Nicole, 22 years old, slipped into the Vet Center one day last year. Small and shy as she was, her 18-month-old son, Jonathan, seemed almost bigger than she. She held him tightly to her chest, as if for comfort and protection. "My husband is a vet. I heard you might be able to help him," she said.
A petite Asian American, Nicole looked like a teenager in blue jeans and a flowered camisole. Sitting on the edge of the couch, she handed her baby a toy and began her story, her beautiful eyes overflowing with tears. "Since Brandon--that's my husband--came home from Iraq nine months ago, he's a different person. He has nightmares, talks in his sleep. The worst part, though, is that he's so withdrawn. He won't talk about what he went through. His eyes look hollow," said Nicole, her own eyes reflecting confusion and concern. "He's no fun anymore, so I go out dancing by myself--just to relax, or maybe to make him jealous. It seems like the only way to get his attention is to make him mad. I'm just about to give up."
"So what made you decide that today was the day to come to the Vet Center?" I asked her gently.
"Brandon is in jail," she whispered. "I called the police last night because he grabbed me and pinned me against the wall. I was really scared. My mother made me take out a restraining order against him. I called his dad, and he's going to bail him out and get him a lawyer. His dad is a Vietnam veteran, and he told me about the Vet Center. He said he's going to have Brandon call you. Can you help him?"
"Of course. The Vet Center is here to help Brandon--and you, too," I assured her. "I'll get him right in as soon as he calls. Can you tell me what happened?"
"It's embarrassing," she began hesitantly, head down, shiny, long, black hair covering most of her face. "I went out drinking with my girlfriends. After I got home, Brandon and I had a few more beers. He wouldn't talk to me--just sat there drinking his beer and watching CNN like he always does. I pleaded with him to look at me. Well, maybe I actually screamed at him, and I think I might have said that he was a wimp posing as a big, tough Marine. He still just ignored me. Then I grabbed the remote, threw it down, and stamped on it. That's when he pinned me up against the wall. I couldn't believe how fast he reacted, and he had a terrible look in his eyes.
"I want you to know that I love Brandon," Nicole said looking up, her voice a little stronger. "He's really smart, a hard worker, and an awesome father," she said--he'd taped bedtime stories, even sang lullabies, and sent them from Iraq so Jonathan could hear the sound of his voice. "We were so close before he was deployed to Iraq, and we stayed close while he was over there," Nicole continued. "Even though we had only been married for three months before he left, we didn't fight in e-mails and phone calls like some couples did." She paused and looked down. "I'll admit that some of his letters freaked me out a little and made me wonder what kind of a person I married. That's because he had to kill people, including some civilians who got caught in the crossfire. I asked him not to tell me any more about that, because I really couldn't handle it. I tried to stay supportive, but maybe he started to pull away from me after that. "
A Painful Transition
I met Brandon a few days later. Tall, fit, and handsome, he was every inch the Marine. But despite his stoic military bearing, he looked exhausted. "I can't believe what's happening," he said, drawing a hand through his close-cropped, blonde hair. "When I was in Iraq, I told myself that if I ever saw Nicole again, I'd show her every day how much I love her. Yet, last week, I pinned her against the wall and called her a bitch." Then his voice turned almost pleading. "But why does she get in my face and taunt me? Why is she so demanding and unappreciative? It might sound strange, but living with Nicole is more stressful than being in Iraq. At least I knew what was expected of me there."
Now, back at home, Brandon was suffering the classic symptoms of PTSD. He had nightmares, his sleep was fitful, and he never felt rested. When awake, he was on "full alert" all the time. "I fight the urge to drive as fast as I can down the middle of the road, like we did in Iraq to avoid being hit by IEDs," he said, describing what was going on for him. "I see things out of my peripheral vision--suspicious characters at the side of the road or potential snipers on rooftops. Every time I go through a door I feel like flinging it open in case there's somebody sinister behind it. I've actually done that a few times and put holes in the wall."
At home, all he wanted to do was zone out in front of the TV and watch coverage of the war in Iraq, which Nicole hated. "She says it puts me in a bad mood. Maybe so, but I feel like I have to keep up with what's happening with the war." Brandon also suffered from a pervasive sense of alienation and loneliness, the feeling that that he had no place in civilian society and wasn't sure he even wanted a place in it. "It wipes me out to be on campus," he said. "I don't belong there. I stick out like a sore thumb, with my short hair and my tucked-in shirt and my Marine Corps values--the best values in the world by the way. I believe in duty, honor, discipline, and sacrifice," he continued, "and I do my best to live by my code. But, no one on campus gives a shit about any of that. Everyone in this town is a bleeding-heart liberal. They don't know what sacrifice means. I miss my Marine buddies. Sometimes I wish I would have stayed in, but having a family is even more important to me than the Corps, so I decided to get out."
Worst of all was his growing sense of estrangement from his wife, the sense that their marriage was falling apart and he was helpless to stop it. "I love Nicole, but we can't get along," he said hopelessly. "She says I'm like a ghost to her. We were madly in love at one time. What am I going to do? I'm afraid she thinks I'm a monster because I had to kill people. I'm a trained killer and I did what I had to do. My unit was depending on me. In my dreams, I'm in a small clay hut all alone. The insurgents are coming at me, and then they turn into demons. I need my wife to comfort me, but I can't tell her what I'm going through."
Brandon said he loved and respected Nicole. She was a great mother, a hard worker, who'd saved most of the money he'd sent her from his paycheck (unlike some wives and girlfriends who'd spent it all and racked up huge credit-card debt besides). "But if we keep going on this way, our love for each other will be destroyed," he said. "I see my dreams slipping away, and I feel powerless to do anything about it. I don't understand what's happening. Did I survive the war just to see everything I want in life slide out of my grasp?"
As in all trauma treatment, the first consideration is safety and stability. Ironically, the fight and subsequent restraining order provided safety, stability, and the motivation to address the problems and stay in therapy. Nicole felt safer living apart from Brandon while he got his hair-trigger responses under control. Brandon was welcome to stay with his cousin for awhile and was able to see Jonathan at his father's house. He stopped drinking, concentrated on school, and settled into weekly therapy. Brandon and I agreed that the three months before his court appearance was perfect for our work together because he wasn't experiencing daily upsets while living apart from Nicole.
When I suggested Eye Movement Desensitization and Reprocessing (EMDR) and explained it a bit, he expressed some reluctance to focus on the painful memories and some skepticism about the "weird idea" that moving his eyes back and forth would be effective. So I showed him a DVD featuring Francine Shapiro, Bessel van der Kolk, and other therapists, as well as several EMDR clients, including a Vietnam veteran, who described how the procedure helped free them from the past. I buttressed the case by telling him that while nightmares and flashbacks are very troublesome and painful, avoidance is by far the most dangerous aspect of PTSD--in fact, it maintains the fear and vigilance and the constant preoccupation with the war. "Avoidance also becomes a way of life," I said and described some veterans I know who'd spent many years avoiding almost everything and everybody in their largely unsuccessful attempts to stay calm. There's no healing without exposure to the memory and the emotions that go with it, I added.
I explained further that the brain naturally tries to process trauma by reviewing experience, but the images and emotions are so vivid that nightmares and flashbacks result. So the opposite, also completely natural, tendency kicks in and the brain tries to avoid the pain by numbing the emotions. At this point, the information can't be processed, and the cycle just repeats over and over again--the natural healing process getting caught in a kind of gridlock. EMDR is designed to break the gridlock and keep the information processing system active so that healing can occur.
Finally, I reassured him that I'd seen this procedure work in hundreds of EMDR sessions since I was trained in 1992, and that its effectiveness had been accepted by the American Psychiatric Association, the Department of Defense, and the Department of Veterans Affairs based on a number of controlled studies. "Okay," he said, "if I have a chance of getting the same relief as the people in the DVD, it's worth a shot." I assured him that we wouldn't go ahead with EMDR until he felt fully prepared.
The next week I introduced Brandon to EMDR. After teaching him the eye movement--simply following with his eyes as I moved my hand from side to side in front of his face--I used an EMDR procedure developed by Deborah Korn and Andrew Leeds called Resource Development and Installation. I asked Brandon to bring a positive memory to consciousness along with the images, thoughts, emotions, and body sensations that went with it. I wanted to help him strengthen his access to positive memories that would serve as an internal resource while he was reprocessing the traumatic memories.
As he moved his eyes back and forth he was to "just notice" anything that he experienced in his mind or body, not trying to control where his mind went or discard any information that spontaneously occurred. Brandon chose a memory of the night he proposed to Nicole. He pictured himself sitting close to her, and then we began the first set of eye movements. When I stopped the eye movements and said, "What are you getting now?" he said, "I can't believe it. I can feel my arm around her and her head on my shoulder." I said, "Go with that," and started another set of eye movements. When I stopped, he said, "I can smell her perfume, and I feel this warmth in my heart." We continued the process with several more sets of eye movements during which the positive sensations strengthened.
At the end of the session, Brandon looked amazed, almost giddy. "I haven't felt this way since before I left for Iraq," he said. "I didn't realize how numb I was. I wish I could call Nicole and tell her." He said he thought that by the next session, he'd be ready to use EMDR with the terrible memory of what happened in Baghdad that was giving him his worst nightmares.
Using EMDR on Fearsome Memories
The next week, Brandon reported that he'd remained conscious of the feelings of tenderness and intimacy toward his wife, and that this had given him comfort when he woke up with a nightmare. Now, he felt ready to focus on his most painful memory--a street fight in Baghdad in which a young mother was killed. Brandon and six other Marines had been ordered to search a house for weapons. An Iraqi man came out of the house pointing an AK47 rifle at them and dragging with him a woman holding a baby girl. The Marines opened fire, killing both the man and the woman. The baby, who was not wounded, fell into the sand.
I asked Brandon what mental image represented the memory. He said, "I see the Iraqi man with his AK47 pointing at us. He has a beard. And I see the woman beside him in her black robe. She's holding her baby."
I said, "What words go best with the image that express your negative belief about yourself now?"
"I'm a bad person."
"And what would you rather believe about yourself?"
"I'm a good person."
"What emotions and physical sensations are coming up for you?"
"Anger. Guilt. And this is weird a sensation in my finger." He rated the intensity of the disturbance at 8 on a scale of 0 to 10.
"Okay, Brandon, notice the image, the words 'I'm a bad person,' the sensation in your finger, and follow my hand with your eyes."
As Brandon's eyes moved back and forth, he held his breath and seemed to be intently surveying a fascinating inner landscape. After about 30 seconds of eye movement, I stopped and asked what he was experiencing. He said, "I actually feel myself pulling the trigger. I feel it in my hand and finger. I feel the recoil of the rifle."
I said, "Go with that." This time I kept the eye movement going a lot longer. His face was pale and he was breathing hard. I stopped the eye movement when his breathing got easier and said, "Take a deep breath. What are you getting now?"
"I feel more relaxed. It's a white desert-style house. They weren't poor. The guy is yelling something in Arabic. He lifts up his weapon and we shoot. I'm seeing him go down and then her go down. The screaming child falls in the sand. I have a big lump in my throat. I feel regret. I don't know if I shot her. We don't know who hit them. I almost feel ashamed."
I said, "Go with that," and began another set of eye movements.
When I stopped the set Brandon said, "I remember yelling for an interpreter. The lieutenant ran over and asked what happened. He picked up the baby and handed it to an old woman who was screaming and crying. The lieutenant said we were justified in killing the man, but who killed the woman? No wonder I can't stand to hear my son cry. When I first came home, every time my son cried, I put him down and asked Nicole to take care of him. She never asked why. He had a similar sound and was about the same age. I'm getting the chills. I can hear the little girl's blood curdling, ear-piercing screech. I can see her. We killed her mom. She'll grow up thinking we are psychotic killers. It hurts my chest. I can feel my heart beat. I can see the guy getting shot, and somehow I can feel it. I feel like I'm getting shot. Why does it hurt so much?"
"Go with that." During this set, intense emotion was visible in Brandon's whole face and body. Tears rolled down his face and then subsided. I kept the eye movements going as I softly encouraged him to stay with the process. "It's in the past," I said. "Just notice it and let it go by." It was a long set and I had time to think about the meaning of the experience for Brandon.
Though I didn't say it to him because I wanted to stay out of the way of spontaneous processing, I thought to myself that he might be experiencing a paradox that is common with war trauma that Steve Silver and Susan Rogers have written about: warriors are both powerful and powerless. They're authorized to use deadly force to dominate the enemy. Yet there's every possibility of that same lethality being used against them. This dichotomy causes enormous inner confusion. I stopped the eye movements as I saw Brandon's face and body relax. It was as if the emotion was a wave that had crested, released its energy, and broken gently on the shore. "Deep breath, Brandon. What are you getting now?"
"I let it go. It wasn't my fault. It was his fault. It stopped hurting and went away. I can remember it, but it went away. I feel lighter. I shot; that's the way I was trained. It would have been stupid not to shoot. I was obligated to protect the guys in my squad. It's fortunate we all walked out of there. I made it home, and I'm going to give my son the best life I can give him."
"Go with that." At this point about two-thirds of our 90-minute session was over. We did several more sets of eye movements as the minutes passed. Brandon's associations spontaneously turned to the present and the future. He remembered Jonathan's first birthday, his son's beaming face covered with cake. He wondered what Nicole was doing right now and empathized with "what she's had to put up with--me being gone and being the way I am right now." He imagined the orphaned child being raised by the strong extended family that's typical in Arab culture and "going to one of the Iraqi schools that the Marines helped build. I'm hoping she'll be as happy in her own lifestyle as my son is in his."
In the last 10 minutes of the session, I asked Brandon to bring up the memory that he targeted at the beginning of the session. He said, "It's unfortunate the woman died, but I don't feel that I'm in the wrong. It doesn't hold the same meaning and pain. I'm a compassionate human being, and I did what I had to do. I'm glad to be alive and living with that memory instead of the alternative--which is to have died in Iraq. At that point, he rated the degree of emotional disturbance at 0 on a scale of 0 to 10.
When Brandon came in the next week, I asked him to bring up the memory we worked on with EMDR and rate it on a scale of 0 to 10. He said it was still a zero. We went on to process several other war memories with EMDR with positive effects.
About three months after Brandon first came to see me, he appeared before the judge, who thanked him for his service to the country and indiciated that he was impressed by his work in therapy. The judge said, in essence, "Please don't let this happen again," and ordered him to participate in an anger-management program. Brandon actually liked the program, and found he was much better at managing his negative emotions during interactions with Nicole.
Soon after Brandon started the anger-management program, Nicole requested that the restraining order be lifted, and he moved back in with her. At one of our final joint sessions, they told me that Nicole is pregnant with their second child, a prospect that made them both happy. Brandon said he planned to finish the semester at college and then the two of them would move back to San Diego, where Nicole's family lived. It was hard to say good-bye to Brandon, but I think all three of us felt optimistic about the future.
By Christine Courtois
This case is especially relevant, given the numbers of soldiers returning from Iraq and Afghanistan, and the numbers who are reported to have ongoing post-traumatic symptoms up to and including post-traumatic stress disorder (PTSD). Therapists, whether in Vet Centers or other practice settings, can expect an increased demand for treatment by this population. And as this case illustrates, PTSD can profoundly affect not only the primary sufferer, but also spouse/partners, children, members of the extended family, and the community at large. Thus, therapists might be required to treat one or more members of the family in addition to the primary client.
This case reports on the effective treatment of Brandon's PTSD symptoms following his arrest for threatening his wife. It graphically describes the difficulty this soldier and his wife had with his multiple transitions: his role as soldier/killer while in the war theater; his return to civilian life, where he continued to experience the hypervigilance he needed in the war zone, in addition to numbing; his return to his young wife and son and to the roles of spouse and father; his resignation from the Marine Corps and his new role as a student. In all of these roles and transitions, he experienced challenges to his sense of self. He further experienced challenges in his search for security among those who might understand what he'd gone through during the war and afterward (his Marine buddies, his wife, his extended family) and in his increasing despair and disillusionment with his new life (his wife's lack of support, fellow students' lack of understanding). These only served to underscore and intensify his discomfort and his PTSD symptoms. For her part, Nicole felt like a different husband had returned, who was unlike her formerly attentive, loving spouse. She was frantic for his attention, both for herself and for their son.
Research findings support Eye Movement Desentisization and Reprocessing (EMDR) as one of the effective treatment interventions for the symptoms of PTSD. This case illustrates its effectiveness and shows how different themes and life events can get intertwined in post-traumatic reactions. However, Nancy Errebo fails to describe the staged approach in the use of the EMDR protocol in that there is no mention of any assessment or the development of a treatment plan (including the choice of what technique might be most effective) before the procedure was implemented. This is a serious omission and is not faithful to the eight phases of EMDR treatment as specified by Francine Shapiro, who developed the treatment protocol.
Additionally, Errebo makes no mention of the use of education with this couple, who obviously were in need of basic information about war trauma, post-traumatic reactions and symptoms, and the effects of PTSD on the individual and on relationships. Pre- and postdeployment information covering these topics is becoming more common in the military, and Errebo could have asked whether any such education had been offered. If so, she'd have had a foundation for providing additional information to the couple to increase their understanding of Brandon's reactions.
This case description also doesn't describe the full sequence of treatment, including joint sessions with the couple, nor is mention made of any intervention with Nicole while the couple was separated. She's obviously young and quite naive, in need of basic information, and possibly in need of her own individual treatment. In reading this case, I'm reminded of Susan Johnson's work with traumatized couples and the education she offers them about the need for secure attachment and mutual support as they face whatever crises are at hand. Relational education, in addition to other educational efforts, might have made it easier for this couple to understand how Brandon had been changed by his war experience and why Nicole's support was so important. She also needed to learn that taunting him was not only a problematic way of dealing with relational difficulties, but dangerous as well. In a similar vein, Brandon needed to understand Nicole's distress when he was emotionally unavailable to her and to their son.
Finally, Errebo seems to view a second pregnancy as a sign that all is well with the couple and that the future is rosy. Although this might be the case (they both describe each other as good and dedicated parents), it might also be overly optimistic. A second child will surely pose additional challenges for them as they renegotiate and restore their relationship and cope with their transitions. A more encompassing treatment might have helped this couple to move more slowly in their relational renegotiation, and to have more time for themselves and their young son before expanding their family.
Christine Courtois is correct that the case description is missing aspects of the treatment. The original draft of this case delineated the eight phases of EMDR, described its psychoeducational features, and included suggestions for Nicole's individual treatment. But because of space limitations, the editorial decision was made to focus on the human story of a veteran's war experience and its aftermath.
EMDR's eight-phase treatment can't be summarized here, but it's conceptualized in terms of Francine Shapiro's Adaptive Information Processing (AIP) model, which informs the psychoeducation of clients about trauma reactions. According to AIP, the brain's inherent information-processing system that normally integrates experience can be overwhelmed by high-arousal events. Memories, whether, "large-T traumas" like war or "small-t traumas" like childhood humiliations, are stored with the emotions, sensations, images, and beliefs generated by the original experience. When something external or internal stimulates these memories, one is helpless to avoid feeling the anger, fear, or shame associated with the traumatizing event, however inappropriate the reaction may be in the present circumstance.
EMDR facilitates the processing of these memories and the transmutation of their inherent physical and emotional states. At the beginning of the treatment, a thorough history would be taken to identify what resources the client could access to feel safe and in control during and between sessions, the earlier events that set the groundwork for the pathology, the triggers that cause present disturbance, skills necessary for future positive action, and so forth. These would be targeted for EMDR processing as necessary to resolve the treatment issues.
I agree with Dr. Courtois that relational issues are crucial for veterans. Unfortunately, a variety of factors made joint counseling impossible in this case. Otherwise, Susan Johnson's Emotionally Focused Couple Therapy (EFT) would indeed have been a wonderful addition to the treatment plan.
Finally, I think Dr. Courtois misunderstands me when she writes that I "view a second pregnancy as a sign that all is well with the couple and that the future is rosy." I also believe that a second child will pose additional challenges for this couple. My optimism is based on Brandon's responses to EMDR treatment. Processing his traumas and increasing his internal resources placed him on a more positive trajectory, which I expect would benefit both him and his family.
Christine Courtois, Ph.D., is in private practice in Washington, D.C., specializing in the treatment of adults traumatized as children. She's cofounder and clinical consultant to The Center: Post-Traumatic Disorders Program at the Psychiatric Institute of Washington, D.C. She's the author of Recollections of Sexual Abuse: Treatment Principles and Guidelines and Healing the Incest Wound: Adult Survivors in Therapy. Contact: cacour firstname.lastname@example.org.
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