Recent studies suggest that more than a third of combat veterans of the Iraq and Afghanistan wars will require mental health treatment, with one in eight soldiers experiencing symptoms of Post Traumatic Stress Disorder (PTSD). Worse yet, most cases of PTSD aren't diagnosed until six months or more after returning home. Another fact aggravating this looming mental health problem is that only half of the soldiers requiring treatment may actually seek it, because many veterans view admitting symptoms of stress after combat as a weakness, or fear the stigma of a diagnosis and the negative impact this may have on their careers.
My own clinical experience has shown me that marriage therapists can be of tremendous help to military veterans and their families by focusing on relationships instead of the individual's PTSD symptoms. I've found that veterans who are reluctant to admit to combat-related stress problems will often enter couples counseling if they believe their marriages are at stake. Moreover, couples therapy can motivate spousal support, a factor that's crucial to helping vets recover in ways individual treatment doesn't.
Phillip and Connie
Phillip and Connie had been married for four years and Phillip had just completed his second tour in Iraq. They'd had some problems earlier in their marriage, especially after the birth of their first child. With Connie never completely in favor of Phillip's joining the military, they'd argued frequently after his first tour in Iraq, and his redeployment had led to even more bitter fights. But after this second year of separation, they each believed that they'd learned from the experience of living apart and had grown to more fully appreciate each other. When they were reunited at the airport, they were filled with excitement, certain that everything was going to be okay. Within 24 hours, however, Phillip would be arrested and a devastated Connie, with bruises on her arm where her husband had grabbed her, was beginning to believe that they should divorce.
Following this incident, Phillip had been court ordered to an anger-management program and a friend of theirs had referred them to me. They described the fight which led to Phillip's arrest as not much different than the old fights they'd had between his two deployments, but were startled by how fast it occurred and how early in their reunion. He wasn't even sure what it was Connie had tried to ask him, but he'd felt like he was being barraged with questions. She felt Phillip shut her out if she asked anything about the service or his tour in the Middle East. Phillip experienced his wife as irrationally angry and "out of control," but also acknowledged that even Connie's physical closeness made him somehow edgy.
This is extremely common in veterans. Phillip wasn't responding to Connie's questions so much as to the internal state of arousal caused by her perceived intrusion. Then when, after an especially heated confrontation, Connie had tried to leave the room, Phillip had grabbed her arm really hard. He'd never touched her before like that and admitted that he'd never felt quite that enraged and confused before either, except in combat.
In their first interview, Phillip and Connie alternated between stony silence and rapid-fire accusations of what was wrong with the other one. I evaluated them for safety issues and asked for their commitment to avoid any further abusive actions, particularly any negative physical contact. Then I asked them not to work on their marriage until the next couples session, but to have a brief discussion about whether they thought I was the right therapist for them and, if so, to make individual-evaluation appointments as the next step. I wanted each of them to think about and make a commitment regarding their desire to work with me. More important, however, I wanted them to have one small, doable task to perform in the next few days.
After they decided they wished to work with me, I had an individual session with each. During his session, Phillip described combat-induced PTSD symptoms, a heightened startle response, disturbed sleep, and restlessness, as well as irritability and impatience, including road rage. However, he refused to even consider PTSD treatment. What had inflamed Phillip and led to his fight with Connie was, he said, her insistence that he talk about his war experience. Most combat veterans with whom I've worked try to protect themselves by not thinking or talking about the war, and try to protect their families by not sullying them with the details of their combat experiences. Traumatized individuals often describe feeling that their experience was diminished or betrayed by trying to explain it to those they don't believe can understand what they've gone through.
In her session, Connie said that the two years her husband had been away were like a mystery to her. She talked about Iraq and the military as though they represented a betrayal by Phillip. She just wanted to have some sense of what had happened to him during his tours. The idea that they were supposed to ignore all that time apart and the perception that there were secrets between them felt like an open wound. She didn't want to talk about the war per se, but she did need to feel they were reconnected.
Small Things that Work
By the time they reach my office, veterans and their wives are typically overwhelmed by fear, guilt, and anger. My approach to couples therapy focuses on immediately lowering physical arousal, and then training the partners to help each other manage their stress and anxiety. Once both Connie and Phillip agreed to work with me, my first goal was to help them lower the arousal level between them. I asked them to locate some small, everyday experiences that either worked or failed to work for them. Phillip mentioned that Connie used to touch him in ways that could be tremendously comforting. Connie yearned to reach out to her husband, but it was just too painful when he'd flinch, recoil, or yell at her for touching him. Touch in this case was a pivotal issue for them, given Phillip's highly aroused physiology.
We discussed the startle reflex and how normal this reaction is in combat veterans, and Phillip was able to talk a bit about other ways in which he was easily startled. He then said that as long as he could see that his wife was near him and as long as she didn't touch him from behind, it was usually okay. Connie realized that perhaps part of the reason she kept startling him was that she often touched him on the small of the back, which previously had been an intimate, reassuring touch for both of them. I asked her to try touching Phillip right in the center of the chest, which can be an immensely warm and intimate touch. My initial work with couples is generally focused on these small, mundane agreements, rather than on trying to solve big problems or build intimacy.
I've discovered that one of the worst things one can do with a highly aroused, flooded, volatile couple is to try to increase their closeness too quickly. Suggesting that they have dinner dates or spend more time together may only serve to further stimulate their nervous systems and overwhelm them. To help them grasp why it can be so difficult to talk about certain charged subjects, I try to normalize their experience by explaining how physical arousal can lead to a decrease in neocortex activity, including organizational skills, short-term memory, concentration, empathy, creative and abstract reasoning, and self-examination skills. To give them a picture of what they're experiencing, I even describe the specific areas of the brain affected. In the process, they learn that their difficulties aren't so extraordinary and that these heated conflicts don't mean that they're stupid or awful, even if they do awfully stupid things to each other.
So with Connie and Phillip, I went over a number of rather mechanical strategies they could use to calm their discussions of their hot-button issues--like setting agendas, evaluating the importance of various topics, and listing subtopics. We also looked at other strategies, such as scheduling partnership meetings, taking half-hour breaks, using nonverbal gestures to change the direction of discussions, maintaining agendas or lists of topic areas, as well as individual relaxation techniques, such as the Quick Calming Response, hot showers, and physical exertion, among others. My emphasis is on creating predictability and safety for each partner by reducing unplanned and out-of-control discussions.
Phillip was having problems with erections, but was unwilling, prior to therapy, to even discuss this with Connie. He eventually admitted that he thought he might just be finished in that department. She'd thought that the few pounds she'd put on while he was away made her less desirable. We discussed the biological connection of stress and sexual response. I asked them to take the focus off of performance, erections, penetration, and orgasm, and consider instead pleasure and the ebbs and flows of enjoyment in their intimate experiences, from casual touch to sexual intercourse. Again I encouraged a mechanical approach in which their initial discussion of sex wasn't to be in the bedroom but at the dining room table, accompanied by paper and pen, even perhaps by sex-related books. Typically I ask about and begin education on sexual issues early in treatment, based on my belief that physical intimacy is a crucial issue when people have been traumatized and that delaying the discussion of sex can make it seem more dangerous or overwhelming than necessary.
Later in our work together, we focused on understanding relapse. I pointed out that the goal of treatment isn't a perfect relationship, and that everyone experiences old triggers and may respond with their most primitive defenses. The goal for when that happened was that they should learn how to quickly use their new skills and agreements to avoid getting derailed. The relapse discussion is extremely important, because when couples are unprepared for relapse, they feel profoundly disappointed and injured when it occurs. Phillip and Connie experienced small regressions repeatedly during our work, when some argument or behavior looked like "the bad old days," but we were eventually able to normalize and even celebrate these as learning experiences.
Maintaining the Couples Therapy Focus
The dramatic events of war or any other trauma can engross a therapist, and yet it's always important to remember the contract with the client, which in this case was couples therapy. Too much of an initial focus on PTSD here would have risked my appearing to side with Connie and would have derailed work on the relationship between the two of them.
Will Phillip and Connie ever need to really talk about the combat situations he faced in Iraq? I'm not sure, but he may find that additional sharing makes them feel closer. Combat veterans, like any other traumatized people, often feel like they're totally alone in their experience. What couples therapy can offer them is the opportunity to reestablish the primary connection to an intimate other. In their spouses, these soldiers have the potential to experience profoundly healing support. If the partner can take negative behaviors less personally, develop skills for helping the veteran, and lower their own arousal level, healing can take place through the relationship.
The Case Isn't Over
At the end of treatment, Phillip still didn't think that he had PTSD because, after all, so many others went through as much or more than he did. He still reacted strongly to loud noises at times or would catch himself getting edgy with Connie or their child. But he'd learned ways to calm himself down and avoid exploding, and both he and Connie agreed that these charged moments were less frequent. She said that even though they still had work to do, she felt much closer to Phillip.
Even without being experts in PTSD, couples therapists can offer returning soldiers a great deal of help. Explaining to couples how their brains and bodies work can allow them to recognize how natural their responses are and to realize that their fears and anxious responses--and even their bad behaviors--are normal human reactions. These negative reactions don't signify that they're incompetent or unlovable, just that they're not connected with each other. By understanding their experience in biological terms, many couples can more readily forgive themselves and each other for the terrible things they may have said and done, or even thought, and begin rebuilding their relationship.
By Robert Scaer
Although he admits that it doesn't substitute for the primary treatment of PTSD, Don Ferguson argues here that couples therapy can help in the treatment of combat stress in vets returning from Iraq. He tries to show how, within the context of couples therapy, such techniques as subtle exposure, psychoeducation about the physiology of trauma, and facilitating conversation about the war can dampen the exaggerated fear response some vets experience with their spouses.
While Ferguson showed sensitivity to this issue, the case report doesn't make clear that he went far enough in avoiding any suggestion of a "mental" or psychological defect in his framing of Phillip's symptoms. Any therapist working with vets needs to understand the important role shame plays as an obstacle to their seeking or accepting therapy. The initial trauma of combat often is even exceeded by the trauma of being diagnosed as having PTSD, a stigmatizing label that's seen as a profound character weakness by both the peers of vets and their superiors.
From the initial contact, it's crucial when working with vets like Phillip to explain that their symptoms are physically based and rooted in how the brain works when confronted with situations involving extreme danger. Any implication that insight-oriented, traditional psychotherapy is necessary must be avoided. I've found that somatic approaches like EMDR, Somatic Experiencing, and Thought Field Therapy, if they're initially presented in ways that honor the sensitivity of vets to stigma and the implication of character weakness, can be the most effective ways of addressing their needs.
While the relatively peaceful resolution of conflict reported here is a helpful start, the question remains of how this couple will deal with the likely resurgence of Phillip's fear-conditioned memories of combat. The fact that he'd already exhibited some violent behavior is a red flag for potential further abuse. Without a great deal of additional individual therapy for Phillip and couples therapy for both partners, they'll remain at risk, and it's the therapist's responsibility to insure that the potentially abusive partner accesses the treatment resources necessary to prevent further violence.
I appreciate Robert Scaer's emphasizing that couples therapy isn't a substitute for focused treatment of PTSD. My contention, however, is that, with the lack of readily available services and reluctance of many vets to obtain treatment, couples therapy offers an avenue to help. A skilled couples therapist can provide a safety valve for a volatile marital situation and invite each partner to seek any additional help required. This can afford the vet a first step toward PTSD treatment.
The distinct advantage offered by couples counseling in these situations is that it addresses Scaer's concerns about labeling veterans. In my approach, the emphasis is never on the diagnosis of either partner, but rather on calming their interactions and reestablishing a safe connection. The advantage of this work is that it can be practiced in the daily activities with the partner, rather than merely in a therapist's office.
The problem for the couple, of course, isn't the veteran's heightened physiological response to extreme danger, but that this response also occurs when a seemingly benign interaction occurs. This sudden anger, irritability, or fear overwhelms the partner and shames the veteran, and both experience the event as a serious rejection. This creates a repetitive cycle of intimacy failures that will result in estrangement between the partners if left unattended.
My point in presenting this case is to encourage marital therapists to be open to veterans and their partners, and to treat the relational issues as they would those in any other diagnostic category. But as Robert Scaer points out, the marital therapist also should be aware of available resources and encourage the traumatized veteran to seek PTSD treatment.
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