With Victor and Sage: Process-Experiential Couple Therapy and PTSD

*David Alexander

CREDO Center Far East, Japan

*Corresponding author: David Alexander, CREDO Center Far East, PSC 557, Box 302, FPO, AP 96379, Japan

Received: August 25, 2014; Accepted: September 24, 2014; Published: September 26, 2014

Abstract

Victor is a Marine officer who deployed into combat in Iraq and Afghanistan a combined five times between 2002 and 2012. Over the course of his deployments he lost more than twenty-five young Marines under his command, and was personally involved with extended firefights that lasted more than five hours. After his third deployment, his wife, whom we will call Sage, began noticing significant shifts in his personality and way of relating to her. A few months after his fifth deployment they separated, because from her perspective he didn’t feel anything for her, and she “couldn’t live like that.”

Introduction

Once Sage moved out of their house, Victor self-referred to a military behavioral health clinic and was quickly diagnosed with PTSD. He started individual weekly treatment with a staff psychologist at the clinic that same week. Sage agreed to move back in a few months later, on the condition that they seek couple therapy together, to try to find a way forward. They found my door, and I have now been seeing them together for 10 months, using a process-experiential approach to family trauma care within a structural systems framework. I offer a brief vignette from my work with them in this case report.

Methods & Assessment

Process-experiential forms of couple therapy focus on the adult attachment bond between two people as the primary client in any therapeutic encounter [1]. Emotionally focused couple therapy, which is my orientation of choice, has been empirically validated as an effective approach not only in treating relational crises, but also in systemically addressing common individual problems [2]. Other experiential and relational forms of couple therapy have long been shown to effectively treat anxiety, depression, addictions, eating disorders, and etc [3].

Susan Johnson has been successfully treating survivors of childhood trauma using process-experiential couple therapy for almost a decade, helping couples to “construct relationships that enable partners to face [their] trauma” and to experience positive psychological change [4]. In her model, she suggests that initial and subsequent assessment of clients’ trauma-related distress be measured not in terms of the traumatized partner’s mental state, but rather (1) the level of personal integration of the trauma, in terms of the traumatized person’s ability to acknowledge the trauma event(s) and to cope with its memory, and (2) the level of the relational integration of the trauma, in terms of the other partner’s familiarity with the trauma narrative and the extent to which he or she is able to play a part in the traumatized partner’s coping strategies [5].

In my own work with families in the aftermath of psychological trauma, much of which happens to be combat-related, I most often see couples after an initial diagnosis of PTSD is made, in which case my work will usually take place concurrently with the traumatized partner’s individual work with another clinician. For this reason, I do not often make use of individual assessment tools such as the Clinician Administered PTSD Scale for DSM-5 [6]. Rather, I make use of a relational assessment that has been used extensively in empirically-validated couple therapies, so that I can track a couple’s ability to trust and depend on each other, especially under conditions of chronic distress. The relationship questionnaire designed by Bartholemew and Horwitz is one of the tools I use most commonly [7]. It was originally designed for use with young adult couples, which accounts for most of my client population, and it has been used and suggested for use by a number of process-experiential couple therapists who work with traumatized populations [5]. The Bartholemew and Horwitz questionnaire maps a couple’s thinking about dependency and attachment, and has the potential to serve as a great addition to a therapist’s observation of a couple’s attachment behavior. As often as the questionnaire is completed, a combination of the results, the therapist’s observations, and the couple’s observations can be thematically triangulated to come to some compulsions about the growth occurring during therapy [8].

Treatment Vignette

Victor’s initial response to the questionnaire indicated some significant concerns with regard to his ability to trust, to remain vulnerable with, and to depend on Sage in relational ways. As we discussed these results, and collaboratively brainstormed where we might start in our work, we noticed together that Victor struggled with finding the emotional stamina to even stay in a conversation that seemed to contain expression of Sage’s relational needs. This is a common difficulty among couples struggling to recover from trauma, and it is also a focus of process-experiential couple therapies in general, so it seemed to al of us a good place to start [5].

To work on developing emotional stamina we combine three elements for relational experimentation. The first is an ancestor of one of Minuchin’s structuralist techniques called “speaker-listener,” which has found a place in many different approaches to couple care in recent years [9]. The second is an old process game called “fishing,” which evolved from Eugene Gendlin’s concept of “focusing” on felt experiences with unassigned meanings to encourage insight [10]. The third element consists of some body-oriented movement exercises borrowed from Ron Kurtz’s Hakomi method, aimed at evoking and assigning meaning to process blocks that interfere with free self-donation and other-reception in relationships [11].

Here’s how it works. Victor and Sage sit knee to knee, across from each other – their chosen position, because Sage likes to hold both hands, and Victor is usually able to manage the anxiety that comes with that degree of distance and closeness. They go over rules for the speaker, and rules for the listener, according to the old technique, and then I offer the beginning of a statement that they each, in turn, must complete while remaining in physical contact with each other. The statements I feed them start out somewhat innocuous, but build towards intimacy – especially focusing on their early days of romance and the sensations of their first touches.

Once we reach some resistance, and it is clear that Victor’s emotional stamina is being tested, we try to stay with his experience of wanting to withdraw, pausing the exercise, and breathing into the feeling of light distress. This is where the process game comes in. If he is able to stay with the experience, and begins to bear it more comfortably, with at least a manageable level of distress in the moment, Sage can ask for a meaning that might be in there somewhere. I used to have to give her a cue, based on my intuition, but now she is mostly using her own. If he can assign a meaning to his feeling of distress as they get close to intimacy, and depending on what meaning arises, Sage is learning to collaborate with him in further meaning-making, or meaning assignation. If this is working, and if they can find a rhythm, it can ultimately have an impact in reconsolidation when the moment of experience is past.

Occasionally Victor finds that, in the process of assigning meaning to a felt experience that is unlocked in the moment by movement toward intimacy with his wife, this meaning seems connected to some very particular adverse experience from his time in combat. In such cases I will occasionally take the reins back from Sage and see about moving into some transferent meaning making in our sessions. It has happened twice that Victor actually experiences the distress of being close to intimacy with his wife and the distress of being close to certain moments of his time in combat as one and the same. In those moments something very interesting is poised to occur.

As he undergoes in vivo therapy in his individual work, and gets closer to his experiences in combat, beginning to bear them more fully, he simultaneously grows in the ability to get closer to Sage, and to more fully bear the weight of intimacy with her. This is an easy connection to make within most modern understandings of trauma theory [12]. However, I think it is also possible that this concurrent growth can be stimulated from the other direction. In his work in remaining present to Sage in our exercises, I believe that his ability to remain present to his traumatic experiences as they are invoked and sustained in his in vivo therapy can be heightened.

This brings me to the third part of our time together, which we rarely reach, but gives a good conclusion to a short clinical vignette. If Victor is able to bear some distress in relation to his wife without needing to hide from it through withdrawal, and is able to assign some meaning to the distress, we then sometimes try some more body-oriented work. Sage holds up her hands to him in alligator-arms fashion, and while focusing on his distress and its meaning, Victor tries to slowly reach towards her hands, noticing any resistance and seeing about making some meaning there also. Last month a sort of miracle happened in the middle of such work – Victor threw off the game entirely, picked up his wife, and held her on her chair for more than 15 minutes. She wept, and he pressed his head into the nape of her neck and let her tears run down his face. Afterwards, he commented that “for just a minute it was like I was crying through her tears.”It was the first time they had even embraced for many months.

Some Conclusions

Victor’s and Sage’s relationship has not drastically changed in the aftermath of that moment, nor are they suddenly in each other’s embrace constantly, and able to freely give and receive attention and nourishment from each other in intimate friendship whenever they please. Progress is still slow. In fact, we discussed the Bartholemew and Horwitz questionnaire together again soon after that event, once we had come near the 9-month mark of our therapeutic relationship. Although Victor expressed little change in his ability to see Sage as someone whom he can depend on in every circumstance, marking only very modest growth in terms of that category in the assessment model, he is finding it less painful and more possible to have emotionally-laden conversations with her without withdrawing, especially in therapeutic sessions, where a third party provides some stability and containment for him. He is also finding himself to be more attached to Sage in terms of friendship, and this clearly marks growth in another category. He still fears some intimate moments, but he is able to relate to her as a constant companion and claims to prefer her company to anyone else’s, or to being alone. This is a change from when we began working together, and it is something Sage claims to have noticed herself.

According to process-experiential theory, games and techniques should always give way to focusing on something spontaneous breaking free from the depths of a human being in the process of a therapeutic encounter, so that it can be integrated into experience in the present moment [13]. For Victor, this integration included the spontaneous realization that in one moment of time he was actually sharing an emotional response with his wife after PTSD, and that her pain in that moment was connected to his. In fact, it came with the realization that all of her pain, her fears and her healing is ultimately caught up in his. From a process-experiential view, this is a tremendous movement toward relational healing after traumatization [13].

For Sage, the moment when her husband picked her up and held her while she cried after so many months of feeling alone – this was more than a spontaneous movement open for integration and consolidation. It was more than a mark of growth in their relational health. It was a moment of hope, and in living with PTSD, a little hope can go a long way.