10. Domestic & Foreign Warzones - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
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10. Domestic & Foreign Warzones

Therapist Resources > Therapy Books > Opening the Can of Worms-Cple

Opening the Can of Worms, Complications in Couples and Couple Therapy
by Ronald Mah

The therapist should be aware of populations or clinical presentations with a greater likelihood of PTSD.  Certain presentations, individuals, and communities may have a greater occurrence of traumatic events.  For example, there can be correlations among eating disorders, borderline personality disorder, and PTSD.  Either the eating disorder or the borderline personality disorder may be an initial presentation or diagnosis that can lead to exploration for trauma experiences such as childhood abuse or chronic stress.  Specific populations or communities also may be more vulnerable to its members suffering from PTSD.  Motamedi (2011) reporting on the experience of inner city youth in and around Oakland, California, interviewed teenagers who exhibited PTSD symptoms from chronic experiences of stress and trauma.  One teen had a very close friend killed in drive-by shooting.  His friend was the sixth person he knew that had been killed.  Motamedi referenced research presented at the 2010 Annual Meeting of the American Academy of Child and Adolescent Psychiatry (AACAP) that nearly half of all inner-city youth may suffer from post-traumatic stress disorder (PTSD), and 30% may be severely clinically impacted by the condition.  Marina Post, a fourth-year medical student at Baylor College of Medicine, Houston, Texas gathered questionnaires from 65 subjects from 12 to 28 years of age in the Houston-based study.  Subjects were asked about flashbacks, three types of numbness and avoidance symptoms, and two different hyperarousal symptoms.  Of the 63 participants (50 males and 13 females), 49% met the criteria for PTSD, with a cutoff of 35 out of 85. The average score for females was 45 (P =.02), compared with 33 for males (P =.03).  80% of subjects reported two or more traumatic events.  "Of 17 potential traumatic events, the average subject reported having been exposed to 5.6 of them during the course of their lifetime.  Traumas were divided into those that occurred in the community (such as seeing someone arrested or being forced to do something bad) and those that occurred in a domestic setting (such as rape or physical abuse at home).  Traumas were also divided into direct (such as medical trauma) and indirect (such as having seen a dead body).  The most commonly reported trauma, at 63%, was having witnessed a friend or family member being beaten or shot" (Otrompke, 2010).

The therapist should note the demographic background of clients in individual, couples, or family therapy.  Especially, in private practice situations with self-referring clients, the therapist may error in assuming that the current socio-economic status presented by a client was his or her status in his or her formative stages.  While middle and upper-class (affluent) individuals can experience chronic stress and trauma, they do not contend with living in an overtly violent and dangerous community.  Although an adult may not be readily identifiable as an inner city survivor, someone who has ascended the socio-economic ladder may have long standing effects from chronic stress or trauma.  For example, Randy had a great future as a professor of cultural anthropology at a prestigious university.  In his early thirties, he was a designated "golden child" being mentored for the highest echelon of the department.  He would be up for tenure soon.  Head of the department and even chancellor of the university was not out of the question.  He had the beautiful wife, children, and house.  It looked great for him.  Then his wife found credit card receipts from massage parlors.  Some charges were excessively high compared to others.  When traveling overseas to do research and lecture, Randy sometimes went to spas for some needed R&R.  Sometimes, he opted for the "happy ending" with his massage.  The extra charge was for the masseuse to masturbate him to climax.  Not every time, but once in a while.  Needless to say, his wife's discovery of his indiscretions threw his idyllic world into turmoil.  His wife demanded that they go to couple therapy.  Deeply shamed and unable to explain his actions, Randy committed to the hard work of therapy.

As couple therapy waded through layers of issues, the therapist discovered that elegant professional academic Randy had been born and raised in one of the ugliest ghettos in America.  His mother had been a prostitute and his father long gone doing life without the possibility of parole for a litany of capital crimes.  A brother and two cousins were killed from drug and gang related violence.  He was 13 and then 15 years old when he witnessed one and then another die in drive by shootings.  Randy refused to get into details, but admitted that he had seen and done a lot more bad things… really bad things as a child and teen.  There had been a teacher, an older cousin, grandma, and especially one of the O-G's (Original Gangsters) who saw his intelligence and supported and guided him to stay in school.  They encouraged… even demanded his ambitions to make it out.  Paulo, the older gang member had slid into… had been seduced by the gratuitous glory of protecting the hood.  He had bought into demanding respect without really understanding self-respect.  And, in his mid-thirties realized the trap that he was caught in.  Charismatic and intelligent he knew he had wasted it all.  He had no hope for himself.  Sooner or later with the life he chose, he told Randy he would be a D-O-G- a Dead Original Gangster.  Paulo saw himself in Randy.  If he was doomed, at least he could guide one young lion out of the hood.  Paulo had pushed Randy to want more… be more… and do more.  And Randy had.  Randy went to his classes and did his homework… in between his gangbanging.  He received a National Merit Scholarship.  He went away to college… then a graduate school and a research fellowship.  He left it all behind.  That was his old life.  It was different now.  He was Professor Randy.  Or, so he thought.  His trauma had come out of the hood with him.  Despite his success academically, vocationally, and making a lovely family, the horror of what he'd experienced and done stayed with him.  Sometimes, memories and feelings ambushed him.  Drinking helped at times to block it.  And so as it turned out, did "happy endings."

The therapist must stay socially and politically versed about circumstances and situations where and for whom trauma may be common.  Professional study to stay abreast of research is recommended by psychotherapist associations.  Professional journals and mass media are sources to access.  Recent media coverage has fostered greater social awareness and reduced personal stigma about the potential traumatic mental consequences of warfare.  The description of impoverished inner-city communities as domestic war zones provides conceptual linkage to veterans with warfare trauma.  Statistics of recent wars show PTSD as a continuing consequence for many veterans.  A fact sheet from veteransnewsroom.com notes,

Approximately 300,000 veterans of the Iraq and Afghanistan wars – nearly 20% of the returning forces – are likely to suffer from either PTSD or major depression, and these numbers continue to climb.

By fiscal year 2005, the VA's own statistics indicated that PTSD was the fourth most common service-related disability for service members receiving benefits. (Veteransnewsroom.com, 2011)

There is improving acceptance and understanding about the impact and prevalence of and subsequent diagnosis of PTSD among military veterans.  The syndrome of characteristics was identified in prior eras as "shell shock," or "combat or battle fatigue" and considered with explicit moral negativity.  Soldiers were expected to stay strong and stand tall despite death and destruction from wars in antiquity and Biblical times in strange lands long vanished, Indian campaigns and the Civil War on American soil, and battles in foreign war zones from Mexico to the Philippines, to the Battle of Belleau Wood, the landings at Iwo Jima, Omaha Beach, and Inchon, the battle for Hue, Desert Storm, and Fallujah.  This negative perspective persisted with the arrival of thousands of Vietnam War veterans into the American medical system and society through the late 1960's and 1970's.  Veterans complained about psychodynamically oriented treatment looking into childhood experiences rather than the horrors of warfare.  The medical and professional establishment asserted that their emotional and psychological breakdowns were not the consequence of preexisting issues, with war experiences being only a triggering factor.  Treatment implied that breakdown was only possible because of older weaknesses.  Reacting to this profoundly discrediting stance, veterans' advocates during and after the Vietnam War promoted a new view: emotional and behavioral disturbances after combat were a normal response to the grisly realities of war.  "They asserted that the veterans had been all right before the war, and if they were having trouble afterward, it must be because of the war"(Clymer, 2010, page 30).  This directly confronted traditions from thousands of years of stigma attached to a syndrome of reactions and behaviors from the brutal violence and horror of warfare.  "Consider the viewpoint of the Greeks of Homer's time, a warrior culture if ever there was one.  In that heroic age, it was universally assumed that any war-related mental suffering of the kind currently labeled PTSD stemmed from an inherent moral deficit or weakness of character.  According to some authorities, The Odyssey was a disguised account of Odysseus's struggle with PTSD.  They see him as a psychological wreak, crippled by war-induced hallucinations, flashbacks, irrational fears, nightmares, depression, and explosive anger, all of which are recast as a series of adventures with externalized monsters.  Using metaphors and exaggerated adventures, Homer succeeded in composing an epic poem about a crippled hero that's endured through the ages" (Clymer, 2010, page 29).

As the position that a characteristic pattern of response existed to the experience of excessive military sanctioned violations against humanity gained support, the American Psychiatric Association (APA) adopted the diagnosis of PTSD in 1980.  The diagnosis served to destigmatize the psychological effects of war.  Combat horror can psychologically destabilize individuals in characteristic ways.  However, the PTSD diagnosis still risks pathologizing individuals.  The historical denigration of war-related trauma responses is based on the fact that not all veterans are similarly affected.  Making PTSD a psychiatric disorder does not make this point less compelling.  Why does one veteran "get" PTSD while another does not?  The implicit answer remains the historical response that something is wrong with the one who does.  Clymer recommends an approach that reeducates veterans that their responses are normal human responses to extraordinary stresses.  This normalizes PTSD behaviors and "enables him to experience more options for himself.  It holds him accountable, and is an essential part of his recovery" (page 32).  PTSD symptoms can be presented as solutions to prevent or protect oneself from recurrence of pain.  The symptoms, vulnerability, and the desire to avoid pain are deemed to be normal human responses within a larger spectrum of human behavior.  The affected veteran is not considered permanently ill or disabled.

An importance nuance to working with veterans with PTSD is dealing with what has been called the "Combat PTSD Trinity" or the Predator-Prey-Witness triangle (PPW).  The typical trinity or triangle of PTSD has three roles: the Predator, the Prey, and the Witness.  Leitch and Miller-Karas (2010, page 38) point out that in no other potentially traumatizing situation are individuals "predator and prey and witness, sometimes all three at once."  In other trauma circumstances the roles tend to be more distinguishable, because different people fill the roles.  A person who is molested or raped is the prey, while the perpetrator (molester or rapist) is the predator.  Someone who observes the violence such as a spouse to the partner abusing the child (or the child watching domestic violence) is the witness.  The prey may also be the witness as in the case of a spouse both being abused and watching the child being abused.  "In combat zones, however, these three roles often are experienced simultaneously, with the corresponding physiological arousal: as prey, the biological impulse may be to flee; as predator, to fight- often with great ferocity and rage (if a buddy has been killed, for example)- and as witness, to freeze while terrible events unfold before one's eyes" (page 39).  Mark Dust served four years active duty in the US Army in the Infantry.  In 2005, he was blown up by a roadside IED (improvised explosive device).  He was involved in firefights and witnessed both insurgents and US soldiers get blown up.  He lost his battle buddy from basic training to an IED.  Initially, not wanting to admit to having PTSD for fear of being labeled a "broke dick," his blog seeks to share knowledge about trauma and how it affects the body's natural balance.  Dust described the Predator-Prey-Witness triangle from the perspective of one who did not realize that he had PTSD when he was discharged.  He asks rhetorically, "How is the nervous system supposed to deal with being all three of these roles at the same time?  I argue that it can't.  Nature has shown us you are generally either a predator or prey.  Have you ever seen a lion chasing a wildebeest being chased by something trying to eat it?  I believe the constant stress of being both the predator and the prey along with witnessing traumatic events twelve hours a day over the course of a year long deployment is the primary factor in servicemen developing PTSD.  Our nervous systems are simply not designed to handle it" (Dust, 2010).

Working with PTSD recovery is can be complex work supported or hindered by the couple or family system, as much as PTSD affects these systems.  Research about Vietnam War veterans not only have found significance incidence of PTSD but also of it affecting marital functioning.  A complex version of the PPW triangle may be activated in the couple or family, creating another war zone- a domestic war zone.  The PTSD affected partner experiences him or herself instinctively as the prey while acting in a manner that causes his or her partner to see him or her as the predator.  The partner feels like the prey as the PTSD affected partner goes into erratic and threatening behavior.  The partner's impatience and criticism can intensify the PTSD affected partner's experience of being the prey.  If there is a third member of the family, that person may be the witness to the partners predator-prey dance.  The third member may be the prey or predator as well depending on the flux of interactions.  Simultaneous to enacting a predator or prey dynamic, either partner may witness their actions with horror.  As the amygdala activates the sympathetic nervous system into stress/danger responses, the neo-cortex sees the illogic of the reaction.  Protective instincts and values of the PTSD activate against him or herself  The PTSD affected partner sees him or herself failing as a spouse or partner.  Shame for harming ones partner builds and purposeful emotional distancing intensifies reflexive emotional numbing.  Removing oneself from the relationship and perhaps, from life becomes an option.

"Riggs, Byrne, Weathers, and Litz (1998) found that 70% of 26 PTSD-diagnosed veterans reported clinically significant levels of marital distress, contrasted to only 30% of 24 veterans without PTSD.  Roberts et al. (1982) and Carroll, Rueger, Foy, and Donahoe (1985) compared Vietnam combat veterans diagnosed with PTSD to non-PTSD combat veterans and noncombat veterans.  The first study (n D274) indicated that veterans with PTSD scored higher on the Minnesota Multiphasic Personality Inventory Family Problems scale and significantly higher on clusters of problems dealing with intimacy and sociability.  The second study (n D60) showed that the PTSD group had significantly more problems with self-disclosure, expressiveness, and physical aggression toward their partners and with global relationship adjustment.  A subset of 932 Vietnam veterans from the National Survey of the Vietnam Generation was divided into a group with PTSD (n D231) and a group without PTSD (n D736); the PTSD group reported significantly more marital problems, as measured by Marital Problem Index (Jordan et al., 1992).  An Israeli study with families of 382 combat veterans found a positive correlation between rates of PTSD and marital conflict (Solomon, Mikulincer, Freid, & Wosner, 1987)" (Spasojevic' et al, 2000, page 206-07)

Sometimes veterans, their families, and people in general do not see war trauma as a heroic battle like Odysseus battling against an externalized PTSD, but as personal failings.  Ann, a veteran of the Iraq war tried to reach out to family while dealing with memories of how her best friend and protector from sexual harassment had died in her arms, horrific injuries from burns, and the deaths of many of her friends from a Vehicle Borne Improvised Device (VBID)- a car bomb the day after she left the base.  "'But every time I tried to explain what had happened and how bad I felt, my parents and husband got angry with me, telling me to get a grip; that was past was past.  So I shut up' …As the therapy group continued, she revealed deep anger at her husband, who regularly attacked her verbally, calling her a 'fruitcake' and much worse"  (Leitch and Miller-Karas, 2010, page 28-29).  When they are more compassionate and supportive, it still remains that "Friends and family of veterans who are experiencing feelings of extreme vulnerability, rage, hypervigilance, and many of the other emotions that often follow the experience of combat, don't know what to make of their strange behavior and want their loved one back" (page 31).  Active duty survivors of military service with PTSD had more anxiety about intimacy than non-sufferers.  Their partners also had more fear about PTSD than partners of veterans without PTSD.  There may be a reciprocal influence of the veteran's anxiety causing partners to mirror that anxiety.  Partner anxiety may be a natural consequence of problematic intimacy interactions with the PTSD-affected partner.  In contrast, partners without PTSD issues may have had more productive interactions in intimate relationships.  Good versus bad experiences thus would help develop more confidence about intimacy.  Another explanation is that "the differences may arise because of some bias in the selection of partners.  That is, people who are anxious about intimacy may be attracted to partners who are similarly anxious and therefore do not make intimacy demands" (Riggs et al, 1998, page 97-98).  This possible explanation may be important to consider with non-PTSD affected couples where there is significant emotional reactivity or emotional intensity or drama.  The therapist may need to examine how and why a partner would be attracted to and continue to accept problematic relationship drama.  "Why would you be attracted to such emotionally draining and painful drama?" could be a rhetorical therapeutic question implying one should not be so attracted because of problematic consequences.  On the other hand, it may be a revealing question.  Attraction to such drama may have individual psychodynamic roots important to consider for how they affect the couple's dynamics.

3056 Castro Valley Blvd., #82
Castro Valley, CA 94546
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
office: (510) 582-5788
fax: (510) 889-6553
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