To the average person, discussing the historical origins and context of scientific ideals is unlike the concrete expectations from discussions on the history of popular inventions and world events. If one were to ask the man on the street about the origin of the cotton gin or the airplane, specific people, locations, and exact historical context could be summed up in a simple sentence or two. While historians may disagree on the general causes of the Civil War for example, the explicitly recognizable events, major players, and historical fall-out remains obvious and irrefutable. This is not the case when speaking about Posttraumatic Stress Disorder (PTSD) and its official historical recognition. Researchers Kalampalikis, Delouvee, and Petard (2006) remark that when thinking of Relativity, a scholar might imagine a sepia image of Einstein in Berlin, but when the same person is asked about stress or psychology, nothing like that will come to mind (p. 24).
Understanding Starts With The Name. Even the term for the symptoms and actions stemming from PTSD are in contention. Depending on the side of the clipboard one is standing on, the underlying reaction to a PTSD diagnosis may differ. This is especially true for the warrior culture (Hall, 2008) of the military where calling something a disorder burdens the new owner with a social stigma that may further block the exploration of restorative processes and even hamper healing (Shay, 2006). “Numerous studies over the past two decades suggest that when individuals are officially recognized to have a mental illness, they are placed into a cultural category that damages their material, social, and psychological well-being” (Kroska & Harkness, 2006, p. 325).
To be injured in the line of duty is honorable (Shay, 2006); to have a diagnosed disorder is to be flawed with weakness (which is against warrior culture). If the goal is to describe what the patient is going through with respect to what may have caused it, calling Posttraumatic Stress Disorder an injury (vice disorder) may be more appropriate.
This semantic problem should not be taken lightly when discussing PTSD and the potential therapeutic approaches to treatment. In the military culture, where lauds and labels, even personal tribulations (Hall, 2008) are worn on the chest of its membership, the hazards of being labeled as weak or broken are enough to sway PTSD’s victims from seeking the help they need (Armstrong, Best, & Domenici, 2006; Grossman, 2009; Hall, 2008; Shay, 2006). “When a military service member’s arm is shot off, do we say that he or she suffers from a Missing Arm Disorder?” (Figley & Nash, 2007, p. xvii). Just as Figley and Nash point out, this is ludicrous. Yet returning combat veterans who have combat-related affects to brain function rather than a visible injury are treated as though they are somehow at fault for the injury instead of a victim of it.
And It May Be On The Rise. Grossman (2009) explains that PTSD (or the recognition of combat-related psychological trauma) has been around since the beginning of warfare. Some researchers suggest that we have actually increased our propensity for contracting PTSD through technology. Col. Jaffee and Kimberly Meyer (2009) from the Defense and Veterans Brain Injury Center in Washington, DC, write that advanced body armor may be to blame for the spike in PTSD cases. “The use of advanced body armor has increased the survivability of today’s wounded warrior. Fewer penetrating brain, abdominal, and thoracic injuries are sustained compared to previous conflicts. This, coupled with rapid air evacuations, has led decreased mortality from combat-related polytrauma” (p. 1292). In an ironic twist, the increased ability to stay alive during combat has led (for some) to an increased difficulty of surviving trouble-free after combat.
What it Looks Like. “Some 15% to 40% of war veterans develop PTSD. By its nature, this is a disorder that puts tremendous difficulties in the way of the injured veteran’s personal relations and functioning” (Figley & Nash, 2007, p. 138). The affect PTSD has on the service member and his or her family is revealed in many forms: nightmares, flashbacks, psychic numbing, withdrawal, detachment, and personal violence or short-tempered outbursts may be listed by the layperson. Some of the more hidden costs paid by PTSD sufferers are alcohol and drug abuse, increased sexual desire (or dysfunction), cutting, criminality, reckless behavior (on and off duty), and hyper-arousal (Armstrong, et al., 2006; Grossman, 2009; Hall, 2008; Jaffee & Meyer, 2009; Shay, 2006).
How Bad. “Recent studies suggest that the severity of the posttraumatic reaction and the perceived threat during the traumatic event are better predictors of the average time it takes injured trauma survivors to return to work than is the severity of the injury” (Figley & Nash, 2007, p. 132). Worse, without early intervention and recognition, the symptoms can cultivate into other, more complicated, symptoms (Grossman, 2009). For some, symptoms may not surface for months or years after the traumatic event (Hall, 2008), but the injury, when presented, is as fresh as the day it was born (Figley & Nash, 2007). MFT practitioners must be aware of the culture of the patient, the social ramifications of diagnosis on the service member and his or her family, and how the severity of any physical injuries may affect the gravity of the psychological injuries. “The relationship between physical injury and PTSD may be circuitous: physical injury increases the risk for developing PTSD, and PTSD in turn affects the physical healing process” (Figley & Nash, 2007, p. 132).
“Given the large number of armed services members currently returning from Iraq and Afghanistan dealing with PTSD, attention to effective treatment modalities is critical” (Sherman, Zanotti, & Jones, 2005, p. 626).
Major Components of Therapy. For the service member, volumes of research have been presented to assist professional counselors with the attitudes and positions necessary to effectively help PTSD sufferers. Dr. Lynn Hall (2008) writes that mental health professionals should make an effort to understand the culture and mindset of the warrior culture before they get their first patient. Once there, even more information and therapeutic techniques become easily accessible.
Single-issue techniques like stress or anger management address the issues showing stress and displaying anger. Sleep and relaxation techniques are taught to aid PTSD sufferers overcome the disposition of not being able to sleep well or lessen hyper-arousal (Armstrong, et al., 2006). But that is not enough in many cases; PTSD is far more complex than a one-solution fix can provide. Professional mental health providers must first acknowledge that the service member needs something more than simple (traditional) intervention. One soldier was told by an “Army psychologist [she] was not only unable to help, [but] she labeled him a conscientious objector and refused to continue seeing him as a client” (Paquette, 2008, p. 145). A failure to understand the very nature of the injury, and then to treat it in such a way that calls attention to some kind of abnormality, instead of the injury, can be devastating (Hall, 2008). “The returning troops need to know there is a place where they can unburden their souls and receive forgiveness by ‘confessing’ their transgressions. The concept has been used by certain religions for centuries, and the modern therapeutic process often imitates the ritual, with a few adjustments” (Paquette, 2008, p. 145).
Systematic Approach. Which brings us to a more balanced and broad-spectrum treatment methodology. Figley and Nash (2007) have written extensively “about PTSD and the family, including a five-phase treatment approach that draws upon systems, family stress, and family therapy theories” (Sherman, Zanotti, & Jones, 2005, p. 626).
In systems theory the attention is directed away from the individual and his or her individual problems that are normally viewed as stand-alone issues and moves the gaze toward relationships and issues of relationships between individuals. For systems theory to be effective, blame (finger-pointing and guilt association) must be removed and labels like good and bad must be treated as relative statements describing the situation in context with the surroundings (Bevcar & Bevcar, 2000) rather than value judgments. The entirety of the problem, its cultural and social surroundings, roots, and reactions are assessed and treated as a whole. This is very different than the single-issue approach that resembles a band-aid method of treatment stopping the bleeding, for example, but not removing the bullet.
“Common sense and clinical intuition tell us that families are dramatically affected and are instrumental in the veterans’ recovery. Unfortunately, clinicians have few resources available for guidance in serving these families” (Sherman, Zanotti, & Jones, 2005, p. 626). As systematic approach would involve what is going on at home and work, as well as what is going on in the head of the patient. Systematic theory is not completely disinterested in looking at the past, but its primary concentration is an acknowledgement and appreciation of “the present, on the here-and-now rather than on the past (Bevcar & Bevcar, 2000, p. 65).
Role of MFT
“The family experience of PTSD can become one-sided in that the entire family unit can expend considerable energy helping the veteran. Although this strategy can be functional at the time of diagnosis and/or acute crisis, this approach reinforces the identified patient role of the veteran and ignores the partner’s needs” (Sherman, Zanotti, & Jones, 2005, p. 627). In a family situation, there is more at stake than merely the mental health of the returning service member. MFT can step in at any phase of the treatment, but systemic theory would prefer access to the family from the very beginning. “Wives of traumatized veterans are one of the various groups of persons who have been identified as suffering psychological consequence of traumatic events which they did not experience first hand, but through their close proximity to a direct victim” (Figley & Nash, 2007, p. 137).
For a family in crisis, both parties may appear to have played either an active or passive role in their current situation, but systemic theory is noncasual in nature (Bevcar & Becvar, 2000) and therefore recognizes that the best step forward is made by recognizing and admitting that the present is what it is and must be dealt with more actively than the past. Communication and education for service member spouses and support groups is key (Hall, 2008). The benefits of these outlets of communication for the returning member represent cannot be understated. MFT can help educated the entire family unit about the difficulties (their) veterans have communicating with friends and family who they may perceive as either completely self-absorbed, disinterested, or simply unable to understand the feelings and internal conflicts related to the war they are experiencing (Armstrong, et al., 2006; Hall, 2008; Grossman, 2009).
The focus of MFT therapy must be on what is happening, as opposed to why it is. MFT will help identify who exactly are the affected parties in the relationship? MFT can act as the free-agent third-party to discover which roles each family member plays and in what way their awareness of these roles will aid in understanding their unique attitudes and affectations. Boundaries for the affected relationship must be defined. Are these relationships consciously acknowledged, and how well are the lines of communication and resolution defined? MFT can help families who may struggle with these questions work through the solutions.
PTSD is more than a simple anger management problem. A person (military or not) suffering with PTSD is as injured as a person missing a limb from a roadside bomb or car accident. The societal problem with PTSD, the one that makes the recognition and treatment so complicated, is that often times PTSD is an invisible injury. Some in the military may view the PTSD sufferer as a person with a defect or somehow at fault and weak for having the disorder. Historical and cultural understanding of this injury is critical to bringing the nature of its complications to the table when talking about effective treatments. Once identified, a systematic approach is best in order to address all the ingredients (surface and lurking) that are causing the infliction to affect the healthy coping of the soldier or sailor. To address each of these variables, MFT may be the best option. The family and friends of service members are uniquely positioned to recognize abnormal (for them) behaviors and (if educated as first responders) can play a major role (in concert with the mental health professionals) of helping the service member find the strength to adjust to the new situation they find themselves in upon return.
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