Academic journal article American Journal of Psychotherapy

Two War-Torn Soldiers: Combat-Related Trauma through an Intersubjective Lens

Academic journal article American Journal of Psychotherapy

Two War-Torn Soldiers: Combat-Related Trauma through an Intersubjective Lens

Article excerpt

The author, himself an Iraq war veteran, presents a contemporary psychodynamic understanding, known as intersubjective therapy, of combat-related Post-traumatic Stress Disorder (PTSD). At the onset of this case example, the patient was highly suicidal and his PTSD symptoms had not responded to a first-line treatment: manualized cognitive processing therapy. Robert Stolorow's intersubjective, psychodynamic approach to traumatic emotional experiences was then selected for treatment, and illustrates how combat in Afghanistan shattered this soldier's world and self experience. Therapeutic action arises from this intersubjective perspective by providing a relational home so that unendurable emotions can be borne, processed, and integrated to achieve a more constant and individualized sense of self. Being a two-person model of therapy, the author also describes how his work with this traumatized soldier affected him, ultimately contributing to his own sense of authentic existing. The author discusses the need for therapists to recognize and acknowledge to traumatized patients their shared finitude and the ubiquity of trauma. In the Postscript, the patient describes what he felt was therapeutic and contrasts this to his previous experiences with manualized cognitive processing therapy.

KEY WORDS: intersubjective therapy; psychodynamic therapy; cognitive processing therapy; war trauma; PTSD

INTRODUCTION

My experience with combat is personal. I have deployed to Iraq and felt the blast of improvised explosive devices, or IED's. I have seen fire flash from AK-47 muzzles pointed at me. I have comforted soldiers waiting outside of combat hospitals for word on their wounded buddies. During the past decade, I have also listened to accounts of combat experiences from my patients that I will never forget. I have tried to help them mourn losses, including the death of friends and the loss of a sense of being-in-the-world. By providing a relational home for the traumatic experiences of many combat veterans, I am able to understand the guilt and shame that many of them feel. I understand why some severely traumatized veterans feel as if they deserve to die, why they feel more at ease sleeping under a bridge than rejoining the communities they fought to defend. And through my work, I understand better my own feelings of alienation from the rest of America after participating in a decade of military campaigns since 9/1 1 .

Since the beginnings of the wars in Iraq and Afghanistan, I have been struggling to understand the experiences of the traumatized service members I treat. Looking back, I believe I was also struggling against the pull to focus purely on the biology, symptomatology, and pharmacology of PTSD that Harold Kudler describes as recurrently emerging in the history of treating combat trauma (Kudler, 2007). Instead of behavior or psychopharmacology, I have always been drawn to understanding the meaning of symptoms for my patients, and felt that the standard first-line treatments for Post-traumatic Stress Disorder (PTSD), based on the Veterans Administrations and Department of Defense Clinical Practice Guidelines (VA/ DoD, 2010) did not adequately address some of these areas. The meanings of symptoms and experiences is the purview of psychodynamic therapy (Ursano, Sonnenberg, & Lazar, 2004), and so I turned to it. Psychodynamic therapy is currently considered to have Level C evidence for PTSD (VA/DoD, 2010, see the Evidence Rating System). In the first years of the wars, I read numerous psychodynamic writers from various perspectives on trauma to try to finding a meaning for combat's effects. But the developmental focus I found in classical psychodynamic understandings of trauma did not seem to fit traumatic events that occur in adulthood. Some examples include the self-psychological approach described in Ulman's and Brother's book The Shattered Self (1993) , Chertoff's ego-psychological approach to trauma (1998), and Dori Laub's (2005) understanding of trauma that is embedded in object relations theory. …

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