Following completion of a quantitative and qualitative outcome analysis into the effectiveness of transactional analysis (TA) in treating combat-related PTSD (Harford & Widdowson, 2014), I have been pondering over a loose assortment of observations, inferences and unanswered questions arising from the results gathered and conclusions formed. Though there is little purpose in repeating here what can be found in considerably more depth within our research paper, instead, I would like to suggest a few interesting departure points for further discussion- and, ideally, extensive research- including an appeal for greater attention to the interplay between the therapeutic and political domains, as explored by the radical psychiatry movement and, earlier, the likes of R.D.Laing and Wilhelm Reich.
Beginning at the beginning, then, consider the prominent influence of childhood trauma as a predisposing factor in the aetiology of combat-related PTSD. Nine of the fifteen male veterans studied in our research revealed histories of abuse, neglect, or other family dysfunction prior to joining up (Harford & Widdowson, 2014, p.39); a feature highlighted by Jo Stuthridge, based on her own clinical observation that 'in every case in which posttraumatic stress symptoms escalated over time...the client revealed a history of childhood trauma' (Stuthridge, 2012, p.239) and, also, the U.S. Department of Veteran Affairs, which noted that 'increased risk of PTSD...is associated with...early conduct problems, childhood adversity (e.g. parental loss, economic deprivation) [and] family history of psychiatric disorder' (Schnurr & Friedman, 1997, p.13) before suggesting a distinct diagnostic category of “complex PTSD” to reflect this more fundamental psychopathology.
We might say, then, that these veterans, subjected to extreme, or repeated misattunement during childhood and then, later, exposed to military trauma, have doubly-dissociated, multiply-fragmented selves. They exhibit traits of personality disorders that predate their trauma symptoms, arising from an underdeveloped hippocampus, limited capacity for impulse control and affective self-regulation, the lack of a secure base (Bowlby, 1969), object constancy (Mahler, Pine & Bergman, 1975) as yet unattained and so on. As such, they are ill-equipped to withstand combat scenarios, without a fully-functioning neocortex- or Integrating Adult (Tudor, 2003), in TA parlance- to soothe limbic reactivity, render implicit memories of those trauma explicit, or autobiographical and, therefore, unable to be 'aware of and accept disowned parts (i.e. ego states)...[or] contact other people while maintaining a sense of self' (Korol, 1998, p.115).
All too often, this vulnerability to PTSD deriving from insecure attachments is exacerbated post-active service by 'poor social support' (Schnurr & Friedman, 1997, p.12) and a lack of appropriate care and reparation from the military, health authorities and governmental agencies. As one veteran reported of a protracted dispute with the UK Department of Work and Pensions, “they send you another batch [of forms], then another batch...then they say the've lost it...You go from one office to another to another...they keep on passing you- like pass the parcel” and, thus, 'the unintegrated experience of trauma is reenacted through...repetitive patterns of transference' (Stuthridge, 2006, p.275), the client's relational expectations rigidify and symptoms deteriorate. If this complex co-morbidity weren't challenging enough, therapists will often be contending with the pernicious impact of addictions and other lifestyle problems that attend veterans' understandable desire to 'disengage from [unmet relational] needs and emotions and...evade the memory and its devastating impact' (Erskine, 1993, p.184). Eight of the fifteen men examined by our study, for instance, disclosed problematic relationships with alcohol, prescribed medication and recreational drugs (Harford & Widdowson, 2014, p.38).
In these potentially lethal circumstances, an effective multidisciplinary approach is indicated and, as such, consensual contact between the client, specialist health and support agencies and the therapist concerned is the only ethical way forward. Ideally, any active addictions and lifestyle problems should be addressed first. The therapist, meanwhile, focusses on co-creating a mutually trusting therapeutic relationship, strengthening the veteran's Integrating Adult (Tudor, 2003) capacity for self-regulation and self-reflection and working through any emerging transference, rather than addressing their PTSD head-on. Of course, treatment won't necessarily proceed in this tidy sequence. As one veteran recalled, “I was the teacher and you were learning from me”, or, as another commented, “It seems as though I can pick the topic; what I want to talk about, what's important to me”, and, often, it is therapeutic to follow their lead- though always mindful that the 'first goal of any trauma therapy must be helping the client to contain and reduce hyperarousal...[or] putting on the brakes' (Rothschild, 2003, p.4). Nevertheless, designing treatment in this way is consistent with established TA models, where the highest priority is 'Stabilization...establishing physical and emotional safety' (Pomeroy, 1998, p.337) and, also, psychoanalytic approaches, where, instead of self-medicating with alcohol, or drugs, clients are taught 'any of a number of deep-relaxation exercises [and] processes akin to self-hypnotic techniques that promote a form of physical and mental self-control' (Davies & Frawley, 1994, p.205-6).
The latter calls our attention to the crucial role of psychoeducation in this work. Psychoeducation strengthens the Adult ego state, the neocortex, which veterans need to quell their permanently activated fight-flight-freeze response and 'learn to reflect upon and integrate their...archaic states as well as past introjects, and to draw on them in the service of present-centred relating' (Tudor, 2003, p.202). So, why is it that I hear of veterans being prescribed breathing exercises with little explanation of their neurological affect-regulating purpose? I can understand, therefore, why some veterans are reluctant to try them. Veterans are highly-skilled and resourceful individuals, with detailed knowledge of intricate weapons systems, navigation tools and the arcane bureaucracy within the military. Further, it is not uncommon for them to be more expert in managing people- often in chaotic life-or-death situations- than the supposed experts providing their care and rehabilitation. Consequently, I believe we do them a patronising disservice if we assume that the discourse of trauma- the intertwined functions of the limbic system, hypothalamus, left-brain and right-brains, implicit, explicit and autobiographical memory, adrenaline and cortisol- are beyond their understanding. For example, one veteran remarked, “You've explained to me the processes that are taking place in the body...and [my brain and thinking] have been...defragmented like a computer...and things slowly, but surely are starting to...find their place again”. Notice, too, that five of the fifteen-veteran cohort presented with paranoid features (Harford & Widdowson, 2014, p.39) and, therefore, thorough explanation of the psychobiology behind my interventions and any associated “homework” proved essential to engendering mutual trust, openness and respect.
In particular, I have found the wealth of diagrams furnished by TA theory invaluable in strengthening veterans' neocortical capacity to bring coherent meaning to their phenomenological experiences; one individual emphasising in typical fashion the importance of, “the transactional [diagrams]...I'm a visualisation kind of person...There's your Parental [ego state], there's the Child and...you can see how it overlaps and how it all fits together”. By way of illustration, take the veterans' recurring motif of the army as a substitute parent figure- sometimes compensating for past misattunements with structure and discipline, while, at other times, compounding relational failures with bullying and abandonment. It was often helpful, here, to sketch out the Cultural Parent model (Drego, 1983) and complete the respective: 'Etiquette....the transmitted [rules] for thinking, behaving and valuing...the Technicalities, or...actual organization of the material and social life [and]...Character...socially programmed ways of feeling, handling biological needs, emotional expressions' (Drego, 1983, p.225) that captured the nature of their surrogate introject [see Figure 1].
Cultural Parent of the British Army
(Harford, 2014- after Drego, 1983)
And what of the prevailing Cultural Parent within the health and social care services veterans encounter in the aftermath of trauma? And that of the wider civilian and political society they find themselves immersed in upon returning home? I would like to make a plea here for greater application of the social model of mental illness, whereby 'levels of mental distress among communities...[are] understood less in terms of individual pathology and more as a response to relative deprivation and social injustice, which erode the emotional, spiritual and intellectual resources essential to psychological wellbeing' (Friedli, 2009, p.III). Several veterans participating in our study were beleaguered by the debilitating side-effects of psychiatric medication- including highly addictive benzodiazepenes,which, in some cases, had been prescribed for years with scant improvement in their mental health and precious little attention to intrapsychic and interpersonal reintegration. Compounding this situation, I noticed what appeared to be 'a direct causal relationship between enforced attendance at benefits eligibility assessments and related health assessments, [including] the arrival of related written correspondence' (Harford & Widdowson, 2014, p.61) and worrying spikes in the anxiety and depression measures gathered during their therapeutic journeys.
More controversially, several veterans reported being fully aware of the dubious political motives for their presence in the second Iraq war of 2003 and, more recently, Afghanistan; of their difficulty reconciling extreme traumatic experiences with the doubtful necessity of experiencing them at all. On a personal note, I have felt increasingly uncomfortable lately with my perception of a growing fetishisation of militarism in our culture for political, or commercial ends: the red poppy infamously co-opted by the far right (Dearden, 2014), the government's programme of World War One “celebrations' and a festive television advert by a supermarket (Fogg, 2014) all leaving a bitter taste in the mouth. I wonder what this means for my ongoing work with the traumatised subjects (grammatically and constitutionally) of all this geopolitical, party political and consumerist opportunism? I am curious to know more about how the veterans themselves view their place in our current epoch. And I wonder, too, what the radical psychiatry tradition would make of it all?
Radical psychiatry posits that much psychopathology originates not in the individual's deficits and dysfunctions, but, rather, 'the mystified oppression of people who are isolated from each other' (Steiner, 1981, http://www.claudesteiner.com/rpbrief.htm). This results in alienation- or, in traumatic terms, dissociation- from their cognitive, affective and somatic selves and, also, their interpersonal capacity to enjoy mutually beneficial relationships. Steiner (1981) goes on to outline the introjective power of such internalised shame and oppression, whereby, 'When a person has incorporated in [their] own consciousness the arguments that explain and make legitimate [their] oppression, then mystification and alienation are complete. People...will blame themselves for their failure, accept it, and assume that they are the source and reason for their own unhappiness' (Steiner, 1981, http://www.claudesteiner.com/rpbrief.htm).
Reading this, a specific veteran comes to mind who astonished me by reporting that their traumatic story had been dismissed as fabrication by medical professionals on account of its disjointed and contradictory chronology. Of course, trauma impairs autobiographical memory and, with it, the ability 'to organize remote events into a verbal narrative...to form a narrative self, a “me” who persists over time...[allowing] integration of conflicting experiences' (Stuthridge, 2006, p.273). Thus, the veteran is blamed for their unconscious defensive response to the inescapable kill, or be killed dilemma, transferential expectations of misattunement are confirmed and hope for recovery retreats further from view. To borrow from a precursor to The Radical Therapist's deconstruction of the mental health industry, 'the medium is the message' (McLuhan, 1964, p.7), which, for me, underlines the necessity that we therapists, with our variously ambivalent Cultural Parents, are not complicit, unconsciously or otherwise, in our returning veterans' battles.
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