By Sara Moore

In the years since the United States invaded Iraq, thousands of Americans have come home with visible scars from their time in battle. Thousands more bear different kinds of scars, those that aren’t visible to the naked eye but impact the emotional and moral compass and can be just as devastating as physical injuries.

As a licensed clinical social worker who has treated military members for 10 years, Katherine Castelo has seen these psychological scars up close and has worked to heal them and help service members and family members struggling with the effects of prolonged war.

She was one of the first clinicians in the Washington, D.C., area to accept TRICARE insurance, and for the past 10 years she has primarily treated post-traumatic stress disorder, moral injury and reintegration issues in service members and their families. She has also donated her time to the Tragedy Assistance Program for Survivors (TAPS), a nonprofit organization that provides unlimited free grief counseling to families of fallen service members, and Give an Hour, a national organization that provides free mental health services to military members and their families.

While PTSD has gotten the most media attention during the wars in Iraq and Afghanistan, Castelo said she has seen a rise in moral injury, which is a relatively new term, but describes a concept that has existed as long as war.

Katherine Castelo has seen the psychological scars of war up close and has worked to help service members and family members overcome the effects of prolonged war. | Photo credit USO photo by Joseph Andrew Lee

“If while serving their county, a service member does something, or is a part of something, that violates their moral code or a deeply held belief, it could lead to an internal moral conflict or feelings of shame or guilt,” Castelo said. “These feelings could stem from one’s own action or inaction or even by witnessing the distress of others. This can cause shame, guilt, anxiety, depressions, anger and questioning the meaning of life.”

Moral injury often overlaps with PTSD and survivor’s guilt and these issues can contribute to reintegration issues, where a service member has difficulty adapting to family and community life, Castelo said. As a military spouse, Castelo has seen these issues manifest not only in her mental health practice, but also in her personal sphere of friends, which includes combat veterans and military family members. Deployments and reintegrations are often just as hard on family members as they are on service members, she said, and many have to deal with the grief and loss of death or injury.

“The toll of combat stress impacts not just the service member, but the entire family,” she said. “Military family members serve as well.”

To help lessen the toll of combat on service members and families, Castelo and others in the military mental health field are working to reduce the stigma surrounding seeking mental health treatment, she said. Sometimes military members will start care but stop abruptly because of that perceived stigma or because of the difficulty in processing traumatic memories. Additionally, service members sometimes have trouble trusting their clinicians or believing they truly understand their experiences, she said.

While the clinicians may not have experienced the same traumatic events as the service members they treat, they are still susceptible to their own kind of emotional distress, something called compassion fatigue. Compassion fatigue occurs when mental health professionals succumb to the toll of hearing multiple trauma stories and processing difficult emotions, Castelo said.

“We are trained clinicians and do have the ability to manage what we hear, but we are also human,” she said, adding that she learned through experience not to take on too many clients and how to cope with compassion fatigue.

Transcendental meditation has helped Castelo maintain balance in her life, as has strong self-awareness and a solid network of colleagues and friends, she said. She also limits her number of clients to a manageable level, even though it can be difficult to do at times.

“There is a high volume of those who need care and every one of them deserves it,” she said. “I would like to help every one of them all of the time, but that isn’t realistic.”

Ten years of treating military members and their families has taken a toll on her, Castelo said, with the most difficult lessons coming as she has fully understood the price of war through the eyes of her patients. However, she has also seen bright spots when military members who need help receive it and recover.

–Former Army Sergeant Sara Moore separated from the Army in 2008. She works for the Defense Logistics Agency as a communications specialist.