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

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 9/11.

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 psycho-pharmacology, 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. Although I learned much from these authors, I came to appreciate Boulanger’s statement in Wounded by Reality that much of psychoanalytic theory and treatments were not developed to address problems that arise in adulthood, such as the effects of combat or rape (2007). Over the past decade, I realize that I have also been trying to find direction in the face of my own emotional trauma from war. I struggled to understand the ravages of war on service members and myself from a psychoanalytic perspective, but no perspectives I found seemed to explain adequately what we experienced. As I realized later, context and the subjective experience of trauma were absent from approaches I was utilizing.

It was not until I discovered the writings of Robert Stolorow, a contemporary author writing about psychodynamic therapy, that I began to understand adult-onset trauma and found a place where my and other veterans’ experiences were understood. His writings, particularly Trauma and Human Existence (2007), which was based on his own experience with trauma in addition to his work with patients, were eye opening to me. Although Stolorow arrived at his understanding of trauma through his own experiences and work, his ideas apply to trauma with a far different content, such as combat. My adoption of his ideas has saved me and many of my patients from the isolation and despair of living in a shattered experiential world following combat. Instead of looking at the distant past of childhood to understand more recent trauma, which is standard in classical psychodynamic therapy, I shifted my focus to subjective experience and context. I shifted from an intellectualized, distant construction of the internal mind of a patient to a stance of empathic introspection that followed the patient’s affect. I strove to understand context of emotional states as soldiers and I tried to connect with each other. I had ordered Stolorow’s book Trauma and Human Existence while I was still in Iraq, and carried it with me. I read it repeatedly, trying to squeeze every bit of wisdom out of it that I could. My patients were noticing the change in my approaches with them. I shall always remember the first soldier back then who said to me: “Wow doc, you get it,” after we discussed how his sense of safety had changed with a shattering of absolutisms, as Stolorow would say. Looking back, Stolorow’s writing also saved me. Reading his book was personal for me. It provided a relational home for my own anxiety in the face of mortality, or Being-towards-death, a term Stolorow borrows from Martin Heidegger. His book was more like a companion in the darkness of trauma, helping me to understand and bear the experiences of being in a combat zone. Otherwise, I was left in my isolation, only with answers that seemed to blame my childhood fantasies about my parents for the mortars exploding outside my office.

Thesis

In this paper, I shall describe a case of combat-related PTSD through an intersubjective lens. At the time of writing this, the summer of 2011, I had been fortunate to treat Major B twice per week in psychodynamic psychotherapy for eighteen months. I selected this patient and this approach for treatment with Level C evidence (psychodynamic therapy) because he had not improved after a lengthy treatment with manualized Cognitive Processing Therapy (CPT), which has Level A evidence as a form of cognitive therapy (VA/DoD, 2010). In fact, the treatment with CPT was interrupted when Major B became suicidal and was voluntarily hospitalized. I shall present some clinical material from our work together, and the understanding he and I reached about his world and self-experience. I shall start with his military history prior to the clinical material. Since intersubjective therapy takes the experience of both therapist and patient into account, I shall also discuss how our relationship has affected both of us, including how it influenced my processing of my own traumatic experiences. Through my discussion, I hope to show you how Stolorow’s phenomenologic, contextualist approach to trauma can lead to the bearing of guilt, shame, and mortality between two human beings in a therapeutic relationship¹.

Major B: The Search for Hope

Major B was a military pilot, married, and in his mid-30s when I met him. He reported no significant problems as a child, other than his parents’ divorce when he was a teenager. While it was upsetting, he denied the divorce had a lasting effect on him. He followed two of his elder siblings’ footsteps, and attended a military academy for college. Upon graduating, Major B entered flight school and was assigned to fly bombers, which he never particularly liked because they are large and not maneuverable. He had wanted to fly fighter jets. During the invasions of Afghanistan and Iraq, he flew missions in both countries, dropping bombs. Afterwards, he sought out positions with ground involvement in the wars, not only from a sense of patriotism but also to get out of flying bombers. He was given an assignment as a Forward Air Controller (FAC). He then deployed to Afghanistan, where he worked with Special Forces units to coordinate air strikes.

As a FAC, Major B accompanied Special Forces teams on missions. His job was to liaison with pilots and coordinate where their bombs should fall. Because Special Forces units are typically in high risk situations, this means that the FAC also has to operate weapons, becoming a functioning fighter within the team. Major B went off base in Afghanistan almost daily, sometimes twice a day with different teams, away from the protection of a base perimeter. He frequently operated their .50 caliber machine gun in vehicles. Major B was involved in numerous fights with the Taliban throughout the deployment and called in numerous airstrikes. He killed more than 100 people either with his personal weapons or through directing bombs onto targets.

After Major B returned from Afghanistan, he noticed problems in his functioning right away. He had been reassigned to his original community within the military, bombers. He had to go through refresher training, and he struggled. He argued with instructors who wanted to focus on training for rare emergency procedures; he felt they needed to practice dropping bombs and providing close-air support to small combat teams. He felt contempt for his peers. They had never been in combat, and they asked him questions, such as “Did you kill anyone?” that showed a naïve, almost sophomoric understanding of the experience. Although Major B’s wife joined him at this base, he felt very distant from her as well. He was depressed, isolated, and increasingly irritable. He drank alcohol to lessen his irritability and nightmares. Just like many other combat veterans, he responded to his feelings of disconnection to Americans who had never been deployed by trying to return to a place where he felt more comfortable and connected. This meant either combat or at least a country in Southwest Asia, such as Pakistan. After a little more than year of being back in the bomber community, Major B was selected to be a military attaché. These are military service members who serve at embassies as liaisons with similar armed services within the host nation. They often work for the Defense Intelligence Agency (DIA), which is the military equivalent of the CIA.

Major B sought out and was given an assignment to Pakistan. He told himself it would be his last adventure before he would “throw in the towel” on his military career and get help. But the job in Pakistan proved too much for him, his relationship with his boss and the isolation he continued to feel were too much. His depression and PTSD reached new intensities. He became numb to everything and felt utterly alone. His wife, living stateside, felt disconnected from him and wanted a divorce, his boss there felt Major B was not performing his job well, nightmares kept him awake at night, and his sense of vulnerability had him ever focused on the cars around him on roads. Which one of these was going to destroy him first? Although he was in Pakistan, when he was alone at night, he could still hear the voices of some of the people he killed in Afghanistan screaming their last words. During his last weeks in Pakistan, he became hopeless and suicidal. He wandered the streets of Islamabad alone at night, waiting for someone to murder him. Unfortunately, in his mind, it never happened. Up until the day he acquiesced and sought help in Pakistan, he felt suicide would be easier than the emasculating experience of acknowledging his PTSD and admitting he needed help.

When Major B revealed his shattered state to his supervisor and the embassy medical staff in Pakistan, he was immediately flown to back to the United States. He knew this would end his military career. He was told he would be medically retired from the military for PTSD in just a few months. He was also began treatment with a therapist who used manual-ized CPT, which, as described previously, has Level A evidence for PTSD (VA/DoD, 2010). A psychiatrist also started him on sertraline (Level A evidence for PTSD) for PTSD and depression, and quetiapine for nightmares, insomnia, and as an augmenting agent for depression. He was told there was no need to bring his wife to the area; his retirement would come quickly. He lived in a hotel room alone. A few months turned to nine months. His symptoms of depression and PTSD, per his description, improved only marginally during this time. Major B felt one good thing had still been allowed, he work a bit in the DIA headquarters. At least some of the people there understood his experience. They had been traumatized too. But the DIA grew weary of waiting for his medical retirement. He was sent back to work for the military. Again, he was reassured that it would only be a few more months until he was medically retired.

Major B was then transferred to a nuclear monitoring command to await his retirement. On his first day there, he realized he did not belong. No one had ever been deployed. No one had killed anyone. His new boss there was surprised to learn that he was waiting medical retirement, and told him he did not want to know or hear about the Major’s PTSD. His co-workers instantly mistrusted him and he was given little or nothing to do. He felt an excruciating singularity. He then learned the crushing news: his medical retirement process actually had never started. His doctors had failed to complete the paperwork. He had been waiting nine months, alone in a large city, in vain.

For three days, Major B lost all hope and lay in his bed feeling only despair. When he finally got up, his intent was to commit suicide. He planned to drive his car into an embankment at high speed. Instead, Major B decided to try one last way to find hope again. He drove to an hospital emergency department, and was admitted. This is where we met. I was the head of inpatient psychiatry at the military hospital. I had come back from Iraq just a little over a year earlier. When the Major informed our inpatient treatment team that he was “fed up” with the manualized CPT he had been getting and was angry about his doctors’ failing to help him with his medical retirement process, I offered to see him myself as an outpatient after he was discharged from the hospital. I was drawn to working with him. I told myself that I could not stand by while someone who had done so much for our country lived in such a shattered state. I hoped I could help him cross the chasm between his emotional experiences and the present world of United States.

He noticed my Iraq Campaign Ribbon on my uniform, and responded to my offer: “You’ve been there, so you’ll understand.” Perhaps he meant more than being in a particular place. I know now that there was more than patriotism behind my desire to help him. I too had felt the uncanni-ness of recognizing my finitude and thus, had been immersed in darkness similar to the one he in which found himself. Because the extensive, nine-month treatment with CPT had not helped—and possibly worsened—Major B’s depression and PTSD, I decided to use intersubjective therapy to help him understand and bear the meaning and experiences that were underlying his depression, PTSD, and suicidal symptoms. The psychodynamic therapies are grouped together in the CPG. Intersubjec-tivity therapy is a form of psychodynamic therapy and thus has C level of evidence for PTSD treatment (VA/DoD, 2010); I also continued the Major on sertraline (Zoloft), but I discontinued quetiapine for his insomnia and anti-depressant augmentation because it was ineffective and caused mild weight gain. I then prescribed an FDA-approved medication for chronic insomnia: eszopiclone. Although I have written about intersubjective therapy as a possible model for short-term psychodynamic therapy for combat-related PTSD (Carr, 2011), I realized from the beginning of my work with Major B that short-term therapy probably would not address his complicated symptoms. Thus, I planned for long-term therapy that would help Major B through the medical retirement process and transition to civilian life.

Stolorow’s Intersubjective Approach to Trauma

I immediately focused on understanding Major B’s subjective experience of the world after his trauma. I tried to hold in mind a few intersubjective attitudes taken from Stolorow’s writings. These include (1) the primacy of affect, (2) the radical contextualization of emotional life, (3) striving to understand the patient’s experience and organizing principles through empathic introspection, and (4) the conceptualization of trauma as unbearable affect (Carr, 2011, p. 474).

I also relied heavily on Stolorow’s descriptions of the phenomenology of trauma. In Trauma and Human Existence, Stolorow described several effects of emotional trauma on how a person experiences the world. The affected areas include a shattering of one’s sense of both safety (the loss of the absolutisms of everyday life) and time (loss of temporality); the loss of significance of socially defined norms (the tranquilizing illusions of the “they”); and the forced recognition of the inescapability of death (authentic Being towards death). These effects combine to give traumatized people an exquisite sense of singularity, shame, a pervasive sense of dullness, and estrangement (an ontologic unconscious state). I have used Stolorow’s ideas at times as a starting point for both me and my patients to begin to put words to their experiences. Having this understanding often gives my patients a sense that I get what they are enduring. Major B suffered many of these effects of trauma, and I shall try to weave some examples into the discussion of the case material.

Guilt

Soon after Major B and I started our work together, I realized that he suffered from an exquisite combination of shame and guilt, as did many others returning from combat. We had to continuously address these two areas in our work together. Both of these powerful feelings go hand in hand with the isolation and singularity that unbearable emotional trauma brings.

Major B’s guilt came to the forefront within the first few sessions: It involved what he did in Afghanistan. He focused on his guilt about those he killed—often in the name of protecting himself, his team, or completing their mission. He often maintained that given the same circumstances, he would kill the same people, but that did not make it any more bearable. The source of his guilt was a key disjunction between Major B and his former therapist. It contributed to why his stopped working with her. He said that she never understood that the violence he witnessed in Afghanistan did not bother him, even though it bothered her greatly. Instead, his feelings about the violence he inflicted haunted him. Within our first few sessions he so intensely described one instance of the violence he inflicted in Afghanistan that now neither of us can forget it.

Major B recounted that his Special Forces unit would engage groups of Taliban fighters in ground combat, drawing out as many of the enemy as possible; then he would call for air power backup to complete the mission. But one mission was different for him. The emotions he experienced became unendurable. He was unable to find a relational home in which to process them. We entered into a discussion of this experience through a discussion of a recurring nightmare, in which he can’t stop killing people:

This session was moving to me. We stayed with his emotions and tried to bear them together as long as we both could. As he described the scene, I, too, could hear boys screaming. Just like the Major, I was uneasy and anxious as we ended the session.

In listening to Major B’s account of this horrifying experience, I too was traumatized. For much of the rest of the day, the experience took me out of my focus on normal everyday activities. I continued to hear and feel the screaming. The experience stayed with me for several more days. I found myself trying to process it with the help of others, mentioning the story to other providers and supervisors. I was more than mentioning it. I was trying to find a relational home to bear and process the uncanny feelings that being confronted with the deaths these teenage boys stirred in me. After several days the screams and anxiety faded from me, and, for the most part, I once again became absorbed in my day-to-day existence.

This uncanniness and anxiety when confronted with mortality is what Stolorow talks about as authentic Being-toward-death (Stolorow, 2007). He uses terms such as that from Heidegger’s Being and Time (1927/1962) to describe the effects of unendurable traumatic emotions. From an analyst’s, non-philosophic perspective like mine, authentic Being-towarddeath refers to being forced to recognize that each of us is alone in bearing our own inescapable (yet indefinite) death that might occur at any time. And in the wake of this realization and the anxiety that accompanies it, “the everyday world loses its significance” (Stolorow, 2007, pp. 34-40; Carr, 2011).

Major B, had been unable to return from his authentic Being-toward-death to a significant, everyday world. After that moment in Afghanistan, his sense of time collapsed. Unlike dropping bombs on voiceless aggressors in previous missions, Major B had felt a human connection with the boys he had killed that day in Afghanistan. He had heard them scream for help and understanding, and he heard them find neither. He recognized their mutual human frailty and for the Major, killing them was unbearable.

Without a relational home to process such traumatic emotions, Major B had not been able to give his feelings any meaning through language—an essential part of maintaining a sense of being according to Stolorow’s perspective (2007). Stolorow notes that unendurable emotions then become dissociated when they cannot be processed with others. And without a way to bear these emotions, the traumatized individual senses deadness, dullness, and a loss of vitality. This is what Stolorow calls ontologic unconsciousness, or “a loss of one’s sense of being” (2007, p. 26). It was the loss of affective aliveness. Major B continued to experience this ontologic unconscious state when he returned from Afghanistan and failed to reconnect with his family and former pilot friends.

Shame

As Major B and I continued to explore his guilt from his experiences in Afghanistan, we both began to understand how it was intimately linked with shame: shame from the isolation he felt in his traumatized state and shame about who he had become after combat. Tremendous shame arose from a fundamental belief that he could no longer handle combat because he needed help with the unbearable emotions attached to his combat experience. Just as Stolorow described the source of trauma as the unbearable emotions attached to an event (and not the events themselves), the emotions that combat generated in Major B overwhelmed him. He believed he could not seek out other people to help him bear and process his feelings about killing large numbers of people. He often told me that beginning with his days at the academy he bought into the John Wayne military persona: the stoic tough guy who nothing bothered. Major B’s need to hide negative, painful emotions from other people contributed to his difficulties in processing feelings after combat. His experiential world began to shatter because he could not share—and thus process and integrate—his overwhelming feelings. And because Major B felt that he was not living up to that ideal of a stoic masculine hero, he felt tremendous shame. And though Major B has been through treatment, he still wrestles with admitting to his problem and then seeking help, which he perceives as emasculating.

Major B’s shame arose not only from his emotional reaction to combat, but also from fear about who he had become after combat. Immediately after killing, he managed to feel no emotions. And although this was adaptive in those moments of continued combat, this ability to deaden emotions scared him. He feared the combat experience had turned him into an emotionless killing machine that could not be disengaged. He feared committing monstrous acts outside of combat.

When he returned from Afghanistan, Major B could not pick back up with the life he previously led. Additionally, authentic Being-toward-death stripped his present day-to-day activities of significance. When he did have opportunities to process his emotional experiences and perhaps bear his sense of anxiety and uncanniness, his fellow pilots enforced on him the stoic masculine persona of their community, with questions like, “How many did you kill?” They couldn’t tolerate, much less discuss, the guilt and shame he felt and they sought to deny the emotional impact of his actions. But he could no longer tolerate denying his painful emotions into order to fit himself in with them. Working as a bomber pilot was his “they” in Heidegger’s terms that had regulated his affective life prior to his combat exposure. But he could not return to everyday life with them and deny what he had felt about our shared fragility. That life could no longer distract him from the inescapable eventuality of death for all of us. His situation left him feeling utterly alone, reinforcing his ontologic unconscious state. A sense of dullness, separateness, and depression pervaded his existence. Major B struggled to find antidotes to this deadness. His subsequent adventures, such as heavy drinking and seeking out an attaché position in Pakistan, might be seen as attempts to find an antidote to his unbearable lack of a sense of being. After learning that some veterans had become violent towards loved ones, he also began to fear that he, too, might resort to violence as an antidote for his disturbing emotional states and sense of estrangement.

Two Sessions

Several weeks into our work together Major B reported he was greatly disturbed by a radio show he had listened to about a veteran with PTSD.

It ignited a series of dreams in which it was clear to me that he was trying to process his unbearable shame and guilt and come to terms with his experience of the world after combat. At this time in our work, he continued to wrestle with depression, hopelessness, and shame. He enacted these feelings in our relationship by often arriving late or not showing up to our appointments. For example, he was 25 minutes late for the appointment I present here. Here is much of the session—or as much as I can transcribe from my scribbled notes:

Major B and I continued to work on these themes of guilt and shame and his shattered self-experience. Some other themes emerged, including ambivalence about re-engaging in intimate relationships and doubts about being able to reconnect with a normal life, and we continued to develop these in subsequent sessions. This is some of the next session:

What I Brought to Our Relationship

During some of my sessions with Major B, I felt myself slipping back to my own experiences in Iraq. Although I never saw the level of violence most of my patients describe, the anxiety of facing my finitude almost daily affected me. Bases were mortared frequently. Improvised explosive devices exploded. These moments of overwhelming anxiety and helplessness were unpredictably mixed with boredom and homesickness. When IEDs exploded nearby out of the blue, the blast wave seemed to rush through my body before I even realized what it was. Explosions, sniper fire, and suicides were all occurring regularly and unpredictably. While I was deployed there, my anxiety never returned to a relaxed baseline. My experiences reinforced the unpredictability of death and left me with emotions that have been difficult to process and integrate.

As much as my own experiences in Iraq affected me, therapy with traumatized military personnel has also taken its toll on my sense of a safe, “normal” world. Some dialogues I had with other patients left me in traumatized emotional states because I try to get as close as I can to understanding their emotional experiences to help them bear and process what has otherwise been unendurable for them. This often means I must be vulnerable in my finitude and in my shared humanness. I have to acknowledge that what they feel is a part of the human condition. During the 13 years that I have been a physician in the U.S. Navy, I have shared our mutual finitude with many service members. As I describe in the book chapter “The Loss of Normal,” (Carr, 2013) these experiences have definitely changed me, leaving me more akin to those who have suffered unendurable trauma than those who have not. Just like the people I treat, I have lost many of what Stolorow calls the absolutisms of everyday life (Stolorow, 2007). My sense of time has also changed now. Much of the years since 9/11 is a blur without time for me. I have lost a sense of continuity with the past prior to 9/11. I am disconnected from friends I had before the Navy. I find myself yearning for those times when I watched shows like Seinfeld, which was about nothing. I long to share feelings—other than anxiety and pain—with another person. Sometimes I have to focus not to think about what catastrophic events might happen to me or my family. I know now that these things can and do happen. I have seen them happen in other places and felt the aftereffects. I now connect best with those whom Stolorow would call my siblings in the same darkness (Stolorow, 2007): my patients, other military healthcare providers, and those outside the military who have “been there” in traumatized emotional states and understand our shared mortality.

Being in my own psychoanalysis has helped me to bear and process these feelings.²

While I was providing a relational home to Major B and we began to process, bear, and integrate his traumatic emotional experience, I was joining him in my own similar darkness of trauma. I shared with him the uncanny anxiety of authentic Being-toward-death. In order to help him bear and put words to his emotions, I had to be with him in our human frailty. I provided and received twinship. As we find such twinship to help us bear traumatic emotional experiences, we realize, like Stolorow, that death is, fundamentally, relational (Stolorow, 2007, pp. 47–51). We learn about death by seeing those around us die. It is an inevitable part of life, making the need to bear it universal. Major B needed someone to help him process his emotions about trauma and death so that he could integrate them. I could empathize with him. Combat-related trauma is a familiar place to me. But I also think other therapists who can acknowledge their own feelings about death and trauma can provide twinship to such a shattered experiential world and help their patients bear it.

The Struggle to Persevere

During our continued work, Major B’s administrative status remained in limbo, his shame and guilt persisted. He waited for medical retirement from the military. Major B wrestled to overcome his ontologic unconscious state before he could even begin to process and integrate his traumatic emotional experiences. There were days when he felt too much deadness to leave his apartment. His isolation in a large city re-enacted his excruciating emotional state of singularity and shame. He later told me that during this time he had started each day by deciding whether to kill himself. That is what he meant by losing freedom by having others, such as a family, close to him. He feared he would lose the freedom to end his struggles with his shattered emotional state. He also tried to escape his overwhelming feelings by creating new adventures: going out to bars in rough parts of the city and inciting violence towards himself. He would get drunk and pick fights. He told me after one of these episodes that he was trying to escape his unbearable sense of dullness and isolation.

Major B and I struggled together to bring him into the present. Our goal was for the traumatic past not to feel as unbearable, not to leave him perpetually listening to the Afghan teenagers’ last words, and not to leave him wandering the streets of Islamabad in excruciating isolation. By helping him put words to the shattered state he was feeling in the moment or to the emotions linked with combat that shattered him, I hoped to help him develop a sense of connection with me in the present. The more he might feel understood by another person in the moment, the more he would be grounded with that person in the present. I strove to create such moments of understanding in the present with him. There were days he and I bravely reached towards each other and bore his horrors together. There were other days when he could not face these unendurable emotional states and stayed in isolation, with his feelings dissociated or numbed by alcohol. Some days I could not stay with him in traumatic moments, finding time collapsing for me back to any number of traumas. Sometimes when he described his shame at whom he had become, his ambivalence about enduring a road to recovery, and his desire to “keep my options open” for suicide down the road, I would leave our sessions feeling hopeless. I had a sense at those times that maybe I could not save him. I felt our relationship together would not have a positive outcome. I feared that I could not save him from either eventual suicide or a life of being “comfortably numb” through isolation or alcohol. But I refused to leave him and continued to strive to understand empathically his experience of himself and the world and to help him understand it as well. Through perseverance, we both gained a deeper appreciation of his suffering and his enduring sense of hope.

Mixed in with hopelessness, Major B showed courage and emotional strength. On good days, he was determined to stay with me: to process his feelings, to bear these feelings together, and to integrate them into his world of experience. In those times I sought to provide twinship to him as another human being wrestling with the traumatic experiences of finitude that are inherent in everyone’s life. As a consequence he gradually developed anticipatory resoluteness—another term Stolorow borrowed from Heidegger (Stolorow, 2007). I understand this resoluteness as a more constant and more individualized sense of self that can develop as traumatic emotional experiences are processed and integrated. As experiences are integrated, a person regains a sense of being. Sometimes, as a person regains a stronger sense of being and self constancy, a new sense of what is important in life might also develop, such as family or causes to take up. But the traumatic experiences will not simply fade, never to return. As Stolorow has taught me and I’ve experienced for myself, these rips in one’s world of experience that occur with traumatic emotional states do not ever completely heal without the possibility of reopening again. Instead, with processing and integration, the uncanniness and unbearable emotional states are not as strong nor as intense as in the past. They become better tolerated as one spends more time in the present than in the traumatic past. One can still be transported back to these traumatic emotional states through reminders of them, what Stolorow (borrowing from Harry Potter) calls “portkeys” (Stolorow, 2011). It is hoped that such returns to these states become less frequent and less intense.

In the next three to four months as Major B spent time out of his ontologic unconscious state, he showed an increasing sense of self-constancy. He began to volunteer for activities through the Wounded Warrior organization within the military. The military had developed it as a way to track and help returning wounded-in-combat service members, and Major B was given opportunities to become involved in it. Because of his position as an officer, the organizers of the program offered him leadership roles, which he embraced. He represented Wounded Warriors at meetings and banquets. He shared stories about some of these events with me, and he described feeling a sense of resoluteness in representing those warriors suffering from PTSD. He also appeared to be tolerating the shame and stigma better, particularly in acknowledging his mental health problems, and he had begun to hope others could learn from him. He allowed himself to experience emotions much more so than the John Wayne movie persona could, and he struggled to find a new way to experience himself as a warrior. His PTSD symptoms were resolving, but at times he still experienced a depressed mood with insomnia, a sense of depletedness and low energy. We agreed to change his medication regimen at this time, cross-titrating from sertraline to buproprion (though not indicated for PTSD due to the risk of worsening irritability and anxiety (VA/DoD, 2010), I selected it to target better his depressed mood and low energy). He tolerated this medication change well. About 12 months into our work together he received word that he would be retired from the military. Within a few weeks, he was discussing what his future would be like, including trying to find work and moving in with his wife. We have continued to process what these experiences have meant for him and his future, and his periods of deadness and hopelessness are less frequent.

Conclusion: Therapeutic Action in Contemporary Psychodynamic Therapy

In conclusion, how do I understand therapeutic action in intersubjec-tive therapy, a contemporary psychodynamic approach, as exemplified in my work with Major B? I provided for him a relational home where, as Stolorow describes, “devastating emotional pain can be held, rendered more tolerable, and, hopefully, eventually integrated” (2007, p. 49). This relational home develops through two people sharing their common finitude. There is a twinship in our mortal frailty that we all share, if we allow ourselves to recognize it. I acknowledged and bore with him the fact that traumatic emotional experiences are a fundamental part of human existence. To do so I had to feel the uncanniness with him and recognize the indefiniteness of our shared existence. I had to reach him where he was in his unbearable traumatic emotional state and help him bear it. Seeing my Iraq Campaign ribbons was my “foot in the door,” easing a sense for him that I could understand him. But I don’t feel he meant that comment to exclude other mental health providers who are not in the military. They simply meant I was literally wearing my trauma. Trauma is ubiquitous in our shared finitude. All of us as therapists have experienced trauma, simply as a consequence of living in the world. We all have in common a familiarity with trauma and mortality inherent in a finite existence.

That statement of his to me about the psychiatric unit “you’ve been there, so you’ll understand” was not exclusionary. It was one of hope. And through our work together, he began to feel understood as we bore our common finitude. Through our work together, he no longer felt such intense guilt, shame, and singularity. Although psychotropic medications were prescribed to help reduce symptoms, this case exemplifies how psychotherapy is the crux of treatment for PTSD. The symptoms of PTSD, whose amelioration might indicate recovery, are not the focus. Instead, the goal, as demonstrated through this case, is integration of the experiences of traumatic events into a coherent sense of self. The traumatic experiences become processed memories that no longer intrude repetitively and indefinitely into present-day life. Symptoms, which are important but not a central focus, become less intense and can resolve as this occurs.

My experiences with Major B and other combat veterans, along with my own psychoanalysis, have also helped me to reach an anticipatory resoluteness after my own traumatic emotional experiences. The last 10 years of war have taken a toll on our military system and our service men and women, including me. I have struggled with distancing myself from everyone in order to deal with the pain I witness as casualties come to our hospital every day. It would, in many ways, be easier for me to disconnect from my own close relationships. At work, I sometimes busy myself with jobs that are far away from emotional trauma and thus feel safer for me. But bearing Major B’s emotional experiences with him has helped me refocus on what is important to me. My work with him and other veterans helps me put the uniform back on every day. Major B’s resoluteness inspires me to take up the work in military mental health care that I feel is so important. I have seen that providing twinship to someone lost in the darkness of traumatic emotional experiences can help both of us bear unendurable emotions and move us closer to the light of self constancy and authentic existing. Intersubjective psychodynamic therapy keeps the focus on the patient, while taking into account that all forms of therapy affect and are influenced by the experiences of the therapist. We, as therapists, bring our own injuries into the consulting room, and are all injured to some degree when working with severely traumatized patients. The work is difficult. This form of therapy does not deny this fact, but instead embraces it. By requiring the therapists to acknowledge their own traumatic histories to themselves, it encourages therapists to seek healing and not to let unintegrated traumatic experiences, whether past or due to the work itself, impact a patient’s therapy.

Psychodynamic therapy is considered a level C treatment for PTSD (VA/DoD, 2010) in the current body of evidence. It began as a treatment for childhood trauma, and has struggled to demonstrate efficacy for adult-onset trauma, such as combat-related PTSD (Boulanger, 2007). In my experience, traditional psychodynamic approaches are employed in the treatment of combat-related PTSD when an underlying developmental trauma is contributing to the effects of combat. I hope this more contemporary psychodynamic approach, intersubjective therapy, will find a broader niche in adult-onset traumas such as combat-related PTSD. It may be more effective for patients with multiple traumatic experiences, particularly those with exquisite shame, guilt, or alienation that prevents them from easily forming therapeutic alliances with therapists. When trying to treat patients with as little as six months of combat experience, the need for an approach, such as intersubjective therapy, that focuses on the traumatized state and not a particular traumatizing event becomes apparent. Research is needed to understand more fully the experience of combat-related PTSD and what may separate the experience of active participants in combat during several deployments from the experience of the single-incident assault-oriented therapies that currently dominate practice guidelines. As with other forms of therapy, intersubjective therapy will need to be manualized for empirical testing. As a contemporary, relational psychodynamic therapy, it includes the experiences of the therapist while maintaining an asymmetric focus on the patient. This will be make empirical testing more difficult, but, in my opinion, it will be worth the effort.

Postscript: In His Own Words³

“So he has finally finished, right? Actually, I’ve seen a different side of [him]. I usually get to talk all the time. So this should be an interesting part for you guys. So hopefully I can share with you and elaborate a little bit about some of the pieces about what he spoke about, particularly about me. To be fair, it was probably all true, but I do like to make things up also.

“In any event, I joined the military . . . got started in the military . . .just prior to September 11^th. At my first job I deployed, and I’ve been busy ever since. I was in for 12 years. As you can see, I am finally out [rubs his beard in the video]. But it was a lot of experience and it was very busy. And I’m not the only person who has had a lot of combat experience or done a lot of things and then been unceremoniously dumped back into the normal world. It can be an extremely difficult adjustment. I always found, or I felt at least . . .I felt like in my mind, that I was more comfortable and competent and didn’t necessarily notice any of the symptoms I had while I was around other people that were experiencing the same thing. So it was something that we were all crazy together. Or a lot of the issues I had readjusting or getting back in to a normal life . . .some of that may have been me thinking I was fine when I wasn’t. Some of it might have just been that some of the skills I developed for combat and for war were not, are not, appropriate for normal life. And the adjustment period just wasn’t there for me. So a lot of what I ran into when I finally had to call a “time out” and seek help and treatment for what I was going through was just . . . I got to the point to where I was no longer willing to live . . .in that job or function around people that I didn’t respect or trust or that I had perceived not to have experienced the same stressors and emotions I had.

“And so you, in the civilian world, when you encounter people like me, you are probably going to run into a lot of people like that. They are going to have a difficult time interacting with you because they just don’t trust you. A lot of the isolation I felt—and I’ve kind of worked my way through it—is just that, how could someone who has not experienced the same stressors as me possibly be of any help to me? What could they bring to the table? And to be fair, I had a lot of military help and therapy that wasn’t very useful for me simply because the people that were trying to help me didn’t take the time to establish that they had something to offer me. They tried to sort of dive right into fixing my problems that they perceived me to have based on a couple of questionnaires. They didn’t take any effort to establish a rapport, and to me that was an immediate turnoff. The military and myself [sic] wasted a lot of time and a lot of what could have been useful therapy because I instantly discounted it. I’d show up to get help and not get help because I didn’t care for the person. Even though I perceived some of these people were honest and empathetic and wanted to help me, I couldn’t accept help. This is something that, when I finally started working with [my current therapist], it was a huge difference for me. He didn’t approach me or my problems as ’here’s what’s wrong with you and here’s how we fix it.’ He may have somewhere in his head had a plan, but he certainly didn’t explain it to me. But he sort of allowed me to organically develop a relationship. At least he made me feel like I was coming up with solutions on my own.

“I think you are going to find, when you do encounter people from the military that have issues with their combat-related experiences, it is a much better approach than, ’OK, here is what the literature says about PTSD and here are your four categories of symptoms that qualify and here is how we deal with each one is sort of.’ Take a step back and work on that wonderful bedside manner that some doctors just never seem to have—even in your career field, and let the people just become accustomed and comfortable to you, and even become accustomed and comfortable to the experience of talking about it, before you dive into curing anybody or offering solutions or trying to guide conversations. Let it be a little bit chaotic in the beginning, and take some time. What I found in my transition from military life to civilian life . . .you know I’m not there yet; I don’t feel like I’m cured or good now . . .is that having that rapport and trust. . . that is probably the most important thing I have at this point in my relationship with my therapist. That is what has allowed everything else, all the other gains I’ve made, to materialize. And if I hadn’t had that to begin with—which was kind of my initial experience with military therapy; it was just a waste of time for everybody. And [it] took me from a bad spot and put me into a terrible spot.

“I think I rambled on a bit here. I kind of wanted to get that one key point out that—and I’ll say it one more time—is: there is nothing more important than a positive rapport with your patient. If you can’t get to that point, then everything else, the entire rest of your message just gets lost in this filter of ’I don’t care what you say because I don’t like you.’ Forgive me. It doesn’t have to be like that. They have to respect you and understand that you are there to help. You are not trying to fill a quota of ‘buy a boat.’ You haven’t just read something somewhere and want to apply that.

Thank you for taking the time to hear my story, hear [my therapist], and then hear me [speak] as well. Thank you very much.”

This paper was first presented at the 34^th Annual Conference of the International Association of Psychoanalytic Self Psychology (IAPSP) in Los Angeles, CA, on October 14, 2011. Disclaimer: The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Uniformed Services University of the Health Sciences, Department of Defense, nor the United States Government.