Paper: Combat and Human Existence: Toward an Intersubjective Approach to Combat Related PTSD
Understanding trauma and how to treat it is a serious and important area of consideration in my line of work. Most of the research and methods I have used including Van der Kolk, Janina Fisher, material pertaining directly to dissociative disorders, Gabor Mate and others focus on early childhood trauma, the ACE study, and how disorganized attachment disorder leads to significant distress and maladaptive defenses in adulthood. Therefore I was very pleased to encounter another “tool”, so to speak, for managing trauma, specifically adult onset PTSD. This is a brief psychodynamic therapy based on Dr. Russell Carr’s experiences in the working as a psychologist in the combat arena of the Middle East, and is informed by Dr. Robert Storolow’s intersubjective systems theory and Storolow’s phenomenological-contextualist psychoanalytic perspective as applied to adult onset trauma.
Carr developed this modality based on Storolow’s short book Trauma and Human Existence (2007), which Carr said he carried around with him during his deployment, reading, re-reading, and gradually integrating Stolorow’s Intersubjective Systems Theory approach to trauma into a brief therapy modality. In his book, Stolorow encourages a clinician to focus on how the subjective experience of trauma that has caused the presenting distress has shattered the patients relationship with being. Two methods Stolorow uses to perform therapy with a traumatized patient are empathic introspection (getting a sense of how the trauma feels to the patient) and contextualization of affect (understanding how the trauma affects the patient’s emotional reactions in his day-to-day life). In using this approach, it is necessary to develop a relational stance with the patient – to understand the subjective experience of the patient with as much of the clinician’s self as possible.
Carr determined that due to the logistical challenges of performing therapy in wartime, brief therapy was often all that could be provided to soldiers. Carr found a need form this approach due to the fact that most short-term therapies for trauma orient themselves around CBT. These therapies, while initially effective, have a high dropout rate (over 50 percent), and its effects often are not sustained in the long-term. Carr found necessity in a psychoanalytically informed approach, as he knew that psychoanalytic methods have a lower drop-out rate, and are ultimately more effective in the long term (Shedler, 2010) than CBT. Carr chose the intersubjective approach, because besides this approach, psychoanalytic theories do not address specifically adult-onset trauma without the presence of developmental trauma, and that many of Carr’s patients had relatively stable upbringings.
At the conclusion of the article, Carr states that he would ultimately like to make this brief modality appropriate to other individuals who are suffering from adult-onset PTSD, but who are not combat active or veteran military. In my work, I presently am not treating soldiers in active duty, nor am I treating veterans, per se. Therefore, I am leaving out elements that pertain to this specific origin of trauma. For example, In terms of a critical element of combat trauma, shame, being a soldier would likely add a layer of shame (potentially being seen as weak, and possibly more critically, not being united with his fellow soldiers) that a civilian may not possess. So whether working with shame would predominate the focus therapy with a civilian to the same degree or not is a matter of the individual. I am summarizing the method in terms of treatment of adult-onset trauma the general in a way I might use in my present practice. I am attempting some rudimentary variation of what Carr proposes, as I found his approach meaningful and potentially useful, in my own practice. I strongly encourage anyone interested in what I present to read the full article.
To inform his brief therapy method, Carr is using Storolow’s “intersubjective attitudes” to understand trauma:
Trauma is not the traumatic event, rather it is unbearable affect, or as Stolorow articulates, “an excruciating sense of singularity and solitude”. Besides manifesting as unbearable affect, there are other ways in which trauma presents, which includes loss of time – where past, present and future can seem indiscernible, “ontological unconscious” or loss of sense of being, loss of “absolutisms” or the things we take for granted in life (such as ones’ sense of safety of making it through the night), and informed by the philosopher Heidegger, a “being-toward-death”, or an immediately tangible and pervasive sense of one’s own mortality. Because the experience often has a very negative effect on the patient’s emotional navigation of day-to-day activity, and because trauma can often be extreme, the lack of attunement or even rejection from others can result in shame. Shame is a barrier to becoming attuned with others, and therefore is a barrier to healing overall.
The inability to bear emotions related to trauma is where the problem lies. Intersubjectively, traumatic emotion must be processed with other people through their understanding and empathy to be integrated. The patient must feel held by an attuned other or others who emotionally share the burden pain, with empathy and without judgment. Otherwise, this unendurable emotional state will be necessarily soothed in maladaptive ways – escaping them through dissociation or relegating through the body, where trama is expressed as physical symptoms. According to Carr/Stolorow, only through putting words to these dissociated or somatized traumatic experiences in the presence of an empathetic and attuned individual (or group) can it be processed and integrated.
A Summary of the Method of Brief Intersubjective Therapy for Adult-Onset Trauma:
There are many methods of short-term psychodynamic therapy. I have previously written about two of them in the last blog, and the underlying structure is similar:
1. The intervention is prompt
2. the therapeutic alliance is built rapidly and with a more active stance on the part of the therapist in comparison with longer treatment
3. Goals are specific and time limited
4. A clear focus is identified and maintained throughout
5. That the treatment is time-limited is established from the onset. Elements of the treatment are defined through the specific theoretical lens used.
Phases of Treatment
Phase 1: Initial Consultation and Consent to Treatment
Due to the short-term nature of the treatment, the screening is basic, and looks for factors that would render the treatment appropriate for the patient, or if another intervention is warranted : Is the patient suicidal? What is the source of trauma? Is there co-occurring substance abuse? Is there developmental or brain trauma? In this phase, the therapist engages rapidly, educating the patient on the process (which is uncommon for standard psychodynamic approaches). During the screening, an alliance can begin to be built. The duration of this brief treatment, mutually agreed upon treatment goals, and what the expected partial recovery will look like.
Treatment begins during the first meeting, which in longer term therapy would be reserved for assessment. This method has a basis in the elements of Storolow’s intersubjective systems theory: empathetic attunement, faillability (allowing the patient to inform on trauma more than the therapist’s previous education), and the personal experiences of the therapist pertaining to trauma, as to create a subjective, empathetic alliance is the goal of this first phase.
Phase 2: Address Shame as the Therapy Begins
Shame is a real factor for patients, second only to lack of finding a “relational home” for the trauma. As I mentioned earlier, shame is likely to be present due to the lack of comprehension or even blame and rejection by others as to the way the trauma manifests emotionally in the patient, and transforms their affect, possibly is mitigated with dissociation, which is confounding to others, and effects societal functioning among many other possible symptoms. It is critical that the therapist not participate in this rejection, which will require tolerating the nature of the trauma, as horrifying as it could be, understanding the context for the patient’s feelings through empathic introspection, and refraining from minimizing the emotional experience in attempts to “make things better”. The therapist must always keep in mind the necessity of this trauma to be processed through empathetic attunement, and attunement must be maintained regardless of what material the patient brings.
Phase 3: Sessions About the Phenomenology of Trauma
Once shame is addressed, the next phase is determining how, through the subjective lens, understanding the trauma. This means that the therapist will optimally engage with the patient on the basis of the therapist’s own experience with trauma to understand the patient’s empathetically. However, due to this being short term therapy, the therapist must conceptualize the subjective experience of the patient with some efficiency, so Carr suggests that the therapist describe some possible experiences based on the present understanding of trauma in the form of psycho-education to see if any resonate with the patient. Carr uses, again, descriptions articulated by Storolow (for example, the experience of “flashbacks”). This comparison exercise is done with the stance of fallibility, in that just because these are common experiences on average, they may or may not describe the patient’s experience. As is inherent in this approach, the patient’s subjective experience is paramount.
Putting language to the experience is a necessary step in bearing the trauma, and the psycho-educational approach may be able to hasten that process. Once the words are facilitated, a patient can begin to feel that the therapist “gets it”, and both can begin a dialog. Once the patient feels understood, he can begin to connect with the therapist and the two can start to create the “relational home” where the trauma will be processed, and the “excruciating sense of singularity” is gradually undermined.
Phase 4: Seeking an Intersubjective Key with the Patient
This is a phase that may prolong therapy, as it is akin to a treasure hunt. However, Carr states, “it is probably the most important (phase) for the treatment to be effective”. There will be present in the traumatic experience, a key piece of information that needs to be uncovered that encapsulates the full impact of the traumatic experience. It’s importance lies in its cross-temporality; that it is a unifying factor over the often subjectively fragmented dimensions of time.
The intersubjective key may be happened upon through the therapist articulated some connection he has noticed, which the patient has felt but not been able to isolate through verbalization. Carr finds this discovery often happens unexpectedly, and often weeks into therapy. By this point, the patient feels safer understanding his shame and intense emotion. The therapist follows the basic intersubjective principle of following affect within an empathetic stance, and the opening of the patient’s emotional tableau provide material for the therapist to notice, draw attention to, and therefore the chance of the intersubjective key emerging is more likely at this juncture. As an example, the intersubjective key in the case Carr presents is a sense that the patient held his command leader at fault for what he felt was continually exposing them to unnecessary risk, one case which resulted in the death of his friend.
The emergence of the intersubjective key will almost invariably result in intense emotions. It is critical that these emotions be borne together by both, and regardless of the content of the experience or magnitude of the emotions, and that the therapist remain empathetic. To not do so may result in a catastrophic rupture of the connection between therapist and patient, and a loss of the sense of safety of the relational home. Ross states, “Again, this is why maintaining and empathetic introspective stance throughout each session is so important”.
Phase 5: Providing a Relational Home
The intersubjective key, as discussed in the last section, may result in the peak of emotional processing of the trauma. With a therapist operating from the stance of intersubjective empathy, the relationship in this modality transcends from patient/therapist to “two frail humans caught in the same finitude. The, therapist, through the introspective empathetic stance he has been employing since the first session, may even be reduced to tears himself as the two process the traumatic emotions. This relational home brings words to previously unexpressed emotion, which is how the trauma is acknowledged and integrated. The patient finds the attunement in the therapist that he was unable to find in the “real world”, and this is what allows him to bear and process the pain.
It is important that any relational expression by the therapist, be it tears or even offering a hand to hold, is done through the therapists experience of the patient and in the service of the patient. This is not a time for the therapist to process his own trauma, even if he has used his experience of trauma to understand the patient’s experience, and to share in this experience.
Phase 6: Terminating and Both Moving On
If the termination date is firm (and in Carr’s case, in military setting it almost always is), then both patient therapist may feel a bittersweet resolution to having processed the presenting trauma, but often a desire to continue therapy in more depth and of more conventional material – the patients past, defenses, relationship patterns etc., although sometimes the patient is ready to go, having made headway or even resolved the presenting problem and it is the therapist who wishes to continue.
This is a time for both to recognize that the patient is in the process of improving and has given words to the previously unarticulated nature of the emotional trauma. Perhaps further therapy is indeed warranted. Patient and therapist could make arrangements for this to occur, and possibly with each other.
As stated earlier, Carr indicates in this article that he would like to further develop this modality (specifically for the veteran’s administration. , which would require manualization and testing. He indicates that one avenue might be “phenomenology research”, in which military service members with PTSD report and possibly compare their subjective experience. As a clinician, I certainly see value in the relational approach to addressing PTSD in the population at large as it relates to adult-onset trauma. I am aware of scads of trauma literature, and certainly see reflected in this Carr’s assertion that rarely is adult-onset trauma the focus without also including childhood trauma. Therefore, I appreciate this method for that focus, as well as an opportunity to begin to practice the relational method and to expand my toolbox with another form of brief therapy, and overall approach which I find valuable.