for the betterment of the world" (2019, n.p.).
What appears to be common amongst these concepts is that the spirit refers to a non-material animating principle of life (Thompson & Williams, 2008). Additionally, it encompasses daily lived aspects of one's faith in terms of values and commitments, how a person appropriates beliefs about a God in the world in a journey for selftranscendence and meaning (Dreyer and Burrows, 2005). All of these ideas point to a key concept about the spirit. For many people, this "non-material animating principal of life" encompasses a host of fundamental aspects of their values and commitments and is based, lead or centred on the belief in a God. Although only, a small percentage may choose to have a particular religion stamped on their identity discs, that does not preclude the possibility that many ADF personnel have deeply held spiritual beliefs. These beliefs may be heartfelt and elegantly expressed or they may be as one soldier prayed while climbing the rugged mounts of New Guinea during the Second World War, "Dear God, help me to pick up my feet, I'll put the bastards down" (Neave, 2008, p. 127).
There is considerable overlap between terms such as spirituality and religion. Likewise, the lines between these terms and morality are also unclear. Further, the term "morality" is equally complex and can be used descriptively to refer to certain codes of conduct put forward by a group and accepted by an individual for their own behaviour, or normatively to refer to a code of conduct that, given specified conditions, would be put forward by all rational persons (Stanford Encyclopedia of Philosophy, n.d.). Morality is closely linked to religion and teaching and dogma and the term spiritual morality is sometimes used to describe the codes by which people seek to live in a "Godly way" within their society. The important distinction between morality and spirituality and religion, is however, that morality is led by societal and environmental considerations while spirituality and religion are led by a personal and individual relationship with a God concept.
Whether or not the beliefs of a member have a public and specific religious form or dogma or are privately held, it is at the point at which this relationship with God is fundamentally threatened that a SI occurs. It is reasonable to assume that for those whose religious or spiritual belief offers a compelling way to find meaning and purpose in life, threats to those beliefs can be a significant influence on their overall state of wellness.

What is a Spiritual Injury?
Soldier: 'Padre? Do you think that God still loves me?' Padre: 'Yes but why do you ask that?' Soldier: 'Because I had to kill two men yesterday…' This exchange occurred late one evening between an Australian soldier and an ADF Padre during an operational deployment in the Middle East (Research Subject 209-270420, 2019). This is an example of a SI.
There are a number of important factors to notice in this exchange. To start with it is entirely likely that this event created a number or moral, physical, and psychological issues for the soldier. It is possible that individuals in involved in such incidents with suffer a number of separate but related concerns. Tellingly, the individual had deliberately sought out a spiritual practioner to ask this question. While few ADF personnel will claim a public religious affiliation, anecdotally every ADF Padre will tell stories of the personnel that have come to them prefacing their oftenfundamental questions with statements such as, "Padre, I don't believe in God but…" or "I'm not religious Padre, but…" The religious affiliation of the Research Subject 209-270420 is unknown although the individual specifically asked a question about what "God" thought about their actions during the particular encounter. This implies some level of acceptance of God and perhaps an already established relationship. The soldier is effectively seeking from the Padre approval, forgiveness, or solace for their action as they feel that they have in some way offended, angered or disappointed God.
There is a considerable amount of overlap between the concepts of spirituality and morality and SI and MI. Most importantly, the concepts are not contradictory or in competition. Rather, there is a very natural, cooperative, and complimentary relationship between the two concepts. Two of the most significant commentators in this area, Shira Maguen and Brett Litz describe MI as a: construct that describes extreme and unprecedented life experience including the harmful aftermath of exposure to such events. Events are considered morally injurious if they "transgress deeply held moral beliefs and expectations" (referred to as Potential Morally Injurious Events -PMIEs). Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culturebased, organizational, and group-based rules about fairness, the value of life, and so forth. (US Department of Veterans Affairs [VA], n.d.) MI is more associated with an existential crisis, stemming from the violation of values pertaining to the sanctity of life, than with trauma. Bearing witness to intense human suffering during or in the aftermath of battle it creates an ethical and moral challenge. These challenges cause individuals to struggle with transgressions of moral, spiritual, or religious beliefs and afflicts them with various forms of dissonance and internal conflicts. In this framework, harmful attributions cause guilt, shame, inability to forgive, and selfcondemnation. MI, from this perspective, involves a more abstract cause than PTSD, which is thought to occur after direct contact with a traumatic event (Matthews, 2018).
It is instructive to note that Maguen's and Litz's (n.d.) definition of MI includes the term spirituality. Both MI and SI both share some basic commonalities. Factors such as shame, guilt, sorrow, remorse, redemption, and the need for punishment and/or forgiveness (see Figure 1) are common. The fundamental difference is that a MI is some form of breakdown between the individual and their society whereas a SI is a breakdown in the one-toone relationship between an individual and their concept of God.
Noting the previous discussion, the initial definition of an SI can now be reviewed. It is proposed that a Spiritual Injury occurs when an incident or event creates a break in the relationship between an individual and their concept of God. There is a very natural, cooperative, and complementary relationship between MI and SI but they are fundamentally different concepts. The difference lies in the context of the injury. MI occurs within the context of the broad norms, ethics, or morality of human society. SI occurs in the context of a personal relationship between personnel and their concept of God.

Potential Spiritually Injurious Events (PSIEs)
Borrowing from MI terminology, the events described above can also be thought of as Potential Spiritually Injurious Events (PSIEs). A PSIE is a catalytic event. It occurs when an individual is in a situation, event, or incident that may or may not be within their control and causes doubt in their personal relationship with God. In the "fog of war" the nature of these events and their subsequent effects will often blur, overlap, or collide. These events can be generally be broken down into four types of PSIEs: 1. Witness. Personnel may become spiritually wounded when they witness a traumatic event that is beyond their control. Whilst they may have an alarmingly good vision of the event, they are unable to interact within any way due to a range of circumstances. They may be out of range, or observing the event through some form of sensor or platform without a strike capacity. They may also be directed or ordered not to become involved. This was the case in the Kibeho Massacre.
On 22 April 1995 a United Nations team, comprising largely of ADF medical personnel, were providing aid to the refugee population of a large camp at Kibeho. That morning Rwandan People's Army soldiers entered the camp and began indiscriminately shoot at refugees. Australian troops were ordered not to return fire for fear of trapping the refugees in a deadly cross fire. Over 4,200 refugees were killed. One Australian medic remembered thinking to himself during the event, "Why were we not allowed to fire our weapons to defend these poor refugees? God, I hope I live through this" (Pickard, 2010, p. 111). This PSIE is a demonstration of an event where neither the tactical situation nor the orders provided allowed for the individuals to act. The language used by the soldier has elements of both a plea for protection and a heartfelt question about why they could not interact. Although the order provided to the soldiers was ultimately tactically correct, there would have been many of the soldiers who witnessed this event who could not see the hand of a benevolent God at work. 2. Victim. When a person is affected by an event to the point that they may feel they have directly targeted they can suffer an SI that relates why they were not protected by God. During operations in New Guinea during the Second World War an Australian soldier would write, "It was a war where you learned to trust God. There were not many atheists amongst the infantry in those days" (Neave, 2008, p. 127 ing for war time roles. Some never get an opportunity to practice these skills and feel that they have been denied the opportunity by God to do so. This is a very real frustration as it plays directly to the professional self-image that personnel have of themselves and their military capabilities. One of the strengths of the ADF culture is the cohesion that is formed through stories of previous operational events. The Australian and New Zealand Army Corps (ANZAC) story is a whole of the ADF example of this, but each unit will celebrate its own particular days relevant to its history. Some ADF personnel may feel that they are denied their opportunity to be part of this story. 2 They may see this as a punishment unfairly laid by God. One ADF Chaplain tells of dealing with many logistic personnel both in and out of theatres whose vital roles in particular areas meant that they could not deploy or could only deploy to "soft areas." One former ADF member when told "thank you for your service" by a well-meaning civilian replied "God didn't let me serve so don't thank me" (Research Subject 210-270618, 2019).

Consequences
In a SI sense, the involvement of personnel in a PSIE tends to lead to different consequences. These consequences are stretched widely across the MI, psychology, and psychiatric environments but they have a particular meaning in a spiritually sense. Reviewing the previous examples of SI and relevant literature the three most common are: 1. Guilt. Guilt is a very old emotion and plays a key role in many of the world's religions. It is also a common consequence for trauma victims particularly the victims of combat trauma. In studies of US Vietnam War veterans, it was noted that the survivor "… of Vietnam carries within himself a special taint of war. His taint has to do with guilt evoked by death" (Opp, et al, 1989, p. 159). Guilt can be defined as "the consequence of some real or imagined violation of the conscience, as a feeling of culpability for offenses, and as regret accompanied by self-attribution" (Campbell, 1984, p. 63). One psychiatrist has expanded this by noting that guilt is the "thought and feeling generated when a boundary set by the superego is transgressed" (Campbell, 1984, p. 63). Guilt can also be the commission of a sin. In a religious and spiritual context, sin is an act of transgression against God, divine law or the Commandments of a particular faith (Oxford Dictionary, n.d.). Sin can also be viewed as any thought or action that endangers the ideal relationship between an individual and God; or as any diversion from the perceived ideal order for human living.
In any case, guilt includes both a cognitive component and an affective component. Essentially, guilt is regret over the involvement in an event which has established a feeling of personal responsibility and generates powerful self-condemning thoughts (Campbell, 1984). Guilt can be a particularly condemning consequence, it cannot be expressed in a healthy manner or if the individual rejects social support, giving way to feelings of helplessness and isolation (Kopacz, 2015, p. 2).
Guilt has many facets that may display in former ADF personnel. It can be manifest function which is more obvious or immediate and/or a latent function which is more subtle, underlying, or lingering. Typically, guilt borne of combat related trauma can also be identified as (Opp, 1989): • Survivor Guilt. Personnel involved in a PSIE may carry with them a sense that they should have died, that they do not deserve to live, and that somehow their survival has cheated someone else out of living. Commonly survivors may say something similar to "my mate died so that I could live." In its more extreme form, survivor guilt may also include the convoluted notion that the individual killed his or her friends so that he or she could live. The role that God plays in this that of choice in the sense much that the gift of "free will" given to human kind enabled the individual to make a poor decision. It may also be that the individual feels that God made some arbitrary or unexplained choice to favour the survivor over another. • Demonic Guilt. This form of guilt is based upon an awareness or observation of the enjoyment or satisfaction with being involved in warfare. Being a part of warfare can make them aware of the monster, killer, animal, or devil that can exist in each human being. For some, demonic guilt may result from some experienced joy and power from being engaged in warfare or other aggressive acts, which relieved their sense of helplessness in a combat arena. It may also present as guilt at enjoying an operational deployment whilst they leave close family home alone. • Spiritual Guilt. This grows out of the violation of the individual's reflections on their spiritual/religious teaching against an event. It can come from guilt over feelings of having betrayed or failed to follow their concept of the "word of god." Research Subject 209-270420's question "Does God still love me?" seems to be predicated on some teaching or experience, that reinforced Biblical precepts such as "Thou shalt not kill" (Exodus 20:13). This soldier seems to suffer guilt over breaking a "Commandment." Spiritual guilt can also come for those who feel that God has failed them in in some way as in the case of Research Subject 207-200419 (Negligent Discharge). • Abandonment/Betrayal Guilt. This is typical of Denial PSIE. Some may feel that they did not do enough to support their comrades serving in combat. Others will seek to downplay this guilt with statements such as, "I had it pretty easy, compared to most" (Research Subject 209-270420). This guilt is based in a feeling of helplessness that generates a disproportionate share of responsibility for specific incidents. 2. Shame. Shame and guilt are similar conditions in many respects but are different as they relate to issues within the psyche. "Shame results from a failure to live up to certain internalised standards of behaviour" (Singer, 2004). Military organisations throughout history and across cultures have always made significant efforts to inculcate a way of thinking that emphasise the uniqueness of their particular ethos, values and behaviour. The intent of this is to build a feeling of unity and loyalty as well as an adherence to the needs of the group rather than the individual. This is usually achieved through language, dress, rituals and symbols. For example, the Australian Army's "Rising Sun" badge is probably the most recognisable symbol of the ADF. The badge, like those of specific Corps or units, is not given but earned by members of the particular group. Failure to live up to the values of the group will create shame. Values that cannot be physically expressed, such as mateship, are also critical. This particular value is hammered home to every ADF member throughout their careers and the worst possible crime is not to stand by "your mates." When an individual in this setting feels that they have failed to meet the standards set by these values they experience shame. For example, Research Subject 207-200419 (negligent discharge) refuses to march in AN-ZAC Day commemorations or wear the medals earned on deployment as they are ashamed of the negligent discharge incident. This is seen as a professional failure to be able to "act as a soldier." It follows than that when an individual experience such shame there is a reduction in self-confidence and self-esteem that will affect their ability to perform tasks and actions that may be essential to efficient functioning and unit capabilities. This "internal shame" is devaluing themselves in their own eyes. "External shame" is linked to the perception that others look down on the individual and sees them as inferior or inadequate in some way (Fry, 2016). Accordingly, some may fear being ridiculed or scorned when performing even the most routine and simple actions. Where this has a divine component is if the individual feels that God is ashamed of them. For example, the Australian Army soldier (Research Subject 209-270420) who asked "does God still love me?" is experiencing internal shame over a breech that they feel they have created in their relationship with God. 3. Doubt. As Shay (2003) notes in Achilles in Vietnam in a Homeric or historical circumstance, God has often also been seen as a source of doubt for military personnel throughout the ages. To Shay's ancient Greek and Trojan heroes, the Gods' minds and wills were mystery. Likewise, was their reasoning behind choosing whether to support, punish or ignore the warriors, from both sides, who prayed to them. An example of can be seen during the First World War German soldiers wore "Gott mit uns" (God is with us) on their belt buckles. At the same time that Australians fought for "God, King, and country." In his studies on US Vietnam veterans, Shay (2003) notes that this "sometimes made God (or a god) the target for attribution or causality, responsibility, and blame…. American soldiers felt betrayed, abandoned by God: they became spiritual orphans…. devalued and dropped into a spiritual void" (p. 146). Again, as Shay notes: In an ethical universe run by a just, loving, and allpowerful God, the 'person I was willing to die for' is not supposed to die. Incomprehensibly, he does die…They cannot save, cannot protect, cannot resurrect the comrades they have come to value more than themselves…. God as viewed by Christians, Jews, and Moslems … has the power to save, protect and resurrect and when He does not, He violates the covenant many had thought was passed down to them in religious instruction. (p. 74).
This broken covenant may lead to doubt about the very existence of a benevolent, omniscient, and omnipotent God. For those with spiritual beliefs, this doubt in the existence and nature of God may create an additional distress about the authority of other leadership figures. Worryingly, those who have lost a previously held "spiritual compass" may also lose or see the degradation of other moral, ethical or perhaps even legal beliefs and restraints. Finally, from Shay (2003), "God has vanished and taken it all with him. With God against them or gone, all possibility of virtue seems lost" (p. 148).

Spiritual Arc
The "God gene" hypothesis proposes that spirituality is hardwired into our genetic make-up at the moment of conception. The argument is that the gene in question, the vesicular monoamine transporter 2 (VMAT2), predisposes humans towards spiritual or mystic experiences (Silveira, 2008). Whilst this hypothesis may have some validity, no one is born Christian or Muslim or Zoroastrian or indeed another other religion. Individuals may be born into an environment, family, or culture that has an existing set of spiritual or religious beliefs but whether those beliefs are accepted, rejected, replaced, or reshaped depends on the interplay of a complex set of circumstances and experiences that evolve over a lifetime. This is their Spiritual Arc (see Figure 2). How intense and significant a PSIE and any subsequent SI might be will sometimes depend on where and when it occurs on their individual Spiritual Arc. Although the shape of the Arc may seem to indicate a continual growth in Spirituality, this is not a forgone conclusion rather it is more dynamic and at various points the arc will be pulled in different negative and positive directions. Movement can continue, stop or go off the Arc. For example, it is not known what happened to Research Subject 209-270420 (does God still love me) but for arguments sake, if the outcome of their Participant SI was to turn away from God the individual might have lost other moral, ethical or perhaps even legal beliefs and restraints. Research Subject 211-270618 (don't thank me…) was driven to agnosticism given their experiences and subsequently found interactions with their military superiors were tense and lacked trust. Research Subject 207-200419 (negligent discharge) reported considerable anger with God after the event but over time adopted a much deeper spirituality that that did not take effect until well after their transition from full-time to part-time service.
It is important to note that involvement in a PSIE and a SI does not always lead to negative outcomes. In the same way that muscle is torn during strength and resistance training and becomes thicker and stronger, a SI that tears at a recruit's understanding of God may actually build the relationship. Possibly the first SI suffered by personnel is when they join the ADF. This may be particularly the case given the low rates of national religious affiliation. It is possible that for many their first real engagement with spirituality or religion is when they enter the ADF and have left their home environment. Running parallel to their formation as personnel and their inculcation into the ADF's customs, an individual may only meet a Padre for the first time in their lives if they have the opportunity to attend some form of military related religious service such as a consecration of unit colours. Whilst most religious activities that occur within the ADF are of course voluntary, there is always the means and opportunity for personnel to participate.

Indicators of a SI
Following from the previous discussion on some of the causes and the nature of SI, it is possible now to identify two sets of indicators that can help to understand whether an individual may have and/or be continuing to experience a SI. There needs to be aspects of both of these indicators for a SI to be present. The first set relates to the language being used. Typically, when personnel discuss potential SIs it will be in the form of a question and there will be three components (see Figure 3).
Note the choice of language used by Research Subject 207-200419 (negligent discharge). The first component of the question is an appeal-"why God…" (Research Subject 207-200419). God, in some form (Father, Lord, Allah etc) is named and identified as the principal source or focus of the SI. The appeal can also be implied or inferred by the choice of language that matches the circumstances or nature of the individual and as such God could also be replaced with a personal pronoun such as he/she or you. It is important to note that this is not a question posed to a church, religion or organisation, rather a direct question to the singular presence of God.
The second component is an interrogative-"why." This is where the individual is seeking some understanding as to what, why, or how a PSIE has happened. This is not rhetorical and is a genuine cry for a definitive response to an unanswered question. The comment by the ADF medic at Kibeho, "Why were we not allowed to…" is likewise a demonstration of this. The Kibeho example also points to the third component, the nature or circumstances of the event, the medic is saying that had they been able to fire their weapons they could have defended "these poor refugees" (Pickard, 2010, p. 111). Research Subject 207-200419 also states the nature of their event, that they were allowed by God to be "so clumsy and stupid." The second set of indicators of a SI that an individual may have and/or be continuing to experience a SI relates to behaviour. Research Subject 211-270618, a serving ADF Chaplain, noted that a SI may present as some "form of aberrant behaviour within the unit." In many respects this sort of behaviour from those suffering from a SI may present in a very similar way to mental health issues. This can include depression, anxiety, sexual deviancy, alcohol, and drug abuse (JHC, 2019).

SI Treatment Protocol (Provisional) SITP(P)
The proposed SITP(P) is still provisional as more research and development needs to be completed. Much of the current research into what is referred to across various literature as spiritual/soul/injuries/wounds is focussed on the experiences of the US Army post Vietnam. Noting this, there is a theme within literature in this area that the thinking behind SIs will grow in much the same way that MI as an area of study grew. This can be seen in the growing body of information again albeit US Army related, available post the Iraq and Afghanistan operations. There is obvious general value in this information. The common operational circumstances both nations in the Iraq and Afghanistan theatres also provides useful reference points. The religious and spiritual circumstances of Australians and Americans and indeed with other western allies such New Zealanders, Canadians, and Britons are different and it is not parochial to suggest that an Australian approach and response needs to be taken. To date there is only one directly Australian focussed scholarly article that was available for review (Davies, 2018).
Necessary future research in this area will require a much deeper engagement with veterans to plumb the depths of the scale of the SI profile. It will also require a cross sectional approach across all veteran's communities to identify recurring patterns and behaviours. It is also important to note that the SI concept is not purely restricted to Defence veterans. There may be as many relatable, commonalities between SI related issue that have a Defence focus as there are those that have a first responder focus.
For now, at least there are a number of important observations that will need to be foundations of any treatment approach in a veteran's context.

SI Treatment Continuum. Treating veterans SIs must
begin when the member is still in uniform. It is most often that period of time in which the break between the individual and God occurs. Within the ADF serving personnel are well supported by a large and high professional group of military Chaplains. Whilst there is no compulsion for personnel to see a Chaplain, they are always available. There is likewise no shortage of chaplains or other spiritual practioners in the civilian community but access for many veterans is less easy as many have no experience with spiritual or religious environments and they may simply not know where to go. As a result, any treatment that they may be receiving within the ADF ceases as it cannot be "handed over." Interestingly, if the member has a physical or psychological injury their health care is automatically passed to DVA. The ADF likewise has a duty of care to 'handover' the care of SI to an agency like DVA that in turn could manage this issue and a SI Treatment Continuum can be developed. 2. Defence understanding. It is unlikely that DVA in its current form will be structured to support the treatment needs of SI suffers. As it does with medical and psychological services, it is likely that this treatment will be outsourced to some external organisation such as chaplaincy or church related group. If this occurs that group will need considerable support, training, accreditation, and education to understand the unique cultural aspects of service life. 3. Multi-disciplinary. Any significant incident that occurs in an operational circumstance will be a complicated mix of physical, cultural, emotional, moral, mental, and spiritual issues. It will often occur in the most tumultuous and catastrophic circumstances. It is also very unlikely that it will relate to a single factor but rather a confusing blend of issues that will also change over time. For example, mental or spiritual issues may not emerge as major challenges until after a serious physical wound has healed. This means that other mental, moral, or spiritual issues are treated subsequently. A critical observation that can be drawn from this statement is that the "team-like" nature of the treatment means that all personnel involved will need access to shared information and reporting. Although additional privacy protocols will need to be established, spiritual, moral, medical, and other allied professionals should all meet to discuss cases and contribute to the individual medical files as required. 4. Voluntary. Religion and spirituality are highly personal aspects of and individual's life. Not all will have a religion or faith-based aspect to their lives. As such any form of spiritual engagement or treatment regime must be voluntary. It may be suggested or recommended by a Chaplain or medical professional but it cannot be viewed as a compulsory activity. 5. Non-Denominational. How to balance the faith/denominational based aspects of treatment is a complicated consideration. ADF Chaplains are required to provide a non-denominational and interfaith service to serving personnel. Certainly, on deployments there is rarely the luxury to have Chaplains from every faith in location. The fundamental requirements for nondenominational and interfaith service to individuals must remain, although when appropriate, there needs to be a capacity to include or utilise key religious based rituals, dogma, or activities. The same applies to any form of SI engagements to veterans.
For now, the SITP(P) is likely to have five stages which encompass that (see Figure 4): 1. Spiritual Preparation. There are two times when Spiritual Preparation is valuable. The first is during recruit or basic training. The purpose of this preparation is not evangelising or proselytising but rather information. Here, individuals both with and without some faith context are provided a first point of information within the ADF about the services provided by Chaplains in peace and war. This is currently conducted within the ADF at both basic recruit and officer training facilities. The second time is pre-deployment. The purpose of this training is to prepare individuals for the types of PSIEs and SIs that they may encounter. This is most likely being conducted at unit level by local Chaplains although there is no evidence of an ADF wide approach. 2. Spiritual First Aid. As the name implies this is the immediate supporting action that is applied following a PSIE. This should be delivered by unit or deployment group Chaplains as part of a coordinated response by a multi-disciplinary team following a major engagement, contact, or incident. 3. In Theatre Support. If necessary, the in-theatre support can be extended past the point of immediate injury. 4. Return to Australia (RTA) Preparation. The RTA program is designed to prepare those individuals who feel that they may require spiritual support on during their RTA. The program would be conducted in theatre and contain two components. The first component should be a video that discusses and describes potential spiritual issues that they may face on RTA. The second is a thorough review of the spiritual circumstances of the individual whilst deployed and the possible family/home/unit circumstances on RTA. 5. In Service Spiritual Support. If ongoing support is required then this can be provided through the existing Chaplaincy network. In the event that an individual requires specific faith support for a religious grouping outside of existing representation within ADF, unit and formation Chaplains should reach out to relevant community groups to facilitate this. 6. Handover to DVA. Once an individual has decided to transition to civilian life responsibility for their overall will be facilitated by DVA. Currently, when individual transitions to DVA's care their relevant health documents are provided to DVA to support the determination of requirements for ongoing care. To facilitate this, transitioning personnel will usually have to complete transition documentation and attend medical and dental appointment accordingly. The same should apply to SI. The individual should be given the option to speak to a Chaplain prior to transition. If the individual requests ongoing spiritual care then DVA should be made aware of this need. Establishment of this handover process between Defence and DVA will also require considerable inter-departmental consultation and policy development. 7. External Delivery Care. Likewise, if the spiritual care of a veteran is outsourced to chaplaincy or church related group, then there must also be an equally detailed handover provided.
The SITP(P) will need to be supported by two tool sets: 1. Centralised Reporting. This will be best achieved through in the ADF through the personal reporting system. This will be a paradigm shift for many Chaplains and will raise issues regarding sanctity of confession and related concerns. These are important concerns and will require close management and guidance. The spiritual support and treatment of spiritually wounded individuals must be documented as for any other injures so as to ensure that they receive consistent and relevant support. It will also ensure that the handover of the individual' on-going care to DVA is professionally and efficiently managed. 2. Support Tools. Figure 5 describes the tools necessary to support the effective delivery of the SITP(P). These tools are best thought of as a connected series of modules that will take individuals through each of the stages of the SITP(P). The tools will need to include an explanatory video, website material and will need to be actively managed by the supporting Chaplain.

Conclusion
ADF has an immediate and growing need to address SI. Hopefully, the ADF's operational commitments will diminish in the coming years. Given the past two decades and the volatility of world affairs, however, this hope is not a valid basis for planning. Agencies such as DVA have recognised and are dealing with the physical, moral and mental injuries of veterans. It is time now to consider the role that SIs play within the veteran population. The general academic and scholarly debate in this area is changing and it is likely that concern regarding approaches to SIs will grow in much the same way as MI. The SITP(P) provides a good initial framework to support the conceptual thinking and should move from a provisional program to a formal and established program as soon as possible. The ADF also needs to consider its broader duty of care to its people although currently, many veterans have and will transition from the ADF into a "spiritual grey zone." SI and PSIE will usually occur on some form of operational activity and will usually initially be treated by the ADF Chaplaincy network. When an individual leaves the ADF any physical and mental injuries that occur during service are handed over to DVA for ongoing care, their spiritual needs are not. DVA will and should remain primarily responsible for veteran care including ongoing care of SIs. There is much that the ADF can do to support this but there needs to be a formalised process to manage this.
Ultimately, answering the question posed by Research Subject 207-200419 (negligent discharge) "why did God let me be so stupid and clumsy?' or Research Subject 209-270420's (I had to kill two men) question "does God still love me?" will not be the ADF's to answer. It will be the role of the DVA and it will have to be executed by trained and accredited Chaplains, Ministers, Rabbis, Priests, or other related spiritual practioners within the broader community. These people must be helped to understand the unique cultural needs of veterans and must be trained, supported and facilitated to support this role.

Notes
1 The identity of all Research Subjects in this paper has been withheld for privacy purposes. This paper takes a completely non-denominational ecumenical and interfaith view regarding the issues of religious and spirituality. The use of the term God throughout this paper refers to an individual concept of the existence, purpose and benevolence of some form of higher being or entity. No value, primacy or specific importance will be ascribed to any particular application of belief. 2 The Australian and New Zealand Army Corps (ANZAC) was the name of the combined force that landed at Gallipoli on 25 April 1915. The story of that day is one of the most profoundly important cultural circumstances for both the Australian and New Zealand militaries.

Funding Infromation
This paper has been funded by the Australian Army Research Centre through the Army Research Scheme.