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].
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.
REFERENCES:
McLuhan, M. (1964).
Understanding Media: The Extensions of Man. London: Routledge.
Bowlby, J. (1969).
Attachment: Attachment and Loss (Vol. 1). New York: Basic Books.
Mahler, S, Pine, M,
Bergman, A. (1973). The Psychological
Birth of the Human Infant. New York: Basic
Books.
Steiner, C. (1981). In
Corsini, R (Ed.). Handbook of Innovative Psychotherapies. New York:
John Wiley & Sons. Retrieved from
http://www.claudesteiner.com/rpbrief.htm
Davies J. & Frawley,
M. (1994). Treating the Adult Survivor of
Childhood Sexual Abuse: A Psychoanalytic Perspective.
New York: Basic Books.
Rothschild,
B. (2003). The
Body Remembers Casebook: Unifying Methods and Models in the Treatment
of Trauma and PTSD.
New York: W.W. Norton.
Schnurr, P. &
Friedman, M. (1997). An Overview of Research Findings on the Nature
of Posttraumatic Stress Disorder. In Session:
Psychotherapy in Practice, 3(4)
Drego, P. (1983). The
Cultural Parent. Transactional Analysis
Journal, 13(4)
Erskine, R. (1993).
Inquiry, Attunement, and Involvement in the Psychotherapy of
Dissociation. Transactional Analysis Journal,
23(4)
Korol,
J. (1998). Confluence, Isolation, and Contact in Psychotherapy with
Clients Who Dissociate. Transactional
Analysis Journal,
28(2)
Pomeroy, W. (1998).
Trauma, Regression, and Recovery. Transactional
Analysis Journal, 28(4)
Tudor, K. (2003). The
Neopsyche: The Integrating Adult Ego State. In Sills, C. &
Hargaden, H. (Eds.), Ego States.
London: Worth Publishing.
Stuthridge, J. (2006).
Inside Out: A Transactional Analysis Model of Trauma. Transactional
Analysis Journal, 36(4)
Friedli L (2009). Mental
health, resilience and inequalities. Copenhagen: World
Health Organization
Regional Office for Europe.
Stuthridge, J. (2012).
Traversing the Fault Lines: Trauma and Enactment. Transactional
Analysis Journal, 42(4)
Harford, D. &
Widdowson, M. (2014). Quantitative and Qualitative Outcomes of
Transactional Analysis Psychotherapy with Male Armed Forces Veterans
in the UK presenting with Post-Traumatic Stress Disorder.
International Journal of TA Research,
5(2)
Dearden, L. (2014).
Britain First accused of 'hijacking' the poppy ahead of Remembrance
Day.
Fogg, A. (2014).
Sainsbury's Christmas ad is a dangerous and disrespectful
masterpiece.
