Michael Miller Dissertation

Institute for Clinical Social Work

Experiences of VA Therapists Treating OEF/OIF/OND Veterans with Combat PTSD

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Michael R. Miller

Chicago, Illinois February 2015

Abstract

This qualitative study explored the subjective experiences of 17 Veterans Affairs mental health trauma clinicians as they treat OEF/OIF/OND veterans with war-related PTSD. This researcher used grounded theory methodology to analyze data gathered from participant interviews, interpreting the findings using relational psychoanalytic theory and adult attachment styles. Many participants had family members who were combat veterans. There choice to treat combat veterans was due to feeling comfortable about and a familiarity with military culture and veteran issues. Vicarious traumatization is complex and varied. Many participants stated they have been overwhelmed while others said they were not. Being overwhelmed occurs by levels of awareness and varies. Participants did not follow the 12-session protocol for the Evidence-Based Psychotherapies (EBPs) currently used to treat PTSD (Cognitive Processing Therapy and Prolonged Exposure Therapy). They believe in having veterans integrate and master their combat trauma by developing and creating a trauma narrative over time that may or may not include EBPs. Directly providing combat treatment as a trauma therapist can result in developing more compassion, empathy, humility, and knowledge. Participants were clear about what works and what does not work in terms of developing a formal program of clinical support including clinical supervision/consultation. The study includes clinical implications and recommendations for future research based on the findings. ii

For Sheila, my wife, and to my sons Nathan and Ethan, whose support and sacrifice made this endeavor possible.

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Acknowledgments

I am indebted to my dissertation committee, R. Dennis Shelby, Ph. D., Dr. Lynne Tylke, Ph. D., Dr. James Lampe, Ph. D., Dr. Ida Roldan, Ph. D., and Dr. Jared Cox, Ph. D., for their support and encouragement, and wisdom, for sharing with me their high standard of academic scholarship and excellence. I would like to acknowledge Dr. Lynne Tylke who has been an advocate, consultant, and teacher during my education at ICSW. Thank you for believing in me and being so generous with your support and insights through the years. A special thanks to a colleague, Dr. Jared Cox, Ph.D. He literally joined the dissertation team at the end of my project and his comments and our many conversations have been extremely helpful.

This project would not have come to fruition without the support of Norene McElreath, BSN, RN, a colleague and friend who kept me organized and on track throughout the entire process. Lastly, I am especially indebted to R. Dennis Shelby, Ph.D., the chairman of my committee. Dr. Shelby has been my academic advisor, teacher, consultant and mentor. My life as a human being and my clinical work has been transformed and enriched because of you, Dennis. Thank you for your patience and guidance.

MRM iv

Table of Contents

Page Abstract…………………………………………………………………………………..ii Acknowledgments……………………………………………………………………….iv List of Abbreviations…………………………………………………………………....xi Chapter I. Introduction…………………………………………………………………....1 Formulation of the Problem Significance for Clinical Social Work Statement of the Problem and Specific Objectives to Be Achieved

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Table of Contents—Continued

Chapter

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II. Literature Review…………………………………………………………….6 Development of Posttraumatic Stress Disorder as a Diagnostic Category Historical Contributions of Psychoanalysis to War Trauma Clinical Definition of PTSD from Psychiatry and DSM-V Contributions of Neuroscience to Posttraumatic Stress Disorder PTSD Experiences of OEF/OIF/OND and Vietnam Veterans Research Findings on Vicarious Traumatization Theoretical and Conceptual Framework Theoretical and Operational Definitions of Major Concepts Statement of Assumptions Epistemological Foundation of Study III. Methodology……………………………………………………………….. 90 Type of Study and Design Scope of Study, Population, and Sampling Data Collection Methods and Instruments Procedure for Data Analysis Statement on Protecting the Rights of Human Subjects Informed Consent/Assent

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Table of Contents—Continued

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IV. Introduction to the Results…………………………………………….…102 Participants The Seven Major Categories or Chapters V. Entering the Fray…………………………………………………………..108 Traumas That Paved the Way Families of Veterans Interest in Trauma I Found the VA Conclusion VI. OEF/OIF/OND Veterans Are Different………………………………….123 Tough to Treat They are Kids Very Different Now Conclusion VII. Challenge To the Work…………………………………………………..140 Keeping Them The Bureaucracy Therapist’s Lens Conclusion

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Table of Contents—Continued

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VIII. Relived Trauma………………………………………………………….147 Hard to Hear Taking It Home Checking Out Stories That Stick Conclusion IX. Practice Wisdom…………………………....................…………………..170 Advice What I Did and What I Do Now Being Aware of my Own Stuff Trauma Work Wisdom Military Sexual Trauma Band-Aids Heroes: the Continuum How to Survive The Work Is Rewarding Conclusion

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X. Different Person Now………………………………………………………203 Deeper Understanding A New Point of View Becoming More Aware Conclusion XI. New Ideas for Old Problems……………………………………..........….213 The Way It Is Now What It Could Look Like How We Do It Conclusion XII. Findings and Theoretical Implications………………………………….232 Brief Description of Findings Explanation of Findings Limitations and Evaluations of the Study Clinical Implications Policy Implications Areas for Future Research

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Table of Contents—Continued

Appendices

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A. Informed Consent Form…………………………………………………...274 B. Category Map………………………………………………………………277 C. Reactive Style of Therapist………………………………………………...281 References……………………………………………………………………...283

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List of Abbreviations

CPT

Cognitive Processing Therapy

OEF

Operation Enduring Freedom (Afghanistan War)

OIF

Operation Iraqi Freedom (Iraqi War)

OND Operation New Dawn (Afghanistan War) PET

Prolonged Exposure Therapy

VA

Veterans Affairs

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Chapter I

Introduction Formulation of the Problem The purpose of this research project is to study the experiences of Veteran Affairs (VA) mental health clinicians working with Operation Enduring Freedom and Operation Iraqi Freedom/Operation New Dawn veterans who were diagnosed with war-related posttraumatic stress disorder. Some clinicians experienced vicarious traumatization treating this population. This study utilizes a grounded theory, exploratory approach in order to examine the experiences of these clinicians. Most of the current research addresses the experiences of the OEF/OIF/OND veteran with war-related PTSD symptomatology including flashbacks, traumatic dreams, severe irritability, feelings of detachment, and dissociative states (DSM-V, 2013) but does not systematically address the phenomenological experience of mental health clinicians treating them. This study aims at rectifying this problem by contributing to the deficit of knowledge and data that currently exists and will potentially add knowledge that will increase treatment efficacy.

Operation Enduring Freedom (OEF) is the official name used for the war in Afghanistan and began in 2001. The official name for the war in Iraq is Operation Iraqi Freedom (OIF) and it started in 2003. In September 2010, the Obama administration announced a new operational name for the war in Iraq, Operation New Dawn, in order to

2 reflect the reduction of U.S. troops within that county. The population for this study will be referred to as OEF/OIF/OND veterans.

Significance for Clinical Social Work The goal of this study is to add to the base of clinical social work knowledge by exploring the experiences of Veteran Affairs mental health clinicians who treat OEF/OIF/OND veterans who have been diagnosed with war-related PTSD. Many authors define and explore the concept of vicarious traumatization (Berzoff & Kita, 2010; Bride, Radely & Figley, 2007; Dunkley & Whelan, 2006; Saakvitne, 2002; and Shubs, 2008).

Bride (2007) discusses the pervasiveness of vicarious traumatization among social workers but few studies have emerged with the direct intent to explore the intrapsychic experiences of mental health clinicians specifically treating this population. This study contributes to the body of social work knowledge by providing greater understanding of this phenomenon and how it relates specifically to the relational context between the therapist and the OEF/OIF/OND veteran. This study has the potential to influence policymaking on a micro level within Veterans Affairs by addressing the level of vicarious trauma by supporting clinical consultation or clinical supervision for those clinicians engaged in trauma work within the VA system.

Statement of the Problem and Specific Objectives to be Achieved The Iraqi war has impacted the lives of tens of thousands of OEF/OIF/OND veterans. An aspect of the war that has received national attention is the impact of Posttraumatic Stress Disorder on many of these veterans. In 2008, the RAND

3 Corporation, Center for Military Health Policy Research, estimated that the current prevalence of PTSD among OIF and OEF veterans is approximately 13.8% (United States Department of Veterans Affairs, 2007a). The RAND Corporation in 2007 projected that more than 300,000 OIF and OEF troops have PTSD or depression and 320,000 individuals will potentially have traumatic brain injury (Freedberg, 2006, Tanielian & Jaycox, 2008). For some Veterans Affairs (VA) mental health clinicians, treating these individuals may come at a great cost. Bride (2007), in an article titled, “Prevalence of Secondary Traumatic Stress among Social Workers,” found that 7.8% of the general population experiences PTSD in their lifetime. Among the active social workers Bride surveyed in his study, he found the prevalence of PTSD symptomatology to be much higher than that of the general population at 15% (Bride, 2007).

This study addresses the question, “What are the experiences of Veterans Affairs mental health clinicians working with OEF/OIF/OND veterans who are diagnosed with war-related PTSD,” and three objectives are defined. First, the clinical concept of PTSD in general is explored from a historical stance to the present including the perspectives from psychoanalysis, psychiatry, and neuroscience. Second, three specific features of the Iraqi and Afghanistan conflicts are investigated that may influence the rates of PTSD and other mental health and cognitive disorders among this population: changes in military operations, including extended deployments; higher rates of survivability from wounds; and traumatic brain injuries (Tanielian & Jaycox, 2008). In this study, these features are compared to the experiences of the Vietnam veterans. Third, several clinical terms are defined and delineated: burnout, secondary traumatic stress, compassion stress, compassion fatigue, and vicarious traumatization. Veterans Affairs (VA) mental health

4 clinicians who have experience treating war-related PTSD with OEF/OIF/OND veterans were interviewed. A qualitative study was conducted using grounded theory design.

The idea of studying the experiences of VA mental health clinicians treating this population developed out of the author’s practice of supervising clinical social workers within the VA system and his own personal experience treating combat veterans. This author has treated civilians who have been diagnosed with PTSD since the late 1990’s.

From his own clinical experience, he has found that the war experiences and traumata of veterans with war-related PTSD are qualitatively different from those individuals who did not develop PTSD within the context of a war experience. For some of these VA mental health clinicians, hearing the atrocities and horror of the war experience from these veterans “sends the room spinning” for them. It appears some clinicians experience what is termed an over-identification with the material that leads them to experience the symptomatology of vicarious traumatization. For other social workers, it appears they were impervious to any such experience. The personal experiences of this author, coupled with those of the social workers he supervised, led to the idea of developing an exploratory, qualitative approach where this phenomenon can be studied among VA mental health clinicians treating OEF/OIF/OND combat veterans Defining the problem for this study began with the assertion that the experiences of VA mental health clinicians treating OEF/OIF/OND veterans diagnosed with warrelated PTSD has largely been ignored. The literature is prolific with defining the PTSD experiences of this veteran population (van der Kolk, 2002; Hogue, Castro, Messer, McGurk, Cotting & Koffman, 2004; Pietrzak, Goldstein, Malley, Johnson, & Southwick, 2009; and Shen, Arkes, Kwan, Tan & Williams, 2010) and it is equally abundant in the

5 clinical explication of vicarious traumatization as a clinical construct and how its effects impact some therapists who treat trauma survivors (Jenkins & Baird, 2002; Saakvitne, 2002; Dunkley & Whelan, 2006; Bride, Radey & Figley, 2007; Shubs, 2008; and Devilly, Wright & Varker, 2009). However, the literature is nearly silent on the work of VA mental health clinicians specifically treating this population (Horrell, Holohan, Didion & Vance, 2011). Without studies addressing the work of these professionals working with these veterans, there is little data against which the experiences of these clinicians can be evaluated. Given that some mental health professionals experience or develop vicarious traumatization, this study raises the following question: is the vicarious trauma, as experienced by some VA mental health professionals, related to the intensity and PTSD experiences of the veteran (the “horror� of it), or is it more related to the clinician’s own personal and developmental history, or both?

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Chapter II

Literature Review This section summarizes the pertinent literature describing posttraumatic stress disorder among the OEF/OIF/OND and Vietnam veterans. The relationship of vicarious traumatization to the Iraqi and Afghanistan wars is examined.

The occurrence of posttraumatic stress disorder among Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans has been well documented and researched (Freedberg, 2006; Tanielian & Jaycox, 2008; and Pischke & Hallman, 2008). The prevalence of Posttraumatic Stress Disorder (PTSD) among these veterans is approximately 13.8% (United States Department of Veterans Affairs, 2007a), which equates to more than 300,000 Iraqi and Afghanistan veterans (Freedberg, 2006; Tanielian & Jaycox, 2008). For some mental health professionals, treating these individuals may come at a great cost due to vicarious trauma.

The PTSD experiences of OEF/OIF/OND veterans are qualitatively different, generally speaking, compared to those of the Vietnam era. These differences are due to several factors: political climate of the nation regarding the support of Iraqi and Afghanistan troops; new technology regarding body armor, weaponry and vehicles; the Iraqi and Afghani wars are considered urban conflicts due to terrain in which the fighting takes place that makes the aftermath of the killing and maiming of the enemy and US troops much more visible; changes in military operations; and multiple deployments

7 required of the OEF/OIF/OND veterans which did not exist to this extent during the Vietnam War (Freidman, 2005; Hogue, et al., 2004; Leibstone, 2005; Medved, 2005; Tanielian & Jaycox, 2008). For many OEF/OIF/OND veterans, these differences coalesce to create a syndrome known as complex post-traumatic stress disorder, defined as prolonged and repeated trauma rather than the simple post-traumatic disorder experience based on a single, traumatic event (Herman, 1992). It is the repeated exposure to the complex post-traumatic stress disorder syndrome, that is, the hearing of these traumatic narratives over and over again, that create vicarious traumatization in some mental health clinicians.

Three important issues must be addressed in order to understand the subjective experiences of the participants in this study as they treat these veterans: defining the clinical concept of PTSD from the psychoanalytic, psychiatric, and neuroscience perspectives; understanding the nature and types of PTSD experiences of the OEF/OIF/OND veteran compared to that of Vietnam veterans; and delineating the clinical concept of vicarious trauma with related terms.

Development of Posttraumatic Stress Disorder as a Diagnostic Category Combat-related stress disorders have existed for as long as humankind has engaged in warfare. In the short history of the United States, relative to that of the rest of the world, several terms have been used to describe this phenomenon. During the civil war, it was characterized as soldier’s heart. In World War I it was labeled shellshock, and World War II, it was known as battle fatigue. Throughout the Vietnam War, it was called Vietnam Syndrome (Marmar, 2009). Later, during World War I and throughout WW II,

8 shell shock and battle fatigue terms and symptomatology were redefined as the “traumatic neuroses of war” or simply “war neuroses” (Abraham, 1921; Creasey, 1921; Freud, 1921; Jones, 1921; Kardiner, 1941; Dane, 1949; Herman, 1992; and van der Kolk, 2000). Many veterans that suffered from “war neuroses” experienced at least one single severe traumatic incident such as being blown up or buried or both by shell explosion (Dane, 1949) and their symptoms often included intense continuous headaches, severe irritability, sensitivity to noise and light, insomnia and battle dreams, varying forms of impotence, intense fatigue, depression, total inability to work and amnesia for various periods of time (Dane, 1949). In 1980, posttraumatic stress disorder (PTSD) was included for the first time in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, and has been identified as one of the anxiety disorders (Marmar, 2009).

Currently, battle fatigue is the approved US Army term for combat stress symptoms and reactions. Signs and symptoms of battle fatigue include simple fatigue, anxiety, depression, memory loss, physical function disturbances, psychosomatic forms, and disruptive forms of behavior (Department of the Army, 2003).

Historical Contributions of Psychoanalysis to War Trauma This section summarizes the historical and clinical development of war neuroses and trauma from the psychoanalytic community. It begins with Ernest Jones in 1918 and ends with Robert Stolorow’s theoretical contributions in 2011.

In 1918, Ernest Jones, the British neurologist and psychoanalyst, read a paper titled War Shock and Freud’s Theory of the Neuroses to the Royal Society of Medicine in London. He presented the first psychoanalytic theory of the etiology of the war neuroses.

9 Jones’(1921) theory is primarily based on Freud’s theory of neuroses. This theory includes several concepts: neurotic symptoms are volitional in origin, they are the product of an intrapsychic conflict the person has failed to satisfactorily resolve, the wish leading to the neurosis is an unconscious one, current repressed wishes cannot directly create a neurosis, and the primary repressed wish that is ultimately responsible for the neurosis is always of a sexual nature (Jones, 1921). Jones explains that “fear” can be divided into three parts: the reaction to external danger (mental state of fear) and may include flight, concealment, defense by fighting and at times attacking; the affective or emotional response to fear which includes a state of anxious preparedness and watchfulness and motor tension; and the affective or emotional response can develop further into a condition of dread or terror which can cause paralyses, indecisiveness and mental confusion. The term that Jones (1921) gave to this state of dread and terror was morbid anxiety.

According to Jones (1921), morbid anxiety comes from the ego-libido, which is the narcissistic portion that is directed inwards and which constitutes self-love. Morbid anxiety, then, is the intolerance of narcissistic sexual hunger (ego-libido) that leads to dread in the presence of real danger. For the soldier, wounded self-love is manifested in the “lack of sociability, sexual impotence, lack of affection for family and friends and feeling that his or her personality has been neglected or slighted” (Jones, 1921, p. 57).

Jones is clear that the reaction to external danger (fear) and the development of affective states (anxious preparedness and watchfulness) are normal, healthy reactions and do not constitute the development of a war neurosis. It is the development of dread or terror, morbid anxiety that leads to the pathogenic development of a war neurosis. Jones

10 is equally clear that the war neurosis is not a new one. It is revived and reinforced from older, unresolved conflicts. In terms of Freud’s metapsychology, Jones’ (1921) model is based on the economic view (interplay of psychic energy).

Ernest Jones was concerned about creating a theory that explained the phenomenon of the war neuroses. The idea of vicarious traumatization did not exist at this time. However, Jones’ idea that war neuroses can revive and reinforce older and unresolved conflicts can be generalized to vicarious traumatization. That is, clinicians’ unresolved conflicts from the past can influence the present.

The Symposium on Psychoanalysis and the War Neurosis held at the Fifth International Psycho-Analytical Congress in Budapest on September 1918 did not sit well with Freud. The papers presented by Ferenzi, Abraham, and Simmel did not adequately address the concepts of trauma and the war neuroses in general. In 1920 Freud wrote Beyond the Pleasure Principle. In it, he defined the concept of the repetition compulsion and how it related to traumatic dreams. The repetition of the traumatic dream leaves the individual in a passive and helpless state. According to Freud, the reason the individual unconsciously experiences the repetitiveness of the traumatic event is because the person is attempting to master the pain and the emotional conflict. Dr. Shelby defines “mastery” as an ability to gradually assume an active position and the individual is less prone to reactivity (personal communication, November 4, 2011).

One of the most important contributions that Freud wrote about in Beyond the Pleasure Principle (1920) was his concept and definition of trauma. He explained that surprise or “shock” overwhelms the mental apparatus and stimuli breaks through the protective shield: “We describe as ‘traumatic’ any excitation from outside which are

11 powerful enough to break through the protective shield. . . .” (Freud, 1920, p. 33). This definition of trauma is clearly based on the economic view of his metapsychology.

Freud (1920) also explained two more concepts related to severe trauma in Beyond the Pleasure Principle: the death instinct and distortion of time. Freud taught that severe trauma can unleash the death instinct, the drive that strives to disconnect—to undo what the libido has bound together. Trauma can also have an impact on one’s perception of time. Perception is a higher-level conscious activity and when trauma is reactivated, the experience of time collapses (Freud, 1920).

In 1921, Freud stated that the war neuroses “has been made possible or has been promoted by a conflict in the ego” (Freud, 1921, p. 1). For Freud, the war neuroses were based in drive theory and conflict within the ego. In Beyond the Pleasure Principle, Freud (1920) made significant and important contributions to our understanding of trauma and the war neuroses.

Similar to Jones, Freud was concerned about developing a theory that explained the phenomenon of shell shock and war neuroses. The psychoanalytic concepts of transference and countertransference were still in infantile stages of definition and development. However, it can be argued, that Freud’s definition of trauma, “a break through the protective shield,” may be used to explain what occurs in the experience of vicarious traumatization. The clinician hears the replay of the traumatic event and becomes a witness to what the patient is experiencing. At that point, the clinician is not only listening to what the patient is describing as traumatic but becomes a participant to the event. The clinician may experience “an increase of stimulus too powerful to be dealt with or worked off in the normal way” (Freud, 1917, p. 275) which causes a “break

12 through the protective shield.” The clinician becomes intrapsychically overwhelmed and “this must result in permanent disturbances of the manner in which the energy operates” (Freud, 1917, p. 275) and may thus lead to vicarious traumatization.

Creasey (1921), a Freudian analyst, succinctly explained the prevailing Freudian view of the time regarding the war neuroses: War did not cause the war neurosis; it brought it to the surface. The history of every shell-shock case would reveal weak spots all along the line of the individual’s character building. Something happened in infancy, a little later possibly something else happened, and a little later something else happened, until the shocks incident to war, or else self-pity and brooding, “let the cat out of the bag” and revealed itself in symptoms, shell-shock. The strata may be likened to the weak threads in the cord, not visible, but a strong pull causes a break, or reveals the weakness in the threads all along the line. Every case of shell-shock is nothing more nor less than traumatic hysteria; it has been coming up for years.

Accident or some shock merely determined it (pp. 365, 372).

This is the beginning of the tension between one’s character and one’s pre-existing vulnerability, and the experience of war neurosis as a “new and distinct” trauma.

The Freudian view of the war neuroses was to be challenged by the up-andcoming British school of object relations of which William Ronald Dobbs Fairbairn was recognized as one its founders. In 1943, Fairbairn wrote the book, Psychoanalytic Studies of the Personality. In it, he spells out his theory of the war neuroses in chapter three titled, “The Repression and the Return of the Bad Object (with a special reference to the ‘War Neuroses’).”

13 Fairbairn maintained that we all internalize “bad objects” (Fairbairn, 1943a). Bad objects refer to the infant/child’s internalized phantasy of the non-responsive parent. The internalization of bad objects is an adaptive mechanism where the infant/child can regain control over the traumatizing, or depriving dependency situation (Grotstein, 1994). The child internalizes his bad objects because they force themselves upon him and seek to control him. The child would rather be bad than to have bad objects. In becoming bad, the child is taking upon him or herself the badness that appears to reside in bad objects and the child purges his or her parents of their badness. This brings about a new situation that becomes tolerable for the child: the child’s objects are then good and the child is bad.

The libido turns inward to the bad object and the “parental bad object is washed clean” (Tolleson, 2008).

For Fairbairn, the phenomenon of the war neuroses is the release of repressed bad objects. The traumatic experience “is one which serves to precipitate a psychopathological reaction through the activation of pre-existing, but hitherto latent, psychopathological factors” (Fairbairn, 1943b, p. 257). This is an unconscious process brought about through the internalization of bad objects.

The chief predisposing factor in determining the breakdown of a soldier, according to Fairbairn, is separation anxiety or infantile dependence on internalized objects (Fairbairn, 1943a). This type of anxiety can be alleviated in a totalitarian system where the individual transfers his dependency from familial objects to that of the regime (Hamilton, 1994; Fairbairn, 1943a). The totalitarian system has it weakness: it only remains a good object to the individual when it experiences national success. When it fails (the collapse of the authority of the superego), the regime becomes a bad object and

14 the socially disintegrating effects of separation anxiety begin to assert themselves on the individual (Fairbairn, 1943a). With the disintegration of group morale, the individual is at the mercy of acute anxiety from the imminent return of vengeful bad objects (Hamilton, 1994; Fairbairn, 1943a). The Armed forces cease to perform a superego function and reverts back to the condition of a bad object: “For in his eyes every word of command is equivalent to an assault by a malevolent father, and every spoonful of ‘greasy’ stew from the cookhouse is a drop of poison from the breast of a malevolent mother” (Fairbairn, 1943a, p. 81).

Fairbairn’s theory of war neuroses is not based on drives and is not a conflictbased model. Rather, it is based on a deficit model. The deficit occurs in the context of failure in the early-on environmental provision, that is, failure in the relationship between parent and infant (Stark, 1999).

Like Jones and Freud, Fairbairn defined a theory about the war neuroses but placed it within the context of object relations and the return of the bad object. Central to Fairbairn’s theory is the idea that traumatic experiences precipitate “psychopathological reaction through the activation of pre-existing, . . . latent, psychopathological factors” (Fairbairn, 1943b, p. 257). This aspect of his theory can be applied to vicarious traumatization. The clinician can experience pre-existing, latent pathological factors which come forth as the clinician countertransferentially experiences the patient as a “return of the bad object.” A potential problem with Fairbairn’s theory is that all impulsive aggressive behavior, fantasies, dreams, and inhibitions are all attributed to bad objects.

In 1941, Abraham Kardiner published his seminal work, The Traumatic Neuroses

15 of War. His theory of the war neuroses became the bible on the subject extending through the 1970’s (Shephard, 2000). Kardiner defines a traumatic neurosis as “a type of adaptation in which no complete restitution takes place but in which the individual continues with a reduction of resources or a contraction of the ego” (Kardiner, 1941, p.

79).

A traumatic event injures the ego, which means the adaptive process becomes altered. This creates instability within the ego structure: “The ego cannot ‘repress’ the outer world or the demands of the organism, but it can contract itself, shrink and withdraw” (Kardiner, 1941, p. 162). Kardiner describes the ego as an organ and he likens the contracted or collapsed ego to an amoeba: “The reaction is like the contraction of the pseudopodia of an amoeba” (Kardiner, 1941, p. 162). With the “effective ego,” the ego organization pushes the outer world away. The opposite occurs when the ego contracts, shrinks or collapses: the outer world overwhelms the ego. When this occurs, the individual does not have the necessary resources to push the outer world away (Kardiner, 1941).

When restitution of the ego does not take place, alterations in adaptation occurs which cause three specific changes to the individual: the individual’s unconscious conception of himself becomes altered, the meaning of the outer world becomes altered, and the internal regulating apparatus governed by the autonomic system is thrown out of consonance with the voluntary system. The new adaptation is compatible with the new shrunken ego and is characterized as disorganized and mixed with regressive elements (Kardiner, 1941).

Kardiner explained that the war neuroses not only activates a pre-existing

16 neurosis (the war acting as a precipitating agent), it can also create a new neuroses that produces tension between activating the old neuroses and the addition of a new illness (Kardiner, 1941, 1959). The major difference between Kardiner’s theory of the war neuroses and that of classical Freudian theory is that of adaptation: the traumatic neuroses of war are the result of an adaptive failure and are not conflictual illnesses.

Kardiner’s explanation of how the ego shrinks or withdraws due to traumatic events can be used to help account for vicarious traumatization symptomatology. When the clinician has experienced too many traumatic assaults on the ego (the repetitive nature of hearing, witnessing, and participating in trauma stories), and the ego is unable to push the outer world away, then the ego shrinks or collapses and the outer world overwhelms the ego and the clinician’s ego adaptive qualities no longer exist. In addition to having old neuroses activated, the clinician can experience a new “neurosis” (vicarious trauma) as well, independent of any pre-existing ones.

Roy Grinker and John Spiegel (1945) published the book, Men Under Stress, which described their findings and treatment of United States Army Air Force fliers of WW II. Earlier in the war, Grinker and Spiegel treated ground force veterans fighting in Africa. During this time, they refined a new treatment that was introduced by another psychiatrist: the use of sodium pentothal. Roy called this new technique “Narcosynthesis” because he believed that the sodium pentothal created “an actual synthesis of repressed traumatic material into consciousness [and] almost always occurs with a dramatic improvement” (Grinker & Spiegel, 1945, p. 170).

For Grinker and Spiegel, “Narcosynthesis” was an abreactive experience— an emotional release of the traumatic material (Grinker & Spiegel, 1945). However, in

17 treating the combat fliers, they discovered that the use of sodium pentothal did not have an abreactive affect like it did among the ground veterans. They shifted their theory from one of abreaction to that of regression of the ego: “Severe anxiety is always secondary to regression and dependence of the ego, and its meaning is that in its regressed position the ego has been deserted by all the forces which could help and protect it” (Grinker & Spiegel, 1945, p. 130). Grinker redefined the term Narcosynthesis in order to reflect the shift in their theory of the war neuroses: The actual therapeutic gain accrues from the use of sodium pentothal when repressed painful or traumatic events and the repressed anxieties and hostilities connected with them are not only exposed during the treatment, but accepted by the flier’s ego . . .

This is the process which we have called narcosynthesis, since under the action of the drug and with the aid of the therapist the previously repressed or forgotten feelings and memories are synthesized by the ego (Grinker & Spiegel, 1945, pp. 170-171).

Within their theory of war trauma, there was no development of a new neurosis.

All combat veterans react to the harsh realities of war according to how their previous psychological patterns have prepared him. “After the initial blow, the reaction is internalized and repetitive according to the previous patterns of the personality” (Grinker & Spiegel, p. 349).

Roy Grinker’s theory of war trauma is based on imbedded, repetitive (unconscious) personality patterns that manifest when a traumatic situation is experienced. This too can be related to the concept of vicarious traumatization. The way in which the clinician processes and internalizes the plethora of traumatic war experiences from patients can be based on ones previous psychological patterns.

18 In his book, Stress Response Syndromes, published in 1976, Mardi Horowitz synthesized a theory of trauma based on a cognitive-psychodynamic approach that addressed patterns of defensive coping and efforts aimed at counteracting dysfunctional beliefs, and disturbances in self and others. Horowitz’s classic first edition (1976) contributed to establishing posttraumatic stress disorder as a diagnosis in DSM III (1980).

According to Horowitz (1976, 2001, 2011), stress responses include six phases: the event; outcry; denial, numbing, and avoidance; intrusion, pangs, and repetitions; working through; and restoration of equilibrium (completion) (Horowitz, 1976, 2001, 2011). Horowitz’s model is based on internalized self-schemas: A self-schema is an organized compendium, a patterned aggregation of elements, and a package of usually unconscious associated meanings about the self. Each self-schema is a constellation of such subordinate elements as body image, role, scripts for relating to others, symbols, values, fears, desires, constraints, intentions, expectations, action plans, and styles of self-control (Horowitz, 2011, p. 104).

Self-schemas define self-organization. Horowitz places states of self-organization on a continuum that includes five dimensions: harmonious self-states, mildly conflicted, vulnerable self-states, disturbed self-states, and fragmented self-states. Horowitz methodically outlines the differences between adaptive and maladaptive responses to trauma. With an adaptive response and prior to the traumatic event, the individual has internal working models that match schemas of the self and others that create well-being.

The trauma event occurs and the person experiences an internal working model that does not match schemas of self and others. Emotional alarms engage and the individual

19 utilizes regulation to modulate emotions. The person then reassesses the situation, revises schemas, utilizes support systems, and modifies repertoires of schemas of self and others.

Simultaneously, the individual engages in emotional-relational efforts at restoration with trial and practice of new behaviors based on endurance and hope. The person experiences post-traumatic growth and is eventually restored to well-being (Horowitz, 1976, 2001, 2011).

With a maladaptive response and prior to the traumatic event, the individual has internal working models that are unstable due to contradictory schemas of self and others.

The individual experiences approach-avoidance dilemmas, problems in relating, and confusions or contradictions in feelings (Horowitz, 1976/2011). After the trauma event occurs, the individual experiences an internal working model of a new situation that does not match schemas of self and others. The event activates latent contradictory schemas.

Emotional alarms engage and the individual experiences severe moods and frozen states.

The person utilizes over control to avoid dreaded emotional states. Inhibited or distorted information processing occurs which prevents reassessments of situations and modifications of schemas (Horowitz, 1976/201). Simultaneously, the individual engages in compulsive repetitions and negative emotional recognition, and behaviors are inappropriate due to excessive numbing or flooding of emotion. Repertoire of schemas remains contradictory and does not match new situations. The person experiences more severe dilemmas, symptoms, problems or extreme avoidance (Horowitz, 1976, 2011).

Even though Horowitz’s theory of stress response syndromes is based on other treatment models including the cognitive-behavioral approach and neuroscience, his theory is placed within the overall psychodynamic framework. This is evident in his

20 treatment approach. Horowitz describes and defines individual character organization variations regarding treatment interventions: inhibitory operations with histrionic personalities, switching maneuvers with compulsive personalities, and sliding meaning with narcissistic personalities (Horowitz, 1976, 2001, 2011).

Mardi Horowitz clearly states that trauma and PTSD cannot be solely explained through cognitive-behavioral or psychodynamic approaches. To explain the phenomenon and integration of traumatic states he believes both modalities are essential. His theory encompasses the breadth and depth of individual dimensions and variations of traumatic reactions. It provides a comprehensive framework for vicarious traumatization. If the clinician processes traumatic narratives and has pre-existing maladaptive self-schemas including the “activation of latent contradictory schemas” (Horowitz, 2001, p. 152) and self-organization states, especially those in the mildly conflicted and vulnerable areas of disorganization, according to Horowitz, this combination creates maladaptive trauma responses (Horowitz, 1976, 2011). For the clinician, this can create vicarious traumatization symptomatology.

Anna Ornstein, self-psychologist and psychiatrist, wrote a compelling chapter in 1994 titled, “Chapter 9 Trauma, Memory, and Psychic Continuity.” In this chapter, she introduced the idea that traumatic memories can threaten the preservation of psychic continuity over time.

Psychic continuity is defined as the sense of being the same person throughout one’s life even though one experiences changes in the body, mind, personality and the environment (Ornstein, 1994). Psychic continuity is disrupted by traumatic memories that are not integrated because they become “incongruent with one’s self-perception”

21 (Ornstein, 1994, p. 136). Integration of traumatic memories has a conflict built into them: though they are feared because of the potential to experience the original event, they demand verbalization and expression to self and others (Ornstein, 1994).

Ornstein believes that many traumatic memories are experienced through disavowal which creates a “state of mind in which emotional detachment, that is, the numbing of affects, makes adaptation to and survival of traumatic memories possible�

(Ornstein, 1994, p. 137). The concept of disavowal contains a split: experiences as they are lived and as they are remembered. The integration of traumatic memories into one’s life narrative depends on the healing of this split (the undoing of disavowal). This creates the reestablishment of psychic continuity (Ornstein, 1994). Ornstein explains that this process of integration is based on the therapeutic dialogue in which the reconstruction of traumatic memory fragments is mutually undertaken by both patient and therapist (Ornstein, 1994).

Though the healing of the vertical split may never be complete, patients may become somewhat free of traumatic symptoms. When the traumatic memories are accompanied by a sense of deep and profound sorrow, anger, and grief, this indicates that an increase in self-cohesion is occurring. This makes it possible to modulate affects that had previously threatened the self with fragmentation (Ornstein, 1994).

Traumatic memories often contain contradictory affects. This is due to the difference between the meaning the experience had for the child and the meaning it has for the adult who is now re-experiencing it (Ornstein, 1994). An essential way to establish psychic continuity over time is to distinguish between the affects of the lived experience and the way the adult experiences the memory retrospectively. Remembering

22 trauma supports self-cohesion while not remembering threatens it (Ornstein, 1994).

According to Ornstein, the concept of disavowal is what maintains traumatic symptoms as well as the disruption of psychic continuity, which prevents a cohesive sense of self from developing. For some clinicians, disavowal, with its vertical split, helps to explain part of the phenomenon of vicarious traumatization.

Doris Brothers (2008), a self-psychologist and intersubjectivist, explained in her book, Toward A Psychology of Uncertainty: Trauma-Centered Psychoanalysis, that experiences of existential uncertainty emerge from, and are continually transformed within, relational systems. She defines psychology of uncertainty as “the complexities of human experience [that] are thought to elude all attempts to find authoritative, irreducible, transcendent explanations, and the unique nature of each psychoanalytic relationship” (Brothers, 2008, p. 3). She places this context within relational psychoanalysis by suggesting that relational theorists differ significantly from object relationists.

Brothers (2008) explains that relational psychoanalysis moved the focus from the individual to relations among individuals. The reason that a relational perspective is unavoidably uncertain is due to the problem of otherness, or alterity (Brothers, 2008).

That is, the relationship with the other is not harmonious and sympathetic through which we put ourselves in the other’s place: we experience the other as resembling us, but “exterior to us” (Brothers, p. 7). Our psychological lives are filled with uncertainty.

These experiences of uncertainty involve the awareness (mainly conscious) that since we are entirely reliant on others (as they are on us), and we cannot dismiss the alterity of others (or that which is alien and “other” in ourselves), psychological survival is never a

23 sure thing (Brothers, 2008, p. 7).

Brothers presents three ideas about trauma that has guided her work: (a) trauma is relational; (b) trauma is a complex phenomenon involving both a shattering experience and efforts at restoration; and (c) trauma goes hand in hand with dissociation. The profound experience that characterizes trauma threatens one with annihilation. Brothers (2008) believe that we all have “systemically emergent certainties” (SEC) which condenses our beliefs about the conditions under which we expect our needs for a selfsustaining relational exchange to be met. Trauma occurs when these certainties that are created in order to stabilize one’s relational worlds are destroyed and expose their falsity.

This means nothing is truly certain in this existential existence and trauma reminds us of that fact (Brothers, 2008).

Trauma is relational and often involves the betrayal of trust in oneself and in others. This betrayal of trust directly impacts the selfobject experiences on which selfhood depends. This places a greater emphasis on the relational experience of trust.

What shatters the organization of one’s self-experience is the profound disruption in one’s trusting relationship with others and not just one’s fantasies about oneself and others (Brothers, 2008). For this reason, the horror of self-annihilation that is experienced by trauma not only reflects disruptions within one’s regulatory processes, but since one’s experience is intricately interconnected with others, the horror is, to some extent, felt by all involved. From the perspective of relational systems, Brothers (2008) believes that all traumas are, to some extent, shared.

Traumatic experiences are often dissociative in nature. Dissociation may be understood as a means of simplifying experience through a drastic reduction of

24 experiential complexity. Through dissociation, one’s experience is ruled by simple, ridged beliefs that are clung to with desperate intensity (Brothers, 2008). Brothers suggests that such rigid and restrictive patterns are likely to be found among analysts who have endured trauma as well. Since much that traumatized patients bring to the analytic relationship, including their vulnerability to retraumatization tends to stir memories of analysts’ own traumas. This may remain largely out of analysts’ awareness and “their old trauma-generated patterns of relating may again take hold” (Brothers, 2008, p. 65).

Brothers (2008) contends that psychoanalysis is a trauma-centered endeavor in “which both analysts and patients are drawn together by their common need for sanctuary and healing” (p. 61). It is only within the context of relationships that the excruciating experiences of existential uncertainty associated with trauma can be transformed. From this perspective, transference and countertransference can be redefined in terms of uncertainty transformation. The lives of the patient and analyst are equally immersed in uncertainty, and both contribute equally to the relational patterns that often come to shape their interactions. Much of what transpires between patient and analyst may be regarded as bringing about the transformation of experiences of existential uncertainty for both (Brothers, 2008).

Brothers concept of ‘systemically emergent certainties” can be generalized to the vicarious traumatization experience of the clinician. Vicarious traumatization can result when these certainties are destroyed. Brothers mentions the rigid beliefs and restrictive patterns that come about through trauma experiences. It can be argued that vicarious traumatization can also create rigid beliefs and restrictive patterns. She specifically addresses the vulnerability to retraumatization of the analyst who has a trauma history.

25 This can also occur with a clinician who has experienced vicarious traumatization: listening repeatedly to patients’ traumatic narratives can retraumatize them.

The last psychoanalytic theorist that will be discussed in this section of the literature review is Dr. Robert Stolorow. His contribution to the field of psychoanalysis and trauma came from two books. The first was written in 2007 and is titled, Trauma and Human Existence: Autobiographical, Psychoanalytic, and Philosophical Reflections. The second he wrote in 2011 and is titled, World, Affectivity, Trauma: Heidegger and PostCartesian Psychoanalysis.

Stolorow is an analyst, intersubjectivist, and a philosopher. He and his collaborators developed intersubjective-systems theory. Intersubjective-systems theory is phenomenological (meaning its focus is on worlds of emotional experiences), hermeneutic (it seeks interpretively to illuminate the structures of meaning that organize worlds of experience), and it is contextual (experience is within formative contextual systems). Intersubjective-systems theory insists that analytic understanding is always from a perspective shaped by the organizing principles of the inquirer. There are no objective or neutral analysts (Stolorow, 2011).

Within intersubjective-systems theory, two central themes emerge relating to trauma: the contextuality of emotional life in general and of the experience of emotional trauma; and that the possibility of emotional trauma is built on the basic constitution of human existence (Stolorow, 2007). Trauma is constituted in an intersubjective context in which severe emotional pain cannot find a relational home in which it can be held. In such a context, painful affective states become unendurable—that is, traumatic (Stolorow, 2007).

26 Stolorow’s (2007, 2011) view regarding emotional trauma is that it produces an affective state whose features bear a close similarity to the central elements of Heidegger’s (German philosopher) definition of anxiety, and that it does this by “plunging the traumatized person into a form of authentic Being-toward-death” (Stolorow, 2011, p. 38). This is experienced as anxiety—the collapse of everyday significance and the resulting feeling of uncanniness (Stolorow, 2011). Death always belongs to our existence due to our “futurity and finitude” (Stolorow, 2011, p. 38).

The meaning or key to understanding trauma, according to Stolorow, is found in what he called “the absolutisms of everyday life.” Stolorow quotes Heidegger regarding absolutisms: When a person says to a friend, ‘I’ll see you later,’ or a parent says to a child at bedtime, ‘I’ll see you in the morning,’ these are statements . . . whose validity is not open of for discussion. Such absolutisms are the basis for a kind of naïve realism and optimism that allow one to function in the world, experienced as stable and predictable. It is the essence of emotional trauma that it shatters these absolutisms (Stolorow, 2011, p. 44).

Trauma shatters the absolutisms of everyday life. Such shattering plunges the traumatized person into a form of authentic Being-toward-death—the loss of significance, the uncanniness. Being-toward-death is essentially anxiety and that in anxiety the significance of the everyday world collapses (Stolorow, 2007, 2011). With trauma, it tears apart the context of everyday certainties that sustains us and that we take for granted. These certainties suddenly fall apart and we are faced with the unprotectedness of our existence (absolutisms of everyday life are shattered). For Stolorow (2011), the

27 integration of trauma states can only occur “in the context of an affect-integrating relational home, [where] traumatized states can cease to be traumatic, or at least cease to be enduringly so” (p.50).

Robert Stolorow’s (2007, 2011) view of trauma, authentic Being-toward-death and its accompanying anxiety and symptomatology (i.e., isolation from others, acute withdrawal and numbness), can be related to vicarious traumatization. While listening to traumatic stories, the clinician may vicariously experience the shattering of “the absolutisms of everyday life” by plunging the therapist into a form of authentic Beingtoward-death, where the significance of the therapist’s everyday world collapses. Death, then, becomes the possibility for the clinician. While one experiences the authentic Being-toward-death via vicarious traumatization, one is utterly and completely alone.

This explains the acute withdrawal, numbness and isolation one experiences.

Clinical Definition of PTSD from Psychiatry and DSM-V The term posttraumatic stress disorder has its origins in modern psychiatry. The disorder was first named and defined in 1980 with the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders. Prior to this, psychiatry was heavily influenced by the psychoanalytic tradition and subscribed to the concepts of shell shock, combat neuroses, war neuroses, and trauma neuroses as defined and used during the First World War. According to the current Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (2013), Posttraumatic Stress Disorder (PTSD) occurs when individuals directly experience the event; witness the traumatic event in person; learns that the

28 traumatic event occurred to a close family member of close friend (with the actual or threatened death being either violent or accidental); or experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related). They also experience the following four distinct diagnostic clusters: re-experiencing, avoidance, negative cognitions and mood, and arousal (DSM-V, 2013).

Re-experiencing covers spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks or other intense or prolonged psychological distress.

Avoidance refers to distressing memories, thoughts, feelings or external reminders of the event. Negative cognitions and mood represents a myriad of feelings from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event.

Arousal is marked by aggression, reckless or self-destructive behavior, sleep disturbances, hypervigilance or related problems (DSM V, 2013).

In 1980, when the psychiatric community officially defined posttraumatic stress disorder, it lent credibility to the hundreds of thousands of veterans who suffered from shell shock and war neuroses (Kutchins & Kirk, 1997). It eventually paved the way for veterans to receive psychological treatment and monetary compensation for this disorder.

As defined by the psychiatric community, in order to be officially diagnosed with PTSD, one must meet conditions in the areas of re-experiencing, avoidance, negative cognitions and mood, and arousal. Like trauma, some theorists believe that PTSD symptomatology is on a spectrum (PDM, 2006; Herman, 1992) and that many individuals who suffer from it do not meet the full criteria as outlined in the DSM. In a study

29 conducted by Pietrzak, Goldstein, Malley, Johnson, and Southwick (2009), this is exactly what these researchers set out to expose.

Pietrzak, Goldstein, Malley, Johnson, and Southwick (2009) reported in their study of older OIF/OEF veterans that 22.3% (134) met screening criteria for partial PTSD and 21.5% (120) for full PTSD. A total of 557 National Guard OIF/OEF veterans completed survey scales relating to PTSD, health and psychosocial functioning. The study found that the partial PTSD group had greater anger and hostility than the nonPTSD group, but less anger and hostility compared to the full PTSD group (Pietrzak et al, 2009). This study did not address the younger OIF/OEF population. It did not take into account the prevalence of mental health and interpersonal issues that existed before these individuals enlisted in the National/Guard reserve. Because partial PTSD is not a diagnostic classification and may not be routinely identified, clinicians may underestimate the magnitude of impairment associated with partial PTSD in these veterans and they may not receive treatment. This study is important to the definition of PTSD because it places the definition on a spectrum from partial to full. This means the population of those Iraqi and Afghanistan veterans who suffer from partial to full PTSD symptoms are well in excess over 300,000. This makes the original estimate much more pervasive and profound.

Contributions of Neuroscience to Posttraumatic Stress Disorder Contemporary psychoanalytic theory has embraced the advent of neuroscience.

This is especially evident in the publication of the Psychodynamic Diagnostic Manual (PDM) in 2006. The manual states “the PDM is based on current neuroscience, treatment

30 outcome research and other empirical investigations” (PDM, 2006, p. 1). The manual is a “diagnostic framework that attempts to characterize an individual’s full functioning—the depth as well as the surface of emotional, cognitive, and social patterns” (p. 2). The PDM provides a compendium of contemporary psychoanalytic thought regarding mental health disorders and syndromes and is to be considered a complement to the DSM. In the section of the manual titled symptom patterns, the PDM describes psychic trauma and posttraumatic stress disorders: Critical distinctions have been made between catastrophic or shock trauma, and cumulative or strain trauma; among infantile, childhood and the adult-onset psychic trauma, and between the nature of the traumatic event, the traumatizing process and the subject’s response to it. Response to trauma varies also with a person’s mental and physical state, personality resources, and the effect of previous trauma history (PDM, 2006, p. 101).

Hence, the PDM (2006) embraces elements of historical psychoanalytic trauma theories and integrates them within the framework of neuroscience.

Van der Kolk (2002) has explained PTSD from a neuroscience perspective relating to brain structures and function. He states that individuals with PTSD dissociate certain sensations and emotions and these experiences do not fade with time. When these individuals are confronted with aspects of the original trauma, they have psychophysiological reactions and neuroendocrine responses that develop into a conditioned response to certain reminders of the trauma. They develop abnormalities in the neurotransmitters that regulate arousal and attention (van der Kolk, 2002). The limbic system and the brain stem generates emotions that contradict ones conscious attitudes and

31 belief which may cause these individuals to behave irrationally when responding to stimuli that is typically neutral (van der Kolk, 2002). Van der Kolk (2000) suggests the reason individuals who suffer from PTSD cannot integrate their trauma is because extreme arousal leads to a failure of the central nervous system. Van der Kolk’s work is important for mental health therapists working with trauma patients because the neurophysiology of trauma needs to inform treatment, not the other way around.

Yovell (2000) offers a striking example of how he used original psychoanalytic approaches and neurobiological findings related to traumatic memories within the framework of a case study. The neurobiological constructs allowed Yovell to shift from a classical psychoanalytic conflict model to a deficit model relating to memory problems (due to chronic hippocampal damage). Yovell (2000) also explained that individuals with PTSD present with hippocampi that are compromised and hypersensitive amygdalae, which may overwhelm their hippocampi rendering them incapable of retaining interpretations. Thus, it may be better to deliver interpretations when the individual is emotionally calm and able to process and remember them. For Yovell (2000), psychoanalytic theory must go beyond the current neurobiological understanding of the mind, but it must never contradict it. This is a powerful example of how an analyst used neuroscience to inform his practice to the extent that he changed from a conflict model to a deficit model in order to support the patient’s neurophysiology.

PTSD Experiences of OEF/OIF/OND and Vietnam Veterans In order to understand the PTSD experiences of OEF/OIF/OND and Vietnam veterans, it is essential to understand some of the differences between the conflicts. First,

32 the ten-year conflict in Vietnam produced approximately 60,000 KIAs (killed in action) and several hundred thousand wounded. The United States OIF and OEF casualty rates are much lower than during any year of the Vietnam conflict (Leibstone, 2005). Second, there is no Iraqi enemy capable of over-running either U.S. forces based in Iraq or the Iraqi government battalions being trained by the U.S., while such anti-U.S. and antigovernment forces existed in Vietnam (Leibstone, 2005). Third, today’s effective U.S.led joint and combined military capabilities did not exist during the Vietnam conflict, nor were U.S. digitized network-enabled troops operating there in the sophisticated way they do today (Leibstone, 2005). The daily losses of Vietnam would not have been as rapid or numerous if the U.S. military had operated the way it functions currently (Leibstone, 2005). Fourth, the U.S. military power and technologies of that time were weak and not as organized as compared to that of today. Iraq and Afghanistan are desert regions with less vegetation compared to that of Vietnam and the OIF/OEF soldier is trained with advanced U.S. technologies (Leibstone, 2005). These factors allow for smaller deployed troops in tenuous locations compared to the poorly trained, mass deployed troops of the Vietnam-era (Leibstone, 2005).

Dr. Matthew Freidman (2005), Executive Director, National Center for PTSD Veteran’s Administration, White River Junction, Vermont, provided testimony for the United States House of Representatives on the subject of veterans and PTSD. He explained that a major difference between Vietnam and OIF/OEF (Iraqi/Afghanistan) veterans with PTSD is the American public’s support of its veterans and the advances in PTSD and treatment since the 1970’s. Many OIF/OEF veterans are returning to a nation that recognizes their heroism and sacrifice. Unfortunately, most Vietnam veterans

33 returned to a divided, hostile public. This kind of homecoming appears to have intensified many of these veterans’ PTSD symptoms (Freidman, 2005).

Dr. Freidman (2005) also explained that current research suggests that in individuals who develop PTSD, no matter what the cause, the syndrome looks the same.

It is important to note that not all trauma researchers agree on this point. For example, Dr. Judith Herman (1992), in her seminal work, Trauma and Recovery, contends that not all traumas are created equal. She advocates for the need of a new concept in defining PTSD because the existing diagnostic criteria are derived mainly from “survivors of circumscribed traumatic events—they are based on the prototypes of combat, disaster, and rape” (Herman, 1992, p. 119).

The current nosology of PTSD does not address the qualitative differences of those who have experienced prolonged, repeated trauma. With these individuals, Dr. Herman explains, the symptom picture is often far more complex: “Survivors of prolonged abuse develop characteristic personality changes, including deformations of relatedness and identity” (Herman, 1992, p. 119). According to Herman, the PTSD syndrome that best describes prolonged, repeated trauma is “complex posttraumatic stress disorder” (p. 119). The Psychodynamic Diagnostic Manual (2006) supports this concept: Posttraumatic stress disorder (PTSD) has become a widely employed diagnosis residua of psychic trauma. It needs to be emphasized that PTSD constitutes a spectrum of complex and multifaceted conditions with different levels of adaptive interference and different meanings to the individual (PDM, 2006, p. 100).

Trauma exists on a continuum; a spectrum from simple to complex posttraumatic stress disorder and the manifestation of symptoms are different on this continuum

34 according to several factors as described by Herman and the PDM. This concept is vitally important for understanding the qualitative differences of PTSD that exists between the Vietnam and OIF/OEF veterans, generally speaking. Both Vietnam and OIF/OEF veterans experience PTSD, however, due to advances in technology, fighting in a predominantly desert terrain without the cover of vegetation, and most importantly, required to serve multiple deployments, many OIF/OEF veterans do in fact experience prolonged and repeated trauma. For many of these veterans, their PTSD experiences can be clinically defined as complex posttraumatic stress disorder making their trauma experiences qualitatively different, generally speaking, than those of the Vietnam War. It was from the Vietnam Conflict that the concept of PTSD eventually developed and became a permanent mental health disorder (Kutchins and Kirk, 1997). For years, many Vietnam Conflict veterans suffered with PTSD symptoms. In fact, a study conducted by Brooks, Laditka, and Laditka (2008) analyzed the long-term effects of military service on mental health among veterans of the Vietnam Conflict. They used data from the National Survey of Veterans (NSV), a nationally representative survey of noninstitutionalized U.S. Vietnam Conflict-era veterans conducted in 2001(28 years after the end of the Vietnam Conflict). The study compared a number of mental health outcomes among Vietnam War-era veterans who served in Vietnam and those who served elsewhere during the same time period (Brooks et al., 2008). The sample identified veterans in any service during the Vietnam Conflict (August 1964 to March 1973), included 3,937 veterans who served in Vietnam and 3,833 who served elsewhere and was comprised of noninstitutionalized veterans living in the continental United States (Brooks et al., 2008).

35 The dependent variables included 6 measures of mental health well-being and the independent variables consisted of demographic information and the war experience. The findings concluded that veterans, who served in Vietnam, even 28 years after the end of the conflict, have notably poorer mental health than those who served elsewhere during the same period (Brooks et al., 2008). Vietnam veterans who were younger than 60 years of age had greater than 3 times the adjusted odds of receiving treatment for PTDS, compared with those who served elsewhere (Brooks et al., 2008).

Unfortunately, these veterans returned home to a hostile nation that was not interested in welcoming and accepting them back or understanding their war experience.

For many of these traumatized veterans, the overt hostile public displays and lack of public acceptance created disastrous, long-term consequences for them (Brooks et al., 2008).

Fortunately, one of the most important lessons the nation learned from the Vietnam Conflict was that of creating a public milieu of support for returning OIF and OEF veterans. This clearly is a major difference between the Vietnam and OIF/OEF conflicts. However, even among the OIF and OEF conflicts, a significant difference exists between the two.

Hogue, Castro, Messer, McGurk, Cotting, and Koffman (2004) conducted a study to assess the mental health of combat duty Iraq and Afghanistan veterans. The sample for this study included members of four U.S. combat infantry units (three Army and one Marine Corps). They were given an anonymous survey that was administered to them either before their deployment to Iraq (n=2530) or three to four months after their return from combat duty in Iraq or Afghanistan. The subjects whose responses met the

36 screening criteria for major depression, generalized anxiety, or PTSD were higher after duty in Iraq (15.6% to 17.1%) than after duty in Afghanistan (11.2%) or before deployment to Iraq (9.3%) (Hogue et al., 2004). The largest difference was in the rate of PTSD. Exposure to combat was significantly greater among those who were deployed to Iraq than those deployed to Afghanistan. The all-volunteer force deployed to Iraq and Afghanistan and the type of warfare conducted in these regions are very different from those involved in past wars (Hogue et al., 2004). Responders to the survey who had been deployed to Iraq reported a very high level of combat experiences, with more than 90% of them reporting being shot at and a high percentage reporting handling dead bodies, knowing someone who was injured or killed, or killing an enemy combatant (Hogue et al., 2004). Close calls, such as having been saved from injury by wearing body armor, were reported frequently. Veterans who served in Afghanistan reported lower but substantial rates of combat experiences (Hogue et al., 2004).

The implications of this study are important. First, the rates of major depression, generalized anxiety or PTSD were higher after duty in Iraq (15.6% to 17.1%) than after duty in Afghanistan (11.2%). Second, the largest difference was in the rate of PTSD among Iraqi veterans because they were significantly more exposed to combat than those in Afghanistan. This supports the notion that Iraqi veterans have higher incidents of PTSD than Afghanistan veterans (Hogue et al., 2004).

The last difference that will be discussed (between the OEF/OIF/OND Wars and the Vietnam Conflict that substantially increased PTSD) is location and length of deployments.

Shen, Arkes, Kwan, Tan and Williams (2010) studied the effects of Iraq and

37 Afghanistan deployments on PTSD diagnoses. They obtained a random sample of active duty enlisted personnel from four services (Army, Marines, Navy, and Air Force) serving between 2001 and 2006 from a TRICARE beneficiary database and linked deployment characteristics from the contingency tracking system. The sample consisted of 678,227 enlisted personnel from all services and represented a 25% random sample of the population without PTSD and 100% of the PTSD population (Shen et al., 2010). The dependent variable in the study is whether an enlisted person was diagnosed with PTSD anytime between 2001 and 2006. Three explanatory variables were included: deployment characteristics, service characteristics, and demographic information (Shen et al., 2010).

They found that deployment to Iraq and Afghanistan increased the odds of developing PTSD substantially, relative to those in other duties, with the largest effect observed for the Navy and the smallest effect for the Air Force (Shen et al., 2010). A deployment longer than 180 days increased the odds of PTSD by 1.11 to 2.84 times compared to a short tour. For the Army and Navy, a deployment to Iraq/Afghanistan further exacerbates the adverse effect of tour length. Even with a short tour, deployment to Iraq still results in an odds ratio of 3.70 for developing PTSD (Shen et al., 2010).

From the previous studies cited, four factors can be summarized regarding the type of PTSD experiences of the OIF/OEF soldier compared to the experiences of the Vietnam soldier. First, the type of warfare conducted in the regions of Iraq and Afghanistan are very different from those of past conflicts. Second, because of technological advances, Iraqi and Afghanistan veterans are surviving more “close calls� than their counterparts in the Vietnam War. Third, a deployment to Iraq/Afghanistan substantially increases the odds of veterans developing PTSD with those deployed to Iraq

38 being the highest (15.6% to 17.1%) compared to those sent to Afghanistan (11.2%) (Hogue et al., 2004). A short deployment to Iraq results in a 3.70 ratio for developing PTSD. Fourth, a deployment longer than 180 days increases the odds of developing PTSD even more (1.11 to 2.84 times).

According to several studies, major differences exist between the OEF/OIF/OND wars and the Vietnam Conflict. However, there are significant differences between the Iraqi and Afghanistan wars as well. From the research previously cited, it became clear that the OIF (Iraqi) soldier is exposed significantly to more combat than those deployed to Afghanistan. This automatically puts an OIF soldier more at risk for developing PTSD. Serving repeated deployments to Iraq also increases the odds of these veterans developing complex posttraumatic stress disorder due to the prolonged, repeated nature of the traumas.

It is important to note that these studies overly rely on self reports of symptoms based on surveys. This is problematic because it has been reported by frontline clinicians that military personnel (i.e., OIF and OEF veterans) often under report or fail to report PTSD symptoms.

Research Findings on Vicarious Traumatization For some VA mental health professionals, working with OEF/OIF/OND veterans and others who experienced severe war trauma and who developed PTSD can come at a great cost. Therapists are required to sit with the suffering of others and remain empathically connected to them and are often exposed to the veteran’s repeated recall of the traumatic event(s) in order to help them integrate the experience. Through this

39 process, therapists are repeatedly exposed to these traumatic events through vivid imagery (Bride, Radey, & Figley, 2007). Over time, therapists may experience similar PTSD symptomatology as that of their clients’ experience. This phenomenon is known as vicarious traumatization or vicarious trauma.

Vicarious traumatization (VT) was first coined by McCann and Pearlman in 1990 and Pearlman and Saakvitne later refined the concept in 1995 (Pearlman & Saakvitne, 1995). It refers to a transformation in the therapist’s (or other trauma worker’s) inner experience resulting from empathic engagement with the client’s trauma material. These effects are cumulative and permanent, and evident in a therapist’s professional and personal life (Pearlman & Saakvitne, 1995).

The Department of Veterans Affairs (2007b) describes vicarious traumatization as those “permanently transformative, inevitable changes that result from doing therapeutic work with trauma survivors” (United States Department of Veteran Affairs, 2007b, p. 5).

It is based on the trauma theory called constructive self-development theory (Saakvitne, 2002). According to the theory, people construct their reality through the development of cognitive structures. These cognitions are then used to interpret events (Dunkley & Whelan, 2006). Trauma can disrupt the therapist’s cognitive schema in one or more of five fundamental need areas: safety (feeling safe from harm by oneself or others), trust/dependency (being able to depend on or trust others and oneself), esteem (to feel valued by others and oneself and to value others), control (the need to be able to manage one’s own feelings and behaviors, as well as to manage others), and intimacy (feelings connected to others or to oneself) (Dunkley & Whelan, 2006).

Several constructs have developed over the years that are somewhat related but

40 different in their meaning and application to vicarious traumatization. These terms include burnout, secondary traumatic stress or secondary PTSD, compassion stress, and compassion fatigue (Bride, Radey & Figley, 2007; Berzoff & Kita, 2010). The concept of vicarious trauma along with the four terms previously mentioned will be examined.

In a study titled “Secondary Traumatic Stress and Vicarious Trauma: A Validational Study,� Jenkins and Baird (2002) examined the measures of secondary traumatic stress (STS; also called compassion fatigue) and vicarious trauma (VT) in a sample of sexual assault and domestic violence counselors, comparing these measures with each other and with measures of burnout and general distress in order to evaluate the concurrent and discriminate validity of the two trauma-related measures. Three scales were used to assess secondary traumatic stress or compassion fatigue constructs: Compassion Fatigue Self-Test (CFST) for psychotherapists, which has two subscales assessing PTSD-like symptoms (CFST-CF), and burnout (CFST-BO). Jenkins and Baird (2002) explained that the symptoms of secondary trauma are nearly identical to PTSD symptoms; the main difference is that the traumatized person may develop PTSD, whereas the one hearing about the trauma may develop a secondary traumatic stress disorder. These researchers stated that in 1995, Figley renamed secondary traumatic stress (STS) compassion fatigue (CF) because it is a normative occupational hazard for trauma workers and mental health professionals. Also, this term is preferred because it is less stigmatizing. A burnout aspect was incorporated into the theoretical base in order to capture the energy depletion characteristic of secondary trauma or compassion fatigue that represents the exhaustion of providing ongoing support to the trauma ridden victim (Jenkins & Baird, 2002).

41 Jenkins and Baird (2002) define vicarious traumatization as the permanent “transformation in the inner experience of the therapist that comes about as a result of empathic engagement with clients’ trauma material” (p. 424). The main symptoms of vicarious trauma are disturbances in the therapist’s cognitive frame of reference, “identity, world view, and spirituality . . . affect tolerance, fundamental psychological needs, deeply held beliefs about self and others, interpersonal relationships, internal imagery, and . . . physical presence in the world” (Jenkins & Baird, 2002, p. 424). Verbal exposure to traumatic material theoretically changes cognitive schemas regarding both self and others in five key areas representing major psychological needs relevant to trauma: trust, safety, control, esteem, and intimacy. The TSI Belief Scale, Revision L (TSI-BSL) measures disruptions in the five-need/schema areas for self and others of vicarious trauma (Jenkins & Baird, 2002).

According to Jenkins and Baird (2002), the construct of burnout is far better developed both in theory and in measure validation than are the two trauma-related constructs (VT and STS). Burnout is conceptualized as a defensive response to prolonged occupational exposure to demanding interpersonal situations that produce psychological strain and provide inadequate support. The Maslach Burnout Inventory (MBI) is widely accepted as the best validated measure of burnout. The MBI contains three subscales assessing Emotional Exhaustion (EE), Depersonalization (DP), and reduced Personal Accomplishment (PA) (Jenkins & Baird, 2002).

The sample for this study consisted of 99 counselors recruited from eight sexual assault and/or domestic violence agencies. Sexual assault agency counselors were 35% of the sample (n=35) and domestic violence counselors 17% (n=17); 48% worked with an

42 agency that served both populations. Almost half were volunteers (46%) and more than half paid staff (63%) with some who did both (15%). The sample consisted of 95 women and 4 men. The agency directors were approached via letter and phone calls to determine the centers’ interest in this study and then participants completed questionnaires (Jenkins & Baird, 2002).

The Compassion Fatigue Self-Test for Psychotherapists (CFST) reported internal consistency reliability alphas range from .86 to .94; factor analysis indicated one stable factor reflecting depressed mood regarding work, and fatigue, disillusionment, and worthlessness. The Cronbach’s alphas of .84 for the CF (Compassion Fatigue) subscale, .83 for the BO (burnout aspect of the compassion fatigue subscale), and .90 for the CFST-SUM (compassion fatigue total score sum) were obtained for this study (Jenkins & Baird, 2002).

Vicarious trauma was measured with the TSI Belief Scale, Revision L. This instrument measures disruption in five cognitive schemes or beliefs and contains ten subscales. Scores obtained include a total score calculated from the sum of all responses; a higher score indicates greater disruption. The average score for mental health professionals is 166.83. For this study, Cronbach’s alpha was .95 for the total score; subscale alphas varied from .62 to.83. The overall internal consistency reliability of this measure has been replicated by several studies (Jenkins & Baird, 2002).

The MBI is a 22-item self-report inventory appraising the three burnout dimensions of emotional exhaustion, depersonalization, and reduced sense of personal accomplishment, as well as a total score. The EE scale entails being mentally and emotionally overextended and exhausted by one’s work and the DP scale refers to a

43 detached and impersonal response toward one’s clients. The PA scale is related to positive feelings such as competence and success in work with people, and is reversed to indicate burnout. High EE and EP and low PA scores indicate greater degrees of burnout (Jenkins & Baird, 2002). For this study, Cronbach’s alphas of .91 for the MBI-EE subscale, .81 for MBI-DP, .92 for MBI-PA, and .91 for the summary score (MBI-SUM) were calculated (Jenkins & Baird, 2002).

Symptoms of general psychological distress were assessed utilizing the SCL-90R. This measure is a widely used multidimensional self-report inventory and examines general psychological symptom patterns for the last 7 days. The Global Severity Index (GSI) indicates general psychological distress. For this study, a Cronbach’s alpha of .77 for the GSI was calculated (Jenkins & Baird, 2002).

Staff/volunteers’ personal victimization history was evaluated through the TSI Life Events Checklist, indicating which of 19 potentially traumatic events they had survived and/or witnessed. This data was used to identify individuals whose histories suggested possible greater vulnerability to clients’ traumas similar to their own.

Regarding personal trauma histories, 55% reported either sexual assault or domestic violence (Jenkins & Baird, 2002).

The scales and subscales for this study are: CFST (Compassion Fatigue); CFSTCF (Compassion Fatigue with PTSD-like subscale); CFST-BO (Compassion Fatigue with burnout subscale); TSI-BSL (vicarious trauma); MBI (burnout); MBI-EE (burnout with emotional exhaustion subscale); MBI-DP (burnout with depersonalization subscale); MBI-PA (burnout with personal accomplishment subscale); GSI (general psychological distress); and TSI-Life Events Checklist (personal victimization history).

44 The results showed evidence of good concurrent validity for the CFST (compassion fatigue) and TSI-BSL (vicarious trauma) and appropriate associations with general psychological distress for the CFST (compassion fatigue), TSI-BSL (vicarious trauma), and MBI (burnout), but inadequate evidence for concurrent validity between measures of burnout (CFST-BO, compassion fatigue burnout subscale and MBI, burnout) (Jenkins & Baird, 2002).

Concurrent validity associations supported the first two hypotheses. First, high correlations of the CFST-SUM (compassion fatigue total scale score) and CFST-CF (compassion fatigue with PTSD-like subscale) and the TSI-BSL (vicarious trauma) showed good concurrence. Second, these three correlated similarly with the GSI (general psychological distress). For the third concurrent hypothesis, the moderate and small correlations between CFST-BO (compassion fatigue with burnout subscale) and MBI (burnout) were not large as predicted. The major aspects of discrimination validity for the CFST (compassion fatigue) and TSI-BSL (vicarious trauma) summary scales were adequately supported (Jenkins & Baird, 2002). The construct validity of both traumarelated measures was supported by their differential associations with counselors’ prior trauma history, consistent with the CFST-SUM (compassion fatigue total scale score) and CFST-CF (compassion fatigue with PTSD-like subscale) scales’ item content as measures of trauma symptoms, and by the independence of TSI-BSL (vicarious trauma) scores from that history, which is consistent with its emphasis on cognitive beliefs (Jenkins & Baird, 2002). CFST-CF (compassion fatigue), which has the largest component of PTSD-like symptoms, differentiated therapists with a history of sexual assault or domestic violence from those without, providing evidence of criterion-related

45 validity. Finally, the factor analysis provided a comprehensive picture of the differentiation of these measures into a factor primarily concerned with trauma and general distress and one centering on burnout (Jenkins & Baird, 2002).

The findings related to the CFST (compassion fatigue) suggest a reformulation of its conceptual structure regarding the component of burnout, specifically, a return to Figley’s emphasis on the Compassion Fatigue (CF) scale as the center of the construct and away from the more recent incorporation of burnout as a content domain (Jenkins & Baird, 2002).

The results of this study also suggest that trauma therapists experience secondary traumatic stress and vicarious trauma both similarly and somewhat differently. The observed symptoms appear to result from assimilating other people’s traumatic material and have general distress plus some burnout as a shared symptom manifestation.

However, secondary traumatic stress and vicarious trauma differ conceptually in their relative emphasis on emotional/social versus cognitive symptomatology, and differ empirically in these measures’ item content and correlates (Jenkins & Baird, 2002). There is adequate evidence that neither of these measures is reducible to the other, and that their associations are not merely shared response bias. For practical application, using the TSIBSL (vicarious trauma) and CFST-CF (compassion fatigue with PTSD-like symptoms subscale) together will help in distinguishing therapists struggling primarily with the cognitive impact of trauma work from those suffering primarily PTSD symptoms and negative experiences with clients (Jenkins & Baird, 2002).

In a personal case study titled, “Shared Trauma: The Therapist’s Increased Vulnerability,” traumatologist and psychoanalyst Karen Saakvitne (2002) clarified

46 multiple levels of vulnerability to traumatization for the therapist. Direct or primary traumatization refers to the direct effects of exposure to traumatic events, as perceived or experienced by you. Secondary traumatization refers to the effects of experiencing the traumatization of others whom you love and for whom you feel responsible. Vicarious traumatization refers to the transformation of your inner self as a result of your empathic engagement with traumatized clients in the context of a helping relationship (Saakvitne, 2002). Vicarious traumatization, then, is the negative transformation of the inner experience of the therapist as a result of their empathic engagement with and responsibility for traumatized patients (Saakvitne, 2002).

Saakvitne believes that many clinicians are currently experiencing multiple levels of traumatization. She explains that vicarious traumatization affects the same general aspects of self that are affected by traumatic life events: self-capacities (affect management, object constancy, self-worth), frames of reference (identity, world view, and spirituality), basic beliefs and psychological needs (safety, trust, esteem, intimacy and control), and realms of perception and memory (verbal, somatic, visual imagery, emotional, relational, and behavioral) (2002). For Saakvitne (2002), “each of us responds to traumatic events through a personal lens shaped by our previous experiences, our most salient psychological needs, and our unique emotional style” (p. 446).

In an article titled “Vicarious Traumatization: Current Status and Future Direction,” Dunkley and Whelan (2006), compared and contrasted countertransference, burnout, secondary traumatic stress and compassion fatigue with vicarious trauma. They suggest that some therapists experience nightmares, intrusive thoughts, disturbing imagery, anger, sadness, and anxiety that relates to their client’s traumatic material. For

47 these researchers, this is the clinical definition of vicarious trauma (Dunkley & Whelan, 2006).

Countertransference experiences of painful images, feelings and thoughts can also accompany work with trauma survivors. However, these researchers explain that the concept of vicarious traumatization is broader than countertransference as it not only considers characteristics of the counselor, but also of the situation (Dunkley & Whelan, 2006).

Burnout refers to the psychological strain of working with difficult populations and is a progressive state of fatigue and/or apathy. Symptoms can include depression, loss of compassion, cynicism, boredom, discouragement, emotional exhaustion, depersonalization, and reduced feelings of accomplishment (Dunkley & Whelan, 2006).

However, Dunkley and Whelan (2006) believe that the literature on countertransference and burnout reflects two separate lines of thinking. Regarding countertransference, the counselor’s personal characteristics determine his or her response to the client’s trauma, while burnout places an emphasis on the characteristics of the stressor. By comparison, vicarious traumatization views the counselor’s response to the client’s trauma material as formed by aspects intrinsic to the individual therapist as well as characteristics of the situation (Dunkley & Whelan, 2006).

According to Dunkley & Whelan (2006), Figley introduced the term “secondary fatigue” or “secondary traumatic stress disorder.” These terms refer to the behaviors and emotions resulting from helping or wanting to help a traumatized person. The symptoms are based on the diagnostic conceptualization of PTSD and include re-experiencing, avoidance or numbing reminders, and persistent arousal (Dunkley & Whelan, 2006).

48 Unlike vicarious traumatization, secondary traumatic stress disorder gives limited attention to context and etiology, restricting its focus to observable symptoms. Vicarious traumatization involves a consideration of the individual as a whole and places the observable symptoms in context (Dunkley & Whelan, 2006).

Secondary traumatic stress can also be operationalized as compassion fatigue, which is the natural consequence of working with people who have experienced stressful events. It is most prevalent in those who help trauma survivors (Dunkley & Whelan, 2006). Its reaction develops as a result of the helper’s exposure to his or her clients’ experiences and his or her empathy for them (Dunkley & Whelan, 2006).

These researchers concluded that, of all the terms they defined and discussed, vicarious traumatization was the most appropriate term for identifying the unique effect that working with trauma clients has on the mental health professional. It incorporates both internal and external influence and considers the individual as a whole. In addition, the term itself is unique to trauma work (Dunkley & Whelan, 2006).

Shubs (2008) presents very different findings in a case study article titled: “Countertransference Issues in the Assessment and Treatment of Trauma Recovery with Victims of Violent Crime.” According to this article, three definitions of countertransference exists, each of which lend themselves to different clinical understandings and responses when working with victims of violent crime.

The first is the “classical impediment theory” (Shubs, 2008, p.158). This is the classical Freudian definition of countertransference as the unconscious reaction of the therapist to the patient’s transference: Because the therapist’s reactions were felt to be interfering in the work of the

49 therapy and were serving as an obstacle to treatment and to the analysis of the patient, this perspective has been referred to as a the impediment theory.” (Shubs, 2008, p. 158) The second is vicarious traumatization. When working with trauma victims, some therapists discovered that their own capacity to process the trauma of the patient was being stressed and overwhelmed (Shubs, 2008). Shubs states: “They were experiencing a range of reactions and responses that were common among themselves and that were independent of unresolved neurotic conflicts” (2008, p. 158). These responses from therapists are within the normal range of reactions when being exposed to traumatic experiences through their retelling, especially as the therapists listen empathically. The therapist experiences the trauma, “even as a result of someone coming in and just talking with us” (Shubs, 2008, p. 159). The therapists’ experiences can be defined as a nonpathological countertransference response because they are consistent with an understanding of countertransference as an impediment (it has the potential to interfere with the therapeutic process). However, they also serve as a complement to that perspective because they do not interfere with the ability of the therapist to be empathic, compassionate and appropriately responsive to the patient (Shubs, 2008).

The third definition of countertransference is the totalistic perspective. Shubs expands on the work of Wilson and Lindy (1994) in order to propose a third definition of countertransference. According to Shubs (2008), Wilson and Lindy (1994) defined two types of countertransference experiences for some therapists as they work with trauma patients: Type I Countertransference being avoidance (empathic withdrawal and empathic repression) and Type II Countertransference being overidentification (empathic

50 disequilibrium and empathic enmeshment) (Shubs, 2008). These countertransference types are based on the concept of “empathic strain” (Shubs, p. 159). Empathic strain occurs when empathy is broken “under the stress of being able to apprehend the traumatic story . . . [and] results from those interpersonal events in psychotherapy that weaken, injure, or force beyond reasonable limits the salutary therapeutic response to the client” (Shubs, 2008, p. 159). Empathic strain and vicarious traumatization are synonymous terms. Shubs’ Type III Totalistic Communicative countertransference definition refers to the total emotional reaction of the therapist to the patient and is based on the intersubjectivity of the psychotherapeutic dyad of patient and therapist. Shubs explains: The therapist and patient are then seen as mutually influencing participants in an interaction where each impacts and affects the experience of the other. The thoughts, fantasies, and feelings of the therapist may be seen to reflect some aspect of the patient’s experience and may be examined to illuminate that experience which is unconsciously being communicated (2008, p. 161).

Shubs’ (2008) Type III definition includes Type I and Type II of Wilson and Lindy’s (1994) model. Countertransference Type I and Type II responses are based on a one-person model of psychotherapy. They are content-based (the therapist is reacting to the content of the patient’s material) and are rooted in the impediment theory. Shubs’ Countertransference Type III definition is based on a two-person model and encompasses a relational view of countertransference reactions and utilizes concepts as splitting, projection, projective identification, and intersubjectivity that exist between patient and therapist (Shubs, 2008). It includes content-based as well as process-based interactions of the therapist. This means that the therapist informs the client of the relational material

51 that both therapist and client experience in the therapeutic process and includes countertransference material from all three types (Shubs, 2008).

Shubs’ work is extremely important because it is the only study that this author has found that places vicarious traumatization within a countertransference framework and within a psychoanalytic relational psychology. Even though his work was confined to victims of violent crime, Shubs’ model can also be generalized to those therapists who work with war veterans and war-related trauma.

In a more recent case study, Berzoff and Kita (2010) present very different findings from that of Shubs. For them, compassion fatigue and countertransference are two different concepts that derive from different sources and serve different functions.

Countertransference has evolved over the years to mean many different things.

The most contemporary view of countertransference (from the relationalist’s perspective) is defined as an intersubjective process, which emphasizes the inextricably related aspects of two sets of transferences: the therapist’s and the patient’s (Berzoff & Kita, 2010).

Enactments often occur within a countertransference. That is, the therapist may find him or herself unconsciously acting as the perpetrator, the victim, or the rescuer of the traumatized client. Countertransference responses are ubiquitous to every clinical encounter whether one is working with traumatized clients or not (Berzoff & Kita, 2010).

Compassion fatigue refers to reactions that emerge from the therapist’s overexposure to client suffering, and is not present in every clinical encounter.

Compassion fatigue is not an enactment (Berzoff & Kita, 2010). It is what happens to those whose job it is to continually support others who suffer and, as a result, are themselves exposed to such suffering. According to Berzoff and Kita (2010), mental

52 health professionals can be expected to be vulnerable to both countertransference and compassion fatigue.

Bride, Radey, and Figley (2007) set out to evaluate the reliability and validity of ten assessments that are used to assess compassion fatigue. These scales include Compassion Fatigue Self Test, Compassion Satisfaction and Fatigue Test, Compassion Fatigue Scale, Compassion Fatigue Scale-Short, Professional Quality of Life Scale, Secondary Traumatic Stress, Impact of Events Scale, Impacts of Events Scale-Revised, Trauma Attachment and Belief Scale, and World Assumptions Scale.

These researchers also defined and clarified secondary traumatic stress and compassion fatigue. Secondary traumatic stress is the natural behaviors resulting from knowing about a traumatic event experienced by a significant other. The stress results from helping or wanting to help a traumatized person (Bride et al., 2007). Secondary traumatic stress is nearly identical to posttraumatic stress disorder. It includes PTSD symptoms of intrusive imagery, avoidance, hyperarousal, distressing emotions, cognitive changes and functional impairment. Compassion fatigue is a more “user-friendly� term to describe the phenomenon of secondary traumatic stress (Bride et al., 2007).

The ten scales that were analyzed, the researchers found that eight of them had some type of validity (i.e., factor, concurrent, predicative, or discriminate) and the validity for one scale had not been reported (Bride et al., 2007). All the scales reported a range or an individual score of reliability. The researchers concluded that each instrument measures specific aspects of compassion fatigue and that clinicians should be clear what aspects of compassion fatigue they want to identify and monitor (Bride et al., 2007). Care should be used in interpreting scores on any of the ten scales reviewed because the

53 measures are intended as screening instruments only and the scoring guidelines are conservative to insure that compassion fatigue is identified where appropriate and not to identify compassion fatigue in someone who is not experiencing it.

The theory behind vicarious trauma and secondary traumatic stress is that clients expose therapists to traumatic stories over time and the therapists themselves develop trauma symptoms. Some researchers have challenged the theoretical framework of vicarious trauma.

In a study conducted by Devilly, Wright, and Varker (2009), they set out to perform an assessment for secondary traumatic stress (STS), vicarious trauma (VT), and workplace burnout for Australian mental health professionals who work in a clinical setting. There were 152 therapists randomly selected to participate in this study through the mail. All participants completed the following self-report scales: Victimization History Scale, Depression, Anxiety and Stress Scale, Copenhagen Burnout Inventory, Secondary Traumatic Stress Scale, TSI Belief Scale-Revision (measures vicarious trauma), Interpersonal Reactivity Index (measures empathy), and Interpersonal Support Evaluation (measures perceived social supports) (Devilly et al., 2009). Demographics were obtained and work-related variables were analyzed. According to these researchers, vicarious trauma was defined as a “cumulative transformative effect upon the trauma therapist [while] working with survivors of traumatic life” (Devilly et al., 2009). They explained that even though the construct of vicarious trauma has a theoretical base, there is little empirical validity testing of either the construct or the sole measure used to asses it (Devilly et al., 2009). The concept of burnout was defined as a “psychological syndrome in response to chronic interpersonal stressors on the job” and included the

54 symptoms of work overload, limited support, role conflict, and role ambiguity (Devilly et al., 2009, p. 374).

The researchers found that secondary traumatic stress, vicarious trauma, and burnout are highly convergent constructs, but the measures for secondary traumatic stress and vicarious trauma do not display construct validity whereas burnout does (Devilly et al., 2009). It was found that work-related stressors (such as burnout and being new to the profession) best predicted therapist distress. The researchers found that the three constructs of secondary traumatic stress, vicarious trauma, and burnout mainly appear to measure the same phenomenon, and both secondary traumatic stress and vicarious trauma are better predicted by the model for burnout than their own theoretical models (Devilly et al., 2009). Exposure to patients’ traumatic material had no significant impact on STS, VT or burnout which, according to these authors, contradicts the theory and research of Figley, Pearlman and Saakvitne, the originators of these constructs (Devilly et al., 2009).

It was also determined that the impact of working with traumatized patients appears to be overestimated. The sample size of this study was small and care must be taken when generalizing the findings.

Other researchers have found the opposite to be true, that vicarious trauma and secondary traumatic stress are ubiquitous to the counseling profession and that therapists suffer from these conditions. Bride (2007) set out to determine the pervasiveness of secondary traumatic stress among a sample of social workers. He conducted a study in which he sent out the Demographic Information Questionnaire (DIQ) to 600 master-level social workers who were randomly selected from 2,886 social workers licensed in a state in the southern United States. The total respondent sample was 282. The DIQ requested

55 standard demographic information and aspects of the participants’ professional activities such as length of social work experience, field of practice, work-related activities and hours worked. The DIQ also asked three questions relating to trauma and traumatization of the clients served and of the participant. The Secondary Traumatic Stress Scale was also used which assessed intrusion, avoidance, and arousal symptoms associated with secondary traumatic stress (Bride, 2007).

The results demonstrated that 15.2% of the participants reported secondary traumatic stress symptoms occurring in the preceding week, at a level that meets the diagnostic criteria for PTSD (Bride, 2007). The lifetime prevalence of PTSD in the general population due to all traumas is estimated at 7.8%. Independent of other traumas that social workers may directly experience, the rate of PTSD in social workers due only to indirect exposure is twice that of the general population (Bride, 2007). Nearly all (97.8 percent) of the respondents indicated that their client population experienced trauma, and most (88.9 percent) indicated that their work with clients addresses issues related to those client traumas (Bride, 2007).

Clearly, social workers are indirectly exposed to trauma as a result of their work with clients. The implications of this study are profound because the prevalence of PTSD among social workers versus the general population was more than double. This is significant because the social workers in this study were not specifically treating traumatized veterans yet their percentage of developing PTSD symptomatology exceeded that of the general population. However, this study is difficult to generalize because it was confined to a single state and the sample size was small.

In an article titled, “Treating Traumatized OEF/OIF Veterans: How Does Trauma

56 Treatment Affect the Clinician?� Horrell, Holohan, Didion, and Vance (2011) describe various factors that may increase vicarious traumatization, secondary traumatic stress and burnout among VA clinicians working with OEF/OEF veterans. The researchers discuss the rewards for treating these veterans as well. The authors delineate three specific areas that may affect clinicians working with this population: (a) patient factors, (b) clinician factors, and (c) organizational factors within the VA (Horrell et al., 2011).

A number of patient factors were identified. These veterans presenting for outpatient mental health treatment are young (over 60% of OEF/OIF veterans diagnosed with PTSD range in age from 18 to 29 years) and more likely to be female, single and employed. Compared with veterans of previous eras, OEF/OIF veterans attend fewer psychotherapy sessions, miss appointments at a higher rate, and drop out of treatment more frequently (Horrell et al., 2011). Poor attendance and the high dropout rate may have an impact on clinicians’ motivation to provide treatment. A positive finding is that OEF/OIF veterans who do complete treatment show greater improvement in self-reported PTSD symptoms compared with Vietnam veterans (Horrell et al., 2011). For clinicians, there may be a sense of urgency to treat these young veterans because in working with veterans of other eras, we now know the result of letting PTSD go untreated for 30 or more years. Treating active National Guard troops or reservists who present for treatment and who are likely to deploy, has a significant impact on clinicians providing trauma treatment (Horrell et al., 2011).

Alleviating PTSD symptoms, and then having the patient return to combat, can be extremely stressful for clinicians. One of the most complicating patient factors are patients presenting with comorbid diagnoses (i.e., substance abuse, depression, anxiety

57 disorders and traumatic brain injury). Estimates indicate that between 12% and 22% of returning OEF/OIF veterans will be diagnosed with a brain injury (Horrell et. al., 2011).

Many of these veterans are less able to participate in the cognitive processing components present in various treatments (i.e., current PTSD therapies in the VA involve Prolonged Exposure Therapy, and Cognitive Processing Therapy). Also, unpredictable and erratic behavior that may arise in and out of session may be difficult to manage and can be incredibly stressful for clinicians (Horrell et. al., 2011).

With treating OEF/OIF veterans with comorbid disorders, which disorder should be treated first? Clinicians may feel overwhelmed with the complexity of these treatment quandaries. Lastly, many of the OEF/OIF veterans have acute onset PTSD (Horrell et al., 2011). They can be aggressive, have higher levels of dissociation, anger, and shame compared with delayed onset PTSD. This presentation can pose significant stress for clinicians treating them (Horrell et al., 2011).

Several factors, including theoretical orientation, training, supervision, military affiliation, personal trauma history, spiritual and religious views, level of social support, and self-care activities, may provide either protective or risk factors in clinicians working with this population (Horrell, et. al., 2011).

Level of training, experience, and supervision working with traumatized patients is related to clinician outcomes. For example, novice clinicians may be more at risk for developing vicarious traumatization (VT), and deficits in trauma-specific training are associated with VT symptoms (Horrell et al., 2011). For experienced clinicians, ongoing training, professional development, and organizational support have been recommended as means of preventing VT. Peer supervision may offer social support and help normalize

58 VT experiences (Horrell, et. al., 2011).

One’s previous experience with the military, or lack thereof, may have both positive and negative impacts on the clinician. Civilian clinicians may be challenged to understand the language, belief systems, and the culture of the OEF/OIF veterans they serve. Clinicians who have served or come from military families may have more intense and personal reactions to working with returning veterans (Horrell et al., 2011).

Personal trauma histories of clinicians working with returning veterans may impact their risk for VT and burnout. Although estimates vary across studies, the authors maintain that more than one third of clinicians or trainees report a personal history of trauma (Horrell, et. al., 2011).

Clinician’s religious beliefs or spirituality may also affect their reactions to working with OEF/OIF combat veterans. Vicarious traumatization tends to damage a person’s sense of meaning, connection, and hope. Spirituality may be a way regaining that hope (Horrell, et. al., 2011).

Social support and self-care factors have been identified as possible protective factors against VT. Holistic self-care and countering personal, professional, and spiritual isolation were identified as protective factors (Horrell, et. al., 2011).

The authors of this study quoted the research findings from Bober and Regehr (2006) who found that the primary predictor of VT was the number of hours spent working with traumatized patients. The best preventative measure against VT appears to be a balanced workload (Horrell, et. al., 2011).

The last area that the authors offer as contributing to the well-being of clinicians treating OEF/OIF veterans is organizational factors. In the vast VA system, its

59 organizational structure can have both benefits and drawbacks. In many VAs, one clinic provides the majority of services for OEF/OIF veterans. It is important for specialty clinics who serve these veterans consider the balance and size of a clinician’s caseload, as both of these components have been identified as risk factors for VT (Horrell, et. al., 2011).

Continual exposure to suicide risk, anger, and aggression from this population may place undue strain on clinicians who are faced with a caseload of veterans with similar symptoms. It is also recommended that providers have some control over selection of new cases to promote caseload balance (Horrell, et. al., 2011).

Encouraging a diversity of professional roles is an important protection against VT. This may include staff support in committee leadership, training endeavors, research, and teaching. Including clinical case conferences, peer-support meetings, or regular supervision, even for licensed professionals, are recommended (Horrell, et. al., 2011).

Attending to group think processes is also important, such as facilitating team dynamics where healthy disagreement and conflict are reinforced. This can ensure that when a staff member becomes disillusioned or hopeless, others are available to reset optimism and hope. Agencies should routinely share both clinical successes as well as staff accomplishments in order to maintain hope and optimism within the clinic (Horrell, et. al., 2011).

To date, this is the only article that this author has been able to find that specifically addressed vicarious traumatization of mental health clinicians treating OEF/OIF veterans with PTSD within the VA system. The research authors work at the Center for Traumatic Stress at the Salem VA Medical Center, Salem, Virginia. They used

60 a composite of many clinicians they have observed over the years and their own experience in order to identify the various factors that contribute to VT and burnout. For this author, the most compelling aspect of this research article was the identification of organizational factors that contributed to VT and burnout.

Beradino (2014) conducted a qualitative dissertation titled, Vicarious Traumatization: Mental Health Professionals Who Work with Combat Veterans with PTSD. The experiences of six clinicians, along with that of the researcher, were analyzed through heuristic research methodology. Five core themes emerged from this study: empathy, identity concerns, stressful milieu, burnout, and paradigm shift. The findings indicated that vicarious traumatization is a cumulative effect related to the five core themes that are influenced by numerous factors including obstruction of empathy, a poor support system, and divergent administrative and clinical agendas. Four of the participants reported the adverse impact that institutional and administrative forces played in contributing to vicarious traumatization. The researcher noted that if clinicians are denied empathic attunement with a suffering veteran, this experience creates alterations in their worldview personally and professionally.

In conclusion, the research suggests a vast difference of academic opinion regarding the constructs of burnout, secondary traumatic stress, compassion stress, compassion fatigue, countertransference, and vicarious traumatization. In fact, a few studies were diametrically opposed to each other regarding the existence of secondary traumatic stress and vicarious traumatization. Some argued that these constructs exist and have validity and others argued the opposite. These differences in opinions may be explained by the various ways in which the constructs continue to be defined and

61 redefined, according to the researchers’ perception and experience. These constructs are embedded in a phenomenological, hermeneutic, and contextual frame (Stolorow, 2011).

Is it any wonder, then, that multiple definitions and conclusions exist regarding them?

However, for the sake of this study, the term, vicarious traumatization will be used to reference those secondary PTSD symptoms that some VA mental health professionals develop as they work with traumatized veterans.

Theoretical and Conceptual Framework The purpose of this study is to elucidate the experiences of Veterans Affairs mental health clinicians treating OEF/OIF/OND veterans with war-related PTSD. The experiences between clinician and veteran occur in a relational matrix that also includes countertransference reactions. The data from this study was analyzed, evaluated, and discussed from such a relational psychoanalytic model: intersubjectivity-systems theory as well as contemporary psychoanalytic countertransference concepts.

From Classical Psychoanalysis to the Relational Tradition.

Psychoanalysis has evolved over its more than one hundred year history regarding its conceptual and metaphorical models regarding pathology and its treatment. Classical psychoanalysts supposed that the patient’s psychopathology originated from the patient, which was based on an imbalance of forces that created internal conflict. This became known as the conflict model of psychopathology and is known as a one-person psychology (Stark, 1999). Later, when the British and American schools of object relations were formed and self psychology emerged, a shift occurred within

62 psychoanalysis. For these analysts, the patient experienced a deficiency-compensation model that is described as the patient’s internalization of traumatic parental failures.

These parental failures form deficits. The deficit is thought to arise in the context of failure in the “early-on environmental provision” between infant and parent (Stark, 1999) and is treated through the corrective experience by the therapist who was experienced by the patient as a new self object.

Although the relationship between therapist and patient is acknowledged, this is still an “I-It than an I-Thou relationship” because of the one-way relationship between someone who gave and someone who took versus a two-way relationship that involves give-and-take based on mutuality and reciprocity (Stark, 1999). For this reason, self psychology and other object relations’ schools that are based on a deficiencycompensation model and focus on the corrective experience have been described as a one-and-a-half-person psychology (Stark, 1999).

A third shift has occurred in psychoanalytic thought over the last thirty years and is known as the “relational tradition” or relational psychoanalysis (Mitchell & Aaron, 1999). Relational theorists believe that what heals the patient is neither insight nor a corrective experience. What heals is interactive engagement with an authentic other and the therapeutic relationship is at the heart of this healing process: patient and therapist together engage in a co-evolving, reciprocally mutual, interactive dyad with each participant initiating and responding (Stark, 1999). Regarding the patient/therapist nature of relational psychoanalysis, Stark (1999) explains: In the relational model, it is the negotiation of the relationship and its vicissitudes (a relationship that is continuously evolving as patient and therapist

63 act/react/interact) that constitutes the locus of the therapeutic action. It is what transpires in the here-and-now engagement between the patient and therapist that is thought to be transformative (p. xxi).

No longer is the emphasis on the therapist as an object (object of the patient’s sexual and aggressive drives) and the therapist is not an object of the patient’s narcissistic demands, or an object of the patient’s relational need to be met and held (Stark, 1990). For this reason, relational psychoanalysis is considered a two-person psychology. In other words, the central metaphor of the traditional psychoanalytic model is the isolated mental apparatus achieving compromises between conflicting internal forces. The central metaphor of the relational model is the larger relational system or field in which psychological phenomena come together and in which experience is “continually and mutually shaped” (Stolorow, Atwood, & Brandchaft, 1994, p. ix). Like other psychoanalytic traditions, great variation exists among the relational tradition as well.

However, this study utilizes the intersubjective-systems theory as the relational/intersubjective model in which the experiences of Veteran’s Affairs mental health clinicians working with OEF/OIF/OND war-related PTSD veterans was analyzed, evaluated, and discussed.

Intersubjective-Systems Theory.

Robert Stolorow, in conjunction with other collaborators, developed intersubjective-systems theory. Stolorow believes that the primary assumption that has guided his work is that the only reality that is relevant and accessible to psychoanalytic investigation (empathy and introspection) is “subjective reality—that of the patient, that

64 of the analyst, and the psychological field created by the interplay between the two” (Stolorow, 1988, p. 332). Intersubjective-systems theory is based in phenomenological inquiry and a “contextualist theoretical perspective” (Stolorow, 2011, p. 2). According to Stolorow, intersubjective-systems theory is centered in three closely interrelated elements of the psychoanalytic method: it is phenomenological, it is hermeneutic, and it is contextual. Stolorow (2011) explains: It is phenomenological—its focus is on worlds of emotional experience. It is hermeneutic—it seeks interpretively to illuminate the structures of meaning that organize worlds of experience. And it is contextual—it grasps experience and its horizons as being constituted within formative contextual systems (p. 2).

Intersubjective-systems theory is a “phenomenological contextualism” (Stolorow, 2011, p. 2) meaning that, phenomenologically, it seeks to investigate and illuminate organizations or worlds of emotional experience. It is contextual in that the organizations of emotional experience take place, both developmentally and in the psychoanalytic situation, in relational or intersubjective contexts (Stolorow, 2011). Intersubjectivity theory is both experience-near and relational (Stolorow & Atwood, 1996, p. 182).

Developmentally, intersubjective transaction patterns recur within the developmental system that emerge with thematic patterns and meaning-structures that unconsciously organize future emotional and relational experiences. For Stolorow (2011), these patterns are unconscious and prereflective; they usually do not enter the realm of reflective self-awareness.

The prereflective patterns, as described by Stolorow (2011) relate with Wallin’s (2007) explanation of early memories that are actions or interactions that are called

65 “invariant representations” and are neuronal patterns located in the cortex that store experience as “forms independent of variations in detail” (p. 76). That is, these early experiences are always the same. They become frozen, absolute with no variation and become predictable. They are presymbolic representations of experience and include somatic and emotional memories that are encoded in bodily sensations and affective reactions. Because these memories are presymbolic, they occur before the acquisition of language and are preverbal. These somatic and emotional memories are specifically tied to the following brain structures: limbic system, amygdala, autonomic nervous system, neocortex, and the right brain hemisphere (Wallin, 2007).

These nonverbal encoded actions of the patient are often experienced by the therapist as a projective identification within a countertransference context. Projective identification “is the process through which we project onto (or into) another what we cannot bear in ourselves. Then we relate to the other in such a way that he comes to identify with what we have projected” (Wallin, 2007, p. 127). Projective identification also includes the disowned aspects of the therapist that are then identified and projected into the patient. Although projective identification is considered a defense mechanism, it is also a form of nonverbal communication (Wallin, 2007) and, according to Dr. Lynne Tylke, “is used by the therapist in order to understand what the patient cannot put into words. Projective identification is the true experience of an empathic experience” (personal communication, April 2, 2012). Dr. Ida Roldan explained that projective identification is also a means “for the therapist to get in touch with what is disowned in oneself” (personal communication, May 4, 2012).

These prereflective (unconscious) organizing principles, according to Stolorow

66 (2011), are formed within intersubjective experiences (relational contexts) and are the basic building blocks of personality development. They emerge in the psychoanalytic situation in the form of transference, “which intersubjective-systems theory conceptualizes as unconscious organizing activity” (Stolorow, 2011, pp. 19-20). “The psychological field formed by the interplay of the patient’s transference and the analyst’s transference is an example of what we call an intersubjective system” (Stolorow, 2011, p.

20).

The system aspect of the theory is defined in the moment. Dynamic systems are formed by the interaction between two human beings (dyadic systems), specifically, when those systems are formed by the interplay between two subjective worlds (intersubjective systems). These systems form the unique field of psychoanalytic inquiry (Stolorow, 1997b).

Dynamic systems theory is concerned with how complex systems produce “patterns that evolve in time” (Stolorow, 1997b, p. 339). Stolorow (1997b) explains the concept of change within these systems: “The process of change within dynamic systems is nonlinear and discontinuous, as changing contexts and changing conditions within the system assemble the elements into radically different patterns of coordination unanticipated by prior configurations” (p. 339).

Affectivity is another element that is important in intersubjective-systems theory.

Stolorow believes the shift from drive to affectivity moves psychoanalysis from an intrapsychic to an intersubjective model because affective experience is regulated, or misregulated within an intersubjective system of reciprocal mutual influence from birth onward (Stolorow, 1997c, p.865).

67 Central to affectivity is Stolorow’s definition of trauma as “an experience of unbearable affect” (Stolorow, 2007, p. 9). Trauma is formed in an intersubjective context in which severe emotional pain cannot find a relational home in which it can be held. “In such a context, painful affect states become unendurable—that is, traumatic” (Stolorow, 2007, p. 10). This author believes that trauma occurs within some therapist/patient dyads when the therapist is unable to create a “relational home” because countertransference reactions become too intense and overwhelming. When this occurs, both participants experience unbearable affect and they become emotionally dysregulated—they become traumatized.

Neurobiology of Attachment and Trauma.

In this section, an overview will be given of the current neuroscience research as it relates to the neurobiology of attachment theory and trauma.

Allan Schore (2002) explains that healthy neural as well as psychological development in early childhood is dependent on the attuned responsiveness of early attachment figures. Siegel (1999) explains that the experience of the mind and body corresponds at the neural level to patterns in the activation of brain cells. The firing of these neuronal patterns establishes synaptic connections in the brain that determine the nature of its structure and functioning. As Siegel (1999) stated, “neurons that fire together wire together” (p. 26). This refers to any two cells or systems that are repeatedly active at the same time. They will become associated or linked, so that activity in one facilitates activity in the other (Siegel, 1999). This association or linkage of systems explains how the structures of the brain are associational. When the infant is soothed by a mother’s

68 voice or by a mother’s touch, these incoming stimuli trigger activity in the baby’s brain and those neurons that fire in synch link up. In this way, experience—especially experience that is repeated—shapes the circuitry of the brain and enables the baby to predict or expect experiences based on these patterns (Wallin, 2007).

The brainstem modulates arousal and regulates the autonomic nervous system (ANS). Schore (2003) refers to this as the “physiological bottom of the mind” (p. 82).

When a person becomes highly aroused, the activation of the sympathetic side of the ANS activates and the fight, flight or freeze response occurs.

In the brainstem is a double-branched cranial nerve called the vagus that form our individual responses to situations we experience as safe, dangerous, or life threatening.

When we feel safe, the myelinated ventral vagus branch puts on the “vagal brake” (Wallin, 2007, p. 71). This down regulates the sympathetic nervous system by calming the body. The opposite occurs when we feel endangered: the vagal brake is released and we are ready for the fight, flight or freeze response (Wallin, 2007). When past trauma has affected the efficiency of the vagal break, the resulting tendency to fight, flight, or freeze is almost always maladaptive (Wallin, 2007).

The limbic system is known as the emotional brain because it is here that feelings are processed. The limbic system is where the internal and external worlds meet. It is the neural substrate of the emotional self and houses two main structures: the amygdala and the hippocampus.

The amygdala is responsible for our gut reactions to experience. It also translates “near-instantaneous appraisal of danger into physical reactions that prime the body to fight or flee” (Wallin, 2007, p. 72) and the fear system is located within the amygdala.

69 The amygdala registers experience in the form of nonconscious presymbolic emotional memories. Wallin (2007) states: Entirely outside awareness, these linguistically inaccessible traces of the past (particularly the traumatic past) bias our appraisals of experience in the present.

Thus, a veteran scarred by the trauma of battle might hear the backfire of a car on a city street and reflexively drop to the ground in a cold sweat (p. 72).

The hippocampus modulates the amygdala’s bias toward indiscriminate, uncontrolled, hair-trigger reactions. The hippocampus is the brake that engages the parasympathetic nervous system that allows us to calm down when the emergency is appraised as a false alarm (Wallin, 2007). Wallin (2007) explains that while secure attachments allow the child’s developing hippocampus to balance the reactivity of the amygdala, acute and relational trauma can shut down the hippocampus temporarily or inhibit its development, leaving one prone to the overvigilant amygdala. Also, the hippocampus is important in the formation of new memories and includes declarative and non-declarative memory.

Declarative memory is explicit, verbal, conscious memory and is divided into two components: semantic memory and episodic memory. Semantic memory is concerned with facts. Episodic memory is defined as memory for events. This occurs when a person tries to remember something and in the process of trying to remember, new memories are created. The original memory is stored as a pattern of neuronal firing. When a person attempts to retrieve that specific pattern (a specific memory), a subset of neurons becomes activated. However, not all of the original neurons that were involved with the first firing or imprinting of the original memory become activated. These neurons are

70 selective and create a replay of the original experience. This replay is not a perfect recollection of that original experience or memory because not all of the original memory neurons were activated. It becomes a new configuration and not a perfect replica (Palombo, 2009).

In respect to traumatic memories, how is it possible to recall aspects of an experience (memory) that was not recalled previously? When a person becomes extremely stressed and experiences traumata, cortisol increases substantially. The hippocampus becomes damaged due to the high levels of cortisol at the same time the memories are created and stored. This produces distorted or incomplete memories (bits and pieces). Some pieces of the memories may be retrieved later. The damage to the hippocampus from the cortisol appears to be permanent but controversy exists whether this is truly the case or not (Palombo, 2009). Those persons who have had their hippocampi damaged by cortisol have smaller hippocampi. Researchers have established a correlation with PTSD and smaller hippocampus function (Palombo, 2009).

Layered over the brainstem and limbic system is the cerebral cortex. This layer makes sense of our experience and organizes our interaction with the world. The frontal cortex is known as the executive function of the brain and makes possible conscious thought, planning, memory, deliberate action, directed attention, and abstract reasoning (Wallin, 2007). It is the center of language and includes those ideas and mental representations that can be raised to the level of awareness. “The frontal cortex can be seen to provide the neural substrate for the symbolic/representational, reflective, and mindful dimensions of the self� (Wallin, 2007, p. 74).

The most advanced area of the cortex is the prefrontal cortex and is divided into

71 two main sections and includes cognitive intelligence and emotional intelligence. The area of cognitive intelligence is located in the dorsolateral region. It is known as the rational mind. It allows us to consciously think about our experience, deliberately directing attention to our perceptions, memories and ideas. It is the location for our working memory (Wallin, 2007).

The middle prefrontal cortex is known as a mediator of attachment behavior, affect regulation, social communication and mentalization. The area that sits directly behind the eyes—the orbitofrontal cortex, appears to be responsible for the decoding of emotional signals through the ability to read nonverbal cues (Wallin, 2007). This area is also known as the seat of human attachment (Schore, 2003; Palombo, 2009). Damage or deficit in this area is associated with difficulty in managing one’s emotions, determining one’s impact on others, and responding appropriately to others’ social signals and states of mind (Wallin, 2007).

A region above and behind the orbitofrontal cortex, the anterior cingulated, also has a major role in attachment, affect regulation, and mentalization. According to Wallin (2007), this area may provide the “neural foundation for maternal behavior, for the implicit and explicit sense of the self, and for the conscious experience of emotion” (p.

75).

A third region of the middle prefrontal is known as the insula. This area is responsible for giving us attention to, and awareness of, our own bodily states, specifically visceral states. The insula may also be central to our ability to feel the emotions of others; that is, the sight, sound, and feel of others’ affective states (Wallin, 2007).

72 The right hemisphere of the brain is specialized to respond emotionally, holistically, nonverbally, intuitively, relationally, and receptively. The right brain is known as the neural substrate for the reflective or mentalizing self. It is also thought to be the seat of the unconscious and of Freud’s primary process (Wallin, 2007). The left hemisphere is the seat of conscious thought and is known as Freud’s secondary process.

It represents experience linguistically and is logical and linear. According to Wallin (2007) “Its primary unit of information is the word” (p. 78).

Right Brain Dysfunction and Self-Deficits.

Allen Schore (2002) explains that the stress of maltreatment in childhood is associated with adverse influences on brain development and it is now thought that a dysfunctional and traumatized early relationship is the stressor that leads to PTSD. Schore believes that “severe trauma of interpersonal origin may override any genetic, constitutional, social, or psychological resilience factor” (p. 459). Traumatic attachment experiences negatively affect the early organization of the right brain and can cause a myriad of problems and issues throughout one’s life. These include deficits in adaptive functions of emotional understanding and reacting to bodily and environmental stimuli, distinguishing the self from the other, generating self-awareness, and identifying a corporeal image of self and its relation to the environment (Schore, 2002).

Schore (2002) specifically explains the consequences of traumatic attachments into adulthood. Adults severely abused in childhood and diagnosed with PTSD show reduced right hemisphere activation during a working memory task and neurological studies of adults confirm that dysfunction of the right frontal lobe is involved with PTSD

73 symptomatology and dissociative flashbacks (Schore, 2002).

Psychological patterns are also patterns of neural organization. It is important to understand the neurobiology of attachment and trauma because of the repetitive nature of the attachment/traumatic experiences that shape brain circuitry and brain structures. It is through the relational process that such traumatic experiences can be reworked and integrated. Regarding this principle, Stolorow (2011) explains: In the language of intersubjective-systems theory, interpretive expansion of the patient’s capacity for reflective awareness of old, repetitive organizing principles occurs concomitantly with the affective impact and meanings of ongoing relational experiences with the analyst, and both are indissoluble components of a unitary therapeutic process . . . the analytic bond must be able to withstand the painful and frightening affect states that can accompany cycles of destabilization and reorganization (p. 32).

Stolorow (2011) contends that it is through the transference meaning of the experience of the patient being understood that the mutative power manifests and the patient weaves that experience into the analytic experience. The opposite can also occur when the analyst is unable to regulate painful and frightening affective states through countertransference reactions.

Stolorow, Brandchaft, and Atwood (1987) defined the concept of countertransference in broad terms as a “manifestation of the analyst’s psychological structures and organizing activity” (p. 42). Countertransference has a critical impact in shaping the transference and “codetermining which of its specific dimensions will occupy the experiential foreground of the analysis” (Stolorow, et al., 1987, p. 42). Transference

74 and countertransference together form an intersubjective system of reciprocal mutual influence and the interaction between the differently organized subjective worlds of patient and analyst (Stolorow, et al., 1987; Stolorow & Atwood, 1992).

From an intersubjective-systems theory perspective, both analytic neutrality and the idea that transference can develop without contamination are illusions (Stolorow & Atwood, 1997a). When transference is understood as an expression of unconscious organizing activity, it becomes apparent that the transference is codetermined by contributions from the analyst and by structures of meaning into which these are assimilated by the patient. In other words, transference is always evoked by some quality or activity of the analyst that is then interpreted by some archaic or early developmental organizing principle of the patient (Stolorow & Atwood, 1997a).

If analytic neutrality is an illusion, what is an alternative stance where both participants can make ongoing, codetermining contributions? According to Stolorow and Atwood (1997a), it is empathic-introspective inquiry. Empathic-introspective inquiry seeks to illuminate the principles unconsciously organizing the patient’s experience (empathy), the principles unconsciously organizing the analyst’s experience (introspection), and the relational interplay of shared psychological fields between the two (intersubjectivity) (Stolorow & Atwood, 1997a). For the analyst, this means that the level of inquiry requires continual reflection on the involvement of his or her own personal subjectivity and theoretical assumptions—seeking to always analyze the intersubjective nature of the analytic dialogue (Stolorow & Atwood, 1997a).

What about objective reality? Donna Orange (1995) explains: Each participant in the inquiry has a perspective that gives access to a part or an

75 aspect of reality. An infinite—or at least an indefinite—number of such perspectives is possible. . . . Since none of us can entirely escape the confines of our personal perspective, our view of truth is necessarily partial, but conversation can increase our access to the whole. . . . Perspectival realism recognizes that the only truth or reality to which psychoanalysis provides access is the subjective organization of experience understood in an intersubjective context . . . Such a subjective organization of experience is one perspective on a larger reality. We never fully attain or know this reality but we continually approach, apprehend, articulate, and participate in it. (pp. 61-62).

Stolorow (1998) supports this view by explaining that “objective reality is unknowable by the psychoanalytic method” because all psychoanalytic understanding is interpretive, meaning it only investigates subjective reality “as it crystallizes within the intersubjective field of an analysis” (p. 425). Stolorow, Brandchaft, and Atwood (1987) explain “subjective reality [include the realities] of the patient, the analyst, and the psychological field created by the interplay between the two” (p. 4). Intersubjectivity theory maintains that “closer and closer approximations of ‘what is really going on’ are gradually achieved through an analytic dialogue in which the domain of reflective selfawareness is enlarged for both participants” (p. 425). For Stolorow, Brandchaft, and Atwood (1987), objective reality consists of “concretizations of subjective truth” (pp. 45).

Countertransference and Countertransference Reactions.

In some of the earliest mentions of countertransference, Freud characterized it as

76 a hindrance to effective psychoanalysis and therapists were exhorted to overcome “any such impediment to their full participation in the therapeutic process” (Brandell, 2004, p.

106). Over the years, the concept of countertransference has evolved and changed and is now considered not only ubiquitous to the psychoanalytic situation but an important, essential, and core aspect of the therapeutic process (Freud, 1915; Winnicott, 1949; Heimann, 1950; Racker, 1953; Racker, 1968; Wolf, 1979; Gill, 1982; Goldberg, 1994; Thompson, 1994; Dalenberg, 2000; Brandell, 2004).

The theoretical construct of countertransference reactions for this study was based on the work of Wilson and Lindy (1994) and Wilson and Thomas (2004). Wilson and Thomas (2004) define countertransference reactions as the “therapist’s affective, somatic, cognitive and interpersonal reactions (including defensive) toward the client’s story and behaviors” (p. 20). Wilson and Thomas (2004) explain that empathic strains, those processes which interfere with the therapist’s ability to sustain empathic inquiry, lead to the development of countertransference reactions. Wilson and Lindy (1994) define empathic strain as “interpersonal events in psychotherapy that weaken, injure, or force beyond due limits a salutary response to a client” (p. 27).

Many potential sources of empathic strain working with PTSD clients include: affective dysregulation in the therapist while listening to emotionally intense trauma histories; cognitive disillusionment produced in the therapist by confronting the realities of human cruelty, malevolence, willful infliction of pain and suffering as well as neglect, emotional indifference and ruthless egoism; the subtleties and nuances of trauma specific transference states in which the therapist is cast into various roles (e.g., judge, lover, perpetrator), that may be difficult to manage therapeutically; the all present affectively

77 dysregulated states of the trauma patient that tax the therapist’s coping strength and lead to fatigue; trauma stories that reactivate personal vulnerabilities in the therapist, including unresolved issues of childhood development and trauma; lack of education and training in traumatic stress, PTSD, stress disorders and inadequate knowledge of the dynamics of PTSD; and rigid, ideological adherence to a specific school of psychotherapy and intellectual dogmatism in respect to PTSD as a fixed entity. From this dogmatic perspective, PTSD is only defined as an anxiety disorder rather than a dynamic, fluctuating state of prolonged stress that influence symptom production, selfpresentations, and somatic processes at any given time (Wilson & Thomas, 2004, p. 57).

In their book, Trauma and The Therapist, Pearlman and Saakvitne (1995) offer six factors that define countertransference: the therapist’s affective response to the client (i.e., client’s identity, presentation, material, interpersonal style, and history); the therapist’s transference to the client, based upon his or her own history; therapist’s responses to the client’s transference to the therapist; the therapist’s defenses against his or her affects or intrapsychic conflicts aroused by the client and the material in the session; any responses that hinder a therapist’s ability to be therapeutic to the client or impede the therapy; and therapists’ unconscious responses to their client. These six factors have historically defined the psychoanalytic concept of countertransference and can also induce empathic strain within the therapist leading to countertransference reactions.

Dalenberg (2000), in her book, Countertransference and the Treatment of Trauma, identifies six specific areas of countertransference reactions with respect to working with traumatized clients: the inadequacy of language in trauma treatment (e.g.,

78 therapists avoiding, mishearing, and minimizing traumatic material of the client); countertransference responses to client doubt and reality-testing disturbance; countertransference struggles with blame and shame (e.g., focus on containing and eliminating countertransference and the advice to avoid sharing countertransference feelings are sources of shame in trauma therapy and the therapist); countertransference responses to repetition compulsion (e.g., with a repetition compulsion, the individual is consciously or unconsciously seeking mastery, absolution, integration, or arousal and with nonmotivated repetition, mediated through habit or conditioning, can lead to unwanted repetitive outcomes which can make it difficult for the therapist to tolerate the client’s rage, terror, disgust, hatred, and longing); countertransference responses to anger and perceived manipulation; and the management of boundaries and sexual countertransference (Dalenberg, 2000).

For Dalenberg (2000), these areas of countertransference responses are unique to working with traumatized clients and can certainly tax the empathic response of some trauma treating therapists and produce empathic strain leading to countertransference reactions that interfere with the therapeutic process.

Modes of Empathic Strain: Therapist’s Reactive Styles.

Wilson and Thomas (2004) explain that when empathic strain occurs empathic attunement gets “challenged or rendered inadequate in the face of the patient’s transference or self-presentation” (p. 86). Empathic strain can happen in a variety of ways and results in countertransferential responses. It is often experienced as increased tension, anxiety, problems with focus, concentration or attention, or increased autonomic nervous

79 system activity (heart rate, respiration) (Wilson & Thomas, 2004).

Empathic strain can also manifest in somatic forms as muscle tension, sleepiness or drowsiness, gastric distress, headaches, fatigue, or more idiosyncratic reactions like rubbing ones eyes, localized muscle spasms and urinary urgency. Empathic strain may be conscious or unconscious in nature and can be associated with rapid shifts in emotional states (anger, disdain, fear, horror) and cognitive processes (fantasies of escape, thoughts about nonclinical activity) (Wilson & Thomas, 2004).

It is possible that empathic strain can be a projective identification countertransference experience and that the therapist is feeling what the patient is feeling nonverbally. That is, as Dr. Lynne Tylke explained, “the patient’s experience is transferred or projected so that the therapist holds and contains the stimulation from the patient’s amygdala” (personal communication, April 2, 2012).

Empathic strain results from those interpersonal events in psychotherapy that weaken, injure or force, beyond reasonable limits, a positive therapeutic response to the client. For Wilson and Thomas (2004), countertransference reactions (CTRs) are only one source of empathic strain, however, they believe that in the treatment of PTSD, CTRs are conceivably the primary cause of treatment failure.

Building on the works of other researchers, Wilson and Lindy (1994) developed a schema for understanding modalities of empathic strain in the treatment of PTSD. It is a two-dimensional representation, based on Type I and Type II modes of countertransference reactions (CTRs), crossed by the axis of objective and subjective countertransference processes (See Appendix C Reactive Style of Therapist). Objective CTRs are normative, expectable, affective, and cognitive reactions experienced by the

80 therapist in response to the client’s personality, behavior, and trauma story. Subjective CTRs are personal reactions that originate from the therapist’s own personal conflicts, or unresolved issues from life-course development (Wilson & Thomas, 2004).

The combination of the two axes of countertransference processes (Type I and Type II CTRs axis and objective/subjective axis) produces four distinct styles of empathic strain: empathic withdrawal, empathic repression, empathic enmeshment, and empathic disequilibrium (See Appendix C Reactive Style of Therapist). Though a therapist may experience one style more than another, it is possible to experience any or all of the styles of empathic strain during the course of treatment of a traumatized client (Wilson & Thomas, 2004).

Empathic Disequilibrium is considered to be a normative, objective, affective reaction and relates to Type II countertransference, which is normative-overidentification associated with reactions of the therapist to the trauma story of the client.

The features associated with empathic disequilibrium include disequilibrium of personal states, shifts in well-being, uncertainty, vulnerability, and security (Wilson & Thomas, 2004).

Empathic Withdrawal is also considered to be a normative, objective, affective reaction and relates to Type I countertransference reaction of normal-avoidance. The features of empathic withdrawal consist of withdrawal from empathic attunement, separation, avoidance, unconscious defenses, feelings of uncertainty and inadequacy, reliance on blank façade, and misperceptions of transference (Wilson & Thomas, 2004).

Empathic Enmeshment is personalized, subjective idiosyncratic reactions to the trauma story of the client and is associated with Type II (overidentification)

81 countertransference reactions. The feathers of empathic enmeshment include personalized affective reactions, activation of personal issues, tendency to cross boundaries, over involvement with the patient, excessive amplification of attunement responses, and reciprocal dependency (Wilson & Thomas, 2004).

Empathic Repression refers to personalized, subjective idiosyncratic reactions to the trauma story and is associated with Type I (avoidance) countertransference reactions.

Features of empathic repression include personal repression memories, conflicts, and unresolved problems aroused by interactions with the patient. Loss of attunement may be severe and damaging to the therapeutic outcome. Withdrawal, denial, and distancing are all defensive styles of empathic repression (Wilson & Thomas, 2004).

It is important to note that Empathic Disequilibrium and Empathic Withdrawal are normative and considered to be universal, objective, indigenous reactions. They are not countertransference reactions. On the other hand, Empathic Enmeshment and Empathic Repression are personalized and are considered to be particular, subjective, idiosyncratic reactions that become countertransference reactions (CTRs). It is only when countertransference processes are elevated to the level of countertransference reactions that they interfere with the therapeutic process and become problematic (Wilson & Thomas, 2004).

Attachment Styles and Type I and Type II Countertransference Reactions.

Research has shown that infants develop some capacity for self-regulation early on. This capacity is enhanced through mutual interactions with caregivers. The caregiver can either enhance and amplify the child’s affect or contain and help reduce the infant’s

82 distress. Children eventually internalize the soothing and regulating functions of adults, who learn to self soothe and regulate their own emotional states. On the other hand, if children have caregivers who are themselves unregulated and incapable of providing a secure base for the regulation of affective states, then children will not be able to regulate their affects (Ringel, 2012).

For Stolorow (2011), developmental trauma originates within a formative intersubjective context where malattunement occurs within the mutual reciprocal childcaregiver system. This breakdown of the child-caregiver system creates painful affect within the child leading to the child’s loss of affect-integrating capacity and thus to an unbearable, overwhelmed, and disorganized state. Painful or frightening affect becomes traumatic when the attunement that the child needs to help in its tolerance, containment, and integration is profoundly absent (Stolorow, 2011). This also applies to some mental health clinicians, who, as infants and children, had tenuous attachments with their caregivers and whose attachment style becomes activated through countertransference reactions with their trauma patients. This can occur with Type I (avoidance) and Type II (overidentification) countertransference reactions.

The avoidance attachment style is comparable to Type I avoidance countertransference reaction. With avoidant attachment, babies seem to be nonchalant and indifferent when separated and reunited with their mothers. They showed independence and autonomy when separated from their mothers and ignored them when they returned. Observations of interactions between mothers and avoidant children revealed that these mothers were rejecting and discouraging of their children’s attachment needs, especially when these children expressed distress, or were overly

83 controlling (Wallin, 2007; Ringel, 2012). Ringel (2012) explains that avoidant adults regulate themselves by deactivating their attachment system. They learn to minimize and defend against experiences of threat, separation, and loss in order not to appear needy and vulnerable. Their self-esteem depends on their ability to overappraise themselves in order to mask their insecurity and vulnerability (Ringel, 2012). The central features of Type I (avoidance) countertransference reactions are loss of attunement, withdrawal, denial, and distancing (Wilson & Thomas, 2004).

The ambivalent attachment style is similar to Type II overidentification countertransference reaction. The anxious-ambivalent child attends to his mother’s every move, becoming extremely distressed when she leaves the room (Ringel, 2012). When mother returned, the anxious-ambivalent child was not easily soothed and responded with ambivalent behavior that included both reaching out to mother and pushing her away and showed signs of clinginess and hypervigilance over mother’s every move (Ringel, 2012; Wallin, 2007). Observations revealed mothers who were inconsistently attentive to their children led to the anxious-ambivalent attachment style of their children. Sometimes these mothers were emotionally available and attentive, at other times, they were absent and distracted. Ringel (2012) clarifies that anxiously ambivalent adults tend to exaggerate experiences related to threat, separation, and loss and to heighten their affective responses to consequences. They also exaggerate their sense of helplessness and vulnerability and to undervalue themselves. The central features of Type II (overidentification) countertransference reactions are loss of boundaries, over involvement, and reciprocal dependency (Wilson & Thomas, 2004).

The disorganized attachment style can also occur with the Type II

84 overidentification countertransference reaction. The disorganized infant, upon reunion with the mother, backed toward her, froze in place, collapsed to the floor, or appeared to fall into a dazed, trance-like state (Wallin, 2007). It is hypothesized that disorganized attachment results when the attachment figure is simultaneously experienced not only as the safe haven but also as the source of danger, “that is, when the child—preprogrammed to turn to the parent in moments of alarm—is caught between the contradictory impulses to approach and avoid” (Wallin, 2007, p 22). As adults, they often use deactivating and hyperactivating strategies. These adults often have a history of trauma regarding attachment figures that evoked both an avoidance of closeness and a terror of abandonment (Wallin, 2007). They are frequently torn by conflicting impulses (to avoid others out of fear of attack or to turn desperately to others out of fear of being alone) and often have over powering and chaotic feelings (Wallin, 2007). The main features of Type II (overidentification) countertransference reactions include loss of boundaries, over involvement, and reciprocal dependency (Wilson & Thomas, 2004).

Attachment styles develop within the infant-parent relationship and have been described as mutually regulated and co-created (Wallin, 2007). Defining attachment theory and attachment styles in this way dovetails into the relational/intersubjective tradition (Stolorow & Atwood, 1992; Stolorow et al., 1987). These relational theorists have identified the relational field between patient and analyst as a “mutual reciprocal influence” and as all-encompassing interactions between patient and therapist (Stolorow et al., 1987) echoing the co-created and mutually regulated infant-parent relationship as defined by some attachment researchers (Wallin, 2007). The mutually regulated and cocreated infant-parent relationship is also based in affectivity. Stolorow and Atwood

85 (1992) explain that affectivity is not a product of isolated intrapsychic experience but is seated in the child-caregiver system of mutual regulation. This same process is extended to the intersubjective field between patient and therapist—a process of mutual regulation and mutual influence.

Theoretical and Operational Definitions of Major Concepts Countertransference reactions: Countertransference reactions (CTRs) are defined as the “therapist’s affective, somatic, cognitive, and interpersonal reactions (including defensive) toward the client’s story and behaviors” (Wilson & Thomas, 2004, p. 20).

Empathic strain: Empathic strain occurs when interpersonal or other factors significantly affect the capacity for sustained empathic attunement and results in the loss of capacity for resonance, synchrony, and congruence in communication with stress.

Empathic strain occurs when the events in psychotherapy weaken, injure, or force beyond due limits a beneficial response to a client (Wilson & Thomas, 2004). Empathic strains lead to the development of countertransference reactions.

Intersubjective-systems theory: Intersubjective-systems theory is a “phenomenological contextualism” (Stolorow, 2011, p. 2) meaning that, phenomenologically, it seeks to investigate and illuminate organizations or worlds of emotional experience. It is contextual in that the organizations of emotional experience take place, both developmentally and in the psychoanalytic situation, in relational or intersubjective contexts (Stolorow, 2011). Intersubjective-systems theory is both experience-near and relational (Stolorow & Atwood, 1996, p. 182).

Transference: Transference is the process and behaviors by which a client relates

86 to the therapist in a manner similar to that in past relationships with significant others (Wilson & Thomas, 2004).

Trauma: Trauma is an experience of unbearable affect and is formed in an intersubjective context in which severe emotional pain cannot find a relational home in which it can be held. “In such a context, painful affect states become unendurable—that is, traumatic” (Stolorow, 2007, p. 10).

Type I CTRs: Type I (avoidance) countertransference reactions involve forms of denial, detachment, distancing or withdrawal from the client (Wilson & Thomas, 2004).

Type II CTRs: Type II (overidentification) countertransference reactions entail forms of overidentification, enmeshment or overidealization of the client (Wilson & Thomas, 2004).

Vicarious traumatization: Vicarious traumatization (VT) refers to a transformation in the therapist’s (or other trauma worker’s) inner experience resulting from empathic engagement with the client’s trauma material. That is, through exposure to client’s graphic accounts of sexual abuse and trauma experiences, and to the realities of people’s intentional cruelty to one another, and through the inevitable re-enactments in the therapy relationship, the therapist is vulnerable through his or her empathic openness to the emotional and spiritual effects of vicarious traumatization. These effects are cumulative and permanent, and evident in a therapist’s professional and personal life (Pearlman & Saakvitne, 1995).

Statement of Assumptions This study is based on the following assumptions noted below:

87 1. Trauma, as defined as a psychological phenomenon, has been changed and elaborated over the years.

2. The dynamics of war are distinctive in its experience. The context creates distinguishable features.

3. A unique feature of trauma has to do with affect and an overwhelming sense of helplessness.

4. Helplessness is recreated in the therapeutic relationship.

5. Vicarious traumatization indicates the possibility that the clinician may be subjected to this type of helplessness.

6. There appears to be a distinct experience of mental health clinicians as they treat the OEF/OIF population.

7. The sample population of mental health clinicians in this study will include those who experience vicarious traumatization and those who do not.

8. The mental health clinicians interviewed for this study will be able to articulate in a meaningful manner their experiences treating OEF/OIF/OND veterans with PTSD and to articulate and convey their experiences.

9. The methodology of this study will capture, organize, and elucidate this distinct experience of mental health clinicians during interviews.

10. Several of these mental health professionals have been exposed to numerous traumatic war histories over time. This has exposed them to psychological trauma and as such, powerful psychological forces will be present. The literature suggests that countertransference phenomenon will be present including the clinical concepts of splitting, projection, projective

88 identification, and intersubjective-systems theory (Wilson & Lindy, 1994; Pearlman & Saakvitne, 1995; Dalenberg, 2000; Wilson & Thomas, 2004; Stolorow, 2007; Stolorow, 2011).

Based upon this author’s professional observations including treating veterans with war-related PTSD and being immersed in supervising VA clinical social workers, the following personal assumptions include: 1. The mental health clinician who becomes overwhelmed with traumatic war related PTSD stories from these veterans appear to have an overidentification/avoidance experience.

2. Countertransference reactions may be tied to the therapist’s previous trauma history and influenced by developmental issues.

3. The attachment styles of the therapist may influence the experience of vicarious traumatization (i.e., avoidant, disorganized, ambivalent).

Epistemological Foundation of Study The philosophical, postmodern worldview that is proposed for this study is Social Constructivism. This worldview states that “reality” exists only in the context of a mental framework or construct for thinking about it. The philosophical basis is that inquiry cannot be value free. If “reality” can be seen only through a theory window, it can equally be seen only through a value window. Therefore, many constructions are possible (Guba, 1990). People seek for an understanding of their world. They develop subjective meanings of their experiences. Meanings and realities are multiple, and they exist in people’s minds. It is important to look for the complexity of views rather than the

89 narrowing of meanings, or for a few categories or ideas. The goal of research, according to social constructivism, is to rely as much as possible on the participant’s views of what is being studied (Guba, 1990; Creswell, 2009).

People engage with their world and attempt to make sense of it based on their historical and social perspectives. This creates worlds of meaning and multiple “realities.” The qualitative researcher endeavor’s to understand the context and setting of participants through visiting the context and gathering information personally. The researcher’s own experiences and background are used to interpret the data that is found.

Qualitative research is largely inductive, generating meaning from the data collected in the field (Creswell, 2009).

90

Chapter III

Methodology Type of Study and Design A grounded theory qualitative process based on methodology outlined by Corbin and Strauss (2008) was utilized in this study. The qualitative methodology allows for the exploration of “the inner experience of participants, to determine how meanings are formed through and in one’s culture, and to discover rather than test variables” (Corbin & Strauss, 2008, p. 12). Data was obtained from interviews with participants and they were screened for appropriateness.

One of the most important characteristics of grounded theory is that the process is “fluid, evolving, and dynamic” (Corbin &Strauss, 2008, p. 13). This allows for decisions to be made immediately as the data is analyzed and as categories develop. Through the process of analyzing data and the development of categories, theoretical sampling often emerges. Theoretical sampling is defined as “sampling on the basis of concepts derived from the data” (Corbin & Strauss, 2008, p. 65) and is based on the idea that data collection and analysis go hand in hand concurrently. This enables the researcher to ask questions in the next interview based on the analysis of the previous interview (Corbin & Strauss, 2008).

Grounded theory is built on the premise that emerging categories guide the researcher in the direction of gathering and analyzing specific data. The emerging categories are then refined and elaborated upon in order to “generate or discover a

91 theory� (Creswell, 2007, p. 63; Corbin & Strauss, 2008). The elaboration of the theory is a fluid process that allows for the sampling to be refined as the research develops.

Scope of Study, Population, and Sampling This study is based on a nonprobability sample and the specific type is known as an accidental sample, sometimes referred to as availability or convenience sample (Fortune & Reid, 1999; Rubin & Babbie, 2008). The subjects consisted of adult men and women who are Veterans Affairs (VA) mental health professionals and who have experience treating OEF/OIF/OND veterans with Posttraumatic Stress Disorder (PTSD).

In the VA system, veterans can only receive treatment for PTSD if they are diagnosed with it by a licensed mental health professional or a psychological/psychiatric resident intern who is working under the license of a mental health professional. For this study, VA mental health clinicians must have worked for the VA at least two years in order to be considered for the sample.

Originally, subjects were to be recruited from a national Veterans Affairs list that included social workers, psychologists, psychiatrists, licensed professional counselors, and psychiatric nurses. This author also intended to recruit participants from the premier VA PTSD residential clinic in Palo Alto, California. However, due to unforeseen political and internal changes that occurred within the VA nationally during the initial phases of this study, this author was instructed by his supervisor to recruit and conduct the interviews at the local VA level. Originally, 20 to 25 subjects were to be interviewed, however, when the study was confined to recruiting participants on a local level, that number was reduced to 17. The participants were recruited either in person or by a

92 telephone conversation. They were explained the nature of the study and invited to participate.

Data Collection Methods and Instruments Data was collected from two separate interviews with each participant. However, three did not have a second interview. Fourteen participants completed two interviews and all were informed that they would be sent a copy of the results and asked to participate in the member checking process. Both interviews were approximately 45 minutes in length. Each interview was audiotaped and transcribed. The transcriptions of the interviews provided the raw data that was analyzed. Memos were written throughout the entire data collection and interview process and were used during data analysis. The memos are an account of the reactions and observations of the interviewer. The interviews occurred in the mental health clinician’s office and one participant’s second interview was conducted over the telephone.

Following a short introductory period, the research participant was asked to describe their experiences treating OEF/OIF/OND veterans with the following openended questions: 1. How long have you been a war trauma therapist?

2. What was the reason you chose to work with veterans?

3. What made you decide to specifically treat OEF/OIF/OND veterans with PTSD? After this introductory phase, participants were asked to direct their attention to their clinical experiences treating the OEF/OIF/OND veterans. The interview process was designed to facilitate honest, unedited, and comphrensive responses from the participants.

93 In order to faciliate the participants’ exploration and reflection of their experiences treating this popualtion, several questions were utilized: 1. What is it like treating OEF/OIF/OND traumatized veterans?

2. Is treating this population rewarding for you?

3. What is the most challening aspect of this work?

4. Was there ever a time you felt overwhelmed by the trauma story of a veteran? If so, please tell me about it.

5. Have you ever felt emotional or empathic detachment working with these veterans? If so, how have these feelings of detachment affected you, the veteran and the session?

6. Since working with traumatized veterans, do you find that you are different now from how you were before you started trauma work? Please explain.

7. After working with traumatized veterans, have you been preoccupied with thoughts and feelings about the trauma? Explain.

8. Have you thought of your veterans as being heroic for enduring their traumatic experiences? Tell me about that.

9. In your experiences with treating this population, have you ever found yourself reapprasing your own beliefs and values? Please explain.

10. If you were designing a program to support VA clinicians working with this population what would you include?

(The questions above were modified from Wilson and Thomas’ (2004) book, Empathy in the Treatment of Trauma and PTSD, specifically the appendix: “Clinicians’ Trauma Reaction Survey Questionnaire.”)

94 The following question was added later due to data collected from previous interviews: 11. With respect to doing trauma work, did you ever feel a sense of threat or feel that your environment somehow is no longer safe as it used to be? Please explain.

These questions were used only for faciliting partcipants’ exploration of their experiences. They were not intended to influence or lead them in any preconceived direction. During the interviewing processes, the particiantps elaborated and expanded their experiences of the dissertation question through their own associative links and thoughts.

Procedure for Data Analysis Every interview was recorded and transcribed. From these transcripts came the raw data that was analyzed. Consistent with grounded theory design, the analysis of the data came from written memos (Corbin & Strauss, 2008). Memos are written data of the analysis (Corbin & Strauss, 2008) and included open data exploration; developing and identifying the dimensions and properties of concepts and categories; asking questions and making comparisons; analyzing the relationships between conditions, actions, interactions and consequences; and developing a story line (Corbin & Strauss, 2008, p.

118). Memos also included the researcher’s emotions, thoughts, and frustrations particularly if the researcher has a sense of what is happening but is unable to articulate it at the time (Corbin & Strauss, 2008, p. 139). Analyzing data through the process of memo writing occurred throughout the research process. The data was analyzed in the following manner: open and axial coding, resulting in theoretical saturation, and the integration of categories. Data processing and analysis occurred simultaneously and ran

95 throughout the course of the research process which allowed for the development of theoretical constructs.

Open coding is defined as “breaking data apart and delineating concepts to stand for blocks of raw data [and] [a]t the same time, one is qualifying those concepts in terms of their properties and dimensions” (Corbin & Strauss, 2008, p. 195). Open coding begins with the first interview and includes the process of scrutinizing and examining the data in depth: a deconstruction process. This level of examination and deconstruction continues with each interview until all the data is “broken apart” and the data is organized into discrete parts. During this process of open coding, the data is continuously being examined and compared as concepts emerge (Corbin & Strauss, 2008).

Concepts are words that stand for ideas contained in data. Concepts are “interpretations that form the product of analysis” (Corbin &Strauss, 2008, p. 159). Once the concepts are identified, their properties and dimensions are defined. “Properties are characteristics that define and describe concepts, [and] dimensions are variations within properties that give specificity and range to concepts” (Corbin & Strauss, 2008, p. 159).

This process of “breaking data apart” includes a line-by-line analysis of all interview content together with all sentences and paragraphs. It is during this process that the researcher begins writing memos: “What I am thinking as I analyze the data . . . asking questions, making comparisons, throwing out ideas, and brainstorming” (Corbin & Strauss, 2008, pp. 163, 169-170). Each memo was labeled with a concept. During this early phase of analysis, concepts and categories were considered provisional. Concepts were scrutinized against further data and added to, changed, or discarded as the analysis continued (Corbin & Strauss, 2008).

96 The data collection and analysis process continues until the researcher is satisfied that he or she has acquired sufficient data to describe each category/theme fully in terms of its properties and dimensions, and until the researcher has accounted for variation, and most importantly, until the researcher can put together a coherent explanatory story.

Throughout the process of analysis, it is important to ask questions and make comparisons. This continues to be a crucial strategy for elaborating the analysis (Corbin & Strauss, 2008).

Corbin and Strauss (2008) teach that open and axial coding go hand in hand. They both occur simultaneously as one continues to break data apart, identifying concepts, and putting the data back together. In doing this, the researcher takes the categories of open coding and identifies one as the central phenomenon to be studied. In axial coding, the process is one of relating categories of information to the central phenomenon category by identifying the following: “(a) what caused this phenomenon to occur, (b) what strategies or actions actors employed in response to it, (c) what context (specific context) and intervening conditions (broad context) influenced the strategies, and (d) what consequences resulted from these strategies� (Creswell, 2007, p. 237). Axial coding also consists of relating categories to subcategories and linking them at the level of properties and dimensions (Corbin & Strauss, 2008).

Analysis of the data begins after the first day of gathering it. Data collection leads to analysis and analysis leads to concepts. Concepts generate questions and questions lead to more data collection. This circular process continues until the researcher reaches the point of saturation (Corbin & Strauss, 2008).

Saturation is the next step in data analysis. Saturation occurs when all the

97 concepts are well defined and explained (Corbin & Strauss, 2008). That is, the development of categories occurs in terms of their properties and dimensions, including variation. It also includes the delineating of relationships between concepts, which is the basis for theory building (Corbin & Strauss, 2008). The researcher finally comes to a point at which the categories are saturated and he or she no longer finds new information that adds to their understanding of the category (Creswell, 2007).

As saturation occurs, the last step in the data analysis process is reached: integrating categories. Integration is “the process of linking categories around a core category and refining and trimming the resulting theoretical construction� (Corbin & Strauss, 2008, p. 263). In this stage, the relationships between major categories are analyzed in order to determine a core category. Integration and the development of the core category requires sifting and sorting through all memos and looking for clues on how all the categories may fit together. Rereading memos, creating the story line, and creating diagrams are all techniques that can help with final integration (Corbin & Strauss, 2008). In order for integration to be complete, all major categories and subcategories must be linked together which creates the foundation for the theoretical structure. This theoretical structure, then, becomes the theory to explain the phenomenon being studied. Once the theoretical structure is identified, the theory is refined by checking for gaps in the logic and reworking those areas by using all the memos that have been written and sorted in order to fill in the information under each major category (Corbin & Strauss, 2008).

When the results are analyzed through the process described above, this researcher presented the results chapters (i.e., the development of the categories and core

98 category) to several of the participants in the study. This step is known as member checking and this process consisted of a third interview. The participants were asked to review the results of the data and were invited to provide feedback. Member checking is an important part of the process because it adds validity to the data analysis and can further define the categories.

Data analysis begins with open coding, progresses to axial coding, and finally culminates in integration. Through this process, the data is examined, deconstructed, and analyzed. Categories are integrated and theory grounded in the data emerges. All the major categories embedded in the data represent the narratives of this sample. The last step in data analyses is member checking. Member checking allows for additional elaboration of the results of the data and provides validation of the analysis.

Statement on Protecting the Rights of Human Subjects The dissertation research question is neither traumatic or painful in itself.

However, the potential risk of accessing difficult or unmanageable emotional material is possible. Some participants may find articulating their experiences difficult or discover new perspectives that challenge their original assumptions. It is possible that participants might question their competency as a therapist due to the vicarious trauma experiences that are elicited.

Research participants were screened for gross signs of mental illness including depression, anxiety, and suicidality. Participants were told they do not need to answer any question that makes them uncomfortable and they can stop the interview at any time.

Participants were informed that if they experience discomfort or distress and would like a

99 referral for debriefing or consultation to a professional, they will be provided with such a list.

The screening criteria included the following requirements: must be a Veterans Affairs (VA) mental health clinician with a minimum of two years prior mental health treatment experience working for the VA; currently provides treatment for OEF/OIF/OND veterans who have been diagnosed with Posttraumatic Stress Disorder (PTSD); willing to discuss their treatment experiences in a lengthy interview including a follow-up interview that will be audio recorded, transcribed, and used as data for a dissertation; and who do so voluntarily and without remuneration.

This research study contributes to the body of clinical social work knowledge in several ways: it discusses the positive and negative experiences of VA mental health clinicians treating combat-related PTSD; it identified vicarious traumatization experiences with many participants throughout the interviewing process and its effects on them; has the potential to influence policy-making within the VA by addressing the need for a formal program of clinical support including clinical supervision and case consultation on the local level; and it contributes to the broader theory of war trauma and its treatment.

There were no direct benefits of participation in this research study. The study, however, offered participants an opportunity to explore and clarify their experiences within the context of the proposed dissertation question. In so doing, most participants were able to deepen their understanding of their experiences as they verbalized and contemplated treating war-related traumatized veterans. It is expected that the specific knowledge obtained from the study will benefit the psychodynamic community and

100 society as a whole.

The findings of this study were compared to the literature on intersubjectivity theory and vicarious traumatization. Some dimensions of the literature were elucidated, while alternative explanations were given. Ultimately, the goal of this study is to contribute to the literature on the challenges facing the dedicated VA clinician working with the OEF/OIF/OND combat veteran population.

Informed Consent/Assent The purpose of the study is to understand and convey VA clinicians’ experiences of treating OEF/OIF/OND veterans who have been diagnosed with war-related PTSD and how these experiences professionally and personally impacted them. Each subject completed an initial forty-five minute, audiotaped interview and most participated in a follow-up interview. The interviews were an opportunity to explain, explore, reflect, articulate, and clarify their experiences as a therapist treating this veteran population. All research participants were volunteers.

The individual interviews were transcribed with identifying information coded in order to protect the anonymity of the research participant. The transcriptions were analyzed for the purpose of completing a dissertation. All of the transcriptions and audiotapes will be stored in locked files in a private office and kept for five years after graduation. Participants were given the opportunity to review the results of the study in order to determine the adequacy and clarification of their responses. The results were presented in a written summary. A transcriptionist was not used during this study.

The research participants were asked how the purpose of the study influenced

101 their interest and caused them to voluntarily participate. In addition, they were asked what risks and benefits they may experience as research participants. After it had been determined that the research participants meet the requirements to participate in the study, they were notified of their acceptance in person or by telephone. The consent form was then introduced and explained as a preliminary requirement prior to the interview process. The inform consent that was used is the Institute for Clinical Social Work Individual Consent for Participation in Research form (See Appendix A Informed Consent Form). The purpose and procedures of the study were explained and the participants’ understanding was assessed. Before the initial audiotaped interview, each participant was given a consent form that was explained to them, which they signed.

102

Chapter IV

Introduction to the Results The results for this study were derived from the following seven chapters after analyzing 33 interviews from 17 participants. Each participant’s story is unique, however, this study is a summary representing a collective voice of all the participants. Each chapter title is a category. As described in the methodology section of this study, every interview was transcribed; each sentence was analyzed and broken down into discreet data. This data was reorganized into seven categories with descriptive properties, and in some cases, subproperties. A member check process was conducted by presenting ten participants with a copy of the seven chapters. Four participants responded to the member checking process. Two follow-up member checking interviews were conducted and two participants sent written comments via e-mail. The member checking processes assisted with clarifying existing as well as providing new information. This introductory chapter provides a description of the participants and a brief summary of the seven chapters.

Every chapter represents a category with descriptive properties (See Category B).

Participants Seventeen Veterans Affairs mental health clinicians volunteered to be interviewed. Fourteen participants were from a VA facility in Southern Oregon. Three participants were from a local Vet Center. Each was informed of the purpose and intent of the study according to the criteria as delineated in the methodological section. No

103 remuneration was offered. Participants ranged in age from 32 to 67 and the average age was 49. Seven of the participants were female and ten male. Three of the participants were veterans (male) and one of them is currently on active duty in Afghanistan. The following disciplines were included: nine Licensed Clinical Social Workers, four Licensed Clinical Psychologists, two Licensed Professional Counselors, one Licensed Psychiatrist, and one Licensed Psychiatric Registered Nurse. The participants’ years working specifically for the VA ranged from two to 22 years. Overall years worked in the participants’ respective disciplines were from six to 35 years.

All participants were interviewed in person for the first interviews. For the second interview, 14 participants were interviewed (three participants were unavailable for the second interview). Of the second interviews, 13 were conducted in person and one by phone.

The Seven Major Categories or Chapters The category Entering the Fray discusses the process of how each participant came to develop an interest in their respective disciplines and how they ultimately found themselves working at the VA with combat veterans. Many of the participants revealed extremely personal trauma stories that had a major impact on their lives. These traumatic experiences influenced them toward their career choice later in life. Most participants explained that they have a family member who is a veteran. They reminisced about hearing war stories, growing up in the military culture, and visiting family members in VA homes and VA medical facilities. These experiences brought a sense of familiarity with veterans and their issues. Several participants became interested in the concept and

104 treatment of trauma due to their own personal traumatic experiences and that of their family members who were traumatized war veterans. For many of the participants, finding employment within the walls of the VA included several different paths: some were looking for better employment, others were veterans themselves and understood military culture and veteran issues, and a few wanted to give back. Regardless the reason, all participants felt comfortable, connected to, and familiar with treating and serving the veteran population. The results derived from this chapter suggest that the participants felt comfortable and familiar with military culture and veterans’ issues. For this reason, they decided to treat combat veterans.

OEF/OIF/OND Veterans are Different begins the process of the participants identifying and understanding the individual characteristics of this veteran population, and how they are different from other veterans they treat. Specific, individual elements were identified that makes this population difficult to treat and that influence the treatment process Participants noted how many of the younger OEF/OIF/OND veterans are developmentally fixed in the stage of later adolescence. The most dramatic differences the participants overwhelmingly noticed between the OEF/OIF/OND and Vietnam veteran were the current political, cultural, and societal attitudes. The OEF/OIF/OND warriors are hailed as heroes as they came home; PTSD is now recognized, and evidence-based treatments offered; and Veteran’s Day is now a national celebration for all veterans.

The Challenge to the Work identifies the most challenging or difficult aspects that specifically affect the treatment process, that is between the OIF/OEF/OND veteran and the therapist. The most fundamental challenge that was discussed is engaging and

105 keeping them in treatment. They often do not stay in treatment long enough to benefit from it. Many of these veterans have characterological or personality disorders or traits that can cause the participants to question themselves and their work. Most participants identified the bureaucracy as a major impediment to the work and include the rules, regulations, directives, and the administrative culture. This also includes the expectation of providing time-limited, short-term, evidence-based psychotherapies that cause a revolving door of veterans returning to treatment three to six months later. Several participants revealed that they do not feel safe working at their facility because of the lack of emotional support they experience. Others revealed that what is challenging the most for them with the work is hearing and processing combat stories because it brings up feeling of helplessness, and hopelessness.

Relived Trauma describes how the participants are specifically affected by the OEF/OIF/OND veteran’s combat stories. When the participants related the combat stories that affected them the most during their careers, many became teary eyed and several wept. This was the most moving aspect of the entire interview process. Many participants acknowledged becoming overwhelmed at times hearing traumatic stories and being preoccupied with the thoughts and feelings that were generated by them. Almost all the participants revealed the specific combat themes that are unsettling, difficult to hear, and that stay with them for years: when children, families, and innocent civilians are killed; the loss, grieving, suffering, and death/suicides of veterans; experiencing a parallel process of intense sadness with the veteran; military sexual trauma; when something personal of the participant (photo of her daughter on her desk) becomes incorporated in a veteran’s combat story; and hearing stories of combat veterans that had traumatic

106 childhoods. For many of these participants, their reactions to these intense, profound combat stories and others throughout the years, elicited a vicarious traumatization response and how it manifests within them. Results became clear: vicarious traumatization is complex, varied, and occurs by levels of awareness. Years later, these participants revealed they are still haunted by these stories and their images.

Practice Wisdom explores the participants’ vast knowledge and experience treating combat veterans throughout their careers. In this chapter, participants were able to compare how they practice as trauma clinicians now versus earlier in their careers; ways that they affect and are being affected by the treatment process; explain the differences treating military sexual trauma and combat trauma; the concerns of the participants about evidence-based psychotherapies and knowing when to use them; specific strategies participants use in order to create a balanced, healthy way of doing trauma work; and various ways in which the work is rewarding. The results described here indicate that the participants do not adhere to the 12-session protocol for the PTSD Evidence-Based Therapies (EBPs) completely. They take time preparing veterans for the EBPs and implementing them when clinically indicated.

Different Person Now describes how the participants have changed since they began treating traumatized veterans. They reported having a deeper understanding into their own process as a human being and as a clinician. They have felt more comfortable, competent, compassionate, knowledgeable, and their professional boundaries have been strengthened. Results from this chapter suggest that providing combat treatment as a clinician can result in developing more compassion, humility, knowledge, and healthier professional boundaries.

107 New Ideas for Old Problems presents the current environment in which the participants conduct their work without having a formal clinical support system and the barriers of implementing such a program. The participants also identified qualities that are necessary in order to develop a successful formal clinical program of support. Most participants were adamant and passionate about the necessity of having a clinical supervision or case consultation program for all clinicians. The results from the participants in this chapter are clear: they identified what does and does not work in developing a clinical support program.

108

Chapter V

Entering the Fray The reason I chose to work with veterans is because I come from a family of veterans. My father is a Korean War vet and so are my uncles on both sides of my family.

The category, Entering the Fray, describes the process of how the participants came to develop an interest in their respective disciplines (e.g., clinical psychology, psychiatry, clinical social work, psychiatric nursing, and mental health counselor) which ultimately led them to work at the Veterans Administration, treating OEF/OIF/OND combat veterans and, in many cases, all combat era veterans. Each clinician’s experience is unique and their paths are diverse.

For all 17 participants in this study, familial experiences provided the milieu in which their interest in the helping profession was influenced consciously and unconsciously. Their experiences included hearing combat and war stories from family members, and witnessing the physical and emotional damage that occurred because of them. Many participants developed an interest in trauma because of traumatic events they were exposed to and the existential struggle they experienced as they came to their own meaning and understanding of these traumatic incidents.

Entering the Fray includes four properties: Traumas That Paved the Way, the experience of significant traumatic events that were life altering and defining; Families of Veterans, including mothers, fathers, grandfathers, uncles, and siblings who are veterans

109 and who served in various war eras; Interest in Trauma, the personal experiences of participants that led to their interest and curiosity regarding trauma and posttraumatic stress disorder; and I Found the VA, the process of how participants came to work for the Veterans Health Administration (VA).

Traumas That Paved the Way When my mother would tell me war stories as a child, I used to find them high adventure. When I got older, I saw them as more serious and deeply sad. I have now started to think that maybe my parents had a certain degree of PTSD. This has also influenced me consciously and unconsciously with my decision to become a nurse.

As the participants described the process of Entering the Fray, many based their experiences on Traumas that Paved the Way by revealing very personal, life-shattering events that influenced the direction of their lives toward their respective disciplines.

I was in a terrible car accident in my early 20s, my best friend passed away and that’s what threw me in this whole social work thing. I felt like I needed to pay back because it was my fault that I crashed the car.

Trying to make sense of the experience, their role within it, and working through profound affective states of survivor guilt, hopelessness, guilt, and depression was the defining catalyst that influenced their decisions to enter the helping profession. “I made a commitment to turn a negative into a positive and I chose a life path of service, and I don’t know if I would have done that if that didn’t happen.”

There appeared to be a process of awareness relating to the experience of trauma

110 and its related affects. During the process of the study, several participants stated that as they discussed their personal trauma histories, they became more aware of affective states associated with the traumas (e.g., survivor guilt, hopelessness, depression, guilt) and how they have impacted their clinical work periodically. “When I talk about guilt-the guilt from that experience in my personal life-I still carry a lot of it because of that situation, and I think that bleeds into my work.” Sometimes their affective states enhance and inform their work. For many, as they listen to traumatic combat stories, they identify with and relate to the combat veteran that expresses survivor guilt, hopelessness, depression, guilt, and issues regarding self identity. Other times, these intense emotions can make the clinical work more difficult when they overly identify with the veteran’s emotive states.

As one participant noted: “I’ve been in tears with them because how could you not? So overwhelmed, absolutely all this trauma that comes at you. When you do a lot of trauma work it affects you vicariously.”

Some explained that their traumas enabled them to identify with the veteran experience. Most participants made it clear that they are not the veteran and have not experienced combat trauma. However, on a humanistic level, they can relate to the dynamics of the veteran’s trauma and its impact on one’s life. “I came from a very abusive family and childhood. I had a lot of depression and anxiety, and I think I gravitated toward veterans because of their trauma. I can relate to it.”

The only combat Vietnam veteran in the study explained that he had been a medic. “The main job was this emergency room function of treating casualties. At times, it was intense, demanding, and horrific.” This participant brought a unique perspective in terms of treating OEF/OIF/OND and other combat Veterans because of his traumatic

111 experiences in Vietnam. His combat and medical experiences informed him of the catastrophic effects of war trauma on the body and the psyche. For him, it is not a theoretical exercise in reading texts books on war trauma and Posttraumatic Stress Disorder and its treatment. Rather, it is firsthand knowledge of the atrocities of war and its aftermath.

One participant grew up in in Ireland. He explained that he did not experience the full force of the violence his country endured, but he saw pubs blown up, and witnessed the aftermath of the violence first hand. He also heard about the violence daily through social media. For him, life and death was a daily part of life, and his exposure to bombs and random acts of violence helped him understand the developmental psychological effects of violence and trauma as it relates to many of the young OEF/OIF/OND veteran’s combat experience.

Our lives are bracketed and framed by war . . . I grew up in Ireland during the conflicts. My grandmother was bombed out of her house five times by the Germans during the Second World War in Liverpool, England. I have a sense of people being caught up in the grand sweep of events. Just imagine how easy it would be to be young and caught up in all of that. It’s important for me to play some part in treating combat veterans.

For several participants, being exposed to catastrophic traumas during their own developmental periods have assisted them in understanding the developmental issues of identity and identify formation with the younger OEF/OIF/OND combat veteran. They have also experienced the existential questions of the purpose and meaning of life that many of these veterans struggle with on a daily basis.

112 When I was 18, my 9-year-old brother was killed in a car accident. He was decapitated. From this young age I had struggles with issues of self and identity, trying to make sense of the loss. Having had this trauma, there are parts of the veteran experience I identify with. It’s not combat. It’s certainly looking for deeper forms of meaning, purpose, and questioning the value of life and what it means.

One participant struggled with alcoholism during his early twenties, which had a profound impact on his identify formation and the direction of his life. “I got sober a week after my 23rd birthday. It resonates with me to be in this place of helping young veterans who are at the crossroads of their developmental lives.” Going through this developmental trauma inspired him to not only become a social worker, but it also gave him tremendous insights into the developmental phases/issues that the younger OEF/OIF/OND veterans currently face, including severe alcoholism and drug addiction.

It appears that for many of the participants who worked through and integrated their own traumas, the process enabled them to be more comfortable approaching and engaging others’ traumas. To experience catastrophic trauma is to be traumatized. To be traumatized means you survived the trauma. Surviving the trauma allows the participants to feel more comfortable approaching others’ traumas: being able to listen, to be affected by, and be a witness to war-related traumatic experiences.

Families of Veterans “I come from a military family, and both my mother and father are veterans. I’m married to one, and I have a son who is also a veteran.”

113 Although, not every participant in this study had family members who were veterans, many of them did. Families of Veterans included mothers, fathers, uncles, cousins, siblings, and grandparents who were veterans and who served in various war eras, including veterans from other countries and foreign wars.

My maternal grandfather was an officer in Eastern Europe in a patriotic nationalistic Army that was trying to win independence during the Russian Revolution. He and my grandmother got married and they went off to war together. They ended up living in exile in Poland for many years. My mother was a war refugee most of her early life. My paternal grandfather, who was in the Army, was killed on the first day of WWI. One participant, a Navy veteran, came from a long line of veterans that goes clear back to the American Revolution. This legacy has given him a sense of duty, an obligation to serve. He served three deployments. Currently, he is on active duty in Afghanistan serving as a captain in the Oregon National Guard.

I served with my sister on my first ship in the Navy. My maternal grandfather was a captain in the Army Air Corp before the Air Force separated out. My paternal grandfather was a petty officer first class in the Navy in WWII. We go back every generation to the American Revolution. I wanted to work for the VA out of a sense of need. It is my duty, my obligation to this country, and my obligation to the military personal that are suffering more that I did when I was in the Navy.

He and many other participants grew up hearing war stories from their family members. “I had an uncle that we lived close to and spent a lot of time with. I heard some of his stories from Vietnam.� Another participant saw first hand the effects of combat

114 trauma on his father. “My father was in WWII. He was a victim of the Battle of the Bulge, and I saw what war did to him.�

Through the process of hearing war stories and observing the impact of war trauma on their family members, these participants explained they felt a familiarity with veterans, their issues, and the military culture.

My grandfather and my uncle were both in WWII. My uncle was an infantryman and was injured. I would visit him at the VA so I was familiar with the VA and had been to a number of them. Toward the last five to ten years of his life, he ended up living in a community living center in a VA facility.

Another participant grew up in San Diego, California, and both of his grandfathers were veterans.

I had a strong connection to the Navy growing up in San Diego because the military was all around me. Growing up, I went to the Navy base with my grandmother in order to go shopping at the commissary all the time.

Living in a Naval town, and visiting the Naval base as a child with his grandmother, created a sense of connection and familiarity with the military and its culture.

Many participants grew up with family members who were veterans. They heard war stories, visited VA facilities where family members were living, and saw, firsthand, the effects of war trauma on the lives of their loved ones. Several participants explained that their family members who experienced war trauma were depressed, sullen, withdrawn, and had nightmares and flashbacks periodically. This created a sense of familiarity with the veteran population, and military culture. More importantly, it gave

115 these participants an understanding of how war trauma can affect the body, mind, and spirit of veterans and their family systems.

For one participant, coming from a family of veterans led him to the doors of the VA. “My dad’s a Vietnam veteran. I have a brother and a sister who are in the Army, and they were both deployed at the same time. I figured I’d check out this population and see how it goes.”

For these participants, the desire to treat this population had more to do with feeling comfortable, having a sense of awareness, and life-long experiences of living with veterans and their issues. Making the conscious choice to work with combat veterans was embedded in their sense of connectedness, understanding, recognition, and familiarity of the military culture and its issues. It was not about rescuing themselves or their family members. More importantly, they did not make the decision to treat combat veterans for the purpose of working through and attempting to master their own unresolved emotional issues or trauma. Instead, these participants felt comfortable with this population and viewed combat veterans as common and familiar rather than unrecognizable and foreign—as alien. These experiences and their familiarity with the military culture are what ultimately led these participants to the doors of the VA.

Interest in Trauma “I have come to appreciate how complex the veteran population is. The single word that captures why I am doing clinical work is curiosity. I became curious about the various aspects of clinical affectation and trauma.”

More than half of the participants in this study revealed personal experiences that

116 led to their Interest in Trauma including the concept of trauma, posttraumatic stress disorder, and trauma treatment. For some, it was rooted in experiences from family of origin and other experiences prior to working at the VA. For others, their interest in trauma developed after the VA hired them.

One participant explained that as a child, she listened to her father’s stories of the Holocaust. Her mother had a nervous breakdown when the participant was seven years old, and this began a life-long pattern of psychiatric care. The participant’s interest in trauma began when she was a young girl. “My father was a very emotionally healthy person. I wanted to know why certain people could be healthy and why others could not, especially after having gone through the same experiences like my parents.” This was the motivation, the reason she became interested in studying and treating trauma.

Another explained that his interest in trauma was specifically related to his uncle, an injured WWII veteran. “I used to think about my uncle and about some of the things he experienced. I thought that I would really like to study, learn more about, and find ways to treat symptoms of PTSD.” The war-related trauma that his uncle experienced became the stimulus for this participant to learn about, understand, and treat the symptoms of PTSD: to have a better understanding of his uncle and what he had gone through.

Having a 20-year-old son became the impetus for one participant’s interest in combat trauma and its affects on one’s life and physical development.

Many of the OEF/OIF veterans are a year or two older than my own son, and they have already spent a year in combat. They experienced such things while brain development is still happening. They are still maturing and have not been on their

117 own yet as adults, and they go straight into a combat zone.

Several participants became interested in trauma after they began working in the VA. Later, some transferred into positions that required them to treat traumatized veterans, while a few others were hired immediately to begin treating combat-related trauma.

I didn’t know anything about the military so I needed to know what that looked like. I started reading about the military and its culture. The impact of war/ combat is so different from our day-to-day lives and I had not thought of that before. I don’t have military family. It was totally foreign to me, but I was willing to give it a chance.

After having treated veterans over time at the VA, this participant, who is a veteran himself, noted that of the various mental health disorders, trauma appears to have the most long-lasting, dramatic effect. The life-long, almost intractable, symptoms of untreated trauma created interest and curiosity in trauma work for this individual.

When you look at the various affective disorders: depression, anxiety, bipolar or addiction, trauma stands out because it has such a detrimental and life-long effect on people. Medications may help with bipolar and anxiety disorders. There is no medication that takes care of trauma. You can address some of the symptoms, but the core problem is still there. This is what got me interested in trauma work.

Lastly, a participant became interested in trauma and trauma treatment because of her previous work as a psychiatric registered nurse in the community before coming to the VA. “Prior to coming to the VA, I was very interested in studying trauma and posttraumatic stress disorder because I encountered so much of it in the community, and I

118 wanted to go deeper.”

The participants became interested in trauma and trauma work through several different ways. Some became interested due to family members’ experiences while others became interested through previous vocations in the community or after the VA had hired them. Regardless of the path, the participants became committed to the process of studying and learning about combat trauma and its treatment. Most of the participants in this study have become certified in several of the VA approved evidence-based psychotherapies designed specifically for the treatment of combat-related posttraumatic stress disorder.

I Found the VA “The reason I chose to work at the VA is because I was looking for something that fit me, and I really like this population.”

I Found the VA is a variation of Entering the Fray and includes the various ways in which the participants in this study came to work for the Veterans Health Administration (VA).

Most participants explained that they wanted to work for the VA because they were looking for better employment and career opportunity; wanted to raise their family in the area; needed a change from their current employment; wanted to give back; were veterans themselves and understood the military culture and veteran issues; and had an interest in working with veterans.

One participant noted how she wanted to develop new skills regarding trauma treatment and how her family of veterans influenced her decision to come work for the

119 VA. “The reason I wanted to work for the VA is because I wanted to move on and stretch my trauma skills and honor my family’s legacy of veterans by giving back a bit.”

Another reported that he was born and raised in a Navy town and came from a family of veterans. Serving in the military was ingrained in him. Some of his best friends enlisted in the military after high school and he vicariously lived their military experiences with them. This instilled in him the desire to give back by working for the VA. I’ve always had this ingrained in me—this deeper drive—especially when I was younger, to be in the military. It was a culmination of things that led me to the VA. My best friends enlisted in the military, and I lived vicariously through them.

It was a way for me to give back, knowing that I had skills that could help veterans. That’s what led me to this work.

A participant stated his reason for seeking out the VA is because of his interest in working with the current younger generation of veterans. He does not want their trauma to become intractable or stuck compared to many of those from the Vietnam era.

I wanted to work for the VA because it would be a good job, and because I have a lot of heart for young men and women trying to put their lives back on track. I don’t want to see this generation stuck in the same way that a lot of Vietnam veterans were stuck.

A participant thought she could not work at the VA because she was not a veteran. However, she learned that did not matter. Over time, she developed an interest in learning about and serving the OEF/OIF/OND population by being exposed to stories from the news. Not without trepidation, she eventually applied to work at the VA.

120 Not being a veteran myself or having that experience, I found it very intimidating.

I was concerned that I would not have what they needed. I knew that if I pushed myself, studied, shadowed, paid attention, and that I was coming from the right place, I could eventually gain the skills to be helpful.

For some, working for the VA was not planned. “I needed a change and someone said to check out the VA. So, I did. I’m glad I’m here because I really do identify with veterans. It wasn’t a planned transition.”

Another stated, “I was ready to make a change. I needed to meet more people from varied backgrounds. One of the reasons I came to the VA was for more career opportunities. I didn’t know anything about veterans.” A participant specifically sought out the VA in order to raise his family in this area.

It was more of the employment opportunity to work for the VA in general. I didn’t have any kind of personal connection to the military, veteran care or veterans in my family—nothing to the mission. My motivation for working in the VA was to come to this area in order to raise my family.

For others, they were not looking to work for the VA. It was happenstance. “I didn’t have it as a goal to work with combat veterans. It just kind of came along.” For one participant, a colleague contacted her who suggested that she apply for a trauma therapist position working with combat veterans.

I had worked with adolescents and thought it was what I was going to do. Then, a colleague who was working here asked me to apply for some openings and he thought I would be a great fit. There was no forethought that this was a calling. I do not have military family so this was all foreign to me. I was willing to give it a

121 chance and I accepted the position.

Those participants in the study who are veterans, their military experience and knowledge of military culture and issues were a natural fit for their interest and work in the VA. One particular participant is a retired Army Major. He was an Army officer and also had enlisted in the Navy. He served 24.5 years active reserve, 15.5 years active duty, and 9 years in a reserve capacity.

Because of my background, I have ‘gravatos,’ meaning, ‘I am military.’ With that, you can break down barriers, and we can talk the talk. Then, I’ve read about war my whole life starting in my teens, especially with WWII, which is endlessly fascinating to me. World War II claimed 50 million lives, and my father was a WWII veteran so that comes into the rub.

For a very small group of others, they found the VA through student or predoctoral internships. “I started working in the VA when I was in my graduate training program. I did my clinical and pre-doctoral internship at the VA.” Another participant stated that when she was in her second year practicum in her MSW program, she knew of colleagues that were working at the VA, and she decided to look into it and was accepted.

“It was sort of an accident that brought me to the VA.” Many of these participants, when their internships were completed, were either offered jobs once their degrees were completed, or they applied for employment later.

Working at the VA was my MSW practicum placement. The next year of my practicum, I was offered the SCEP position—Student Cooperative Employment Program—that trains interns to become full-time employees at the VA if jobs are available once you graduate. Fortunately, I was hired into one of those positions.

122 A clinical psychologist explained that the first time he began working for the VA was as an intern. He worked in this capacity for two years. Several years later, he applied for a position at the VA.

Conclusion The category, Entering the Fray, describes the process of how the participants in this study came to develop an interest in the helping profession, specifically their disciplines and interest in working with the veteran population, and ultimately how they came to work at the VA. Properties in this category include Traumas That Paved the Way, Families of Veterans, Interest in Trauma, and I Found the VA.

123

Chapter VI

OEF/OIF/OND Veterans are Different “One of the biggest differences is how much more ready the older veterans are to acknowledge their mental health, specifically posttraumatic stress disorder issues. The younger OIF/OEF veterans have not had this long-term experience of dealing

with

the shit.�

The second category, OEF/OIF/OND Veterans Are Different, follows. This chapter describes how the participants emphasized individual characteristics of how these veterans are different from other combat era veterans. The three properties of OEF/OIF/OND Veterans Are Different include: Tough to Treat, the process of the participants noticing and identifying specific behavioral and psychological characteristics that appear to be shared among many OEF/OIF/OND veterans during the course of treatment that make treating this population challenging; They Are Kids, the observations of the participants that this veteran population experiences specific developmental issues, and Very Different Times, the explanations of the cultural differences between the Vietnam and Iraq/Afghanistan wars and the current societal attitudes regarding the OEF/OIF/OND veteran.

124 Tough to Treat They can be tough because they drop out of treatment very early and there is a lot with traumatic brain injury, head trauma, so you have complicated cases.

Treating them is one session at a time. At times, they have rage and they are in the victim role and other times they’re not. With this population, it constantly changes.

Defining how OEF/OIF/OND Veterans Are Different begins with the participants’ experiences of clinically treating this population, which for many, is Tough to Treat. The 17 participants of this study described the full continuum of what it is like treating the OEF/OIF/OND population from “challenging, exciting, heartbreaking,” and “it’s a mix of thoughts and emotions,” to “I find it fascinating and very rewarding.”

Tough to Treat includes five sub properties: Characteristics that Influence the Treatment Process, Physiological Trauma, Individual Behavioral Characteristics, Affective Characteristics, and Childhood Traumas.

Characteristics that Influence the Treatment Process.

The participants identified many characteristics that influence the therapeutic alliance, rapport building, and the frame. They reported that many of these veterans drop out treatment early, are not ready to change, and are not committed to the therapeutic process. They “come in only at the urging of a parent, spouse or significant other” one participant noted. When this occurs, they are not engaging in therapy for themselves but at the request of another and because of this, the therapeutic alliance is not developed and they drop out of treatment quickly. One participant stated, “They are younger,

125 involvement tends to be more sporadic. They come in and work on things for a little while, get some information and then disappear again. It is less sustained.” For many of the participants, this dynamic is challenging and disappointing for them. “I think it is disappointing when they get into it and say to me, I don’t want to do this. I don’t want to do the work.”

This population is “tough to engage because they make a quick decision whether they want to work with you or not. You have to engage them pretty quickly.” Another participant noted that this population “will hold you to a higher standard—that of being perfect.” She explained some make an immediate judgment about whether you, the therapist, know what you are doing or not. “It is an all or nothing way of looking at the therapist. The therapist does not know what they are doing and they are not a veteran.”

With others of this population, even if you are a veteran, if you are not of their era or age, then you cannot relate to them. “These OIF/OEF veterans have a sense of unless you have been there, are of my age, my era, you cannot possibly understand me.”

A participant explained that for him, when he treats this population, he says it is gratifying but that he has a difficult time relating to their traumatic experiences. “Hearing some of these trauma stories, you realize that their lives have changed and it’s really hard to relate to that if you have not experienced war and death.”

Denial is another major theme expressed by the participants. The OEF/OIF/OND population, generally, does not want to admit that anything is wrong with them. “My role is so important and delicate in that first encounter because they don’t want to be here and they don’t want to believe they have a problem. They do not want to keep living the way they have.”

126 Another concept that is closely related to denial is their dislike for the label of PTSD because of the stigma that is associated with it in the military and in society.

You get slapped with the PTSD label. It comes from the media and our society in general; also, the government and military. These young guys say that even their higher ups are pretty negative if you have that label of PTSD. For many of these veterans, they exhibit tremendous fear about looking at their trauma. Most want to get on with their lives without having to re-hash their combat trauma experiences. “They have stuffed it so deep or they try to forget about it and our society reinforces that. Society says do not think about it. Just forget it—move on. That is the worst thing they can do.”

Several participants spoke of the quick fix that many of these veterans are seeking. Instead of having an understanding that trauma treatment is a process and that it will take time, many want treatment to be instantaneous.

They tend to be pressured; wanting to get things done; to move quickly; get in, get out. They want immediate skills rather than sitting back and thinking about what happened and how it has affected their mind.

One participant explained that this quick fix phenomenon is rooted currently into the military culture which is mission driven. “Get the job done and move on to the next thing.

I think that is part of it.” It is difficult for the younger veterans to look at and accept the emotional content of their combat experiences. “For them, it is I need to stay driven, to power through this. To me, to be that driven is a defense in order to keep all the emotional stuff at arms length.” Emotionally, they cannot allow themselves to feel. They must stay driven and power on through with their treatment because they do not want to

127 be another emotional casualty.

Another participant believes we live in a society and culture that fosters instant gratification and obtaining information instantaneously. The current age of technology and information fuels consciously and unconsciously this tension between the demands of symptom relief and trauma integration on one hand and the time it takes to get there on the other. “Many of them want it now but yet they can’t see the forest through the trees and realize it’s a process and sometimes a long one.” Explaining this to young combat veterans can be challenging and disappointing when they decide to end treatment.

A number of participants spoke of the revolving door of treatment among some of these veterans. They explained that they briefly come into therapy, get what they need and shortly thereafter, leave treatment. Eventually, they come back to therapy when they experience another trauma and the cycle continues. “Many times they will come and they want a quick fix. They will then go back out and continue what they were doing with their lives and come back to treatment when they are in a crisis again.”

Physiological Trauma.

A few participants discussed the impact of physiological trauma that occurs with this population, specifically traumatic brain injury (TBI) and other physical bodily damage that occurs to these young veterans that have survived improvised explosive devices and other horrific acts associated with war.

With the Vietnam Vets, you can get the compounded issues with the body breaking down and experiencing pain and a lot of chronic illness and disease.

However, with the OIF/OEF veteran, because it is such a different war, they have

128 a lot of damage to their bodies as well. To see that in someone who is 30 with massive chronic pain is really debilitating and hard to sit with.

For these participants, the one factor that is the most complicated to psychologically treat is traumatic brain injury (TBI). It is important to note that TBI is on a continuum from low, moderate, to severe. The participants explained those veterans who are on the spectrum from moderate to severe, and who also have a diagnosis of combat trauma, are extremely challenging to treat because of the organicity or permanency and chronic nature of their behaviors (e.g., organic personality disorder).

With TBI, head trauma, it can be very complicated because of the behaviors and structural damage that has occurred in the brain that is generally permanent. For those on the upper moderate to severe end of the scale, it is not going to get better for many of these folks.

Individual Behavioral Characteristics.

Most participants noted the following characteristics concerning some of the OEF/OIF/OND veterans they treat: anger, rage and irritability; family issues; difficulties finding employment; sleep disturbance issues; impulsivity, and problems focusing. Many of these veterans are angry and rageful for many different reasons. For some, it is directly related to their PTSD symptomatology. For others, the anger comes from their frustration of trying to reintegrate into their families, their communities, and society or both.

You work with these veterans and try to help them deal with the initial shock to their system of going from a year in combat plus all the training they received in the military to civilian life. Unemployment, family, kids, and helping them

129 understand what is going on with them that contribute to them being angry, yelling, and fussing.

Several participants believe that many of these individual behavioral characteristics are directly related to the veterans’ PTSD. “They are very affected by the PTSD. They cannot understand why they are so irritable, they cannot maintain a relationship, cannot sleep or stay focused, and have the urge to avoid people and isolate.”

A participant noted the level of impulsivity that exists in treating this population.

They are quite a bit more impulsive—marked impulsivity. There were two attempted suicides while being here in the residential program in response to relationship stress. There was a massive overdose of drugs. It was very impulsive in the moment. There was not a lot of depression or suicidal ideation before that.

Affective Characteristics.

The affective states of these veterans include profound sadness, sorrow, intrapsychic pain, guilt, survivor’s guilt, and for some, the inability to forgive themselves with respect to the context of their traumatic, war-related experiences.

Sometimes there is sadness to see how deeply affected some of these veterans are especially those that have a lot of guilt for things that happened. They can’t forgive themselves for things they did or they have survivor’s guilt.

Another participant captured the affective states she experiences sitting with and treating this population.

There is an energy shift in the room. It is heavy, worrisome for them. I can almost feel their internal tension of being here. Depending on the nature of their traumas,

130 there is hollowness, a flatness to them.

For another participant, the OEF/OIF/OND population is incredibly challenging and heartbreaking to work with at times because of the level of sorrow and ultimately suicide that exist among this population.

There is so much sorrow and pain in this young population. That is the hard part. You look at some of these lives and the veteran is gone due to suicide. Often, they have left a young family, a young wife, siblings, and parents. Those fractures in the relationships will go on for decades: for the rest of their lives.

Childhood Traumas.

Overwhelmingly, most participants observe that the majority of the OEF/OIF/OND veterans they currently treat or have treated in the past have had some kind of traumatic childhood history. The content of these traumas include physical, emotional, sexual abuse; experiencing domestic violence within their families; being raised by a single parent; families that were broken up or effected by drug use or mental illness; and having alcoholic parents. The veterans that experience childhood trauma before deployment and came back with combat trauma are those who have the most difficulty working through and integrating their traumatic experiences.

What is unique with some of these OIF/OEF veterans is their stuckness. The vets that are stuck the most have had early childhood trauma. Now there are different levels of trauma building on trauma.

Another reported that OEF/OIF veterans, experiencing childhood trauma and family issues, are more vulnerable to war trauma and PTSD.

131 Many described families that were torn apart by drug use and mental illness associated with that and they are more vulnerable to PTSD. They did not come from the 1950’s model of the nuclear family that the Vietnam veterans did. Many experience homelessness, childhood trauma, and abandonment.

It is also important to mention that many participants pointed out the following important principles to keep in mind while treating any combat era veteran: each person has their own unique background; every veteran has a different experience of war; and veterans react differently to their own experiences. Even though OEF/OIF/OND veterans have specific behavioral and psychological characteristics as identified by the participants of this study, the participants utilize these principles as they treat each combat veteran.

They Are Kids With the OIF/OEF population, what I notice is they are kids. Developmentally, they are not fully integrated as a human being. Who am I? It’s almost existential.

What am I going to be? Who am I going to become? What am I going to do?

They Are Kids refer to behavioral characteristics the participants noted about this younger population. Many of these behaviors are developmentally driven and are embedded in the stage of later adolescence. Although not every participant had specifically stated that certain behaviors are developmentally driven, many of them can be identified as such. It is important to note that the participants use the term ‘identity’ in multiple ways, with various meanings.

One of the most prominent developmental issues that many participants acknowledged is that of identity. For these veterans, serving in the military and serving in

132 their respective branch of service is about identity. Belonging to a battalion, company, brigade, division, wing, or squadron creates a profound bond that is described as more intimate and stronger than family bonds. Leaving the military and one’s group can be devastating for many of these veterans and they often experience identity issues. Many do not have a fully integrated identity when they leave the military. “They had a good core group of friends that carried them through their military experience and when they came back home, they are lost. They have difficulty with identity: who are they now after the military?” For many veterans, the affectional bonds they create and experience with each other in their units is a major loss for them when they separate from the military. When they return to civilian life, it is difficult for them to find “a relational home” where they are able to discuss their traumatic experiences unless they keep in touch with their comrades.

One participant discussed how identity issues are often tied to the reintegration process. “Sometimes bringing up these issues around identity formation, and navigating the reintegration process is too much for somebody in their early 20’s because they do not have that level of self-awareness.”

The OEF/OIF/OND veterans are typically younger and are not developmentally able to reflect upon and think about their combat experiences. In comparison, the Vietnam veterans are decades older and many can self reflect and think about who they are and their combat experiences. “Vietnam veterans are tired of living this way. I’ve had enough of this stuff. It has been 35 years.” They often exhibit a level of maturity that is reflective of their life experiences. “Vietnam veterans can have a maturity and the perspective once they begin to let go of the guilt and shame to see the broader picture.”

133 Another participant labeled the older Vietnam veteran’s ability to self reflect and ask questions about their combat experiences as a phase of life issue.

I think part of it is a phase of life issue. They ask the following questions: What was the meaning of this? Why is this still with me after all these years? It’s been forty years ago and why am I still having dreams about this? Why is it bothering me now? Why does it in some cases come back? There is a little bit more curiosity about that and the process of making sense of their life.

Participants placed denial, the inability of many of these younger OEF/OIF/OND veterans to acknowledge that they have problems, within a developmental frame. “Often times, developmentally, they are at a place where they do not really view the difficulties they are having as being of a major concern.” This same dynamic was also noted among the Vietnam veterans when they returned. Many of them, when they discharged from the military, did not admit that they had issues as well. “Developmentally, when the Vietnam guys got back they said, I’m fine.”

Identity issues are not solely unique to the OEF/OIF/OND and Vietnam veteran populations but often occur among other combat war era veterans. This participant believes that the veteran’s identity becomes altered by war trauma, that it changes brain anatomy and physiology.

The war gets infused in their identity and infused in their brains—their brain chemistry, brain physiology, and their brain anatomy changes. They cannot go through developmental stages because they do not have the cognitive capability because their brains are so focused on the anxiety and the fear they experience all the time.

134 A participant made the point that, for many, the age the veteran went to war and experienced combat is the age they became developmentally arrested. The ability to negotiate later developmental stages cease because of the intensity and duration of PTSD symptomatology that interferes with the process.

Each war will lock the veteran in whatever age they were at the time they went to war and were in combat. They cannot move past it developmentally and psychodynamically because they are constantly battling the symptomatology of the war experience. They never leave their war experience. It is still such a huge part of their daily battle with existence.

This appears to be a universal phenomenon among many combat era war veterans.

Unfortunately, the OEF/OIF/OND veterans are the youngest group coming back from the most current wars. Many in this cohort hold the distinction of not being able to reflect on their war-related experiences, have issues with identity, and being developmentally arrested at the age they experienced combat.

During the member checking process, a participant wondered if any of the other participants discussed their experiences with OEF/OIF/OND veterans who joined the military later on in life or who have been in active, military service for many years. She discussed her experiences with this older OEF/OIF/OND population in the member checking interview. Specifically, two older veterans were mentioned. One was 26 years old when he joined and another was 30. They both were enlisted in the Army and assigned to infantry units. For these older veterans, this participant explained that their processing is different from the younger OEF/OIF/OND veteran.

There processing is different in the sense of when they talk about moral injury.

135 Their guilt is different. I’m older and I had life experience although it wasn’t about war. I know I couldn’t possibly have known everything I experienced when I got there but, I wasn’t going in as this hot-headed 18 year old who thinks he’s invincible. I knew I wasn’t. I wasn’t going in as somebody that was naïve to what the political conflicts were about and the reasons we were in war. Some of the decisions that they made surprised them. They were asked to do things that normally they would not have done and they did not say something or stand up for themselves or others.

According to this participant, the older OEF/OIF/OND veterans she has treated view the enemy as a human being and not as an object. One older veteran specifically noticed how many of the younger OEF/OIF/OND veterans are “hot-headed” and, referring to the enemy, they “just wanted to kill them all.” This older veteran found this disturbing. “The reason this was so disturbing to him is because these guys are supposed to have his back and they’re just willing to shot anything and everything and he doesn’t believe in that.”

This same participant explained the way in which the guilt of the older OEF/OIF/OND veteran is different from that of the younger veteran.

How we help the younger OIF/OEF veteran work through their issues related to combat is by saying, ‘How could you have possibly known such and such? You were 18, 19, or 20 years old? You were a kid. Your brain hasn’t fully developed yet. Some of these are the explanations we give to the younger veterans. When you’re 30, your brain has matured and you know better. What do you say to the older OEF/OIF veteran? We are dealing with two very different

136 developmental processes.

This participant also revealed another important developmental difference between the younger OEF/OIF/OND veteran that served four years versus the older veteran who had been in the military for many years, hoping to make it a career and then was discharged for various reasons.

Making the military a career is about who you are. There whole adult life is spent in this military role. I have a bunch of veterans right now that fall into this category. Many of them were medically discharged. Now, they are in their thirties and they have spent a big chunk of their adult life in the military and now there is this big identity piece. This isn’t just about PTSD. It’s about who am I?

Very Different Now “I do not think that when the Vietnam guys came back they were getting free breakfasts at Denny’s.”

OEF/OIF/OND Veterans Are Different is especially defined and delineated by the property Very Different Times that describes the current political, cultural, and societal attitudes of the Iraqi/Afghanistan wars and the OEF/OIF/OND veterans compared to that of Vietnam.

Several participants in this study explained that the PTSD symptoms are the same for the combat OIF/OEF/OND veteran and the Vietnam combat veteran. According to most participants, what is different between the two are the venues, the political climates, and the differences regarding these conflicts including the cultural and societal responses to the wars. This is what makes the OEF/OIF/OND and Vietnam conflicts different

137 outside of the clinical presentation of trauma and PTSD. “Think about the late 1960’s versus 2004 or 2005, the heart of the conflict in Iraq. These were very different times in our history and different ways of reacting to those conflicts.”

Many of the Vietnam veterans came home to a divisive, hostile nation where there were political demonstrations, and the assassinations of John F. Kennedy, Bobby Kennedy, and Martin Luther King. The Vietnam veterans were rejected, and not supported. As one Vietnam veteran participant explained, “We were not well received and it was a divisive time with all the assassinations of JFK and MLK.” During World War II, the nation was united and many people supported the war effort. The enemy was clear and this evil person needed to be eliminated. “Everyone was united against this common enemy, this evil person. With Vietnam, that was not the case—no way.”

The societal attitudes have drastically changed since the days of Vietnam. The nation as a whole was not divisive regarding the Iraqi and Afghanistan wars like they were in Vietnam. Many people opposed the wars but the overall attitude, as reflected in the media, was to disagree with the war but support the OEF/OIF/OND veteran.

Even though there were people completely opposed to the Iraqi/Afghanistan wars, you heard people say, don’t blame the troops for their involvement. You can be against the war but not against the soldiers and others who are making the sacrifice to be over there.

Welcome home events were held nationwide for the OEF/OIF/OND veterans thanking them for their service and acknowledging them as America’s heroes. This is completely the opposite of how Vietnam veterans were treated when they came home.

Another cultural shift that most participants acknowledged is how society

138 currently tends to be about discussing war and posttraumatic stress disorder.

“In our culture, there is a little bit more openness to discussing war and PTSD. During and after the time of Vietnam, PTSD was not considered an actual diagnosis in the DSM [Diagnostic Statistical Manual of Mental Disorders].”

The first time PTSD was acknowledged and entered into the canon of the DSM was in 1980. “We did not have the same treatment and the same vocabulary back then in Vietnam to talk about PTSD like we do now,” as one Vietnam veteran participant noted.

Eventually, this created a level of universal awareness in American culture that allowed media outlets and society in general to discuss and debate the concepts of trauma and war-related PTSD. This collective consciousness regarding PTSD sets the OEF/OIF/OND generation apart from other war era periods. This is a significant difference.

The category OEF/OIF/OND Veterans are Different, addresses the manner in which the participants felt this group is different from other combat era veterans. The participants drew upon many social, political, and developmental concepts in an attempt to understand and explain these differences. In questioning the participants, they acknowledged that many of them compared the younger OEF/OIF/OND combat veterans with the older, Vietnam veterans. They explained that the Vietnam veterans are tired.

They have spent decades dealing with their PTSD symptomatology. So many of them, when they present for treatment, are ready and willing to engage in therapy. However, many of the OEF/OIF/OND veterans are not. Many participants speculated that when the Vietnam veterans returned they were most likely at a similar place developmentally as the OEF/OIF/OND veterans are now.

139 One participant, during the member checking process, explained that when he read the section in this chapter regarding the younger OEF/OIF/OND veterans dropping out of treatment early, it triggered some additional thoughts for him regarding motivational interviewing and the readiness to change stage. He also thought about the differences between Vietnam and the current recognition of PTSD. To me, it’s ironic that the military and the VA are almost 180 degrees from where they were after Vietnam when the diagnosis of PTSD did not yet exist and few people know what to do with it if they knew what they were looking at. Now, soon to be discharged veterans are screened multiple times for PTSD and educated about what to look for, where to get help, but their engagement in help tends to be brief and pragmatic. You could say they are still in denial about the depth of the problem or are in the “pre-contemplative” stage of change.

Conclusion The category, OEF/OIF/OND Veterans Are Different, describes how the participants emphasized individual characteristics of how these veterans are different from other combat era veterans. The three properties include: Tough to Treat, They Are Kids, and Very Different Times.

140

Chapter VII

Challenge to the Work “The challenge is when someone comes in and wants something to happen right now, and are not willing to put the work into it because they are not showing up.

The category, Challenge to the Work, describes the participants’ most challenging or difficult aspects of treating the OEF/OIF/OND population. This category consists of three properties: Keeping Them, the challenge of engaging this population in the treatment process; The Bureaucracy, the rules, regulations, and directives of the larger, administrative, VA system; and Therapists’ Lens, the ways that participants view this population from their own subjective experience.

Keeping Them “The most challenging aspect of treatment for me is engaging them.”

Most participants noted that a major Challenge to the Work is Keeping Them.

How do you engage the OEF/OIF/OND veteran in treatment long enough in order for them to benefit from it? “The most challenging aspect is engagement and getting them to stay in treatment long enough so they can benefit from it.” Another participant described the difficulties regarding the treatment process. “Impulsive flightiness—they are difficult to pin down and hold their feet to the fire in terms of the treatment process.” For some of these veterans, they enter treatment when they experience a crisis and leave when it is

141 over. “The challenge is getting a hold of them and keeping them in a therapeutic relationship. It is very hard. They are a transit population: today they need help and tomorrow they do not.”

Another challenge that was mentioned had to do with dependency on the participants from some of these veterans who are continually in crisis.

About 10 to 20% of the veterans I treat become dependent on and rely on me so much that it almost gets a little bit suffocating due to continual, recurring crises.

This really takes a lot out of me and it just gets exhausting.

One participant noted that this population’s developmental stage often lends itself to characterological or personality traits that can cause a therapist to question themselves and their work.

I think it is challenging because developmentally they are not ready for treatment and sometimes as a clinician, you end up feeling, particularly with veterans who characterologically tend to be more challenging, asking yourself: What am I doing? I’m just spinning my wheels. They are not ready to fully commit to recovery.

Because of these developmental and personality issues of some of these veterans, therapists may question the value of their work. Most therapists want to be helpful and feel they are making a difference in their client’s life. However, working with a population that exhibits these issues daily can tax even the most seasoned and skilled therapist. “Trying to figure out how to motivate or help them gain insight into those patterns can be very challenging.”

142 The Bureaucracy “I think for me, the hardest part is the administration and bureaucracy more than the veterans. “ The Challenge to the Work not only includes Keeping Them but also The Bureaucracy that consist of the rules, regulations, directives, and administrative culture of the VA. Although, not every participant mentioned the bureaucracy of the VA system as a major challenge to the work, several did. For these participants, it is not treating the veteran that is the most challenging aspect of the work but the demands and culture of the system. “For me, the hardest part is the administration and bureaucracy more than the veterans. The veterans are a joy to work with. It’s sometimes the rules and regulations that is the hard part for me.” The participants believe there tends to be a state of constant tension and flux between clinical practice and administrative requirements. The administrative demands in the VA are described by the participants as numerous and cumbersome due to the many levels of the bureaucracy that exist. “The most challenging aspect is trying to do what needs to be done with clients and then also meeting the directives and demands of the system that requires this form and this way of doing it.”

Participants also feel that the bureaucratic and administrative systems dictate specifically the manner in which they are to conduct therapy.

For me the most challenging is the environment. Part of it is being a big bureaucracy and having a lot of rules, regulations, and directives about what I’m supposed to do and how I’m supposed to operate as a therapist. There is this ideal about what I’d like to do versus what I know I can do with the time that I have and it’s hard.

143 For many, there appears to be tension, conflict, and frustration with knowing what they need to do therapeutically with a particular veteran versus what they are expected to do because of what the system demands. Many of the evidence-based psychotherapy time frames for treatment protocols are too short to address the complex, psychological needs of most veterans.

It is hard to work with somebody who would benefit from longer-term work. I have 16 sessions of Interpersonal Therapy for Depression with this veteran and that is not going to maximize the gains while doing the work with him. I cross my fingers, hope, and hang on.

The expectation of providing short-term, evidence-based psychotherapies for many participants is frustrating knowing that the treatment effect for most cases will not be lasting. This creates a revolving door for many veterans returning to treatment six to nine months later and often leads to frustration and feelings of demoralization within the clinician. This aspect of the system also encourages therapists to provide a longer treatment experience—what they are trained to do—in order to effectively treat them, thereby reducing the revolving door phenomenon.

Many participants revealed that they do not feel emotionally safe working at their VA facility because they see a parallel between the military and VA culture. For most participants, this is a major challenge that impacts their work. Many do not feel safe to say what they think and feel about the VA system because of the lack of emotional support. “I fear working here. I think there is a parallel between the military and the VA hierarchy: it is patriarchal, very punitive, and it is fear based.”

A participant stated that his challenge to the work is not the veterans he serves but

144 the higher staff who are over committees that determine the development and implementation of mental health programs. These individuals are not mental health practitioners and have not received training in mental health.

There are a lot of people higher up here at this facility on these committees that do not have much education, training, or experience in mental health, making major decisions about mental health programs. I had all these years of experience and worked at all these places and they were telling me how to do it. It was bizarre.

Therapists’ Lens “Now I have these lenses on of a whole other world that I cannot fathom of the chaos, death, destruction and the hate. I haven’t thought about it. It forced me to really look at these things.”

Therapists’ Lens describes the subjective experiences of participants that influence the ways in which they view and experience the OEF/OIF/OND veterans.

These subjective experiences constitute the most challenging aspect of the work for most participants.

Many, when hearing and processing combat trauma stories, have noticed several affective states while conducting treatment. These include feelings of helplessness, hopelessness, and the inability to relate to their experiences. Several voiced that, at times, they are not sure if they can help them or not. “Treating the OIF/OEF veteran, relating to them, hearing their story, and having feelings of inferiority of whether or not I can help this person is challenging for me.” One participant wished that treatments for PTSD were as effective as the treatment for insomnia because he feels that he is not completely

145 effective treating this population.

What is most challenging for me is that I see a lot of very seriously affected veterans and it gets me that I cannot somehow do a good job of helping them. I wish the treatments for PTSD were as effective as the sleep therapy but it is not and it will never be because PTSD is very complex.

Hearing combat trauma stories daily for one participant is taxing because of their intensity and repetitiveness.

Sometimes sitting with their story is challenging. It fills up the whole room. It is heavy and hard because of that level of intensity and repetitiveness because I do combat trauma work every day. Doing trauma work in the VA is in your face.

Another challenging aspect for some participants is group trauma work. This participant explained that when she facilitates a group of 15 combat veterans, it can deplete her energy.

When you are sitting in a room of 15 veterans who are really traumatized, it can be a lot to hold because of their energy. It can be very draining and depleting and I have to be careful to take care of myself.

One participant, who is both a VA and Oregon National Guard Army clinical social worker, explained the difficulty he has with separating out those two roles, and knowing when to compartmentalize his trauma work so he can be present with his family at the end of the day.

I think what is most challenging is not feeling enough is being done and not knowing when to compartmentalize and shift out of the gears. I would like to think that I can create a boundary with my family time and I have not done that

146 very well, making that separation. I get phone calls all the time, day and night.

The challenge is I cannot be there all the time with these veterans.

Another main challenge for the participants is the realization that they cannot treat everyone. Some combat veterans are beyond treatment for a host of reasons and others will require years and decades to work through their combat traumas. Understanding where the clinician is in the treatment process is challenging and important.

The challenges are you cannot fix everybody. The only thing you can do is to hold space for them. It can take years and decades for them to work through their traumas. I need to have the perspective that sometimes I am at the beginning of the healing process, sometimes in the middle, and, at times, at the end. The only time I get a thank you is at the end.

A participant, during the member checking interview, related how this quote touched her and reinforced the importance of clinicians coming together and sharing their thoughts and experiences.

This quote reminded me that we need to talk more as clinicians because I would have never known that another clinician said something like that. Often, we do not speak to each other about these things and sometimes it would be nice to sit down and have that other person say, “Yes, I feel the same way.”

Conclusion The Challenge to the Work includes the participant’s most difficult aspects of treating the OEF/OIF/OND combat veterans. Properties include Keeping Them, The Bureaucracy, and Therapists’ Lens.

147

Chapter VIII

Relived Trauma I can see the trauma while they’re telling it. I can see what it looks like, smells like, and what it tastes like. You think how helpless this veteran must feel, and is there anything I can do to alleviate that?

Relived Trauma is the third category and describes the process of how the participants are specifically affected by the OEF/OIF/OND veterans’ combat trauma stories they hear. Four properties are included in this category: Hard to Hear, the specific characteristics that participants have identified that make hearing these combat stories challenging for them; Taking It Home, explains the manner in which the participants identify particular aspects of the trauma stories and how they think about, process, and carry them into their personal lives; Checking Out, the participants’ observations of what can bring about emotional or empathic detachment working with this population; and Stories That Stick, describes the specific trauma themes that are unique to the participants and that cause these stories to “stick” for years.

Hard to Hear “Some days I’ve been in tears with the stories I’ve heard because how could you not? I‘ve been so overwhelmed because of all this trauma that comes at me. They are here bleeding in front of me.”

148 Most participants explained that Relived Trauma includes identifying the specific elements of the veterans’ stories and their presentation that make it Hard to Hear. Many acknowledged that hearing the trauma story of an OEF/OIF/OND veteran has overwhelmed them. “When you hear certain stories and see certain pain it becomes overwhelming. As a therapist, we are caring human beings so sometimes stories do affect me.”

One participant noted that hearing trauma stories repeatedly becomes overwhelming for her. “Yes, I‘ve been very overwhelmed. I do a lot of trauma work and it affects me vicariously at times. You feel their pain.” Another explained that with one traumatized female veteran she felt it was difficult to emotionally separate from her. “It was the inability to get a break from her trauma. It was so overwhelming that I almost felt exhausted because it was hard to separate from her.”

It is not uncommon for some of the participants to experience visceral responses to hearing these stories. “I’ve had physiological and emotional reactions to the trauma. It is unsettling. I feel a little bit off balance and have had anxiety and depressive symptoms at times.”

One participant related a personal story in which he was in an extremely dense crowd of people, felt anxious, and had to inch himself to an outside wall in order to stand against it. He explained that he experienced the thoughts and feelings of veterans who have had similar experiences in crowds that he treated. “I found myself wanting to do the same thing they did.” Listening to these trauma stories daily, do they become cumulative over time and embed themselves in the unconscious and then come forward in situations like this?

149 This had never been an issue before in my life. I haven’t had secondary or vicarious traumatization. There are times when, after hearing these things so often, it gets pumped into your unconscious mind and starts to come up from time to time.

Another specifically explained that what is overwhelming for him are, what he coined, trauma dumps. This occurs when a veteran dumps one trauma after another in a short period of time. This becomes overwhelming for this participant. “There are so many traumatic experiences that are discharged one after the other. It is the affective dump of it all.”

Attempting to be empathic, without becoming too overwhelmed while listening to trauma stories, is challenging for some of these participants.

Trying to be empathic without becoming overwhelmed in the moment can be demanding. It is OK to express a little bit of emotion and show that their story has a powerful impact but maintaining and not being so overwhelmed that I cannot be effective is important to balance.

One participant explained when she begins identifying and thinking about her own personal experiences, as she listens to trauma stories from these veterans, that is the point where she feels overwhelmed. “It’s hard not to bring one’s own experiences too much into the equation. When this happens, that’s usually a clue that it’s overwhelming when you start relating too much.”

Several were adamant that hearing and experiencing trauma stories do not overwhelm them. “Impacted yes but never traumatized. I’ve never taken it on personally.” Another said, “I’ve been awed and horrified but I would not say

150 overwhelmed by them.” For them, the word “overwhelmed” means it is too much to handle: to be overpowered by one’s thoughts or emotions.

Overwhelmed to me suggests like it felt it was too much. Has it ever opened my heart? Have I ever cried fully and openly? Yes. Did it ever seem like it was more than I can handle? No. Sometimes it is incredibly sad, very difficult, and powerful.

Some stated they are emotionally impacted and moved by the stories but not overwhelmed.

I am surprised at how emotionally moved I am by their stories and by the emotional impact they have on me. I have never felt overwhelmed and never felt there is any way I can take this. I have been more strongly affected than I expected to be by trauma stories.

In conducting the interviews, it became apparent that the participants separated themselves in two camps: those who were and were not overwhelmed. Remarkably, ten out of the seventeen participants acknowledged they became overwhelmed periodically.

They also explained that at various times, they struggled with their thoughts and feelings regarding what they heard in the moment but did not become ineffective or incapacitated as professionals. This is in complete contrast to the seven participants who adamantly stated they did not become overwhelmed hearing trauma stories in any way. It appears to be a matter of definition for them.

151 Taking It Home “Occasionally, I’ll hear a story and take it home. I catch myself waking up in the middle of the night and having stress for that veteran. “ Sometimes, when participants experience trauma stories that are Hard To Hear, they will Take It Home with them. The central theme regarding this property is that of being preoccupied with thoughts or feelings about various aspects related to the veteran’s trauma or with the treatment process. Nearly all the participants of this study stated that they do experience a preoccupation at various times and find themselves processing it at home.

Several noted that preoccupation occurred more frequently earlier in their careers than it does now. One seasoned participant explained that in order for this to occur today, “It has to be something really big like a suicide which does happen.”

At times, what some participants take home after listening to the trauma stories are restless nights and asking themselves the following question after a challenging session: Did I respond to it the right way? Maybe I should not have said that or reacted this way. , Especially in the beginning I had a couple of restless nights. It happens now but not as frequent. You are consciences to do the best job you can and so I’ll often leave and think, Oh, I should’ve said that or I could’ve done this or maybe next time I’ll do that.

Early on in her career, a participant had a particularly horrific trauma story she had been processing with an OEF/OIF/OND veteran. It evoked feelings of helplessness within her. She found herself waking up at night realizing that this veteran was scheduled

152 to come in the next day and what will she do to help him?

I would wake up at night and I was not specifically thinking about him. I was thinking about work and what am I going to do tomorrow when he comes in. How am I going to help him? I could feel it in my body that I was stressed about how to help him.

The anxiety she experienced regarding this case had a profound impact upon her. Today, she experiences a preoccupation periodically with the stress of trauma work but not like she did in the beginning. “It occurred initially. I have moments, not everyday, when stuff creeps in.”

Another participant explained that even though she has experienced some nights of dreaming about the trauma stories of veterans, she is able to eventually integrate it.

I don’t find myself preoccupied very often with their trauma. I have even dreamt about it a couple of nights but I don’t find myself being stuck there. I am eventually able to work through it by having clinical supervision or processing it with coworkers.

For some, it is not the trauma stories themselves that they take home and process but the veteran’s acute state. “It’s not so much the trauma that I process as it’s their acute state. What I am bringing home is what am I going to do to connect with them, stabilize them, and keep them safe?” For this individual, what he processes at home are those veterans who are psychologically fragile, unstable, and at risk regarding their personal safety: acute. In the same vein, another participant has a preoccupation at times with treatment failures due to the level and intensity of the trauma and the veterans’ inability to integrate it. “I haven’t been preoccupied so much with their individual trauma as much

153 as I really ache for certain folks that I’ve attempted to treat who weren’t able to get beyond their trauma.” This same participant explained that what affects him also is the physical presentation of the veteran. “Another guy I worked with was so affected by anxiety and PTSD he would literally come in and shake. He was in this constant state of anxiety. It gets to me.”

One participant began having a reoccurring nightmare that lasted for approximately three months. The theme was the same: she was an infantry soldier killing people. “It was really horrific. I think I was identifying with some veterans. I do think about it a lot and it has definitely made me more serious than I already was about the work.”

Another preoccupation theme that emerged included stories that teaches this participant something that was not thought about or known before.

Occasionally there’s a story that stays with me and works on me but it’s not often. Those that do usually teach me something like an aspect of the whole trauma situation, life experience, or what veterans have been through that I didn’t recognize before.

He gives the example of how an officer made the decision to put a low enlisted soldier that he did not like out on a listening post and the enlisted soldier was killed. In hearing and processing this traumatic story with this veteran/officer, it dawned on this participant that officers making these types of life and death decisions have a different way of processing and experiencing their trauma then those who only follow orders. According to this participant, generally speaking, those who follow orders have more anger, frustration, and often blame the military and officers for their fate and traumatic

154 experiences. However, officers process their trauma more from a moral injury perspective. These are the types of stories he takes home and processes.

Being preoccupied with the thoughts and feelings of OEF/OIF/OND veterans’ trauma stories creates “residuals” for this participant. He uses the metaphor of stains in one’s underwear to explain it.

Most stains in underwear do not go away. They’re always there and so it’s with each trauma. I think you’re always permanently altered and there’s always residuals everywhere. You’re changed. How do you balance it? That’s the question. I need to try and balance it with other experiences.

How he attempts to balance it is by reminding himself that the trauma he hears and treats are not his experiences. “They are their experience and I don’t have to take them on.”

A participant discussed that what causes a preoccupation is when the veteran’s trauma story directly mirrors an experience of herself or that of her family.

When I hear combat stories from the OIF/OEF veteran, that feeling is triggered where I relate to my own parents and our lives where WWII was always with us everyday. Sometimes it’s painful when it relates to something that you feel you have experienced or your family has.

She also becomes preoccupied when she is attempting to figure out a veteran’s particular situation or issue related to their trauma. “For me it is both: something that hits home and trying to figure things out. I spend a lot of time trying to figure out what’s going on.”

Feeling and experiencing an OEF/OIF/OND veteran’s crisis causes this participant to experience the flight or fight response. He qualifies this by saying he is not taking on their issues, he is only impacted by them. “I’m in my own adrenaline mode and

155 it activates my adrenaline and my own imminent response. I don’t have nightmares, don’t lose sleep, nor do I have I intrusive thoughts about their stories.” He has noticed that he becomes more irritable at home. For him, the irritability is not related to the trauma per se. “It is just the cumulative stress of everything and I think that bleeds over into some of that.” What he takes home is the cumulative stress that periodically “bleeds over” into his personal life and manifests in irritability.

A participant was extremely clear what specifically causes him to periodically become preoccupied with the thoughts and feelings about the veteran’s trauma.

Am I always preoccupied? No. Am I sometimes? Yes. And what all that means to me is there’s work to be done. That, somehow, I’ve not released that individual or it’s not reached me on some sort of level that I have to process.

This participant explained that, for him, when he hears trauma stories, after the veteran leaves, he says a prayer in order to release the energy from the session and the veteran from himself. The most powerful tool he has found is to release them the moment they leave the room. However, at times, he becomes preoccupied with a release that is incomplete or it is activating his own personal issues. “It’s always hard to figure out. I don’t know whether what I’m dealing with is an incomplete release or it’s interplaying with what we call ‘karma crud’ that gets pulled out.”

The participants noted many different themes they tend to be preoccupied with.

For some, it is experiencing restless nights, reoccurring nightmares, feeling helpless about how to treat this person, and thinking about a veteran’s acute state and how will they connect, stabilize and keep this person safe? Other participants noticed treatment failures, stories that teach something not known before, trauma residuals that

156 permanently change a person, trauma stories that mirror one’s experience or that of one’s family, the cumulative effect of stress that manifests in irritability at home, or an incomplete release and having one’s own ‘karma crud’ exposed. These are the issues and themes the participants in this study identified as preoccupations and that they often take home as they listen to and treat OEF/OIF/OND trauma stories.

Checking Out “Sometimes it feels like the grievously wounded person sucks the life out of everyone around them including me. Sometimes, you just want to shut it all off.”

The majority of the participants stated that they experienced emotional or empathic detachment working with the OEF/OIF/OND population. Some reported that when they are too busy, tired, or frustrated with administrative duties, they have a tendency to detach. “If I’m tired from administrative stuff or feeling the pressure to get this report done, it’s harder for me to be really present with a veteran.” Periodically, experiencing personal problems and feeling emotionally taxed can cause emotional detachment as well.

I might take a step back and feel like I don’t want to deal with a given moment. I have enough of my own stuff, or have some emotional distress going on but for the most part, over the course of my professional career, this hasn’t been a significant issue for me.

Empathic detachment occurs for one participant when she is not only busy but also when veterans come into sessions and they are essentially repeating the same things and are not interested in changing or addressing their behaviors. She also notes, that at

157 times, detachment can be helpful.

Sometimes I feel detachment when I’m incredibly busy and veterans are coming in and saying the same thing. I know they don’t want to change and sometimes I’ve felt myself a little more detached. At times, emotional detachment can be very healthy and productive.

For another, empathic detachment occurs when she is clinically “fried” and when her personal issues become activated.

Empathic detachment happens for me when I’m clinically fried because of treating veterans who have layers of trauma—home trauma and childhood trauma—one after the other. I’ve also had to detach when it flips my own issues.

When that happens, I back away and give it some space, maybe 30 seconds or 2 minutes, and then I’m back in the game.

For her, backing away and giving it “some space” allows time for the personal issue that was activated to calm down so she is not emotionally reactive and does not cause harm.

“It doesn’t mean you can’t touch it—the issue—and move with it, because your ultimate goal is not to harm the veteran.”

A participant noted that emotional detachment occurs when the veteran is in crisis and she is unable to accommodate their request for an immediate appointment.

Sometimes wanting more time in the day, people needing appointments when you can’t get them in, and calling you in crisis again and not being able to get them in sooner is difficult and overwhelming. That’s when I can also shut down and detach.

158 Several participants experience emotional detachment when the veteran’s reasons for treatment are questionable. “My detachment comes when I call the person’s motives and credibility into question.” For others, detachment occurs when the legitimacy of the veteran’s trauma story is examined. “The times I feel detached are when I don’t know if the trauma is legitimate.” Not all veterans are seeking PTSD treatment for the right reasons. This participant stated that empathic detachment occurs when he suspects a veteran is feigning their PTSD symptoms in order to obtain a service connection pension from the VA. “For me, it’s when somebody comes in and they’re malingering. This person is exaggerating their symptoms or completely fabricating stuff. It’s obvious they’reattempting to create a paper trail for a compensation exam. This is when I detach.”

Veterans with personality disorders or strong personality traits can create emotional detachment within the therapists who are treating them. For example, male veterans with narcissistic tendencies are extremely difficult to treat for this female participant. “I have trouble with male veterans who display narcissistic tendencies and who are belittling towards women. This is the population I detach from.” She has identified specific treatment characteristics of these veterans. “They constantly test the therapeutic process, don’t change, and question the therapist.” Her reactions to these male veterans are so strong that she prefers not to treat them but to refer them to other therapists.

This participant mentioned that the only time she experiences empathic detachment is when she encounters a sociopathic veteran. At that point, she immediately determines whether she will treat this person or not. “When this occurs, I see an image of

159 a bridge and I ask myself, do I really want to go there or not? It is a very dark and scary place to go.” For her, treating this type of personality can be frightening and unsettling.

One discussed the tension that exists between empathy and detachment that is always present in the treatment process. He believes that in order to be an effective therapist, the clinician needs to be a bit detached and removed. At the same time, the clinician must be empathic in order to feel what the veteran is feeling. This process is described as a narrow tight rope metaphor that requires skill and balance in order to stay on the rope. A clinician does not want to be so empathic and feeling that it interferers with the treatment process. On the other hand, being too detached runs the risk of not being present and engaged with the veteran. “I don’t want to be so detached to where I am totally tuned out and not congruent to where the veteran is at.” The ideal balance is to have a little detachment, staying connected and present with the veteran via an empathic stance.

Detachment occurs, for this participant, when he falls off the “rope” and is unable to maintain his balance between the two areas. For him, emotional and empathic detachment is how a therapist survives. He stated there is a danger with constantly feeling empathic with every situation because eventually, the therapist will be negatively impacted by the trauma. “But you cannot go ahead and feel empathic with everything that is going on in there and stay sane. You lose yourself in the trauma.” This occurs because the clinician is completely immersed in it daily.

Another participant explained the key to trauma work is to remain clinically neutral and at the same time to process the trauma and energy that is present in the room.

A clinician will have problems if they do not learn how to process the trauma and energy.

160 “Because the trauma keeps on coming up, and if you don’t have a way of dispelling it, it builds up inside of you, and then sooner or later you are going to develop either physical or mental illness.” It is imperative that the clinician learns to release the energy that exists in the room—the energy that envelops the therapist and the veteran. “You have to release it because their job is to come in and release some of the energy behind what they have experienced.” This participant believes hearing, experiencing, treating, and processing trauma is about energy. “Everything is about energy. Processing requires you to be present but it also requires you to develop ways in moving through it all. When that happens, you begin to understand and you can release it.” He is emphatic that trauma therapists be able to recognize it is not their job to “take on and own” a client’s trauma.

Empathic detachment is an essential skill for therapists to master in order to survive the work.

How do you keep yourself clinically engaged with an OEF/OIF/OND veteran who is in the end stages of alcoholism and is dying? This is the dilemma for this participant who has treated this veteran weekly for the last eight months. During this period, the veteran completed multiple substance abuse programs and began addressing his combat and childhood traumas. The veteran, however, continued to relapse on alcohol. Eventually, a CAT scan was conducted on his liver and lesions were discovered.

“I think I get to the point where I see clients where this is inevitable. I see where this is going and I start to psychologically back myself out of it and acknowledge this is your path.” The veteran felt the participant detach from him and confronted him about it. The participant responded by saying to the veteran he is going to die and what are we going to do about it? “How do I keep myself in a place where I am clinically giving you [veteran]

161 the best that I can understanding you are probably going to have a catastrophic health event in the next six months or less?” It is difficult for this participant to stay emotionally connected knowing the veteran is going to die soon.

The participants identified several clinical themes that required empathic or emotional detachment working with this veteran population: when their own issues were activated; being too busy; questioning the legitimacy of the veterans’ trauma stories and possible malingering; encountering narcissistic and sociopathic personalities; developing a balance between empathy and detachment; not being too empathic with every traumatic event and being able to release the traumatic energy that is experienced; and detaching when veterans are drinking themselves to death with alcohol. Some participants defined detachment as problematic in various contexts and others as necessary in order to survive the work.

Stories That Stick “Of course that is going to hit and stay with me because he now attached into something that’s mine.”

Nearly all the participants identified specific trauma themes that had an emotional impact on them. These themes are unsettling, difficult to sit with, and often stayed with most participants for years.

For a fair number of participants, the trauma themes that stick include innocent children, women, and civilians who are killed. “I think the trauma stories that stick and are hard to listen to are those that target specific populations: children, families, and innocent civilians.” For another participant, it is the emotional component that becomes

162 activated when he hears about the deaths of civilians, women, and children. “It’s more of the emotional association that this was my brother sort of to speak or, Oh my goodness, that’s someone’s wife or child.” The reason this sticks for him is because he is connected to them, the death of a battle buddy and children and women, in some way. “It is an identification with me—that’s it.” This participant has two young children and since he became a parent, he feels the emotional weight of hearing about children and women being killed by combat veterans.

A common scenario that is described by the OEF/OIF/OND veteran consists of a situation where the enemy is hiding out in a specific location. The soldiers are ordered to enter the village or house and to shot and kill whoever is present. This often includes innocent children, women, and families that happen to be at the wrong place at the wrong time. “There were children in there and they were killed. Those are the types of stories that are hard for me.” For these participants, these horrific scenarios involving children have a profound affect upon them.

This veteran was sent to a location to kill an Al-Qaeda operative. He and his group went to this mud thatched building and were given the OK to spray and pray. There’s to be no prisoner taking. They kick the door in and start shooting.

There are two men in there twenties, a grandmother and two children. They have all been hit and they aren’t dead. This veteran was assigned to the two children ages 5 and 7. He executed them. That’s not what we think of when we think of war. That’s not an enemy. The execution style for me was really tough to hear. He described how the children were looking at him. He described it in so much detail.

You can picture any kid in your life and go there mentally. We were definitely

163 having a parallel process and were on the same track for a while until I was able to jump off.

For some participants, themes of loss, grieving, suffering, and death/suicides of veterans leave a lasting impression. It is the intensity of the loss the veteran experienced including the death of an “Army buddy,” the depth of the suffering and grieving that affects these participants.

A veteran was ordered to attack a truck that was not following protocol at a checkpoint. He carried out his orders and found that he blew up his own guys. If I did that, would I survive this? How would I feel? Would I be able to heal from that? Would I have some kind of self-forgiveness so I could deserve to live? That stuck with me.

Relating emotionally with this OEF/OIF/OND veteran’s trauma story allowed this participant to question her own resiliency and capacity to endure such a catastrophic trauma. For her, it is the level and intensity of the personal suffering of this veteran, the loss of his “buddies” at his own hands, and the inability for him to forgive himself in the depths of his grieving that “stuck.”

One participant explained that it is not trauma stories that stick with him but their deaths. He stated that he has a recurring traumatic experience that truly traumatized him on all levels. This participant walked into the apartment of a veteran he had treated for three years and found his dead body. The veteran’s body was partly mutilated by his cat.

He had another OEF/OIF/OND veteran who was shot and killed by the local police because he was experiencing dissociative symptoms and extreme irritability related to his PTSD symptomatology. This participant explained that these traumatic experiences

164 activated his own personal trauma.

These stories bring up my own trauma history. I accidently shot a kid when I was in the fifth grade. I remember it vividly. I play the movie in my head from start to finish. I’m sure this is part of the reason they stay with me.

Suicides and unnecessary deaths affect this participant the most. For him, suicide is completely and utterly about loneliness.

Suicide to me is such a lonely act. You do it alone and you leave alone. It’s a conscious attempt to end one’s life. Somebody who is that alone, helpless, and detached with any meaning in life is horrible for me. I’ve battled over suicidal thoughts over the last 6 years in dealing with this [OEF/OIF/OND] population myself.

He identifies with the profound sorrow of these veterans and finds himself carrying their pain. He also addresses the societal responsibility of addressing the unnecessary deaths of these combat veterans who periodically are shot and killed because of acting out their PTSD symptomatology.

The deaths that do stick for me are the suicides and the unnecessary deaths that I wonder about. I feel like I can attach to the sorrow of that person somehow and I carry it. It’s the sticky emotional pieces, the visceral, the grief, sorrow, and the death—the finality of it all. It is the betrayal of a society that allows these things to happen and letting the suffering go on the way it does.

This participant is extremely clear that even though he has experienced aspects of the veterans’ hopelessness and helplessness on a deep, personal level, he is always able to harness hope for himself.

165 I’ve always been able to find that glimmer of hope. It may be a pin dot but I know it is going to get better. I’ve been in that spot before or have been really close to it but I know there’s something better for me down the road.

For another, the combat veteran trauma stories that move him to tears and stick are embedded in a parallel process of intense sadness. This sadness is often rooted in loss and suffering. When this participant encounters veterans with this level of sadness and suffering, it mirrors his own experiences.

It’s kind of rare for me to experience their sadness and I become tearful. There’s something about their story that parallels my own experience and I think where I resonant is with their terrible loss and suffering.

Two female and one male participant noted that military sexual trauma (MST) stories tend to affect them. A female participant explained that the reason these tend to “stick more than other stories” is because she is female. MST occurs in a war zone and often by one’s own troops which means that it can happen to anyone.

I think some of the military sexual trauma stories stay with me more just because I am a female and being aware of that. But, for the grace of God, realizing something like that can happen to anybody and especially in a war zone and by your own troops is pretty terrifying. These things stick a little bit more with me.

The second female participant explained that she identifies at times with the MST and other traumas of female veterans. For her, she had a profound, personal identification with a specific traumatized female veteran. “The really acute military sexual trauma of this female veteran, the domestic violence, a child that was taken away, and the neverending brutality of her life, sat close to home for me.”

166 The male participant explained that once in awhile he will think about an MST story and he tries to imagine what that experience is like for him if he were the veteran.

At times, he questions the truthfulness of the male MST stories he hears whether they happened or not.

The ones that pop into my head, for the most part, are the MST ones. There was this story about a male veteran who was assaulted by four guys. Whether they were all black or all white I can’t remember. I then try to picture what that must be like here and there. When I hear a story like that, I also notice that sometimes I wonder how true it may be. Are they full of it or not?

Some trauma story themes stick with several participants on an extremely, personal level. What is it about these particular themes that stick? Why these? These specific stories activate the most private and personal aspects of their lives. When these personal themes are touched, the participants are emotionally affected deeply on a conscious and unconscious level.

A participant explained that she had a picture of her young daughter on her desk one day when an OEF/OIF/OND combat veteran came for treatment. He immediately gravitated toward this picture and said that girl was killed in cross fire and that he had buried her. This veteran wanted to know how this participant knew she was here. “He explained the firefight, and of course, I have a personal connection to this story because that is my daughter.” This veteran described how he tried to save this child and after she was killed, his platoon kept moving on. He stood in front of the platoon with his gun and stated they were not moving until this girl was buried. “He was just weeping in my office about how he killed this girl that I had the picture of on my desk. Of course that is going

167 to hit me because he now attached into something that is mine.” This experience affected this participant to the point that all personal artifacts were removed from her office.

When that was happening, I said to myself, wait a second. You can’t get into my personal things. I had no idea that having a small picture of my daughter would leave me ineffective or that it would trigger a veteran. I no longer have personal things in my office.

Another reported that an OEF/OIF/OND combat sergeant and his two men had over taken an outlying village in Iraq. They knew they were sent to this specific village in order to kill several Iraqi men and were going from house to house. Eventually, they pulled everyone out of a specific house. The women and children in the courtyard were screaming hysterically. The sergeant wound up fighting with one of the Iraqi men. The sergeant pushed this man against the corner of a wall, his skull split open and he died in front of him. “For him, this was really a hard thing to envision. He was left with that memory and I was too.” This participant explained that, later, she had a mini break down that lasted for approximately three months. During that time, she realized how affected she was by this story. “When I had my mini break down, I also saw that image and I realized all of a sudden and I said, oh my God. I think I have been damaged and ruined.”

One reason this particular story may have had such a profound impact on this participant unconsciously is because her brother was horrifically killed in a car accident when she was eighteen and he was nineteen. He was decapitated.

Hearing the stories of combat veterans that had traumatic childhoods stick for this participant. “I feel angry that the parents did not protect the kids, the client. This person has double the amount of trauma from childhood and their military experience.” Where

168 does this anger towards parents who did not protect their children come from for this participant? It stems from her early childhood and the ways in which her parents attempted to protect her given their traumatic war experiences.

Kids are supposed to be protected. I feel this way because my parents did everything they could to protect me and they came from the holocaust. They worked really hard to protect my sister and me. Then, here are veterans coming from a real traumatized place in childhood. What’s going on here? Kids should be protected. I guess that is my core belief.

For many participants, the “stories that stick” section suggests vicarious traumatization is complex and varied. The participants asserted that, earlier in their careers, hearing and processing traumatic war stories occurred more often because they did not have the experience nor the ability to tolerate and develop professional distance concerning them. However, as this chapter reveals, even with the most seasoned and experienced clinicians, traumatic war stories can periodically “get in” when it is least expected because it activates “something that’s mine” or something personal. It can also occur when there is an intense and powerful connection between the clinician and the veteran.

A participant felt concerned after reading this chapter and voiced this during the member check interview.

Reading this section left me feeling a bit concerned by how many may be having personal reactions and being triggered by their own stuff. It surprised me only in the sense that we work so much in a silo. I’m kind of removed from other clinicians’ stuff besides my little two or three person cohort. Either we are not

169 talking about this triggering stuff or it’s not happening as candidly as with others.

This same participant continues to grapple with the information in this chapter. She is not only concerned but worried as well.

These are snippets of clinicians’ stories and you get it all in a row versus once a month or once every six months where somebody will say, this is really triggering. It concerns me because I know how this work can do that.

Unfortunately, I’ve known plenty of people, whether its been my classmates or practicums that were really not healthy doing the work. I think we can be unhealthy in lots of ways but when I read about triggers, I just worry about that individual as well as the care of the veteran.

Conclusion Relived Trauma, describes the process of how many of the participants are affected by hearing and treating combat stories from OEF/OIF/OND veterans. This category consists of four properties: Hard to Hear, Taking It Home, Checking Out, and Stories That Stick.

170

Chapter IX

Practice Wisdom “Initially I didn’t have the skill and I had to learn it in order to work with combat vets. Otherwise, I think you traumatize them.”

Practice Wisdom is the fifth category. In this chapter, participants explored their vast knowledge and experience treating combat veterans of all eras including the OEF/OIF/OND population. They discussed their individualistic approach, philosophy, and techniques related to treatment and trauma work.

This category includes nine properties: Advice, the imparting of general information and counsel concerning the basics of trauma treatment; What I Did and What I Do Now, refers to how participants conceptualized and practiced therapy earlier in their careers compared to now; Being Aware of My Own Stuff, consists of observations about the ways participants affect and are being affected by the treatment process; Trauma Work Wisdom, describes the more advanced treatment techniques that have been amassed by the participants through years of experience; Military Sexual Trauma, explains the complexity and challenges of treating military sexual trauma along with combat trauma; Band-Aids, the participants’ opinions and clinical concerns about evidence-based psychotherapies and knowing when to use or not use them; Heroes: The Continuum, explores the personal views of the participants regarding whether they consider the veterans they serve as being heroes or not; How to Survive, describes

171 specific strategies that some participants utilize in order to continue doing the work in a balanced and healthy way; and The Work Is Rewarding, the various reasons the participants give with how the work is gratifying.

Advice Not everyone can deal with trauma. I truly believe it is a skill you have to learn.

A major aspect of Practice Wisdom is the Advice that many participants shared regarding the fundamentals of treatment and trauma work during the interviews. These fundamentals include four sub properties: the Basics of conducting trauma work including the physical environment; the use of the therapist’s Body and Body States while conducting treatment; the clinical concept of Hope; and specific Advice for New Therapists.

Basics.

Many participants empathically believe that the essential foundation for any therapeutic alliance, or the Basics of trauma work, is being compassionate, listening, and providing a holding space.

When I first meet with them, I am connecting and holding a space of comfort, experiencing mindfulness, and compassion. It’s a very gentle process for me. I sit with their energy and see where they want to go and really listen and connect with them.

This participant is mindful and conscious of listening and connecting with the veterans she treats. This is a gentle process for her. It is not forced or rushed. The

172 therapeutic process unfolds. She also asks four questions when beginning the work: “What brings you here? What gave you the strength to come in? What can we give you in the time that is allotted? And what would you like to see that you don’t have now?”

She finds these questions helpful in providing direction early on in the treatment process and more importantly making the process client or veteran centered by allowing them to go where they need to during the session. “There is no agenda for each veteran.” Another basic that she offers as advice for therapists is giving veterans a tool that they can take home and use that same day. “After establishing rapport with them, I always like to give them something to take home that they can use that very evening that is practical and pertinent and exactly relates to their issue.”

This participant believes that there are four principles that are critical and need to be utilized when treating the OEF/OIF/OND population. “This population is so appreciative of being able to work with someone who will validate and hear them and treat them like a human being with respect.”

Another participant believes that providing a non-judgmental space is critical for the veteran to say anything to the therapist and is central for the healing process.

From my perspective, this challenging veteran got better over time because it was the stability of having the space to talk about things. He knew that, regardless of what he was going to say to me, whether it was kind or not, it was safe because he knew I wasn’t going to cut him out of treatment. I wasn’t going to say you need to suck it up or don’t talk to me that way.

According to this participant, the key is the ability of the therapist to stay connected without judgment while enduring harsh treatment at times so the veteran does not feel

173 dismissed or abandoned. By providing a safe space for honest, open communication without the fear of retaliation from the therapist regardless of what the veteran said, is what allowed the veteran the ability to gain awareness into his life.

One participant stated that working therapeutically with the OEF/OIF/OND population is challenging because “they are mouthy, swear, and they posture.” An important aspect of treating this population is tolerating their anger and posturing.

As long as they aren’t physically putting their hands on me, I’m fine and I will sit and let them complain because I’m not running away from them. When they are done complaining, I’m still here. As long as you can stand there and tolerate that anger and rage, they are going to respect you for that. They feel you are on their team and this strengths rapport.

She explains that many therapists cannot accept and endure the explosive anger of the OEF/OIF/OND veteran and that is one of the reasons trauma work requires skill and the ability to tolerate intense affects. “What I realize is that you have to learn the skill to work with these types of veterans. When they blow up with such explosive anger, I don’t have anything to do with it. I don’t have to solve it. I just sit and listen.” The process of tolerating these intense affects is a way in which trust is developed and at the same time the veteran will test the therapist and the therapeutic alliance. “There’s a piece of trust when you say that I’m with you. We are going to go through hell and the mud and come back out on the other side. Are you really going to be with me? It is through this process that they test you.”

Another important basic of trauma work that several participants mentioned is the physical environment: the office. It was noted that specifically the OEF/OIF/OND

174 veterans do not like the flickering of overhead florescent lighting because it can give some of them headaches and cause irritability due to traumatic brain injuries and other combat symptoms. The use of side lighting or lamps was suggested instead. A participant explained that she attempts to create a safe and inviting office atmosphere by having pictures of nature only on the walls.

I have no pictures of war on the walls. No memories of the military. I have outdoor scenes of Oregon and I use the pictures for grounding when someone dissociates. I have a lot of green plants and just a little something to munch on to ground them. I want to create a relaxing effect that helps when someone needs to be grounded and an office space that is safe and a comfortable nest that the veteran can come back to.

A fundamental concept that is central to trauma work is understanding the nature of Posttraumatic Stress Disorder (PTSD). Several participants explained that PTSD does not require predisposing factors and that anyone who experiences catastrophic trauma is at risk for developing it.

Psychosis is genetic. Bipolar disorder and depression is also genetic but with PTSD, you do not have to have predisposing factors to get it. We don’t know why some get it and some don’t. We can always talk about the statistics regarding a bad mommy, bad daddy, and bad upbringing that made someone get PTSD. The other side of it is that anybody can get it. Even the most cold-blooded warrior can get it. In fact, they are actually prone to it.

Several participants noticed that the majority of the OEF/OIF/OND veterans that they treated for combat PTSD also had traumatic childhoods.

175 I believe there is a close connection between current trauma and poor experiences they had as a child. If you had a good childhood, you develop resiliency and the ability for self-regulation. If you don’t, when you are pressed to the point of trauma, then you are unable to mange it. Ask them about growing up first and find the roots of a predisposition to PTSD. As convincing as this argument is and also the experiences that many of these participants have had of treating many combat veterans with traumatic childhoods, it is important to recognize that not all combat veterans with war-related PTSD will have predisposing factors rooted in childhood. Conversely, not all that had traumatic childhoods develop war-related PTSD.

Body and Body States.

Other participants discussed how they use their Body and Body States during the treatment process. “They are watching my body language.” Veterans often watch and track the body language of the therapist closely: Does the therapist body appear to be open or closed? Is the therapist leaning forward or is sitting way back in the chair? Are the therapist’s legs crossed or not? Are they looking around the room, out the window, or at something else when the veteran is talking?

Regarding body states, a participant noticed that when she becomes triggered in a session, she experiences a gut feeling. “I usually feel things in my gut and when something is going on, I have a body, visceral reaction. I pay attention to that and I never let it go.” Through the years, she has come to recognize the value of paying attention to this visceral, bodily experience when she becomes triggered. When this occurs, she

176 conducts a self-assessment by asking, “What is going on? And what is being triggered?”

If she is unable to analyze and makes sense of her countertransference reaction, she discusses it in supervision. This participant then addresses the event with the veteran if needed or only with herself depending on the context and the issue. She uses intuition and her body states to guide and inform her work.

Hope.

One of the most important qualities that many participants addressed is Hope.

“Working with traumatized veterans takes a special type of person to do that. Have to have the hope that they are going to get better. When you have that hope, that is what gets imparted to them.” Most participants believe treating veterans with severe combat trauma can take months to years. The progress of the work is often slow and incremental. At times, hope fades for some therapists. Several of the participants explained that hope is central in terms of treating the OEF/OIF/OND population because some therapists are convinced that this population will not improve because they are too difficult to treat.

Many participants explained if the therapist does not abandon hope but continues to cultivate it, even through a long treatment process, most of the time the veteran improves.

Another participant is adamant that prescribing medications is not enough when treating this population. They need hope. “Veterans need more than medications. Even if they seem hopeless, if you give them hope, at least with your presence of having positive regard, or being willing to be helpful and hopeful, they will find a way.” One participant believes she has to have realistic hope for the work and the veteran. “I have to be hopeful in this job; to keep that sense of hope in a realistic way, and not being Pollyannaish.”

177 Realistic hope is the foundation of all trauma work. Without it, the work will not move forward.

Advice for New Therapists.

A fair number of participants offered general Advice for New Therapists. They offered many suggestions: seeking out and obtaining good clinical supervision; receiving validation and help; cannot do this work alone or by yourself; keep and maintain clear established boundaries; be able to debrief yourself and process what is occurring when issues arise with the veteran and the therapist; get plenty of sleep; and have a life outside of your work. For one participant, creating balance in your life was the most important piece of advice she can give to new therapists. “You have to have balance in your life. Do not only live trauma and live your work. You have to have your own life and your own hobbies.�

Participants explained one way of obtaining balance is taking care of oneself physically, mentally, emotionally, and spiritually. Surrounding oneself with a core of friends or fellow therapists that one can talk to and receive support from is extremely important.

A participant was adamant about utilizing specific strategies when beginning the process of learning how to become a trauma therapist.

Do not try and read every trauma book and digest every trauma technique out there. Allow the process to come naturally and gradually over time as you gain experience. Otherwise, you can drive yourself crazy trying to do it all and to get it right.

178 With regards to treating the OEF/OIF/OND population, some participant offered the following advice for new therapists: do not look at them with pity, shame, or being limited; be front and center with the veteran envisioning their potential; constantly look for what is possible and asking them what they want for themselves; do not move the veteran too quickly through treatment; the veteran must come to their own conclusions and behavioral shifts completely on their own; and the therapist must have solid trauma training.

A participant offers the following advice for new therapists about how to be in the pure moment with the veteran.

The pure moment means to be completely present with them, with no agendas, and not thinking about techniques. The pure moment goes hand in hand with the holding presence and that is where most of the healing is done.

According to this participant, the “holding presence� is sitting, connecting, and listening to veterans without any preconceived notations of what they or the therapist will say and the empathy to be with them.

What I Did and What I Do Now Early on in my career, I would do Cognitive Processing Therapy and I wanted to see a response, growth, and change immediately after ten sessions. The reality is that it can take years and years.

The Advice that the participants shared in the interviews are based on What I Did and What I Do Now through years of clinical practice and experience. Many learned through trial and error what works and does not work regarding trauma treatment.

179 A participant discussed how early on in her career she wanted to solve the veterans’ problems immediately and jump into the therapeutic work. “So, I’d want to jump start everything into let’s go right into therapy. Let’s get your drinking issue resolved and I’d pile up this plate of things we were going to do and it didn’t work.” The reason this approach did not work is because she made it about her need to get in and fix the veteran. She put her agenda first instead of being veteran-centered. She says that this was a “live and learn” experience because the veteran inevitably relapsed. This participant attempts to be mindful of this dynamic now and approaches it from a different direction. “When they relapse, I say that I may have moved too fast with you and I may have influenced this relapse because this process was more overwhelming for you than what I thought you were ready for.”

In a similar vein, another participant explained that when she began her career, she was more active and controlling in the sessions. “I had to fix them. I had to make sure they were getting their monies worth the work. I’m going to do this right.” Later in her career, she realized that fixing them, doing it right, and making sure they were getting what they paid for was no longer important. “I realized that I don’t fix anybody. My job is to provide a safe, nurturing environment, to ask questions, and reflex back their behaviors.”

Another participant was expecting dramatic, immediate changes to occur when he began treating a combat veteran with a new evidence-based psychotherapy he had learned.

Early on when I was working with this population, I would do Cognitive Processing Therapy and I wanted to see a response, to see significant growth and

180 change immediately after ten sessions. The reality is it can take years and years.

It’s not just the work that we do. It’s that growth maturity process that we all naturally go through including the veteran. Seeing veterans a few years later and observing the changes makes me ask this question: How much of that was the therapy I did versus the maturity and natural development of the veteran’s insight? I think it’s both.

This participant explained how a veteran finished the ten weeks of CPT and appeared to have been getting worse. He worked with this veteran intermittently over a year. A few years later, this participant saw this veteran and noted significant growth in his life. He learned that therapy and the maturation process occur together. It is unknown at times how much therapy becomes internalized especially when veterans drop out of treatment.

This same participant explained that over the years, he denied that hearing trauma stories from the OEF/OIF/OND population did not affect him in anyway. Recently, his view completely changed.

As therapists, we are affected by the trauma stories that we do hear. We are emotionally affected by everything. We are tied to the universe around us. In large part, we are affected in every element of our existence. You hear an emotionally powerful story with a lot of fact behind it and it’s painful. How can it not be? I think as therapists we all feel it but we keep ourselves safe by denying that it affects us when in fact it does.

His reason for therapists denying the influence of trauma stories in their lives is compelling: it keeps them safe. For therapists to admit that the trauma stories they hear affect them require some level of vulnerability and honesty. Some therapists believe that

181 to admit this, there is something wrong with them and they should be able to handle anything that comes their way. If they cannot do that, they are defective. This participant acknowledged that had he admitted this earlier in his career, he would have sought individual therapy immediately and his depression and anxiety would have been addressed and treated sooner. This was an extremely important lesson to learn over the course of his career.

Another participant used to compartmentalize the veteran’s trauma earlier in her career. Over the years, her trauma view changed.

I used to think that if you did A, B, and C, then your trauma won’t be an issue.

That’s not what I believe now. I used to really encourage veterans to put the trauma in a box and then it would leak out and we would get the lid back on it.

What she learned is that trauma symptoms do not stay in the box and that they impact the veteran’s life daily in different ways all the time. “Sometimes it’s in the box and life is good and five minutes later, something triggered the trauma and it’s out again. They are bouncing around in the trauma.” She now believes that the trauma does not go back into the box. “That’s really huge for me because I used to think quit drinking, just stop drinking then your trauma will be minimized.” She has learned that trauma has many emotions and symptoms and that substance use disorders can be a manifestation of trauma symptoms as well. Becoming sober does not stop or minimize trauma symptoms.

The two disorders can influence each other but they both have different causes.

Understanding this relationship changed her trauma view.

Years ago, one participant worried and fussed about how the session would turn out. She had intense anxiety performance and often “scripted” the session, a term

182 meaning making it about her and influencing the direction of the session due to her agenda. Through the years, she learned not to script the session and, instead, be present with the veteran.

I listen to where the veteran is, who the veteran is and just hold space. I guess all those years of what I’ve worked on finds a place to go and seems to flow naturally and the veteran responds much more to that.

This same participant encapsulated her years of experience as a trauma therapist by saying the following: “I listen more and talk less.” This profound concept speaks to her many years of clinical practice and the development of insight into herself and her process.

Being Aware of My Own Stuff “It is a fact that your stuff is going to get triggered and it is critical that you have a means by which you work through it.”

Recognizing What I Did and Do Now enabled the participants to explore ways that they affect and are affected by the treatment process by Being Aware of My Own Stuff. For some participants, Being Aware of My Own Stuff occurs when they encounter cases that activate their own issues.

Combat veterans with characterological or personality disorders can be extremely difficult and challenging to treat. This participant compared it to a battle between the therapist and the veteran.

Treating these types of veterans can be emotionally taxing because you’re constantly engaged in this and it feels like a battle. You’re replaying the combat

183 experience with the veteran through the therapy because they’ve got their toes dug in the sand around their ideas or beliefs because that’s what kept them alive.

According to this participant, these veterans have ingrained thoughts, beliefs, ideas, and schemas that take root and become resistant to change. These veterans are unable to see their behaviors. For trauma therapists, this process is emotionally exhausting because the therapist is constantly engaged in a battle, a tug of war of wills. “These veterans are not willing to entertain any idea that their thinking is wrong.” When this occurs, the therapist and veteran become locked into positions and the battle ensues. The participant explains that when this occurs, therapists need to be aware of transference and countertransference issues.

I recently worked with a veteran like this. His issues were more characterological in nature so we started doing traditional psychotherapy; talk therapy. Met with him a couple times a week when things would get hard. It was a very open dialogue and interpersonally based looking at different types of reactions we'd have including what each other said and doing a lot of transference, countertransference work. The therapist’s work is more about how does your part play out in this relationship and leading to where you are. And through that process, it took a while, but he changed.

When difficult cases like these arise, therapists need to have a process where they can discuss them with colleagues or others. If they do not, it will negatively impact the therapeutic process. “You have to have a venue for addressing these things. If you don’t, you end up acting out in ways that further delay the treatment progress of the veteran if you are not addressing your own stuff.”

184 Other participants noted it is important for them to look back over a session and analyze it by asking several questions: What happened here? I never felt that way before.

Where was I coming from when I said that? That really offended me or made me annoyed, how come? These participants constantly think about the sessions and pay attention to their feelings and thoughts afterwards and throughout the day.

Others explained that dosing off, feeling annoyed, and feeling tired are signs that the therapist is experiencing a countransference reaction and that it needs to be explored.

One participant stated that having an internal barometer assists therapists with being aware if they are thinking too much about a patient or not being engaged enough. When the therapist is too detached and not clinically engaged, and it feels like a meeting with the veteran instead of a therapy session, that is a sign that the therapist needs to be more engaged.

One participant noticed that he experiences a replay or a parallel process of the veteran’s affective states that he is currently treating. After treating a specific veteran, he noticed that he became easily agitated and angry with other people. Analyzing the situation, the participant realized that he was emotionally acting like the veteran he had treated two weeks ago. “I got angry and frustrated like so and so. It is like a replay of what the veteran and I were talking about two weeks ago and I had a parallel process.”

Another reported that the therapist’s issues will be triggered in sessions and that it is imperative that they be addressed.

Depending on your level of intelligence and that of the other person’s, it is a fact that your stuff is going to get triggered and it is critical that you have a means by which you work through it. That’s how you stay sane.

185 This participant believes that “working through your stuff” enables you to stay more physically healthy by “not being vulnerable to cancer, dementia, depression, anxiety and eating disorders.” According to this participant, this often occurs with trauma therapists who practiced for years and did not have a healthy process addressing their countertransference issues and the accumulation of trauma stories. He also mentions that one of the most difficult aspects of therapy is recognizing when the therapist’s issues become activated in a session. “Sometimes the patient is carrying your stuff. You have to be aware of that. That’s a hard thing to do. To figure out when your stuff is in there and being active.”

This participant explains that when a patient is in a victim’s consciousness, the therapist cannot challenge that position because it does not work. The therapist needs to be careful about what is said because the patient has a need of being the victim. When the therapist does challenge the patient regarding victimhood, it becomes about the therapist’s unresolved issues and or protecting the therapist from something. “There is always this fine line. You have to learn to discern in this work.”

Trauma Work Wisdom It is important to realize that when there are two spirits in the room, one is designated the healer and the other the healee. When you view it as a holy encounter by the nature of what we do, you recognize that it is a two way street because there is no difference between you and me.

Reflecting upon Being Aware of My Own Stuff, participants discussed the deeper observations of their clinical work that is rooted in Trauma Work Wisdom. This property

186 has two sub properties: Pearls of Wisdom and Veterans Not the Same.

Pearls of Wisdom.

Many of the participants discussed numerous clinical concepts they have learned and developed over years of practice. A participant, who was retiring after 22 years as a therapist in the VA, explained that the most important piece she learned as a trauma therapist is showing the veteran a real part of oneself.

You have to be real. You can’t be phony because they’ll pick up on it right away.

Be transparent and just be who you are and know that you’ve got skill. You’ve got it and let yourself be with them and go where they need to go.

Others reported that for combat veterans having the courage and the willingness to address their painful emotions leads to understanding, acceptance, and the release of emotional pain. This is the benefit of visiting these difficult and intense affective areas that surpass the theoretical realms of treatment: it becomes experiential, not theoretical.

One participant explained that the word he used to describe this process is digestion.

Digestion is the act of breaking down large particles into smaller ones with the purpose of absorbing and metabolizing them. Metabolize means to change (Webster’s, 1990, p. 745).

This is a wonderful metaphor for the therapeutic process.

Several participants discussed the challenges of treating OEF/OIF/OND combat veterans who also have personality disorders. Some have a prior abusive childhood history that can make them susceptible to borderline and narcissistic features. These characterological traits reinforce their ideas and beliefs about the world that become embedded and fixed over time. This type of trauma cycle “feeds the monster” and

187 becomes self-perpetuating. When treating these individuals, many participants believe that it is important for the therapist to recognize what will and will not work. The participants are adamant: if the issues are truly more characterological in nature, then evidence-based psychotherapies will not be effective; they will not work. Traditional psychotherapy is often helpful with this population. However, it is time consuming and not recognized by the VA as an evidence-based psychotherapy. If these veterans can continue to be engaged in talk therapy, over time, their thinking and behaviors often begin to change. “Evidence-based psychotherapies will not work with personality disordered veterans. You must speak to and treat the personality or characterological traits first.”

One participant explained the reason the EBPs do not work with characterological traits is because the EBPS that they use do not address them. These veterans need a longer treatment process that specifically addresses the personality issues that drive the behavior. “The personality, the characterological piece, is not being addressed and they are going out there and repeating the same cycle over and over again.” Some VA facilities provide an EBP, Dialectic Behavioral Therapy (DBT), that addresses personality disorders or characterological issues and is offered individually and in groups.

However, according to this and other participants, their VA facility does not provide DBT to address personality disorders. This is another reason combat veterans come back into treatment three to six months later. “This is a huge problem of what we do here. We get those recyclers because they have addiction struggles and other stuff that is a by product of the personality.”

This also speaks to another related issue that participants reported. It is important

188 for therapists to think outside of their theoretical orientations and learn to be flexible and utilize other modalities. “You have to think about things outside of the theoretical orientation parameters. You can’t go in and think I’m going to do Cognitive Behavioral Therapy with somebody. You’ve got to be able to use other stuff.”

A few participants noted that part of the training combat warriors experience is how to dehumanize the enemy. By doing this, it is easier for them to take a lethal stance towards that person. They think about and relate to the enemy in terms of how evil, bad and wrong they are and that over time, it reduces them to the level of animals. They are no longer human beings. When the enemy becomes an object, it is easier for the warrior not to question when they have to make life and death decisions. These participants explained that this type of training works in the moment but the problem occurs when the combat veteran separates from the military and now has time to think about and reflect on it. What has been observed during trauma work is that many of these combat veterans experience cognitive dissonance by asking questions: Was that person all that evil and bad? Was their political ideologies tied to their culture? Did they have a choice to fight or not? “They start experiencing a lot of dissonance about their experiences and what they did. Grief starts coming in along with guilt.” The participants emphatically believe that understanding this dynamic is central to combat trauma work and sets it apart from civilian trauma.

Many participants stated that providing trauma treatment for the younger, OEF/OIF/OND veterans is easier compared to other war era veterans because they have not had decades of untreated trauma that becomes embedded in neuropathways. “With the younger veterans you’re working with neuropathways that aren’t as deeply ingrained

189 and it’s easier because in some ways the damage isn’t decades long.”

Even with Vietnam veterans, many of the participants have had success treating them. However, they explained that treatment is deeper and takes more time.

“I’ve had some great successes with Vietnam veterans who re-worked their whole lives and have had felonies, domestic violence, hopeless, and being homeless. It is possible to re-work that kind of complex trauma but it’s deeper.”

For these participants, it is possible to treat decades of ingrained complex trauma patterns but it requires a slower, more in-depth and longer treatment experience. This point is important for novice trauma therapists to understand.

In treating the OEF/OIF/OND veteran, this participant addresses the multiple meanings that can be ascribed to vulnerability. She explains that many of them continue to buy into the military mindset that feeling is weak and vulnerability is bad. This perception enabled the warrior to survive. However, when they separated from the service and are no longer in a war zone, this view often cripples them emotionally by preventing access to the trauma. She believes that generating new meanings regarding feelings and vulnerability enables the veteran to create a new relationship with them.

Feelings and vulnerability can bring about strength and possibility.

PTSD work is being with what is: vulnerability. It is realizing it doesn’t have to mean anything other than the meaning you put on it. Is it weakness or strength? Is it possibility or is it potential for connection? It is looking at other meanings rather than will it destroy me and that it’s bad and out of control.

Some participants reported that treatment is not monodirectional. It is a process that goes back and forth between therapist and veteran. “The people I have been the most

190 helpful for were the people I’ve learned the most from.” The therapeutic relationship transcends technique because it is based on a real relationship with two human beings who connect and relate to each other as equals.

It is important to realize that when there are two spirits in the room, one is designated the healer and the other the healee. When you view it as a holy encounter by the nature of what we do, you recognize that it is a two way street because there is no difference between you and me. You understand as Shakespeare put it, you have dealt with slings and arrows of outrages fortune.

Veterans Not the Same.

When veterans experience combat trauma, they are not the same individuals they were prior to their military experience. Attempting to reconcile who the person was before and after the trauma is challenging and requires the therapist to reframe this for the veteran. One participant uses the “box analogy” in order to explain this concept. He draws a box on a piece of paper and explains that the content of the box contains the veteran’s understanding of themselves, others, and the world prior to their military combat trauma experience. “You generally were taught that the world is a good place and most people, even though they can be mean and rude, generally have good intentions.”

The veteran experiences combat trauma and this intense and profound experience does not fit in the box. “You learned that there’s a fair amount of people in the world that don’t have good intentions and that they want to harm you. Your belief about the world gets changed because you see such atrocities occurring.” These veterans are often exposed to horrific, catastrophic war trauma in parts of the world that they have not been

191 exposed to before. At times, some of them may even adopt a view of themselves that they are as bad and evil as the enemy. All of these new, traumatic experiences and perceptions no longer fit inside the parameters of the original box. The goal of trauma treatment is to create a bigger box so that both pre and post trauma experiences are integrated and make sense for the veteran.

Another participant explains to combat veterans that the military did an excellent job teaching them how to turn off their emotions and how to remain in an intense and angry place. However, the military did a substandard job of assisting them with how to turn off the intense emotional states and learn how to integrate affect appropriately as a civilian. “You weren’t this guy before. You actually thought the world was pretty safe and you could enjoy relationships and go out and do things.” The veteran will not be the same person before the trauma. It cannot happen because that person no longer exists.

“There were things about your life before that are still there but are masked by this cloud of PTSD.” This is an excellent way of explaining to veterans that their traumatic experiences have made them different but it also instills the hope that pieces of themselves, prior to the trauma, exist and that they can find and reconnect with them.

One participant explains to combat veterans that they cannot get beyond being human. Many veterans define themselves as a combat veteran, a Marine or solider, but underneath it all, they are a human being. They do not realize that some of their responses and reactions are natural and appropriate as being human. When this is explained to them, it appears to normalize their experiences. “As clinicians, we need not to over pathologize or overly dissect their humanness.” This is sound advice for all clinicians to remember.

192 Military Sexual Trauma All I cared about was tying to save the person next to me. I wanted to make sure they made it through so I was looking out for my buddy. When you think about that and about that buddy committing that act, it’s even worse.

Military sexual trauma (MST), for most participants in this study, reported that it is one of the most complicated and difficult issues to treat for specific reasons. MST compounds combat trauma and increases PTSD symptoms. There is a betrayal that often comes from the hierarchy: sergeants and others who have power and control over them.

Often times, it is not the enemy that violated them but their own comrades. “There are layers and layers of complex work with MST. It’s extremely complicated because you trust them with your life and don’t question their authority.” It becomes extremely complicated when veterans believe that their superior officers have their best interests at heart. When veterans are in a war zone, they are supposed to protect each other. “Now, I can’t trust the people around me. It’s a compounded trauma where the trust is shattered.”

The individual’s body, mind, and soul have been violated and all sense of trust is gone; no one can be trusted and no one is safe.

The bond that they have with each other and with their peers is unique and you can’t get that anywhere else. They literally rely on each other for their lives. To violate somebody that they have this kind of bond with and trust adds a whole other type of PTSD; a much more intense level.

MST appears to affect veterans at the core of their identity. “For men, it’s really hard on their self-esteem and it seems to devastate their sense of self. It gets at the heart of who they are.” With combat, there may be some guilt if they perpetuated it themselves

193 but with MST and the male warrior, there is much more shame involved because they felt, on some level, they contributed to it. “Some of the veterans with MST that I have treated have said I shouldn’t have been there and not drunk. Others said, I was complicit in my rape.” What’s more masculine than a combat veteran or soldier? When MST occurs among men, it emasculates their masculinity. “MST is so emasculating and another aspect is that those are their peers. Those are the people that keep them alive.”

A participant explained further the complex nature of MST versus combat trauma and the importance of understanding the differences.

There’s no meaning to why somebody did this to me. It creates a big split for them and how do you navigate that? You have two clear pieces here: you were a victim of MST and you are a combat survivor too.

With combat, veterans are fighting for their lives. This has meaning and purpose for them. With MST, there is no meaning associated with the act and this can create two areas that clinically need to be addressed: being a victim of MST and a survivor of combat.

Band-Aids Sometimes I don’t do an evidence-based psychotherapy [EBP] at all. EBPs are not for everybody. Depending on the complexities and the layers of the traumas, I don’t think EBPs are effective. I think it is a band-aid for some of that.

Several participants disclosed their clinical concerns and practices regarding the evidence-based psychotherapies (EBP) they are expected to use regarding combat-related PTSD: Cognitive Processing Therapy (CPT), and Prolonged Exposure Therapy (PE).

194 Some participants reported that it is critical to prepare the veteran for trauma treatment before the evidence-based psychotherapies are used. If the veteran is not prepared before hand, they often do not complete the treatment.

You have to get them ready with some cognitive restructuring before you put them in these intensive treatments. Those that start right away don’t make it; they don’t complete it. There is more damage if you do evidence-based treatments and there’re not ready and they leave early.

It is not uncommon for these participants to take six months or longer establishing the therapeutic relationship with these veterans before trauma treatment begins.

I might take six months before I actually engage in actual trauma treatment because if I just jump into Prolonged Exposure I am going to lose them. The trust and relationship building is really important with this population. Taking the time to build that will have lasing benefit for them versus the three-month turn around.

Most of the participants that treat veterans in the PTSD Clinic reported that they do not follow the 12-session protocol of the PTSD evidence-based therapies because treating complex trauma, which the majority of the veterans they meet have, requires more time and often includes a process oriented approach.

I think most of us do this and we don’t talk about it. Sometimes I’ll do a Cognitive Processing Therapy [CPT] protocol and when that’s complete, if it is helpful, I will work into more process stuff. Otherwise, it’s so cognitively based and it’s putting band-aids on people. It’s teaching a tool and they are out the door.

They come back three, six months, or a year later.

They noticed that the evidence-based protocols only address or ameliorate trauma

195 symptoms because of the 12-session mandate. These participants believe in integrating the trauma by developing and creating a trauma narrative over time. Some participants acknowledge that the EBPs are useful at times but the therapist must be discerning with them: when to use and not use them.

I’m not a fan of the many EBPs. I guess CPT if done very skillfully can be a useful tool for the beginning work of peeling the layers of the onion. But I would say it is very much a first baby step and veterans want more. We have to be discerning in this work.

At times, one participant stated that she does not use EBPs because they are not for everyone.

Sometimes I don’t do an EBP at all. Depending on the complexities and layers of the traumas, I don’t think EPBs are effective. I think it’s a band-aid for some of that and I’m not willing to do it. I base it on a case-by case basis and it usually takes me at least a month before I determine if I ever will do an EBP with someone.

She believes that EBPs are extremely effective when veterans have a single combat or MST trauma experience where this specific incident stands out in their mind as the trauma event. The EBPs are not effective with veterans who have complex PTSD. She noticed that it can take six months to a year for trust to be built and for movement to occur when some veterans present with a complex trauma history.

Several others explained that the reason the VA uses these PTSD evidence-based psychotherapies is because they are quick and easy. “The beauty of the EBPs, and it’s probably why the VA wants us to do them, is because they’re quick and easy; not too

196 much feeling and then the veterans are on their way. It’s not good work.”

Another participant, upon reflecting on this concept during member check disagreed with the previous participant’s views. “I’m not sure that I agree with this view [EBPs do not produce much emotion]. Cognitive Processing and Prolonged Exposure Therapies are hard work and if done appropriately, generate a lot of feeling.”

Participants believe that eventually the VA will need to change their current approach to combat trauma by developing new treatments because the recidivism rate with utilizing the current PTSD EBPs is extremely high from three to six months turn around. The 12-week treatment protocol time for the EBPs are simply too short in order to address complex trauma cases.

One participant specifically discussed a clinical observation she noticed with utilizing Prolonged Exposure Therapy.

My big question with Prolonged Exposure is that it will allow someone to habituate to the trauma but in many cases, someone’s vagal system is so traumatized and shaken they are really deadened and they cannot find joy. You let somebody habituate to the trauma but then they are numbed out.

According to this participant’s experience, many veterans often learn to “habituate” to their trauma through PE but it is not integrated nor mastered. She believes that this often leads to a sense of emotional and intrapsychic deadness and the inability of some of these veterans to experience joy.

Heroes: The Continuum “Heroes? Sure they are. Look what they did. They are standing up for this country

197 and all our freedom. Absolutely. They are America’s heroes.”

“I don’t personally buy it and I think it is part of the era that I grew up in. You weren’t heroic to be in the military when I grew up.”

Nearly all the participants reported whether they viewed the veterans they serve as being heroic or not. Of all the questions asked in the interviews, this one generated the most controversy and emotional reactions among the participants. Fifteen responded to this question. Seven stated yes they viewed them as being a hero and seven stated no.

One participant was not sure.

The seven participants that viewed veterans as being heroic gave numerous reasons: the veterans defended our country and freedom; they did what they had to do and they did it to the best of their ability; they go above and beyond to serve and protect those with them; going in during Vietnam and saving POWs and bringing back their dead; entering military service with the hope of doing something better in selfless service; and being willing to deal with an unknown where you can be killed. Many explained that the veterans themselves do not like the label hero. They prefer to be called warriors. For this reason, these participants do not use the word hero in clinical practice.

The seven participants that stated they do not view veterans as being heroic stated the following: combat experiences forces them to confront an aspect of humanity in themselves but it is not exactly heroic; cannot generalize everyone who has been involved in war as a hero because some have a nonchalant attitude about what they did and some with antisocial tendencies have a desire to gratify murderous, evil impulses; as a society we are inclined to romanticize war and when we label a veteran a hero it minimizes and oversimplifies the clinical work; it is all cartoon character stuff—mystical;

198 the reality of it is that very difficult decisions had to be made in the moment and when they come back they do not feel like a hero; public opinion can swing one way or the other; now they are all flying the flags when they come home but when they came back from Vietnam, they spit on them and called them baby killers—it is all distortion; they were doing their job; and compared to the greatest generation of those in WWII, no, veterans today can do heroic, brave things, but they are not heroes. These participants stated they have respect for what these combat veterans experienced and that many of them have done heroic things in war but not every veteran is a hero.

One participant had a strong reaction to this question.

Heroic? No. I refuse to believe that. First of all there’s a lot of propaganda behind that use. When somebody’s in front of me with bronze stars of valor, silver stars of valor, a real live hard core solider in heroism than sure. The average person was doing a fucking job. It really bothers me from a cultural standpoint that we’ve chosen to glorify war by calling them heroes. For me there is a real distinction between the draftee and the volunteer especially when the draftee went there and performed at an incredibly high level in order to receive those kinds of awards. It doesn’t mean that the person, who didn’t have much, didn’t do things that are heroic, but do I believe that the average troop is a hero? Oh hell no. That makes me sick.

This participant is retired military and has a viewpoint and understanding of this concept that most civilian participants do not have. For him, it takes an exceptional warrior to become a decorated hero with bronze and silver stars of valor. The average individual was doing their job and is not considered to be a hero.

199 How to Survive “With trauma stories, I only have to hear it and witness it. I don’t have to carry it.

It’s not mine. And I generally don’t take it home.”

It is crucial for therapists to develop their own program to address the daily emotional strain and exertion of conducting trauma work. Several participants discuss specific approaches they use in order to keep themselves balanced and healthy.

One stated that in order for him not take trauma stories home, he often drives his car into his garage, turns it off, closes the garage door, puts the seat back, and takes a 20 to 40 minute nap. “Sometimes I will pull off into a rest stop on the way home and sit there for 15 to 20 minutes and close my eyes also. This helps to reboot, restart the hard drive.”

Another explained that he experiences a mirroring process with veterans when he hears and experiences their trauma stories. He asks himself the same questions about the affect and incidents of the trauma that he asks veterans.

I go through the same things after I hear the image. I feel this way when I think about this. I wonder if this would have happened to this person if . . .? I find myself asking the same questions I ask them and processing similar feelings when I hear their stories described. I process it in my own way and by doing that I can work through it.

Another participant stated when she becomes too overwhelmed with the trauma work, she manages the amount of trauma she is exposed to by not scheduling as many appointments.

When you do a lot of trauma work it affects you vicariously. I realize when I’m

200 getting to that point that I have to really back away and not schedule as many patients. I am very careful that I tell people I’m full. I can’t see you for a couple of weeks or a month. I set clear boundaries. I explain that I’m sorry I’m so full and I don’t like to do that but I know I can’t do anything well if I’m that overwhelmed for too long.

This approach must be used judiciously and carefully for it can also back fire by sending the wrong message to veterans by implying that hearing and processing their trauma stories are too much for the therapist and that the clinician cannot deal with it.

Certainly spacing out appointments and pacing oneself as a trauma therapist is an invaluable tool to master as one does this work. However, the therapist must be careful and mindful of the messages that can be interpreted and perceived by the veteran when this is done.

The Work Is Rewarding I have found it rewarding and I didn’t expect this. I was a little bit nervous coming into this work. Is this going to tear the scabs off of wounds for me in terms of my Vietnam experiences? It did not happen.

All participants acknowledged that treating the OEF/OIF/OND population and other war era veterans is rewarding. Some explained that specifically treating the OEF/OIF/OND population is challenging and rewarding for the following reasons: it is rewarding to sit down and provide a safe place for these younger veterans to stare down their monsters rather than continue to avoid them for forty more years like some of the Vietnam veterans; the work is rewarding with the younger population because you are

201 working with neuropathways that are not as deeply ingrained and it is easier because the damage is not decades long; and it is very gratifying because there are successes in mental health and big differences occur in OEF/OIF/OND couples and families.

Other participants noted how the behavioral changes that occur over time is rewarding for them: they begin in denial and throughout the process of treatment they gain more awareness into their lives and they start to make changes; it is rewarding when they shift and begin to feel better by reconnecting to others, becoming more involved with their families and attending public events; by relieving their stress for a moment and providing a supportive environment is incredibly rewarding; to see veterans drop out of therapy early, then come back and leave later on and be OK because they are taking a break, is wonderfully rewarding; it is rewarding when you take PTSD and all that damage it does to people’s lives and make progress; when they enter therapy they present one way and toward the end of treatment, their symptoms have reduced, their perception has changed regarding themselves, others and the world; there have been some real rewarding cases and others that have been a real disappointment; they have been discombobulated and angry all the time, their relationships are getting better because of the impact of medicines, and that makes it interesting and rewarding.

Every participant stated that if they did not believe the work was gratifying and rewarding and that they were making a difference in the lives of the veterans they treat, they would have left the profession long ago. Treating combat veterans is exhausting, taxing, and incredibly stressful. For these participants, finding that the work is rewarding motivates them and is the main reason they continue to come to work and keep treating and serving veterans.

202 Conclusion The category, Practice Wisdom, explores the vast knowledge and experience the participants have gained through years of treating combat veterans from all eras. Nine properties were addressed: Advice, What I Did and What I Do Now, Being Aware of My Own Stuff, Trauma Work Wisdom, Military Sexual Trauma, Band-Aids, Heroes: The Continuum, How to Survive, and The Work Is Rewarding.

203

Chapter X

Different Person Now I have definitely changed my thoughts, values and beliefs about things. We all come in with our own biases, stereotypes, and filters. When you work with a particular population, you start to shift: the way you think and see things. You’re forced to. If you’re going to work effectively with people you’re forced to shift.

Different Person Now is the sixth category in this study and explores the process of how the participants have changed since they began treating traumatized veterans, including the OEF/OIF/OND population. All 17 participants in this study state they are different as a human being or as a therapist since they began treating combat veterans.

This category includes three properties: Deeper Understanding, includes the characteristics or qualities participants have specifically identified since they began trauma work; A New Point of View, describes the reappraising of the participants’ beliefs and values as they treat the OEF/OIF/OND veteran population; and Becoming More Aware, investigates whether or not the participants have felt threatened or their environment is no longer safe due to working with traumatized veterans.

Deeper Understanding Examining how the participants are a Different Person Now commences with a Deeper Understanding into their own process as a human being and as a clinician. Deeper

204 Understanding consists of four sub properties: Judgments, Biases, and Boundaries; Greater Knowledge; Comfortable, Competent, and Compassionate; and Various Insights.

Judgments, Biases, and Boundaries.

Several participants discussed that since they have been trauma clinicians, they are less critical and judgmental about combat veterans, PTSD and the OEF/OIF/OND population.

Basically being aware of my own judgments and criticisms of combat, PTSD related issues and that population is critical. Having my own biases built in before and then through the process of working with them and learning more about their difficulties, I see more about the bigger picture. I feel like I have a deeper understanding of where people who struggle with trauma come from.

It is essential for clinicians to “see” all the complexities that are involved in treating combat veterans including an understanding of early childhood trauma and their PTSD symptomatology. Biases and judgments often occur with the OEF/OIF/OND population when they present as angry and have substance abuse or dependency issues.

Participants explained that in order to be an effective therapist, it is imperative that they continually be aware of their biases and blind spots.

We all come in with our own biases, stereotypes, and filters. If you’re going to work effectively with people you’re forced to shift. If you’re going to hold to those old beliefs, biases, and stereotypes, you can. I’ve seen people do that but they are not very effective in what they do.

For some, they noticed a change regarding their professional boundaries. “I think

205 being a trauma therapist over the years, my boundaries are healthier, stronger and I’m more secure in my skills.” Another participant explained that he has learned to find a balance with hearing and experiencing the trauma stories he hears on a daily basis by creating an emotional boundary.

It has desensitized me in a lot of ways, having to be a little removed because you hear that stuff over and over again. You can’t just feel all those things all the time.

You hear and feel it but you have to have a certain boundary. There’s a certain limit to it and I think when you do that it changes you.

Greater Knowledge.

These participants have noticed they have a more comprehensive knowledge of trauma and PTSD. “I have a greater appreciation for how trauma gets stuck, how damaging it is, and how it encompasses so much.” This knowledge and awareness has enabled some participants to be more aware and sensitive to reactions of individuals they encounter publicly.

I believe I’m a lot more empathic now. I’m way knowledgeable when it comes to PTSD. When I’m out in the community and I’m in different settings, there are times when I pick up on stuff. Based on somebody’s reaction or how they are handling themselves, I’m thinking that guy has PTSD because I’m more aware of it.

Another participant explained that she relates to PTSD on a personal level because, often like the combat veteran, she cannot talk about her work as a trauma therapist to her friends. Her friends who are liberal, antiwar, peace loving, and are into

206 spiritual growth and enlightenment do not want to hear it. “It’s easy not to hear it if you haven’t looked evil in the face everyday.” This participant has gained a real insight into what it is like for veterans who want to tell their trauma stories but nobody wants to listen. Like the combat veteran, the walk of a trauma therapist can be lonely and isolating.

Finding a “relational home” where therapists can discuss their traumatic experiences individually can be difficult.

Comfortable, Competent, and Compassionate.

Some felt the areas they are different now as therapists include being more comfortable, competent, and compassionate. “In some ways I’m a much more competent person. I’m more confident because it challenged me. It’s humbled me and at the same time it gave me more confidence in my abilities as a social worker.” Another feels more competent because he does not get intimidated in certain situations like he used to when treating the OEF/OIF/OND population. He is now able to approach difficult questions with this population and feels confident and comfortable exploring their issues.

A different participant explained he is more comfortable and at ease with the psychotherapeutic group process. “I’m a lot more comfortable sitting and co-facilitating groups with my intern and I love going deeper, doing counseling and psychotherapy. All these things make me very confident.”

Compassion is what this participant has noticed has made her different since working with combat veterans. “One of the ways I’m different is I do feel like I have more compassion than I had. I feel like I am a more feeling being about things than I was before.”

207

Various Insights.

Participants acknowledged various ways they are different now from how they were before they started trauma work. These areas include: being more empathically attuned and recognizing that the therapist will feel uncomfortable at times due to the nature of the work; having an awareness of one’s maturity and development as a person; continue to gain real understanding of the Oregon National Guard, an appreciation for military service, and the level of sacrifice that both the service member and their families make; trusting one’s judgment and intuition more; veterans force the therapist to grow; gaining a deep insight into oneself, the veteran, and cognitive dissonance of their combat experiences; and being more humble, understanding that therapists are not perfect, and having more tolerance and patient with people in general.

One participant explained that working specifically with the OEF/OIF/OND population, he decided to engage in personal therapy again. The trauma work has brought up issues regarding his mortality and other personal issues. “Doing trauma work has pulled out some of the negative affects of my past traumas that I’m still trying to tap back down.”

A participant who is a combat Vietnam medic veteran stated combat veterans are generally courageous individuals. If a dangerous situation occurred, they respond immediately. However, PTSD turns these courageous warriors into emotional cowards.

They do not want to allow themselves to feel and connect emotionally to their pain.

At an emotional level, PTSD tends to turn us into emotional cowards. We don’t really allow ourselves to connect, to feel feelings, to get close, and all of that. So,

208 having said that, I began thinking, how does that apply to me? How have I been an emotional coward? It’s important for me to recognize that in myself.

Another said that one of the most difficult things she encountered coming to the VA were veterans feigning mental health symptoms for secondary gain.

That was one of the hardest things coming to the VA for me is that secondary gain. I didn’t experience that in mental health before because your symptoms are your symptoms and you are here because you don’t feel good. This was definitely a shift for me.

As this participant explained, not all changes are positive. This same participant explained further that since she has worked at the VA, she is a bit jaded and is not as trusting of others as she had been.

I do sometimes feel I’m a little jaded too. My husband senses that at times with me trusting people. I don’t know if it came from working with this population but I’m sure it contributed or, as you get older, you had bad experiences with untrustworthy people. I think it’s a combination.

Another participant explained that he has not had a remarkable shift since working as a trauma therapist. He came into the profession later in life with a fair degree of life experience.

It’s not like I came in real young and my eyes were opened to the trauma and horror of the world. No major shifts in terms of comparing/contrasting the self and the way I was. Maybe some shifts and changes in terms of who I am as a therapist but it is difficult to sort out what’s experience and what is age.

209 A New Point of View I grew up in Los Angeles and San Francisco and was very liberal and antiwar. I never thought in my wildest dreams I’d ever be working with a veteran population in my life. Don’t punish people that are fighting for our country. There needs to be folks that fight for our country. I have really come around in respecting these veterans. We need to protect and help them heal.

Having a Deeper Understanding of the ways in which the participants are different now regarding trauma work, assisted them in questioning and re-appraising their beliefs and values in order to gain A New Point of View. This new perspective has created a deeper understanding and insight into many of their personal lives and how they work as clinicians.

Nearly all the participants noted that their values and beliefs were reappraised as they worked with the OEF/OIF/OND population. These include the following: being conflicted and shaken in the belief that the OEF/OIF/OND combat veteran is a hero because of what has happened in Iraq/Afghanistan and the reasons they were there; grew up with an antiwar perspective and now has an enormous regard for combat veterans and a respect for war; realizing one is working with people at an intense emotional level and the need to connect emotionally with them; re-evaluating one’s life on many levels and appreciating it more; wondering if death is a random act and questioning if there is some divine plan for humanity; what is and is not important in life: questing one’s spiritual beliefs and having a deeper connection with one holy energy; everything that happens to people is part of a divine plan and that good and evil exists in the world; reappraising aging, family, and career development; re-evaluating substance abuse, criminality,

210 combat, and the individual differences between the combat and noncombat veteran; reevaluating the cost of the Iraqi and Afghanistan wars including the political reasons they were there; having more compassion for belief systems that are different from the participants including political and spiritual views; questing service connection pensions for traumatized veterans; and analyzing one’s values regarding war, freedom and the impact trauma has on veterans and their families.

One participant noted the polarity of human behavior: the ability to love and at the same time to destroy. This dynamic has influenced his belief and values regarding human nature. This participant believes that most people are capable of love and loving a child.

At the same time, these same individuals are also capable of committing horrific acts in a combat situation. Integrating these two poles is at the heart of trauma work with combat veterans, including himself.

The human animal is such that put in the right situation, even people with pretty good backgrounds and good moral codes, can be drawn into doing horrendous things. Working with traumatic combat veterans is on the one hand gratifying. On the other, holy mackerel! We are capable of all that. The image I have is that of a stereo amplifier. Whatever is there it can boost to extremes.

Two participants said that their beliefs and values have not been reappraised. One explained that his values have continued to remain consistent. Another stated that some therapists’ values and beliefs regarding war may change as they treat combat veterans.

For this participant, that did not occur because of his upbringing. “Some people’s values and beliefs change around war but I grew up in a family where that was from the start. I understand the human experience better along the lines of trauma and depression.”

211 The second participant said there has been no radical shift or change in his beliefs or values. He grew up in Ireland and is aware of what people are capable of doing including nail bombs in pubs, and executions. “Since childhood I’ve had a strong sense of what people are capable of including how the world works, and the politics of war. I understand all of that quite well.” Combat stories touch him but he finds no surprises that cause him to reappraise his beliefs and values when he hears and experiences them.

Becoming More Aware “My world is not the same after hearing and learning about Military Sexual Trauma. I was naïve about it.”

Becoming More Aware, participants discussed whether or not they felt personally threatened or if their environment is no longer safe due to working with combat veterans.

Eight participants stated they had felt threatened or their environment was unsafe and seven said no.

Those who felt threatened and unsafe at times gave the following reasons: much more aware of safety issues and the environment due to hearing and treating military sexual trauma; is aware of the environment by being more vigilant, strategizing, and planning when it can potentially become problematic; a veteran thought that the company logo on the participant’s water bottle looked like a swastika so the veteran threatened the participant; a participant was stalked by a combat veteran and now the participant locks the office door and when someone knocks on the door, the participant’s heart pounds; a participant had to take a combat veteran off of suboxone, the veteran became extremely angry, “went off,” and the participant was triggered for a few days; another had a bomb

212 threat by a OEF/OIF/OND combat veteran and once in a while, while the office door is open, the participant has a fleeting thought that someone can potentially come in and shoot him; and a participant called a violent OEF/OIF/OND combat veteran on the phone, the veteran verbally accosted the participant, went to the VA, punched walls, and threw furniture after threatening the participant.

The participants who felt safe and not threatened gave several reasons: feels in control of the environment all the time; does not feel threatened because this participant generally provides good customer service, treats people with respect, is collaborative, and can help people settle down; had a few veterans that made this participant feel uncomfortable but does not feel unsafe working with them; and due to this participant’s trauma history, he feels comfortable working with and treating combat veterans and his environment does not feel unsafe.

Conclusion The category, Different Person Now, explores the process of how the participants have changed since they began their work as trauma therapists. Properties include Deeper Understanding, A New Point of View, and Becoming More Aware.

213

Chapter XI

New Ideas for Old Problems There is not enough clinical supervision here at this facility unless you are going for your LCSW. You’re on your own. If clinical supervision is not required but you’re supposed to know all this stuff and practice without making any mistakes, it sets the clinicians up to fail. The VA has failed in regard to clinical supervision or case consultation.

New Ideas for Old Problems is the seventh and final category in this study. This category examines the existing cultural challenges as defined by the participants regarding the absence of clinical support including supervision or case consultation and the offering of various ideas and suggestions if they were designing a program of support for VA trauma clinicians at their facility only. Fifteen participants acknowledged the need and necessity for a formal process of clinical supervision or case consultation. Three properties delineate this category: The Way It Is Now, describes the current environment in which the participants conduct their work without having clinical support and the barriers of implementing a formal program; What It Could Look Like, defines critical qualities that the participants identified in order to develop a successful formal program of clinical support; and How We Do It, identifies specific participatory elements that are required by the participants in order to implement and sustain a program of support for

214 clinicians.

The Way It Is Now The category, New Ideas for Old Problems, originates with the current cultural environment regarding the lack of clinical support, The Way It Is Now. This property comprises three subproperties: Where’s the Support, Solitary Confinement, and Show No Mercy.

Where’s the Support.

One participant noted, through the member checking process, that the VA has, on a national level, a PTSD consultation group that any VA trauma therapist can call or email. This group provides one on one personal support by a VA trauma expert. This participant explained that she utilized this resource. “I have used it a few times and found it helpful.” Participants explained that the existing environment does not provide clinical supervision or case consultation. There is no formal process of support in place at their VA facility. If participants need case consultations, they have to find a trusted and skilled colleague and arrange the encounter. This is exactly what a trauma therapist has to do when a case needs to be staffed.

We don’t have any clinical supervision. We need to have places we can go and talk about cases. Now you have to phone a friend. You have to select people you trust. We all need clinical supervision. In the VA, can you get this kind of group together? I don’t know.

Another participant explains if she has a challenging case, she needs to seek out

215 case consultation on her own. What happens when a trauma therapist has a difficult case that needs to be staffed but does not have the time to seek out and arrange supervision?

The consequences can be disastrous.

We do not staff cases. The only way a case is staffed is if you seek it. I would have to call, consult and set something up. Rarely are cases staffed. We are doing such a disservice to each other as professionals by not doing this.

One participant, who worked for twenty-two years in the VA system, stated the only time clinical supervision was provided is when an employee was in the process of becoming licensed in their field. Once the individual is licensed, clinical supervision or case consultation was no longer required. “After I had my LCSW, there was no regular supervision. You were flying by the seat of your pants. You had to seek out someone, a colleague or a supervisor and it was sometimes difficult to do that.”

According to this participant, when this occurs, a serious dynamic is created that can place the clinician in a precarious situation. “If clinical supervision is not required but you are supposed to know all this stuff and practice without making any mistakes, it sets the clinicians up to fail. I really feel strongly about that.”

Another problem can occur when one is seeking out supervision and the only person available is one’s supervisor who does not have the clinical skill or experience as the clinician. “Sometimes you know more and have more clinical skill than your supervisor. This can be a real problem.”

Some participants attribute the lack of supervision within their VA facility to the bureaucracy and the leadership structure of the national VA system. One participant believes the nature of the bureaucracy creates complacency and a lack of awareness

216 among staff. “You become insulated and do things that you would not do in the private sector.” The layers of leadership often include individuals who are not clinicians or clinically trained that ultimately oversee or influence clinical programs.

The VA is a bureaucracy and it gets treated like a business and people become commodities including staff and veterans. In the VA, it is administrators who are on top who are not clinicians but are acting as if they are. There is not enough connection with the lower line staff because there are too many tiers of leadership. They don’t see a need for clinical supervision.

A participant stated she was surprised to learn, after accepting her position, that there was no formal clinical supervision offered.

I was shocked when I moved here and there was no weekly or monthly clinical supervision. I was licensed before coming here and I had weekly supervision. We met every week, talked out cases, and checked in. We did that in a community mental health center with no resources. How could we not do that here? Why don’t we? It makes no sense to me.

Some are at a loss of exactly how to develop or create a formal program of clinical support and supervision. “Support is really important and I still don’t have a clue how to do it around here. I really don’t.”

A Vet Center participant, upon reading this section of the chapter during the member checking procedure acknowledged how fortunate he is to work in a system that honors and requires clinical supervision.

One of the things that surprises me is that the Vet Centers are a lot better set up for supervision than “the big house” [VA]. After reading this, I did not realize

217 how much better we had it at the Vet Center. But, having said that, I am embarrassed to say that I, as a new team leader, have not been doing such a good job with the whole supervision issue.

Through the process of member checking, and reading this chapter, this new Vet Center team leader came to appreciate how the Vet Center system is better equipped for clinical supervision than the local VA system. As a new team leader, it appears that he became honest with himself regarding his lack of implementing consistent supervision with his staff. Hopefully, after reading the stories of the participants in this chapter who are eager for and want clinical supervision, this team leader will renew his commitment to the supervision process with himself and his staff.

Solitary Confinement.

Several participants discussed the “siloed” effect that exists in their work environment. Many of the various clinical departments, including staff, are physically spread throughout the facility and communicate mainly through e-mail or instant messaging. This creates an isolating environment for them.

We work in our little cells, our units, and there are distances in terms of walking to departments. There are people who work here for 30 years and never meet other key people that are doing similar work. I don’t often hear of what other people do. We interact with a small portion of the population. I don’t think systems are in place to encourage us to get together. Everyone is busy. We are siloed.

Some staff are isolated from others due to physical locations but others report

218 feeling isolated even when their offices are right next to each in the same department.

Another problem is that we are completely isolated amongst ourselves. Our offices are right next to each other but you wouldn’t know that. That is why I feel so strongly that we need to have a mandatory process or consultation group for a year. Then, if you don’t want to go after that, that’s OK. Being isolated and feeling “siloed” is a major issue that several participants discussed. The reasons for this are complex and varied and will be considered in the following sub property, Show No Mercy.

Show No Mercy.

There are other reasons many of the participants experience a lack of support in their work environment and often feel “siloed.” Some believe that the environment blames the clinician when mistakes are made.

The VA does an investigation, a root cause analysis, if it is suspected that the clinician did anything wrong. They say they are looking at systems instead of individuals—at how systems failed. I think you really do feel under the microscope. You feel blamed for things. It’s really a fine line with that.

Another participant stated that it is imperative that clinicians legally protect themselves at all costs because the system is designed to blame. For him, when a suicide attempt has occurred, he reviews the chart to make sure he did not miss any critical documents and that he is legally covered.

I’m not going to have myself taken down by something like this because the system is set up to blame. Because it’s set up to blame, you cannot provide

219 treatment without protecting yourself legally. You have to have the suicide risk assessment in there. You have to somehow make sure that when the peer review meets they don’t have a finger to point. They don’t have grounds.

A participant asserted that the military culture is embedded into the VA philosophy. The VA has adopted the military hierarchy and values that have unconsciously made their way into the consciousness of its employees.

If I show weakness then I will be alienated or I may be perceived as weak or whatever. The irony is that’s the exact same culture and identity of the military.

It starts in the military and the same hierarchy, structure, and values have been essentially transferred and indoctrinated by us.

For many of the participants, the VA culture generates an atmosphere of fear: the fear of making a mistake and being human.

Zero defect policies are what they called it in Vietnam. Mistakes don’t happen.

We are human, it’s war and so of course mistakes are going to happen. It’s a parallel process like the military: showing too much is weakness and don’t make mistakes. This has created some fear for me but I don’t have to buy into the fear or into the belief.

The VA system and culture is only one barrier that affects the lack of support participants experience amongst themselves and in their working environment. Trust is another major barrier. Several participants acknowledged that it is difficult for them to be fallible and admit mistakes to each other because of the lack of trust that exists. “Trust is really a big issue. It’s hard to feel trusting in an environment like this. If you divulge your shortcomings, your inadequacies, then somehow, someone might do something hurtful.”

220 Others mentioned that some clinicians are safe while others are not. This also creates an atmosphere of mistrust that interferes with the process of developing clinical support. “It is difficult to create a culture of support and safety because there are some toxic people here.”

Participants explained that some clinicians have a critical and judgmental manner.

When they ask for help, they are viewed as incompetent or weak.

The safety thing is a big piece around here. There is more judgment than I would like to admit sometimes. Around here, if you ask for help, people wonder what’s wrong with you, you can’t handle it, or you’re burning out. None of these things are accurate.

A participant emphatically stated he will not be involved in a clinical consultation support group because of it potentially impacting his career in a negative way. He believes that what is disclosed in a group setting surfaces in other venues because competition exists among clinicians for leadership advancement. According to this participant, the existing culture supports an atmosphere of discrediting each other.

What I say might affect my advancement down the road if that’s what I’m interested in. I could ultimately be phased out of a position all together because of something I have said or done or a vulnerability I’ve made known.

This participant does not believe it is possible to create a safe environment for clinicians to discuss cases and issues in a genuine, authentic, and transparent way. “You see, this agency is not supportive of helping out clinicians. We are the generalists that have to try to figure it all out when it comes to their psyche.”

During the member checking interview, a participant explained how she did not

221 realize how distrusting her colleagues were of the system for a variety of reasons and that this surprised her.

I don’t necessarily think it’s a super safe environment either but I don’t have as strong of a reaction with it as some of my colleagues. We are siloed and so other clinicians that are connected to more than one service probably experience distrust more than others who are not so connected to other services. Part of the siloing is probably a choice. As you branch out more you realize it doesn’t feel as safe so you stick to your one or two people that you vent to and bounce ideas off and stay small.

This same participant also revealed during the member check interview her desire to develop a private practice when the system becomes too burdensome.

It’s so complicated. I’ve left here many a times in my car as I’m driving away I say, I really should go into private practice. I should go work by myself because the system is so complicated and burdensome with all the layers. And when you know providers are giving bad care and instead of fixing the problem, the veteran is told to go see the patient advocate. It’s ridiculous. If I had my own little shingle, then I could refer patients to those in the community I trust.

One participant disclosed an experience that demonstrates the existing cultural attitudes regarding the lack of clinical support. This participant worked with a young veteran, a man in his 30’s, for a long time and he died on campus while in the residential program. The death was likely a suicide. The participant learned of this veteran’s death five minutes before a scheduled therapy appointment with another veteran. This death was shocking and this participant’s emotions had to be placed on hold until the session

222 was over. A staff meeting was already scheduled and the participant discussed in the meeting the death of this young veteran. The participant felt blind-sided by the unexpected death of the veteran and began crying. “I felt shamed and like I was a very poor clinician because I was reacting in that way. I was trying to bring up how do we deal with the emotions of this.” This participant asked the members of the team how they deal with this type of issue. A colleague answered, “I just stuff it.” This answer completely shocked this participant. “I felt like a freak, totally not understood or supported.” This participant acknowledged not feeling safe with the team. “This has created some fear for me with this team but I will be vulnerable because you have to be authentic and real to do the work.”

During the member checking interview, a participant had a strong reaction to the story above about the colleague that answered, “I just stuff it.”

I just had a recent experience a few days ago where I had a veteran that died due to an unintentional drug overdose. I haven’t had one phone call from a supervisor or from anyone saying, how are you doing? Isn’t that crazy? He was a 32-yearold, OEF/OIF veteran. You read about it in the chart and are you kidding me? No email, no phone call, nothing. That’s nuts. This is my first experience in having a veteran die in that way and it was completely unexpected. It came completely out of the blue and he didn’t even have a substance abuse issue.

This participant processed her feelings and reactions of the death of this OEF/OIF veteran during the member checking interview. She was in complete shock when she learned of his death. She felt sadness for the veteran but her sadness also came from another place.

“It’s really sad and I think it was more of the idea that people here don’t care. We are just

223 here to do the job and the numbers and the status quo.” She explains that unless she has a major issue or problem and brings it to someone’s attention, no one cares.

Nobody realizes that just because we can handle these things doesn’t mean we don’t want to process it. I shouldn’t have to use my family as my support system with things like this. I should have had an opportunity to process it at work first with people that are supposed to be able to help and then go home and decompress with my family if I need it.

This participant has decided to go outside of the VA and pay for her own consultation, in order to support her own growth and development.

This shined a flashlight on this issue for me. He was a human being and it is sad what happened to him and it’s going to continue because we work with a very intense population. If the statistics are true that there are 20 suicides a day among veterans, either intentional or not, it’s going to happen more often in my career than if I’m not working with this population. It’s disturbing.

What It Could Look Like “We need to have some place to compare notes in a safe, nurturing environment where we feel trust enough to say that I’m having problems with this or that is a problem for me.”

A fair number of participants identified specific characteristics that are necessary in order to develop a program of clinical support. This property consists of two subproperties: Essentials, and Not Alone.

224 Essentials.

The participants acknowledged many characteristics that are essential for a clinical support program and consultation group: not being critical; no back stabbing; giving honest, supportive feedback; mutual respect; learning from and supporting each other; environment of clinical exploration; an appreciation of the depth and complexity of cases; staff the good, the bad, and the ugly; have a place for social and emotional support; place where humor and recreation exist; having a sense of community with trusted people one can laugh and cry with; creating a nurturing environment where confidentially amongst the staff is extremely respected; place to explore successful and treatment failures; and where the process is clear including the time of the group, place, and who the supervisor/facilitator will be.

For most participants, creating a safe environment for clinical discussions where clinicians are able to analyze their own clinical process and mistakes is paramount. “Having a support group where it is safe to talk about treatment failures, that I messed up here without repercussions, is extremely important.� A nurturing, safe group environment was defined by this participant as recognizing that clinicians did their best with the current knowledge and information they utilized.

You did the best you could do with the information you had at the time. It may not have been the right information or you should have been picking up on other pieces. But the group gives you honest feedback in a non-critical way.

Not Alone.

Another critical quality that participants identified to be central to a clinical

225 support group is recognizing they are Not Alone in the work. It is important for clinicians to feel that their experiences are shared and understood by other clinicians and that they are not working in isolation.

I would include a mandatory process or consultation group. A place for people to get together and be able to share experiences and stories and normalize the feelings they are having by being in the room. For me, having a built in place to normalize how you are feeling would be important.

Participants pointed out that it is important for all clinicians to realize that they experience struggles and issues with the work and they are human and make mistakes.

This also normalizes their experiences.

Trust and safety provides an environment where you can admit that you have shortcomings, faults, and that we’re not perfect, and we make mistakes. It is an environment where you’re not alone in dealing with something very serious.

Another aspect of recognizing that clinicians are not alone in this work deals with veterans that commit suicide. Unfortunately, when a clinician experiences that, it can be devastating and can cause profound affects to surface including shame, guilt, and incompetence. Having a trusting and safe support group environment in which to process this experience is essential and can help normalize it. “I think that seeing other people that do have some honest struggles, knowing you’re not the only one that had this struggle, or made a mistake, or had a veteran commit suicide, helps and provides each other with support.”

226 How We Do It Having on-going clinical supervision would be very important. We are not going to be aware all the time of when our own stuff is coming in. No humans have one hundred percent awareness about themselves. We can’t.

Some participants identified specific thematic discussion elements that will be required of them in order to implement and sustain a clinical support group. This property contains five sub properties: The Zen Facilitator, Necessary Discussions, Feeling It, More Training, and Wish List.

The Zen Facilitator.

A few participants noted that one of the most important features of a successful clinical support group is having the right facilitator or supervisor.

The experience can go one of two ways. If it is the right clinician or supervisor doing it, it goes very well. If it’s the wrong one, it can feel punitive, more shameful, and you’re worried about evaluation. To put your stuff out there in a group context with your team is a very vulnerable place to be so it takes a lot of skill to do that—a collaborative, non-judgmental stance that the person takes.

It is imperative to have a facilitator or supervisor who can create a nonjudgmental environment that is based on safety, trust and neutrality. In addition, the facilitator must be experienced and skilled. “It’s important to have somebody facilitate who is competent. I think a very supportive environment can happen if you have a very skilled facilitator or therapist.”

227 Necessary Discussions.

In order to have a successful, supportive, clinical program, participants noted they must feel comfortable and safe discussing multiple issues: debriefings about their experiences and what they have learned; address fatigue and burn out; develop less of a model for crisis and more for one of recovery for clinical practice; talk their personal lives if relevant; venue for more discussion about clinical issues then about evidencebased psychotherapies; and discuss suicide and other big issues.

One participant related that several clinicians on his team are more crisis than recovery oriented in the clinical work with veterans. If his team had regular, formal, clinical supervision, he believes the team would be able to discuss the two models, and the anxiety and concerns of the therapists could be explored as it relates to the recovery model.

Some of the clinicians are responding to crises by trying to save the veteran. With the recovery model, there is some dignity in failure and we need to let the line out with veterans. The do nothing approach is often the best approach. You have to manage the anxiety of the clinicians around that and the place to do it is in clinical consultation.

Another explained the necessity of discussing suicides within a clinical supervision support group.

Suicides need to be discussed out in the open. What I decided a while ago was that with my deaths, I wasn’t going to be quiet about it. I would go ahead and discuss it with my colleagues; otherwise, you hide behind the shame that you were an incomplete human being.

228

Feeling It. The heart of any supportive case consultation group is the ability of clinicians to speak about and to their affective states. Discussing their feelings with supportive, trusted colleagues enables them to process their feelings on a deeper level by allowing them to get in touch with their own humanity including all the pain and suffering they hear and experience on a daily basis.

To provide a framework and understanding for all this suffering and pain would be helpful. Formal supervision is helpful when we have a visceral reaction to something that is completely horrifying, or when experiencing tremendous grief or loss attached to the death of a patient or some terrible situation.

In order to do this work, clinicians must know themselves on some level and continually be in touch with their feelings.

As clinicians we always need to understand ourselves better and what it means to work with soldiers. It would be really good for us to continue looking at our own feelings about things in terms of what we might be encountering and periodically checking in.

The process of clinical supervision includes an environment where therapists can explore their thoughts and feelings about all aspects of humanity including their own.

This allows clinicians to remain sane as they work in a world dominated by horror, suffering, and emotional pain.

229 More Training.

Several participants discussed the need for on-going education and training as an aspect of a successful supportive, clinical program. “There’s a meta process in terms of their knowledge and skill base that is growing and expanding so training would be an important piece to keep in mind.”

The participants were specific about the types of training and education to include in their program: education regarding military culture; PTSD and understanding the criteria; training in moral injury; and being trained to know the psychological differences that exist between combat and military sexual trauma. According to the participants, these are the areas that are most lacking in education amongst many clinicians throughout the facility.

A participant explained how he would design and implement a training program for new trauma therapists who completed their education and were coming into the VA. They need to take classes and training to understand how to treat trauma and they would be placed in a series of psychoeducation classes about PTSD for about a year. After that, they would be exposed to evidence based psychotherapies and get trained in them.

A participant who worked at the local Vet Center explained how clinical supervision and training occurs in that VA system. At the Vet Center, the team leader provides clinical supervision to the team and an external review comes twice a month in order to review difficult cases with the staff. Clinical supervision is required and demanded at the Vet Center.

If there are problems with supervision, regional office is called, they come down

230 and investigate, see what’s going on by talking with staff and say, this isn’t OK. They are very supportive on that level. You need that level of power and support coming from the top in order to make supervision work.

The Vet Center also requires a specific amount of training, supervision hours, and cases in order to meet the qualifications and criteria to be a military sexual trauma and family therapist. In the VA system, when a therapist learns an evidence-based psychotherapy, they receive formal training concerning how to utilize and implement the manual and the protocols. The therapist receives clinical supervision regarding a number of cases. Often times these sessions are recorded and the clinical supervisor evaluates them, making sure the specific material and protocols are followed. This often occurs over a period of many months. Once these steps are satisfactorily completed, the therapist becomes certified in that particular evidence-based treatment modality.

Wish List.

As participants contemplated the specific elements they felt were necessary in order to develop a successful program of clinical support, many made the comment that if it were a perfect world, they would include items that would most likely not be considered by the VA. This became the participants’ Wish List, and it includes the following: staff given flexible schedules they can work in order to keep morale; include mediation, acupuncture, and massage for clinicians; trauma therapists do not engage in trauma work full time but have a variety of clinical cases; VA to pay for individual psychotherapy for clinicians; case loads are manageable; first year trauma therapists engage in a consultation group for a year; periodically bring in a veteran who has recently

231 completed PTSD treatment and have this person speak about what their treatment experience was like including what worked or did not work with the therapist; every clinician at the facility to have clinical support and oversight; and hire more administrative assistants to do the more mundane tasks of making copies or greeting veterans so the therapists can remain focused on their clinical work and not be an office assistant at the same time.

Conclusion The category, New Ideas for Old Problems, examines the current cultural challenges regarding the absence of a formal clinical support program including supervision or case consultation. The participants offered various ideas and suggestions for designing a program of support at their VA facility. Properties in this category include The Way It is Now, What It Could Look Like, and How Do We Do It.

232

Chapter XII

Findings and Theoretical Implications This chapter describes the relevant findings and theoretical implications of participants’ experiences treating OEF/OIF/OND veterans with war-related PTSD. The findings and theoretical implications, analyzed through intersubjective-systems theory, adult attachment styles, and contemporary psychoanalytic countertransference concepts, will be discussed and compared with relevant literature. Clinical implications, policy implications, and areas for future research conclude this chapter.

Brief Description of Findings Results of this study reveal five major findings. Each finding is explained in its own section in this chapter. Findings are related to dynamics of treating OEF/OIF/OND veterans with combat PTSD including familial experiences prior to working with veterans and how combat trauma work impacts clinicians; the ways in which VA trauma clinicians treat veterans with complex PTSD experiences; and what is needed for formal clinical support programs.

Finding 1.

The participants had familial and personal traumatic experiences that influenced

233 their interest in the helping profession. Many participants grew up with family members who were combat veterans and saw the effects of war trauma on them. They did not decide to treat combat veterans out of a need to master their own trauma. Instead, they felt comfortable and familiar with military culture, and veteran issues.

Finding 2.

From the participant’s experiences, it became apparent that vicarious traumatization is complex and varied. Many participants stated that they have been overwhelmed, though others said no when clearly they were. Being overwhelmed occurs by levels of awareness that varies.

Finding 3.

Participants reported that they do not follow the 12-session protocol for the PTSD Evidence-Based Psychotherapies (EBPs) because they typically ameliorate trauma symptoms only. The participants believe in having veterans integrate and master their combat trauma by developing and creating a trauma narrative over time that may or may not include EBPs.

Finding 4.

For many participants, directly providing combat treatment as a trauma therapist can result in developing more compassion, empathy, humility, knowledge, and healthier professional boundaries.

234

Finding 5.

Participants were clear about what works and what does not work in terms of developing a formal program of clinical support that includes case supervision/consultation.

Explanation of Findings Finding 1.

The participants had familial and personal traumatic experiences that influenced their interest in the helping profession. Many participants grew up with family members who were combat veterans and saw the effects of war trauma on them. They did not decide to treat combat veterans out of a need to master their own trauma. Instead, they felt comfortable and familiar with military culture, and veteran issues.

Most participants experienced personal, traumatic events that influenced the direction of their career choice and their respective disciplines. Some participants stated that they became more aware of affective states associated with their personal traumas and how this has impacted their clinical work occasionally. These affective states included survivor guilt, hopelessness, depression, and guilt. To experience catastrophic trauma is to be traumatized. As the participants worked through and integrated their own traumas, they survived their traumatic experiences. The participants stated they received therapy in the past or were receiving personal therapy currently. As survivors of trauma, this enabled the participants to be more comfortable approaching, listening to, engaging, being affected by, and relating to the war experiences of combat veterans (Chapter V,

235 Traumas That Paved the Way property).

In 1920, when Freud wrote the seminal work, Beyond the Pleasure Principle, he explained and defined further the concept of the repetition compulsion and its relationship to traumatic dreams. Freud believed that the repetitious nature of traumatic dreams causes the person to remain in a passive and helpless state. The reason the person unconsciously experiences the repetitiveness of the traumatic event is because the individual is attempting to master the emotional pain and conflict associated with it (Freud, 1961/1920). Modern psychodynamic theorists have related the repetition compulsion to various clinical concepts: to process the trauma (Horowitz, 1976/2011); seeking mastery, absolution, and integration (Dalenberg, 2000); and confining it to the repetition of severe trauma, as defined by PTSD (Wilson & Lindy, 1994; Inderbitzin & Levy, 1998; and Corradi, 2009).

Although a past trauma history of the therapist is often cited in the literature as a risk factor for vicarious traumatization (Pearlman & Mac Ian, 1995; Wilson & Thomas, 2004; and Horrel et al., 2011), this is not always the case. In a 2007 study, conducted by Linely and Joseph, titled “Therapy Work and Therapists’ Positive and Negative WellBeing,” the researchers analyzed the potential positive (personal growth, compassion, satisfaction) and negative (compassion fatigue, burnout) aspects of engaging in trauma work. In this study, trauma therapists were asked if they had a personal trauma history.

Those that answered yes reported greater levels of personal growth than those therapists who answered no. The researchers concluded that having a personal trauma history might be a catalyst for greater personal growth (Linely & Joseph, 2007). This conclusion appears to support the findings of the current study. The participants’ personal trauma

236 histories allowed them to experience positive, personal growth as trauma therapists.

Conceptually, there is a difference between working through traumas and identification. Numerous participants had family members who were veterans including mothers, fathers, uncles, cousins, and grandparents. Through the process of hearing war stories and observing the impact of war trauma on their family members, the participants experienced identification with their veteran family members that aided them in developing a familiarity with veterans, their issues, and the military culture (Chapter V, Families of Veterans property).

Laplanche and Pontalis (1973), offered the following definition of the term identification as understood in psychoanalysis: Psychological process whereby the subject assimilates an aspect, property, or attribute of the other and is transformed, wholly or partially, after the model the other provides. It is by means of a series of identification that the personality is constituted and specified (p. 205).

The early psychoanalytic concept of identification can be understood in two ways: “T]ransitively, in a sense corresponding to the verbal ‘to identify’, and reflexively, in a sense corresponding to ‘to identify (oneself) with.’” The first, a transitive process, refers to the action of identifying, meaning, recognizing as identical (e.g., identification of a criminal), or by kind, (e.g., belonging to a specific class) (Laplanche & Pontalis, 1973).

The second, the reflexive process, indicates an act where an individual becomes identical with another person or two people become identical with each other through their thoughts or actions (1973). Laplanche & Pontalis (1973) explain that Freud was familiar with both forms of identification:

237 Freud uses the word in both these senses. Identification in the sense of the procedure whereby the relationship of similitude—the ‘just-as-if’ relationship—is expressed through a substitution of one image for another, is described by him as a characteristic of the dream-work . . . [and as] an active procedure which replaces a partial identity or a latent resemblance by a total identity (1973, p. 205).

For the participants of this study, as children of veterans, they experienced a transitive identification with the ideals of military service, military culture, and military issues. It was not a reflexive identification where the participants became identical with their veteran family member in their thoughts and or actions.

Even though many of the participants reported having family members who were veterans, their narratives did not suggest that they gravitated to the Veteran’s Administration in order to treat combat veterans as an attempt to save, rescue, or treat their family members. In their personal narratives, they gravitated toward their respective disciplines because of a transitive identification process based in their life experiences and familiarity with veteran issues and military culture. Not one participant mentioned in the interviews how their therapeutic work with combat veterans resolved emotional issues related to a family member who was a veteran. Several mentioned that the trauma work helped them to better understand the clinical dynamics that veteran family members experienced.

Finding 2.

From the participant’s experiences, it became apparent that vicarious traumatization is complex and varied. Many participants stated that they have been

238 overwhelmed, though others said no when clearly they were. Being overwhelmed occurs by levels of awareness that varies.

Ten of the 17 participants acknowledged that they were overwhelmed at times by the war stories of OEF/OIF/OND and other combat veterans. Some explained that being exposed or saturated to trauma work daily affects them in a vicarious manner, referring to the concept of vicarious traumatization. Several participants specifically identified areas that caused them to feel overwhelmed: experiencing the “trauma dump” of veterans who related multiple horrific trauma experiences during a single session; attempting to be empathic without becoming too overwhelmed when listening to trauma stories; over identifying with the veteran’s trauma through one’s personal experiences and emotionally “feeling” their pain; and unconsciously internalizing veteran’s experiences to the point of having anxiety attacks in public which was completely new for these participants.

“There’s periods after hearing these things so many times that it gets pumped into your unconscious mind and starts to come up from time to time.” Others had physiological and visceral reactions to the work as well (Chapter VIII, Hard to Hear property).

Seven participants empathically stated that they do not become overwhelmed. For them, overwhelmed meant “it was too much or more than I can handle.” However, these participants reported being highly affected by listening to and treating traumatic war experiences: cried fully and openly; experienced awe, horror, sadness; were emotionally impacted and moved; and found trauma work to be difficult and powerful at times. Even though they had various strong reactions to the traumatic material, they were clear that they were not traumatized (Chapter VIII, Hard to Hear property).

Twelve of the participants noted they have been preoccupied with thoughts and

239 feelings about various aspects of the veteran’s trauma or with the treatment process.

These preoccupation themes included experiencing restless nights; reoccurring nightmares; feeling helpless about how to treat, stabilize, and keep a veteran safe who is experiencing an acute state; treatment failures; stories that teach something new not known before; trauma residuals that permanently change the clinician; trauma stories that mirror one’s experience or that of one’s family; the cumulative effect of stress from trauma work that manifests in irritability at home; or an incomplete release and having one’s own “karma crud” exposed (Chapter VIII, Taking It Home property). Five participants stated they had not experienced a preoccupation with the traumatic material historically or currently.

Many of the participants in this study reported being overwhelmed and preoccupied as they engage in trauma work with the OEF/OIF/OND and other combat veterans. Other participants reported that they were not overwhelmed or preoccupied when clearly, at times, they were. How is this discrepancy explained?

Vicarious traumatization is defined as the “transformation in the inner experience of the therapist that comes about as a result of empathic engagement with clients’ trauma material” (Pearlman & Saakvitne, 1995, p. 31). It is based on the constructivist selfdevelopment theory (CSDT). This is a comprehensive personality theory that integrates psychoanalytic theories including object relations, self psychology, and cognitive theories of trauma (Pearlman & Saakvitne, 1996; Rasmussen, 2005)). In addition, developmental and social learning theories also influenced this theory (Rasmussen, 2005).

Regarding vicarious traumatization, CSDT describes how exposure to traumatic experiences affects the self of the therapist. The constructivist self-developmental theory

240 (CSDT) asserts that individuals construct their realities based on their perceptions and cognitive schemas or maps (Trippany, White Kress, & Wilcoxon, 2004). Therapists manage traumatic material according to their current life circumstances and their early experiences which are based on their interpersonal, intrapsychic, familial, cultural, and social experiences (Pearlman & Saakvitne, 1995). According to the CSDT, symptoms that develop from traumatic events are perceived as adaptations to the events. As individuals are exposed to events that do not fit within their current perceptions of reality, irrational or distorted beliefs protect them and their meaning system from the damage caused by the trauma. Vicarious traumatic responses, then, become adaptive due to hearing clients describe their traumatic experiences frequently. Over time, these adaptive responses become internalized. For example, a VA trauma therapist who works with military sexual trauma extensively may begin to experience the world as an unsafe and dangerous place. If these adaptive responses are permitted to remain, the therapist may engage in behaviors, feelings, and thoughts that are consistent with an unsafe world in order to protect oneself.

Even though the changes in the therapist’s belief system and cognitive schemas are experienced as adaptive, this theory maintains that these changes are pervasive and cumulative. Pervasive because the changes have the potential to effect almost all aspects of a clinicians life, and cumulative due to every encounter the therapist has with a traumatized client has the potential to reinforce these changes in their cognitive schemas (Trippany et al., 2004; and McCann & Pearlman, 1990). According to the constructivist self-development theory, there are five components of the self. These five areas are where the therapist’s distorted beliefs and vicarious trauma reactions occur: frame of

241 reference; self-capacities; ego resources; psychological needs; and cognitive schemas, memory, and perception (Trippany et al., 2004). These five components of the CSDT allow for vicarious traumatization to be experienced as complex and varied.

War trauma and vicarious traumatization are not unitary phenomenon. Both exhibit a wide range of complexity and variation. Participants in this study were able to use their emotional reactions to the trauma in the service of the treatment while others became overwhelmed and preoccupied periodically. For most participants, they related how doing trauma work is difficult, sad, overwhelming, and horrific at times. For some, they remained in this state of negative affect longer than others. However, all participants were able to bounce back, some faster than others, and continue treating and serving veterans. This speaks to the variations within the experiences of the participants. The fluctuations that exist between going down into the negative affective states and then coming back up out of them are on a continuum. Their reaction to being overwhelmed or not by trauma stories is not a definitive yes or no question. It is about levels and degrees of self-awareness as the participants found themselves reacting to the traumatic material.

For example, were the participants reacting to the manifest or to the latent aspects of the trauma stories? That is, were they reacting to the story or to some unconscious part of it or both? Were they realizing that this client they liked did something so horrific that they felt confused? Is some of the veterans experience outside of the therapists’ ability to imagine or is the trauma experience so foreign that the therapist cannot empathize?

Different people are going to be more in touch with their feelings at different times. Some participants may have been more in touch with their affective states during the interviews while others were not. This, too, is on a continuum.

242 Pearlman and Saakvitne’s (1995) contribution to working with individuals of trauma has been significant and profound. Their model is based on the interaction between countertransference and vicarious traumatization and exploring this interaction.

Their theory is based in social constructivism and came from the postmodern movement (Fairfield, Layton, & Stack, 2002; Elliott, 1996; Guba, 1990).

Social constructivism is a worldview where individuals seek to understand the world in which they live and work. They develop subjective meanings of their experiences that are directed toward specific objects or things. These subjective meanings are conveyed and developed socially and historically: “In other words, they are not simply imprinted on individuals but are formed through interaction with others (hence social constructivism) and through historical and cultural norms that operate in individuals’ lives” (Creswell, 2007, p. 21). Four major key constructs define social constructivism: it is relativistic, subjective, hermeneutic, and dialectic (Guba, 1990).

Realities exist in multiple constructions that are socially and experientially based. They are local and specific and are completely dependent on the persons who hold them, that is, relativistic. These realities are subjective because individuals are fused into a single entity where their findings are strictly the creation of the process of interaction between them. Attempting to depict individual constructions as accurately as possibly defines the hermeneutic process. The dialectic process consists of comparing and contrasting the existing individual’s constructions so that each person must confront the constructions of others and come to an understanding of them (Guba, 1990). Guba gives a succinct and clear definition of this worldview: Constructivism thus intends neither to predict and control the ‘real’ world nor to

243 transform it but to reconstruct the “world” at the only point at which it exists: in the minds of constructors. It is the mind that is to be transformed, not the “real” world (p. 27).

Many of the constructs that define social constructivism are central to Robert Stolorow’s intersubjective-systems theory.

Robert Stolorow and his collaborators developed intersubjective-systems theory over the last 30 years. Stolorow believes that the only reality that is relevant and accessible to psychoanalytic investigation is “subjective reality—that of the patient, that of the analyst, and the psychological field created by the interplay between the two” (Stolorow, 1988, p. 332). The central tenet of intersubjective-systems theory is a shift in psychoanalytic thinking from the primacy of drive theory to the primacy of affectivity.

This places psychoanalysis within a phenomenological contextualism. Unlike drives, which originate within one’s mind, affect, or the subjective emotional experience (affectivity), exists from birth and is regulated, or misregulated, all within continuing relational fields (Stolorow, 2007). Intersubjective-systems theory is rooted in three closely interrelated elements of the psychoanalytic method: (a) it is phenomenological, (b) it is hermeneutic, and (c) it is contextual: It is phenomenological—its focus is on worlds of emotional experience. It is hermeneutic—it seeks interpretively to illuminate the structures of meaning that organize worlds of experience. And it is contextual—it grasps experience and its horizons as being constituted within formative contextual systems (Stolorow, 2011, p. 2).

Intersubjective-systems theory is a “phenomenological contextualism”(Stolorow,

244 2011, p. 2) meaning that, phenomenologically, it seeks to explore and clarify the myriads of emotional experience. It is contextual in that the emotional experience occurs developmentally, and in the psychoanalytic setting, in relational or intersubjective contexts (Stolorow, 2011). Intersubjectivity theory is both experience-near and relational (Stolorow & Atwood, 1996).

Developmentally, intersubjective transaction patterns recur within the developmental system that appears with thematic patterns and meaning-structures. These structures unconsciously organize future emotional and relational experiences (Stolorow, 2011). These patterns are unconscious and prereflective. They usually do not enter the realm of reflective self-awareness. These prereflective, unconscious patterns are formed within intersubjective or relational experiences and contexts and form the basic building blocks of personality development. They occur in the psychoanalytic situation in the form of transference, which, according to the intersubjective-systems theory, is defined as “unconscious organizing activity” (Stolorow, 2011, p. 20). “The psychological field formed by the interplay of the patient’s transference and the analyst’s transference is an example of what we call an intersubjective system” (Stolorow, 2011, p. 20).

Applying intersubjective-systems theory to the issue of vicarious trauma provides a valuable framework for conceptualizing and understanding the therapeutic situation. It also is helpful with understanding how vicarious traumatization develops and impacts the therapist/veteran dyad.

When a trauma therapist and a combat veteran come together for treatment, both bring to the “psychological field” their unconscious and prereflective developmental patters or “organizing principles” that were created by a myriad of intersubjective

245 experiences throughout their lives. These “organizing principles” are the emotional conclusions a person has developed from life long experience of the emotional environment, specifically the complex and mutual connections with early caregivers.

These emotional conclusions (organizing principles) become activated through the interplay between two subjective worlds or intersubjective systems of the therapist and the veteran in the form of transference (Stolorow, 1997b; Stolorow, Atwood, and Orange, 2002; and Stolorow, 2011). Both therapist and veteran are attempting to explore and investigate the phenomenon of each other’s emotional experiences through the context of how their emotional experiences were shaped and formed developmentally and currently within the psychotherapeutic encounter. Hermeneutically, they seek to interpret and clarify the meaning of their emotional experiences together. Central to this interaction is the intersubjective viewpoint: This epistemological attitude presume neither that the analyst’s subjective reality is more true than the patient’s nor that the analyst can directly know the subjective reality of the patient; the analyst can only approximate the patient’s subjective reality from within the particularized and delimited horizons of the analyst’s own perspective (Stolorow, Atwood, & Orange, 2002, p. 103).

An essential element to Stolorow’s intersubjective-systems theory is his definition of trauma. Stolorow believes that the possibility of emotional trauma is built into the basic constitution of our human existence. “Whether or not this constitutive possibility will be brought lastingly into the foreground of our experiential world depends on the relational contexts in which we live” (Stolorow, 2007, p. xi). When it is brought to the foreground, Stolorow views trauma as an experience of unbearable affect. Trauma is

246 formed in an intersubjective context in which severe emotional pain cannot find a relational home in which it can be held. “In such a context, painful affect states become unendurable—that is, traumatic” (Stolorow, 2007, p. 10).

Through this intersubjective-systems view of trauma, the concept of vicarious traumatization can be applied. This helps to explain what has occurred with many of the participants of this study who became overwhelmed and preoccupied with traumatic material. Trauma can occur within the therapist/patient dyad when the therapist is unable to create a “relational home” for both parties because countertransference reactions become too intense and overwhelming. This often creates unbearable affect and when this occurs, therapist and veteran become emotionally dysregulated.

Almost all participants identified specific trauma story themes that had an emotional impact on them. These experiences were unsettling, difficult to sit with, and often stayed with most participants for years. These themes included innocent children, women, and civilians who were killed; themes of loss, grieving, suffering, intense sadness, and death/suicides; military sexual trauma; having a personal picture on one’s desk being incorporated into a traumatic combat story; having the skull of an Iraqi man being violently split open; and veterans who had traumatic childhoods and the parents did not protect them (Chapter VIII, Stories That Stick property). Every participant who experienced a specific traumatic theme that had an enduring, powerful emotional response stated they had some personal connection to the material: It is an identification with me . . . We were definitely having a parallel process . . .

If I did that, would I survive this? How would I feel? Would I be able to heal from that? . . . These stories bring up my own trauma history. I can attach to the sorrow

247 of that person somehow and I carry it . . . There’s something about their story that parallels my own experience and I think where I resonant is with their terrible loss and suffering . . . Some of the military sexual trauma stories stay with me more because I am female and being aware of that . . . [T]he never-ending brutality of her life sat close to home for me . . . He was just weeping in my office about how he killed this girl that I had the picture of on my desk. Of course that is going to hit me because he now attached into something that is mine . . . When I had my mini break down, I also saw that image and I realized, oh my God. I think I have been damaged and ruined . . . I feel angry that the parents did not protect the kids, the client (Chapter VIII, Stories That Stick property).

According to Wilson and Thomas (2004), these participants experienced empathic strain. It develops when empathic attunement becomes “challenged or rendered inadequate in the face of the patient’s transference or self-presentation” (p. 86). Empathic strain occurs in a variety of ways, may be conscious or unconscious, and results in countertransferential responses. They can be associated with rapid shifts in emotional states (anger, disdain, fear, horror) and cognitive processes (fantasies of escape, thoughts about nonclinical activity) (Wilson & Thomas, 2004). Empathic strain results from interpersonal events in psychotherapy that weaken, injure or force, beyond reasonable limits, a positive therapeutic response to the client (Wilson & Thomas, 2004).

Countertransference reactions (CTRs) are only one source of empathic strain. However, for Wilson and Thomas, they believe that in the treatment of PTSD, CTRs are the primary cause of treatment failure.

Wilson and Lindy (1994) developed a schema for understanding modalities of

248 empathic strain in the treatment of PTSD and which was later refined by Wilson and Thomas (2004). It is a two-dimensional representational model based on Type I and Type II modes of countertransference reactions (CTRs), crossed by the axis of objective and subjective countertransference processes (See Appendix C Reactive Style of Therapist).

Objective CTRs are normative, expectable, affective and cognitive reactions experienced by the therapist in response to the client’s personality, behavior, and trauma story. These reactions include Empathic Disequilibrium and Empathic Withdrawal (Wilson & Thomas, 2004). They are normal responses and are not considered to be pathological countertransference reactions.

Subjective CTRs are personal reactions that originate from the therapist’s own personal conflicts, or unresolved issues from life-course development. Empathic Enmeshment and Empathic Regression are included in this category and are not normal.

When they are activated, they are pathological countertransference responses (Wilson & Thomas, 2004).

A surprising finding of this study was that the majority of the participants experienced the two normative countertransference responses: Empathic Disequilibrium or Empathic Withdrawal. This speaks to the emotional maturity of the participants and how they have developed their own programs of self-care. Many disclosed during the interview process that they either had personal therapy in the past or are participating in it now.

Empathic Disequilibrium is normative, and consists of objective emotional reactions to Type II associated with an over-identification with reactions of the therapist to the trauma story of the client. The features associated with empathic disequilibrium

249 include empathic strain, disequilibrium of personal states, shifts in well-being, uncertainty, vulnerability, and security. Other participants experienced Empathic Withdrawal. Empathic Withdrawal is also normative and is based on objective emotional reactions to Type I associated with normal avoidance. Features include withdrawal from empathic attunement, separation, avoidance, unconscious defenses, feelings of uncertainty and inadequacy, reliance on blank faรงade, and misperceptions of transference issues (Wilson & Thomas, 2004). Only a few participants had long lasting, countertransference responses related to either empathic enmeshment or empathic repression. Empathic enmeshment and empathic repression are personalized and are considered to be subjective, idiosyncratic reactions that become CTRs. It is only when countertransference processes are elevated to the level of countertransference reactions that they interfere with the therapeutic process and become problematic (Wilson & Thomas, 2004). Such was the case with these few participants.

Some mental health clinicians, who, as infants and children, may have had tenuous attachments with their caregivers and whose attachment style would have become activated through countertransference reactions with their trauma patients. Two specific attachment styles were identified with CPRs for this study: Empathic repression, Type I avoidance CTR has been identified with the avoidance attachment style of the adult, and Empathic enmeshment, Type II overidentification CTR has been compared to the adult ambivalent attachment style (See Appendix C Reactive Style of Therapist).

Adults regulating themselves by deactivating their attachment system characterize the avoidance attachment style. They minimize and defend against experiences of threat, separation, and loss in order not to appear needy and vulnerable. Their self-esteem

250 depends on their ability to over appraise themselves in order to mask their insecurity and vulnerability (Ringel, 2012). The avoidance adult attachment style is identified with the empathic repression, Type I (avoidance) CTR. The empathic repression CTR include personal repression memories, conflicts and unresolved problems aroused by interactions with the patient. Loss of attunement may be severe and damaging to the therapeutic outcome. Withdrawal, denial, and distancing are all defensive styles of empathic repression (Wilson & Thomas, 2004).

Adults who tend to exaggerate experiences related to threat, separation, and loss characterize the ambivalent adult attachment style. They heighten their affective responses to consequences and exaggerate their sense of helplessness and vulnerability.

They also tend to undervalue themselves (Ringel, 2012). The ambivalent adult attachment style is identified with the empathic enmeshment, Type II (overidentification) CTR. The empathic enmeshment CTR include personalized affective reactions, activation of personal issues, tendency to cross boundaries, over involvement with patients, excessive amplification of attunement responses, and reciprocal dependency (Wilson & Thomas, 2004).

Adults who have learned to resort to both deactivating and hyperactivating strategies characterize the disorganized adult attachment style. They often have a history of trauma regarding attachment figures that evoked both an avoidance of closeness and a terror of abandonment (Wallin, 2007). Frequently they are torn by conflicting impulses (to avoid others out of fear of attack or to desperately turn to others out of fear of being alone) and often have over powering and chaotic feelings (Wallin, 2007). The disorganized adult attachment style can also be identified with the empathic enmeshment,

251 Type II, CTR with all its features.

Most participants in this study did not exhibit the avoidance, ambivalent, or disorganized adult attachment styles. A small number of participants exhibited traits of the avoidance and ambivalent adult attachment styles and corresponding CTRs. The majority of the adults in this study exhibited mature, and healthy adult attachment styles.

Finding 3.

Participants reported that they do not follow the 12-session protocol for the PTSD Evidence-Based Psychotherapies (EBPs) because they typically ameliorate trauma symptoms only. The participants believe in having veterans integrate and master their combat trauma by developing and creating a trauma narrative over time that may or may not include EBPs. Over the past few years, the Veterans Administration has rolled out two specific evidence-based psychotherapies for Posttraumatic Stress Disorder for combat veterans: Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PE). The VA brochure titled, Evidence-Based Psychotherapies: Proven Treatments for PTSD & Other Mental Health Conditions in the VA Health Care System gives an explanation about evidence-based psychotherapies: In recent years, a variety of psychotherapies (or “talk therapies�) have been developed and scientifically studied in much the same way we evaluate treatments for physical health conditions, such as high blood pressure or diabetes. This research has shown that psychotherapy is very effective for even the most complex mental health conditions that, not long ago, were considered untreatable.

252 Psychotherapies that are repeatedly shown in controlled research to be effective for a particular condition or conditions are referred to as “evidence-based” psychotherapies (Department of Veterans Affairs, n.d., EBPs).

Cognitive Processing Therapy is a cognitive-behavioral therapy for PTSD and related conditions. The treatment is approximately 12 weekly therapy session in either an individual (50 minutes) or group (typically 90 minute) setting. The brochure titled, Cognitive Processing Therapy CPT, gives the following explanation regarding this treatment: CPT provides a way to understand why recovery from traumatic events has been difficult and how symptoms of PTSD affect daily life. The focus is on identifying how your traumatic experiences changed your thoughts and beliefs, and how your thoughts influence your current feelings and behaviors. An important part of the treatment is addressing ways of thinking that might keep you “stuck” and get in the way of your recovery from symptoms of PTSD and other problems.

(Department of Veterans Affairs, n.d., CPT) Prolonged Exposure Therapy (PE) is a type of cognitive-behavioral treatment that focuses on decreasing symptoms of PTSD. It is an individual therapy that addresses the common causes and symptoms of PTSD in four ways: education about treatment and common reactions to trauma, breathing retraining, in vivo exposure, and imaginal exposure (Department of Veterans Affairs, National Center of PTSD, PE). PE addresses symptoms by decreasing avoidance. The process of addressing the trauma memory is called “imaginal” exposure and the therapist works with individuals to change their thoughts and feelings regarding the trauma. The process of engaging with real life

253 situations is called “in vivo” (in real life) exposure. Activities are identified that the individual has been avoiding due to the trauma. The goal of in vivo and imaginal exposure is to help the individual return to activities that were once enjoyable. PE typically lasts 8 to 15 sessions. The therapist and the individual receiving treatment determine the exact length of time. Each session is approximately 90 minutes in length (Department of Veterans Affairs, National Center of PTSD—PE).

The brochure titled, Embrace Your Life Again: Prolonged Exposure: An Evidence-Based Treatment for PTSD, describes the following benefits of PE: Approximately 80% of clients experience significant gains after 9 to 12 sessions of PE therapy. Specific symptoms are reduced in all domains of PTSD, including decreases in distressing thoughts, feelings, and flashbacks; avoidance of thoughts and reminders of the trauma; being easily startled; and irritability. Improved daily functioning also results from treatment with PE. Clients experience marked reductions in problems that often occur with PTSD, such as depression, anxiety, and anger. Clients continue to enjoy long-term treatment gains after PE sessions end (Department of Veterans Affairs, n.d., PE).

Most participants have been trained in CPT, PE or both and have voiced clinical concerns regarding the practices of these evidence-based psychotherapies (EBPs). Nearly all of them that treat veterans in the PTSD clinic reported that they do not follow the CPT or PE 12-session protocol as recommended. The reason is because trauma treatment is complex and the majority of the veterans that they treat require more time. Other participants in the study, who have been trained in CPT or PE but are not associated with the PTSD clinic, reported the same thing when they treat combat veterans.

254 These participants believe it is critical to prepare the veteran for trauma treatment before the evidence-based psychotherapies are used. If the veteran is not prepared for treatment, they often do not complete it. Most participants noted that many of the veterans they have treated with CPT or PE do not finish and drop out of treatment early on in the process. This often creates a revolving door of treatment for some of the veterans (Chapter VI, Characteristics That Influence the Treatment Process property).

In a 2012 report to Congress (Congressional Budget Office, 2012), it was reported that only 40% of OEF/OIF/OND veterans completed Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PE). Other findings were also revealed: VHA [Veterans Health Administration] data from internal program evaluations indicate that OCO [OEF/OIF/OND] veterans who completed PE therapy attended an average of 11 sessions, whereas those who did not complete the therapy attended an average of 5 sessions; results were similar for patients undergoing CPT. Additional data from a recently published study found that 80 percent of OCO [OEF/OIF/OND] veterans who used VHA’s services and received new PTSD diagnoses had at least one follow-up visit; nonetheless, fewer than half completed the recommended treatment sessions within one year (Congressional Budget Office, 2012).

Several participants believe that CPT and PE are often a starting point for many veterans. After the veteran has been prepared for treatment, completes it, they are often wanting more talk therapy. At that point, many of the participants will engage the veteran in a process-oriented approach.

Many participants have noticed that the EBPs only address the amelioration of

255 trauma symptoms because of the time-limited mandate (12 session for CPT and 12 to 15 for PE). For some participants, when evaluating veterans for treatment, they may not use any of the EBPs because they believe these modalities are not for everyone. They appear to be most effective when veterans have a single combat or MST trauma experience. The EBPs, according to their experience, are not effective with veterans who have complex PTSD. Preparing veterans for treatment can take six months to a year in order for trust to be established and for movement to occur when veteran present with a complex trauma history (Chapter IX, Band-Aids property).

One participant believes that the reason the VA wants trauma therapists to use the EBPs is because “they’re quick and easy; not too much feeling and then the veterans are on their way” (Chapter IX, Band-Aids property). It is interesting to note that some researchers have speculated that having clear protocols for PTSD treatment such as CPT and PE, can serve to lessen ambiguity and decrease emotional involvement for those treating trauma victims (Horrell et al., 2011). The decrease in emotional involvement from the therapist can be suggested as a protective factor for the therapist (Horrell et al., 2011). If that is the case, it comes at a great cost to both the therapist and the veteran.

Although CPT and PE are the treatments of choice in the VA for PTSD treatment, few treatment outcomes of PE and CPT for military-related PTSD have been published (several large-scale trails are currently ongoing). Most of the published studies have been small-sample, open trials (Steenkamp & Liz, 2013).

Two randomized controlled trials (RCTs) of individual PE and three RCTs of individual CPT in veterans have been published—a total of five studies. Of these, only one study examined veterans receiving CPT for combat-related PTSD (Monson, Schnurr,

256 Resick, Friedman, Young-Xu, Y., & Stevens, 2006). The remaining four were either international studies with significant differences from veterans care or studies involving sexual trauma primarily among women veterans. Although the sexual trauma studies are important, they do not speak to the combat trauma of the male veteran. The main finding across these five randomized controlled trials is that individual PE and CPT work at reducing military-related PTSD symptoms. It is not clear for how long—decreasing symptoms to the point of low impairment and distress (Steenkamp & Litz, 2013).

Steenkamp and Litz (2013) summarizes the findings of these studies further: Across the studies, at least half of, but typically most, veterans still met diagnostic criteria for PTSD following treatment. For example, at one-month follow-up in the Monson et al. (2006) trial, over two thirds (70%) of participants in the CPT intent-to-treat condition (drop-out from CPT was 20%) retained their PTSD diagnosis. It is also unclear whether treatments work reliably. Metrics of meaningful change show considerable variability in outcomes: Some patients improve substantially and some very little. PE and CPT thus do not have uniform effects and are not effective for all patients (Steenkamp & Litz, 2013).

These conclusions completely support the experiences of the participants when providing PE and CPT: they are not for every combat veteran. Steenkamp and Litz (2013) also make the argument that PE and CPT in clinical trials do not meet the treatment needs of many veterans and there “incremental value over non-trauma-focused therapies remain unclear� (p. 3). Even though PE and CPT are useful and important for clinicians to learn, a number of veterans with PTSD will require alternative or additional treatment (Steenkamp & Litz, 2013). It is imperative that when evidence-based

257 psychotherapies are presented to clinicians for training and to veterans for treatment that dissemination should include contingencies that recognize the limitations of available EBPs, especially if the evidence demonstrates clear shortcomings related to the effectiveness, acceptability, and tolerability of these treatments (Steenkamp & Litz, 201).

Finding 4.

For many participants, directly providing combat treatment as a trauma therapist can result in developing more compassion, empathy, humility, knowledge, and healthier professional boundaries.

Several participants explained that since they have been practicing as trauma therapists, they noticed positive growth and development in the areas of compassion, humility, and healthier boundaries (Chapter X, Judgments, Biases, and Boundaries; and Comfortable, Competent, and Compassionate properties). For these participants, positive growth occurred after years of working as a trauma therapist.

Although many studies mention the vulnerabilities of trauma therapists that lead to vicarious traumatization and burnout (Pearlman et al., 1995; Saakvitne, 2002; and Shubs, 2008) others have identified protective factors that aid in the prevention of vicarious trauma (Trippany et al., 2004; and Harrison & Westwood, 2009). What about personal, positive growth that can occur with trauma therapists treating traumatized clients?

Hernandez, Engstrom and Gangsei (2010) developed the concept known as vicarious resilience. Unlike posttraumatic growth, which refers to trauma survivors being positively transformed by their trauma experience, vicarious resilience suggests that

258 trauma therapists may be positively affected by the trauma of their clients. Vicarious resilience is a process “characterized by a unique and positive effect that transforms therapists in response to client trauma survivors’ own resiliency (Hernandez, Engstrom, & Gangsei, 2010, p. 237). It is a term for the positive co-creation of meaning and the growth and transformation in the therapist’s experience resulting from exposure to clients’ resilience through the therapeutic process of trauma treatment. It highlights the process whereby therapists are positively affected by clients’ resiliency as they heal in the therapeutic process (Hernandez et al., 2010).

The concept of vicarious resilience captures the participants’ positive growth experiences as a trauma therapist. “I think being a trauma therapist over the years, my boundaries are healthier, stronger and I’m more secure in my skills” (Chapter X, Judgments, Biases, and Boundaries property). Compassion developed more for this participant over the years. “One of the ways I’m different is I do feel like I have more compassion than I had. I feel like I am a more feeling being about things than I was before” (Chapter X, Comfortable, Competent, and Compassionate, property).

Other attributes experienced by participants included empathy, knowledge, and humility (Chapter X, Greater Knowledge; Comfortable, Competent, and Compassionate, properties). In Heinz Kohut’s (1966) seminal paper, “Forms and Transformations of Narcissism,” he presents the origin, development, and functions of two major forms of narcissism and how they are integrated into the personality: the narcissistic self and the idealized parent imago. Later in the paper, Kohut discusses the relationship of narcissism to creativity, empathy, finiteness of existence, sense of humor, and wisdom. For Kohut, these complex and autonomous achievements of the mature personality were derived

259 from transformations of narcissism.

Wisdom is achieved largely through man’s ability to overcome his unmodified narcissism and it rests on his acceptance of the limitations of his physical, intellectual, and emotional powers. It may be defined as an amalgamation of the higher processes of cognition with the psychological attitude which accompanies the renouncement of these narcissistic demands . . . Wisdom may thus be defined as a stable attitude of the personality toward life and the world, an attitude which is formed through the integration of the cognitive function with humor, acceptance of transience, and a firmly cathected system of values (Kohut, 1966, p. 267).

According to Kohut (1966), the development of wisdom or knowledge is a process where an individual’s narcissistic self is transformed. This process of narcissistic transformation is at the center of the participants’ development of empathy, compassion, and humility and speaks to the expansion of a mature personality.

Finding 5.

Participants were clear about what works and what does not work in terms of developing a formal program of clinical support that includes case supervision/consultation.

Fourteen participants in this study stated that there is not a formal program of clinical supervision or case consultation in place at their facility unless you are an intern and in the process of being licensed. The three other participants were from the local Vet Center where clinical supervision and case consultation is a requirement for staff.

260 The 14 participants were adamant and clear about what is not working in their current environment regarding the lack of a formal program of clinical support: clinicians have to seek out trusted colleagues to staff a case; there is an expectation that once individuals are licensed they are expected to know everything and practice without making mistakes which sets the clinician up to fail; the lack of clinical support and supervision is due to the bureaucracy and leadership of their local VA facility; clinicians are too “siloed,” meaning they are physically spread throughout the facility which creates an isolating environment; the VA has adopted the military hierarchy, values and military culture; clinicians believe they cannot appear to be vulnerable or show weakness due to the military culture that has become embedded in the VA and indoctrinated into the clinical staff; the VA generates an atmosphere of fear: the fear of making a mistake and being human; difficult to admit mistakes and be fallible because of the lack of trust that exists among the staff; and some staff are toxic, not safe, critical, and judgmental (Chapter XI, The Way it is Now, Where’s the Support, Solitary Confinement, and Show No Mercy properties). Many of these factors increase the risk of trauma therapists developing vicarious traumatization (VT).

Working with war-related PTSD, participants are at risk for developing safety and trust issues. A basic sense of security is foundational to safety needs. Therapists with trust and safety concerns may feel there is no safe places to protect themselves from real or imagined treats to their personal safety (Trippany et al., 2004). They might experience higher levels of fearfulness, vulnerability, and concern. Trust needs including self-trust and trusting others may also develop in clinicians with VT. Trust needs reflect a persons ability to trust their own perceptions and beliefs, as well as trusting other’s ability to meet

261 their emotional, psychological, and physical needs (Trippany et al., 2004). Working in isolation, not having peer support, and clinical supervision has been identified as important factors that contribute to the development of VT (Trippany et al., 2004; Dunkley & Whelan, 2006; Linley & Joseph, 2007; Harrison & Westwood, 2009; and Karin, 2010; Berger & Quiros, 2014). According to Harrison & Westwood (2009), “Our results suggest it is important to the well-being of therapists, clients, and our communities that no clinician should work with trauma in isolation” (p. 215).

The lack of organizational support is another factor that participants in this study identified that can have a significant negative impact upon therapists and who later develop VT (Pearlman & Mac Ian, 1995; Trippany et al., 2004; Sommer, 2008; and Harrison & Westwood, 2009). Heather Helm (n.d.), in a paper titled, “Managing Vicarious Trauma and Compassion Fatigue,” explained how agencies can negatively impact and influence trauma clinicians: Agency dynamics can greatly influence the level of support practitioners’ receive. At the agency level, it is important to consider whether the culture allows practitioners to seek support and assistance when they are struggling. If the culture punishes for expressing their struggles, the practitioners are at an increased risk of impairment (p. 8).

According to Pearlman and Saakvitne (1995a), agencies that employ therapists who provide services to clients with traumatic histories have a responsibility to help their clinicians decrease the effects or occurrence of VT. Professional development resources that should be available for trauma therapists include opportunities for supervision/consultation, staffing of cases, and continuing education (Pearlman &

262 Saakvitne, 1995a).

Fourteen participants acknowledged the need for a formal program of clinical support and defined exactly what that would require: an environment of supportive, honest feedback; a place of respect, safety, and confidentiality; having a sense of community with trusted people; place to explore successful and treatment failures; to normalize their feelings and experiences; and having a competent, knowledgeable, and skilled facilitator (Chapter XI).

Researchers have noted the importance and necessity of having regularly scheduled clinical supervision/consolation (Pearlman & Mac Ian, 1995; Trippany et al., 2004; Dunkley &Whelan, 2006; Sommer, 2008; and Harrison & Westwood, 2009).

Harrison and Westwood (2009) believe that all clinicians who work with traumatized clients are advised to access ongoing, regular supervision and be part of either formal clinical teams or informal peer supervision groups in order to minimize risk of harm to self and clients (Harrison & Westwood, 2009). Even though clinical supervision is considered important and essential, Pearlman and Mac Ian (1995) found that 64% of trauma therapists reported receiving supervision.

Therapists who work with traumatized clients need supportive, confidential, professional relationships “within which they can process the horrific stories, graphic imagery, and destructive reenactments that are an inevitable part of the work� (Pearlman & Saakvitne, 1995a). Peer supervision groups can serve as an important resource for trauma clinicians. Sharing experiences with other trauma therapists offers support and normalization of VT. This normalization lessens the impact of vicarious traumatization and assists in changing cognitive distortions and helps therapists maintain objectivity.

263 Peer supervision also provides validation and support by allowing them to vent their feelings, and share new information related to the work. Peer supervision has been found to decrease feelings of isolation and increase therapist objectivity, empathy, and compassion (Trippany, et al., 2004).

Rosenbloom, Pratt, and Pearlman (1999) believe that supervision for trauma clinicians should be ongoing and not restricted to prelicensure training: “supervision should foster an atmosphere of respect, safety, and control for the therapist who will be exploring the difficult issues evoked by trauma therapy” (p. 77). Berger and Quiros (2014) specifically explains that trauma-informed supervision include safety, trustworthiness, choice, collaboration, and empowerment. The goals of trauma-informed supervision are to provide the emotional safety for the practitioner so that the work that needs to be done with the client will not be compromised and to continually emphasize self-reflective practice (Berger & Quiros, 2014).

Several of the participants’ concerns about and need for clinical supervision has been supported by the literature. A central concern that was raised by the participants is the lack of organizational support in this area. It has been suggested that agencies implement practices to diminish vicarious traumatization by reducing client caseloads, provide opportunities for counselors to engage in nonclinical aspects of trauma work and offering mental health care for therapists (Sommer, 2008). It is important to note that Horrell (2011) quotes the research findings from Bober and Regehr (2006) who found that the primary predictor of vicarious traumatization (VT) among trauma therapists was the number of hours spent working with traumatized patients. “The best preventative measure against VT appears to be a balanced workload (Horrell, et. al., 2011). It is

264 imperative that all trauma clinicians be provided with some form of a clinical support program that occurs regularly where they can discuss their collective experiences related to the work in a safe, respectful, and confidential milieu. It is also imperative that the agency culture and philosophy recognize the unique needs of trauma therapists and the phenomenon of vicarious traumatization. When trauma therapists are not clinically supported, every system has the potential to become affected: the agency, the therapist, and the client.

Limitations and Evaluations of the Study The process of evaluating qualitative research is arguably different than that of quantitative research. The 17 participants for this study were volunteers. They were solicited through direct, in person contact at two local VA facilities in the Pacific Northwest. According to quantitative criteria, this study is limited in that the sample does not represent the entire population being studied, and is, therefore, not a representative sample. Thus, the ability to generalize to a larger population is limited. Although it is recognized that the sampling techniques for gathering participants encourages voluntary participation and avoids influencing the data sample through possible coercion of participants, it is still, however, a non-probability sample. This undermines the generalizability of the study’s conclusions. It is important to note that qualitative studies identify themes or ideas that lead to further clarification or study. However, their findings cannot be considered conclusive. Such is the case with this qualitative study.

This researcher is a Veteran’s Affairs mental health clinician who provides treatment to all veterans, including the OEF/OIF/OND population diagnosed with war-

265 related Posttraumatic Stress Disorder. This factor is a potential limitation to this study.

This researcher’s personal experiences can lead to assumptions regarding what he expected to hear as he conducted the interviews with the research participants. In order to control for personal bias, he discussed these assumptions and biases with his study advisor. Engaging in ongoing consultation helped this researcher to identify his personal biases as they occurred during all phases of the research process, which included gathering the data, analyzing it, and formulating a theory. In doing this, the influence of his personal biases were identified and minimized.

Corbin and Strauss (2008) explain that when discussing qualitative research, the terms validity, reliability, and truth should not be used because they carry quantitative implications (positivist view) and are not reflective of multiple realities and meanings as posited by social constructivism. The evaluative term that supports the philosophical underpinnings of qualitative research is credibility: “credibility indicates that findings are trustworthy and believable in that they reflect participants’, researchers’, and readers’ experiences with a phenomenon but at the same time the explanation is only one of many possible ‘plausible’ interpretations from the data” (Corbin & Strauss, 2008, p. 302).

According to Corbin and Strauss (2008), they suggest ten criteria for judging the quality of grounded theory methodology: fit, applicability, concepts, contextualization of concepts, logic, depth, variation, creativity, sensitivity, and evidence of memos.

Member checking provided evidence that the results resonated with the participants of this study (Chapter VI, They Are Kids, Very Different Now properties; Chapter VII, Therapist’s Lens property; and Chapter XI, Where’s the Support, and Show No Mercy properties). During the member checking process, these participants were able

266 to see themselves in the story, that it rang “true” to them, and that they did have an emotional reaction to the findings (Corbin & Strauss, 2008, p. 305). The results are applicable to this study population as outlined and discussed in Chapters V through Chapter XI. Several of the findings of this study have the potential to help develop policy, change clinical practice, and add to the knowledge base of clinical social work.

The findings have been organized around concepts and themes, and they were generated from an analysis of the data using a grounded theory methodology. The concepts were developed from their properties and dimensions and have density and variation (Chapters V through XI). The contextualization of concepts refers to the context in which the findings were generated. The findings for this study were contextualized to the experiences of VA mental health clinicians as they treat the OEF/OIF/OND veteran population with war-related PTSD. Findings were generated and grounded within this context.

The findings are logical and the ideas flow, make sense, and tell the story of the participants’ experiences (Chapter IV). The depth of this study is evidenced by the rich, descriptive details of the data from which the findings were generated. It is the “depth of substance” (Corbin & Strauss, 2008, p. 306) that gives the findings life and vitality, and enables them to potentially be used for policy-making and influencing clinical practice.

Variation exists throughout the study and is built into the findings. The participants had different experiences, which were reflected in the dimensions and properties of the study (Chapters V through XI). These variations demonstrated the complexity of the participants’ experiences. Variation was also influenced by the organizational polices, rules, and regulations of the VA nationally; local VA culture;

267 societal values and culture; and professional values and standards (Chapters VI, VII, XI).

Creativity was demonstrated by how the findings were presented in a new way.

Throughout the data collection and analysis process, a new understanding of the concepts of vicarious traumatization, as well as an identification with veteran family members, developed (Chapter XII). Sensitivity occurred throughout the research process. The data was collected in a consistent manner, and the analysis drove and informed the research process.

The last criterion that Corbin and Strauss (2008) suggest is “evidence of memos”.

Over 600 memos were created during the research process of this study. These grew in depth, complexity, and abstraction as the research process progressed. They were referred to and utilized often, and they were instrumental in understanding, defining, and delineating the findings.

This qualitative research study utilized all 10 criteria as suggested by Corbin and Strauss (2008) for judging the quality of grounded theory methodology. However, arbitrarily meeting these criterions do not guarantee quality. “In the end, it is the quality of the findings that matter, and it is this quality that will be judged by others” (Corbin & Strauss, 2008, p. 305).

Clinical Implications Most participants experienced personal traumas. They had family members who themselves were veterans and had traumatic war experiences. Logically, it makes sense that the reason these participants specifically chose to work with the combat veteran population was due to these experiences and the potential for unresolved emotional

268 issues. However, this was not the case. The participants’ personal trauma and familial histories enabled them to feel comfortable with veterans’ issues and military culture. This is the reason many of them chose to work at the VA treating combat veterans. Their experiences actually created a sense of personal growth for many of the participants. This sense of personal growth and development, coming from personal trauma histories and familial experiences, may be understood by the work of Linely and Joseph (2007).

Many participants acknowledge that they were overwhelmed at times by trauma stories of combat veterans. Other participants stated they were not overwhelmed when clearly they were. This discrepancy speaks to how the experience of vicarious traumatization varies and is also influenced by individuals’ level of awareness. The variability and level of awareness can be based upon Robert Stolorow’s (2007, 20011) intersubjective-systems theory. The phenomenological, hermeneutic, and contextual fields are different for each person. Each individual’s early experiences are created through organizing principles that include the thoughts, feelings, and wishes that are developed through interactions with early caregivers and others. They are unconscious and prereflective. These unconscious patterns recur between the intersubjective world of the therapist and that of the client. This “phenomenological contextualism” provides a framework for understanding and conceptualizing vicarious traumatization and the levels of variability and awareness that exist among the participants.

Nearly every participant in this study who has been formally trained in the Evidence-Based Psychotherapies (EBPs) of Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PE) for PTSD treatment of combat veterans have concerns about engaging in these therapies quickly with them. Through their own clinical

269 experience and trusting their clinical intuition, many of the participants prepare veterans first before CPT or PE is used. In some circumstances, these EBPs are not utilized.

Instead, participants use their clinical judgment as it relates to the needs of the veteran.

They provide veteran-centered-care and not manual-centered care. These EBPs work for some clients but not for all. This conclusion is supported by the work of Steenkamp and Litz (2014). The clinical implication associated with this finding is to always trust in and use your clinical experience and judgment when applying any manualized, evidencebased psychotherapy.

Several participants experienced positive growth in the areas of compassion, empathy, humility, knowledge, and healthier professional boundaries as they have been practicing as trauma therapists. Two important clinical implications come from this finding. First, practicing as a trauma therapist does not mean that the therapist is going to always develop vicarious traumatization or other negative characteristics associated with the work. Second, as we grow and develop as human beings and continue in our own personal work, trauma therapy work can be transformative. This idea of transformation is based on the work of Heinz Kohut (1966) and Hernandez, Gangsei, and Engstrom (2007).

All participants in this study described various characteristics of what works and what does not work in terms of developing a formal program of clinical support.

Participants noted several negative characteristics: believe they cannot appear to be vulnerable or show weakness due to the military culture that is embedded in the VA; the VA generates an atmosphere of fear; they fear making a mistake and being human; and difficult to admit mistakes and be fallible because of the lack of trust that exists among the staff; and some staff are toxic, not safe, critical, and judgmental. These characteristics

270 can be associated with issues regarding trust and safety. Trust and safety concerns are often related to vicarious traumatization. It is possible that some of these clinicians who are experiencing these issues are vicariously traumatized. Working in isolation and not having regularly scheduled peer supervision groups or clinical supervision often perpetuates these issues. It is absolutely imperative that these participants engage in some kind of a program of clinical support and that the agency accept and encourage its development and continuance.

Policy Implications Three findings in this study have the potential to influence and develop policy and change clinical practice for VA mental health clinicians on the local and national levels.

First, many participants reported being overwhelmed treating combat veterans. From the participants’ experiences, it became apparent that vicarious traumatization is complex and varied. Second, nearly all the participants noted that they do not follow the 12session protocol for the PTSD Evidence-Based Psychotherapies (EBPs) because often times veterans are not psychologically prepared for them and the participants believe in having veterans integrate and master their combat trauma through developing a trauma narrative over time that may or may not include EBPs. Lastly, all participants noted the importance of developing and engaging in a formal program of clinical support that includes case supervision/consultation.

As the literature describes and this study supports, vicarious traumatization is ubiquitous. The construct and the phenomenon are real and have been verified through many research studies (Horrell, et al., 2011; Pearlman & Mac Ian, 1995; Saakvitne, 2002;

271 and Rasmussen, 2005). An implication for policy change on the local, as well on the national, VA levels is to have novice VA trauma clinicians receive trauma-specific training that includes the military culture, the specifics of combat-related military trauma, and military sexual trauma for a year or more. For experienced clinicians, ongoing training, professional development, and organizational support are necessary as a means of preventing vicarious traumatization and burnout among VA mental health clinicians.

Research has indicated that a sense of control and autonomy are protective factors against burnout (Abu-Bader, 2000). Within the VA, as is the case with many large agencies, some mandates directly affect clinicians’ perceptions of control and may inadvertently increase the risk of vicarious traumatization, including burnout (Horrell, et al., 2011). An example is the 12-session mandate for the PTSD Evidence-Based Psychotherapies (i.e., Cognitive Processing Therapy and Prolonged Exposure Therapy).

The participants of this study discussed how these EBPs do not work for every veteran, and they need to prepare the veteran in many cases if EBPs will even be utilized. Taking this mandate away and giving the clinician more freedom to utilize their clinical judgment and skill may help reduce the level of vicarious traumatization and burnout throughout the VA system.

Regarding organizational factors, it is important for the VA to recognize that VA clinicians who are assigned to specialty clinics (i.e., OEF/OIF/OND, Mental Health Specialty, Homeless Programs, and PTSD Clinics) consider the balance and size of a clinician’s caseload, as both of these components have been identified as risk factors for vicarious traumatization (McCann & Pearlman, 1990). If clinicians are treating primarily PTSD veterans, organizational support for encouraging a diversity of professional roles is

272 an important protection against vicarious traumatization and burnout (Harrison & Westwood, 2009) and may include supporting staff involvement in committee leadership, training endeavors, research, and teaching (McCann & Pearlman, 1990).

Lastly, one of the most important factors that reduces vicarious traumatization among clinicians is some form of clinical supervision or consultation (Pearlman & Mac Ian, 1995; Horrell et al., 2011). Supervision varies from VA facility to VA facility. Some have a formal system in place while others do not. The participants of this study overwhelmingly noted the need for their facility to develop a formal program of clinical support. This may include clinical case conferences, peer-support meetings, or regular on-going supervision, even for licensed professionals. On-going supervision for all clinicians is a recommended practice and enables clinicians to work through challenging and emotional painful clinical experiences (Horrell et al., 2011; Rasmussen, 2005).

Areas for Future Research The participants for this study came from a VA facility and a local Vet Center in the Pacific North West. The participants’ trauma work experiences were confined to these two facilities, their cultures, and the greater culture of the area. Future studies should endeavor to obtain a more heterogeneous sample of not only other VA facilities and their cultures nation wide, but also the cultures in which these facilities reside.

The participants of this study were required to treat combat veterans from all eras.

For that reason, it was not possible for this study to completely focus on the OEF/OIF/OND combat veteran. Future studies should attempt to limit their sample to only the experiences of the OEF/OIF/OND combat veteran.

273 The majority of the participants in this study have only treated the younger OEF/OIF/OND veteran. Very few participants treated the older OEF/OIF/OND veteran.

The experiences of the older OEF/OIF/OND may be quite different according to their development and life experiences. This is certainly an area to consider for future research.

274

Appendix A Informed Consent Form

275 Individual Consent for Participation in Research INSTITUTE FOR CLINICAL SOCIAL WORK

I,______________________________________, acting for myself, agree to take part in the research entitled: An Exploration of the Experiences of Veterans Affairs Mental Health Professionals Treating OIF (Iraqi) and OEF (Afghanistan) Veterans Diagnosed with War-Related PTSD. This work will be carried out by Michael R. Miller under the supervision of Dr. Dennis Shelby.

Purpose The purpose of this study is to clarify how vicarious traumatization affects Veterans Affairs mental health professionals treating OIF/OEF veterans with war-related PTSD. This study involves qualitative research and the research data and information may become part of a permanent record in a published dissertation.

PROCEDURES USED IN THE STUDY AND THE DURATION Research participants will be interviewed by the researcher in the participant’s office, in person or by phone. The interview will last no more than forty-five minutes followed by a second interview. The interview will be audiotaped in a digital format and transcribed into a verbatim text. The data analysis and representation will follow procedures accepted in qualitative research using a grounded theory methodology as defined and described by J. Corbin and A. Strauss. Research participants will not receive financial or any other compensation before or after the study. Questions that participants’ may have will be addressed and answered at any time during and after the study.

Benefits There will be no direct benefits of participation in this research study. However, the study offers participants an opportunity to explore and clarify their experiences through the process of self-reflection, which, for some people, can be a benefit unto itself.

Participants may also find their participation gratifying knowing that they are contributing knowledge that may benefit the psychodynamic community.

Costs There are no costs associated with participation, except the time each participant volunteers for an interview.

Possible Risks and/or Side Effects The likely hood of a substantial amount of discomfort is unlikely. However, an opportunity to reflect on one’s clinical practice can cause some degree of discomfort. As a result, no known risks concerning the participation in this research study can be predicted. If any participant experiences discomfort and would like a referral for debriefing or consultation to a professional, they will be provided with a list of resources for their use.

276 Privacy and Confidentiality Each participant will be assigned a code number or letter to identify his or her audiotaped and transcribed interview material. Participant references to patients and places will also be disguised. Audiotapes and transcripts will be kept in separate files and stored securely in a locked file cabinet. Audiotaped files will be erased when coded transcription is complete. Transcripts and data analysis will be kept for at least five years and then shredded.

Subject Assurances By signing this consent form, I agree to take part in this study. I have not given up any of my rights or released this institution from responsibility for carelessness.

I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. My relationship with the staff of ICSW will not be affected in any way, now or in the future, if I refuse to take part, or if I begin the study and then withdraw.

If I have any questions about the research methods, I can contact Michael Miller (Principal Researcher) at this number (541) 261-9188 (day), (541) 245-2653 (evening) or Dr. Dennis Shelby (Dissertation Chair), at (219) 406-0571.

If I have any questions about my rights as a research subject, I may contact Daniel Rosenfeld, Chair of Institutional Review Board; ICSW; 400 South Street Suite 822; Chicago, IL 60605; (312) 935-4232.

Signatures I have read this consent form and I agree to take part in this study as it is explained in this consent form. _________________________________ Signature of Participant

_____________ Date

I certify that I have explained the research to _____________________ and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward. ________________________________ Signature of Researcher Revised 6 Sep 2006

______________ Date

277

Appendix B Category Map

278 Category Map Chapter V Entering the Fray Traumas That Paved the Way Families of Veterans Interest in Trauma I Found the VA Chapter VI OEF/OIF/OND Veterans are Different Tough to Treat Characteristics That Influence the Treatment Process Physiological Trauma Individual Behavioral Characteristics Affective Characteristics Childhood Traumas They Are Kids Very Different Now Chapter VII Challenge to the Work Keeping Them The Bureaucracy Therapists’ Lens Chapter VIII Relived Trauma Hard to Hear Taking It Home Checking out

279 Category Map—continued Stories That Stick Chapter IX Practice Wisdom Advice Basics Body and Body States Hope Advice for New Therapists What I Did and What I Do Now Being Aware of My Own Stuff Trauma Work Wisdom Pearls of Wisdom Veterans Not the Same Military Sexual Trauma Band-Aids Heroes: The Continuum How to Survive The Work Is Rewarding Chapter X Different Person Now Deeper Understanding Judgments, Biases, and Boundaries Greater Knowledge Comfortable, Competent, and Compassionate

280 Category Map—Continued Various Insights A New Point of View Becoming More Aware Chapter XI New Ideas for Old Problems The Way It Is Now Where’s the Support Solitary Confinement Show No Mercy What It Could Look Like Essentials Not Alone How We Do It The Zen Facilitator Necessary Discussions Feeling It More Training Wish List

281

Appendix C Reactive Style of Therapist

282 Reactive Style of Therapist Type of Reaction (Universal, objective, Indigenous Reactions) Normative | | | | Emphatic Disequilibrium | Emphatic Withdrawal Uncertainty | Blank Screen Facade Vulnerability | Intellectualization Unmodulated Affect | Misperception of Dynamics | | | | | Type II CTR __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Type I CTR (Over-identification) | (Avoidance) | | | | Emphatic Enmeshment | Emphatic Repression Loss of Boundaries | Withdrawal Over-involvement | Denial Reciprocal Dependency | Distancing | | | | | | Personalized (Particular, Subjective, Idiosyncratic Reactions) (Wilson & Lindy, 1994, p. 15)

283

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