by Jim FitzGibbon
I know Post-Traumatic Stress Disorder (PTSD) as a relational dysfunction in which a person’s contact with their environment is interrupted by themselves and by the other. As we know in integrative psychotherapy, when an interruption happens in relationship, contact is restored and integration follows when the group changes. Relief, by restoring ground again in relationship, is found by connecting again in community (I refer here particularly to the valley where I live).
What I have written here is informed by my life experiences. The telling of my healing is informed by having been in the presence of many of the eminent authors listed in the bibliography below but also by being with my colleagues in groups, family and communities with whom I have been fortunate enough to be able to share part of my journey.
When terror is experienced, in a “dissociative cocoon” of shock (Bromberg, 2008: 337), the person is no longer able to differentiate between what is good and what is bad for them. In the absence of talking through and processing, this terror turns into PTSD. This article offers my reflections on PTSD and recovery in the community and I also discuss PTSD in relation to the military.
While working as an EU Monitor in the Bosnian war in 1995, I survived a near-death experience while held captive with others at the hands of the exceedingly popular and now convicted war criminals namely, the Serbs self-declared ‘president’ Radovan Karadžić and Serbian army general Ratko Mladić. The latter declared my death publicly. Aware of this, one of my greatest fears then was that the search for me, as missing in the battlefield Bosnia, would be scaled down. For further details of this experience, please listen to my interview on RTE1 on radio podcast (Ó’Mongáin, 2016). The story of my family’s experience of suffering from the terror of war tells of our journey of loving, through the terror and stigma of PTSD, to find peace and vitality. Now I hope my insight will help the community in which I live to greater wellness. While in captivity with the Bosnian Serbs I successfully used my knowledge of their beloved music by whistling the Serbian tune: Tamo Daleko (2014), thus improving my relationship with my captors. Some of my fellow survivors of this abuse and their families in Montenegro and in The Netherlands remain steadfast among our closest friends.
To give integrity to this article I have set out the paragraphs below as experiences of like with like, i.e., into “Zones of Awareness” (Joyce & Sills, 2001: 27-40). Even though parts (zones) of human experience are whole only when integrated, organising these paragraphs as separate zones, as if they were separate experiences, is a helpful way to explore the phenomenon of healing and integration.
PTSD in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders – 5th ed.)
The DSM-5 (APA, 2013a) is the manual used by clinicians and researchers to diagnose and classify mental disorders. The American Psychiatric Association (APA) published DSM-5 in 2013, culminating a 14-year revision process.
Stress from trauma was published in DSM-I in 1952 under the name ‘gross stress reaction’. It was omitted, however, in the next edition in 1968, after a long period of relative peace! When DSM-III was developed in the mid-1980s the recent occurrence of the Vietnam War provoked a more thorough examination of the disorder.
Inner zone of awareness (Joyce & Sills, 2001)
The inner world of experience of the client is often imperceptible to the psychotherapist. Behind the front of a body-armour, the traumatic process is of relational disconnection (the deepest sadness for a soldier survivor).
This experience of disconnection is bewildering and overwhelming. As a body process it manifests itself as numbness or desensitisation. This feels like intimate contact with one’s own desolate sadness and isolation from loved ones. When in company with what are perceived to be would-be emotionally armour-laden people, military colleagues, or for a man other men, there is extreme fear of being found out as weak and terror of vulnerability emerging. This is an ultimate shame.
In isolation, feeling abandoned and now for real, along with any pre-existing underlying childhood trauma buttons, it all becomes a toxic mix. My felt experience of trying to deny my frailty while failing to transcend and explain my situation was, sadly, the hardest to accept and separate out. The overwhelming shame is experienced as numbness: not allowing the self to be overwhelmed by too painful contact with the environment; acting as if the near-death emergency was continuing in the present, in the room, in the now; unable to relate to the ‘outer zone of awareness’.
In relationship there’s a screaming silence of shame. Suppressed terror and creativity are compressed together and then de-pressed; embodied as with grief in the entry and exit openings of the body. Irritable Bowel Syndrome and grinding of teeth ensue. Hopes fade of being met and understood. Even months and years later after the shock has receded, memory is of the much longed-for, shared, remembered, lovely innocent experience of life so suddenly and mysteriously severed.
That loss is the most painful, as is beginning the grieving of the loss of innocence while resenting the change that had happened; stuck in a painful place. This elephant in the room, without words, weighs heavily on coping resources. Gestalt psychotherapy is most useful. Disbelief and depression easily follow the despair. In a bubble of shame, years pass by just as the whole world seems to have moved on. Selcow (2015) in a film documentary about PTSD, exploring the core of the person, says that when something is hurting people, they fight.
For the returning soldier or survivor of terror, anything to do with ‘normal’ community life, because there’s no emergency happening, appears of no relative interest unless it’s to do with a member of the military unit or the integrity of the whole military unit itself or the territory. This figure formation, leaving emotions in the background, embodied in trained rigidified posture, keeps members distracted from their fear and from what they are missing back home. Pretexted in the underlying ethos and customs of stigma in the service, great discomfort of disconnection is experienced by survivors.
Layers of shame over disembodied shame…for those who came back alive.
Outer zone of awareness (Joyce & Sills, 2001)
This is awareness of the experience of contact with the outer world. Changes in the body and hence personality are explicitly obvious. Anxiety, including the anxieties of others, and also in the workplace, increases and spills out as the frequency of black humour and suggestions of ‘getting on with it’, ‘go back to work’, ‘carry on’ and even ‘I have lost your friendship’ increase.
Along, out of the meaningless silence, come the only definitive words for the change and these are: ‘Post Traumatic Stress Disorder’. The delivery of this diagnosis, by a medical professional, can feel like a final silence breaker but also a double-edged sword with a new life of additional shame about to begin post-diagnosis. The use of these words in line management feels, to the survivor, infuriatingly sad like an ordered withdrawal from contact and much dreaded re-abandonment in ‘no-man’s-land’.
Rather than asking how they are and waiting for an answer beyond the hollow clichés, it seems some people talk to the person as if addressing an object, an ‘It’, mortality itself. This, I believe, is community in disassociation. When this happens the experience is excruciatingly painful for everyone, as though confirming the existence of nothingness, while with the constant fear that the search for understanding will be called off. When there is no support for contact, the ultimate felt experience is of shame, of feeling worthless, a nothing, a rigid feeling of ‘I must be wrong?’
A belief that ‘I am bad’ takes hold.
I ask: ‘Whose is the disorder?’
Middle zone of awareness (Joyce & Sills, 2001)
This consists of thinking, memories, fantasies and anticipations. It includes all the ways we make sense of our internal stimuli and our external stimuli. In short it acts as a mediator or negotiator between the Inner Zone and the Outer Zone.
Struggling to find words to express the new experience arises here in the middle zone. In my own experience, I owe all to the unfailing love in my family as the one thread of truth about which there was no shadow of doubt: our love for one another. I discovered this as I began to allow contact. I allowed love into the now again and into the foreground again. Love of family, beyond words, took on a bright, new perspective and value.
A diagnosis can be viewed by carers as a positive step towards knowing what care to give to the sufferer. While this is positive for professional carers to know what to focus on, the delivery of the diagnosis to an individual becomes both a visible and audible imaginary mountain of shame between themselves and loved ones. The feeling of being the bearer of a ‘disorder’ is disheartening, especially when line management uses the term. The wound opens more. Distress deepens. Hypervigilance originating in the battle field is now applied to control the fear that ‘I will contaminate loved ones and annihilate everyone else’ and ‘I will be persecuted if found out’.
The survivor experiences shame of being different. It is okay to notice and comment on difference. It’s not okay to judge that difference to be wrong. The survivor’s felt experience of this ambivalence in the community as being beyond his capacity to process without support, means that the sufferer easily slips into believing: ‘I am the one who changed and I am wrong.’ This wrong belief cohabits with a belief: ‘They are traumatised with concern for me so I am bad for people who love me’. Further, in vulnerable conclusion: ‘I am unlovable’. This is a fractal in the present relational situation of the original terror that occurred in the there-and- then being re-experienced. Consistent with pushing away figures in the field of the original emergency, in understandable confusion, pushing away safe trusted individuals and safe, caring institutions continues. This can manifest outwardly as listlessness, withdrawal from life, towards deadening of self in the unfortunate belief it’s for the better survival of those you love. I discovered that a type of giving up, ‘playing dead’, can be part of hypo-arousal with somatoform dissociation (Bromberg, 1998; Schore, 2014). Doubts form whether it would have been better to have been killed, like one’s fallen comrades, thinking at least the community could be afforded the dignity of a military state funeral. I can understand how playing dead can precipitate, and the symptoms can be easily confused, with those of clinical depression.
Meaning making in community and the returned soldier
I am intrigued at the exposition during a workshop with Margherita Spagnuolo Lobb of a phenomenon whereby “a community or institutional culture can sometimes exhibit extreme borderline behaviour traits in relationship with ‘different others’” (FitzGibbon, 2015). Erratic behaviour, avoiding contact, denying responsibility, seeing contact as a threat on core self, etc., can be how a survivor and community mutually experience the behaviour of one another. Hence, incorrectly in my opinion, just the survivor is attributed a mental diagnosis. Experienced psychotherapists staying in relationship with clients with the above characteristics of Borderline Personality Disorder feel their attempts at contact betrayed by the other at every turn. Thus, a survivor can experience this same frustration in contact, having no ground of support in place. This is extremely harrowing and acutely re-traumatising, like waiting to be rescued from terror. Unable to resolve the feelings, the frustration becomes embedded.
Intellectually, it appears ambivalent to a soldier survivor that the meaning and support for a military task was clear at the outset and shared meaning was absent afterwards. Information about unusual events is viewed as risky by military authorities. Silence under the Defence Act (Government of Ireland, 1954) and Official Secrets Act (Government of Ireland, 1963) is evoked. War is an unusual event, borne out of an implicit mind-set of the ambivalent values of a few as a result of which everyone suffers. Post- trauma, the soldier, being unable to make meaning of the conflict between his/her internal and external experience, rigidifies with lightning speed and thrust phenomenologically, exactly as had been practiced until perfected on the drill marching square.
There are two other issues that have an impact and I will just mention them briefly here. One is that in the community a sense of ongoing fear of one’s mental illness is justifiable as the Brown (2015) thesis examines the extent to which medicalism and legalism have influenced the legal powers of detaining the mentally ill in Ireland from the late 18th century to date. The other is how in families in Ireland secrets are held.
Inscribed beneath the names of the dead, on a WW1 memorial to those locals who died, from a community in the Warwickshire village of Whichford, are the words: “And those who came back alive.”
As for the war veterans coming home alive, more care would “be acceptance by right, not charity” (Horne, 2015: 5). To the script on the monument (located in Merrion Square, Dublin) commemorating the members of the Irish Defence Forces who died while on peacekeeping duty should be added “And to those who came back alive.”
Yontef usefully outlines that the experience of shame usually includes one or more of the following:
1. “Feeling” inadequate, incompetent, weak, defective, stupid, boring, not enough. These experiences are mixtures of thought and affect.
2. Regarding oneself as disgusting, repugnant to others, loathsome, untouchable, unwanted, a bother or nuisance, not a gift.
3. Being unentitled and unworthy of respect, belonging, success, love, comfort, hence feeling more shame and guilt when these good things happen.
4. Feeling one’s privacy painfully violated by being seen by others, the eyes of the other becoming a glaring spotlight that leaves one feeling transparent, that one’s secrets are exposed to the public glare, and naked and vulnerable to contempt one believes is well deserved.
I am most grateful to Gestalt psychotherapists Yontef along with Lee and Wheeler (1996) who gave words to new ways of resolving shame.
While suffering disconnection the survivor struggles to find common ground for the experience of: “Great fraud, injustice and baseness in the army” (Remarque, 1929: 306) and “Guilt…a word of command has made these melancholy and pitiless of men our enemies, a word of command might transform them into our friends” (212).
In the face of such barbed ambivalence, unable to differentiate in process and finally given the diagnosis of PTSD, it is all a horrific burden on relationships.
DSM-5 and relational neurosis in the boardroom being replicated on the shop floor
‘Order’ is the strongest word of command in form and in spirit; so the word ‘disorder’ bestows the greatest resonance of shame on members subject to Military Discipline:
PTSD debate within the military
Certain military leaders, both active and retired, believe the word “disorder” makes many soldiers who are experiencing PTSD symptoms reluctant to ask for help. They have urged a change to rename the disorder posttraumatic stress injury, a description that they say is more in line with the language of troops and would reduce stigma.
But others believe it is the military environment that needs to change, not the name of the disorder, so that mental health care is more accessible and soldiers are encouraged to seek it in a timely fashion.
Some attendees at the 2012 APA Annual Meeting, where this was discussed in a session, also questioned whether injury is too imprecise a word for a medical diagnosis.
In DSM-5, PTSD will continue to be identified as a disorder.
Nothing can prepare one for the isolating ‘disorder’ experience and nothing is as successful as the isolation felt in keeping the individual’s experience hidden from view.
Tragically, an intended neurosis introjected in military leadership training into the existential script of many, is that self-esteem is built solely on being able to take care of others while being able to take care from others would be seen as weakness. Shame and self-contempt are mobilised to prevent this with devastating effect on contact. In this process shame is further somatically rigidified and, while hurting and shamefacedly breaking contact in a hurtful way, it gives rise to an incorrect feeling of being responsible not only for one’s resulting PTSD but, as well, responsible for the impact on one’s community.
In the military, as in authoritarian hierarchies in general, those in superior position can let out their anger arbitrarily and expect to be obeyed. Those in subordinate position however retroflect in the transaction and live their rage out at another time for example the berated worker comes home and lashes out against his or her rambunctious children. Helpless rage fosters feeling ashamed; controlled rage fosters shaming the other.
(Lichtenberg, 1996: 285-286)
I ask: ‘Whose wound is it?’
A hierarchical, deferential military system is also a performance- oriented promotion system. A high value is put on being a caretaker of all things. When a crisis happens a high value is put on being responsible for everything your unit does and fails to do. This, in my opinion, is a lynchpin of guilt and self-contempt choking off own needs. In oversight, what is missing is compassion for self. Instead, post-trauma, there’s a feeling that: ‘No one gets me’. How can you be compassionate for self when it seems like no-one else is showing compassion. This feeling of loss, unless processed, turns to hurt, chronic withdrawal and despair. Crucially, as a consequence of not accepting one’s own vulnerability and feeling of low self-worth, by appearing to refuse to allow others take care of you when you are vulnerable, it can be experienced by them as if you are without humility and thus arrogant. Thus the impact of the original trauma impacts through into relationships in the family and community. Transgenerational traumatic impact arises when this isn’t processed. This relationship dysfunction is truly a field phenomenon.
There was a twist of loyalty in the broader community: the original idea (if it was a popular decision in the first place) was for the soldier to leave home with fanfare and hope and meet face-to-face with terror and protect the community. On returning, it feels to the soldier that the only one who upholds this original order of things is himself; that everyone else has changed. In a bewildering amnesia everyone else moves on as if the community expects to send young adults to meet terror on their behalf and then expects they will not come back changed by having to meet this terror.
‘Shamefacedly’ unable to separate feelings and duty, with the likelihood of being shamed or punishable or, as in former legal and military tradition, shot as a coward and traitor: “First we are soldiers and afterwards and in a strange and shamefaced fashion individual men as well” (Remarque, 1929: 295). Integration of these parts is the challenge. The following words are my compilation of self-discovery following a conversation with a colleague:
Growing and seeing and not saying anything about the establishment,
Suffering while hoping the field will catch up.
Who was I, who am I?
My shame around my grief not being given the scope in our society.
A psychic thing about the Jim I was.
The dead me.
Healing in the therapy room
I am interested in how playing dead can be part of hypo-arousal and how it is difficult to differentiate between this and depression. Instead of depression I hold open the possibility that it is an ingenious creative adaptation that continues after the danger has passed in order to achieve inner stillness and peace.
The shame of not being able to find words is itself shaming. After an unusual event or trauma everyone is lovingly concerned and curious to know more. In the absence of contact with words, the spaces between these lines are more useful than the words themselves (Bromberg, 1998). While a dissociative cocoon of non-communication persists, right-brain-to-right-brain communication is happening. Creative ways of making contact become more relevant. I discovered that awareness of the visual, voice, movement, music, smell, taste all evoke energy for contact.
A definition of terror is ‘an experience for which there are no words’. “Psychic death” is a term for the experience for which I am grateful to Gordon Wheeler (1994: 52). In my own words, I experienced the scattering of my spirit away from my body leaving soul disembodied and without home. This can be experienced as an extraordinary visual affect as one’s spirit can be seen darting as light over on distant hills, body-self being too threatening a place for spirit to inhabit. Even in adulthood the removal of support for contact is a psychic death that results in disintegration of spirit and rigidification of the body-self. Playing dead while hypo-aroused is common (Bromberg, 1998).
Kepner (1993: 99) expresses this as disconnection from the body as physical ground. Using the Gestalt cycle of experience, he develops a healing strategy as support for the re-sensitization of the body, figure formation, mobilisation, action, contact, breathing and boundary issues in body process. Kepner’s work makes so much sense as it brings ‘ground’ into the healing as a felt experience in the body. In the absence of shared ground there can be no jumping back to vitality. The word ‘re-silience’ comes from the French verb ‘siler’ meaning to jump. The answer can be found in felt experience, in shared silence, rather than in the meaning of words.
Kepner’s (1996) healing tasks outlined and Gestalt approach provides the psychotherapist the means to understand this complex body, mind, spirit and feelings mix and how best to adapt therapeutic interventions.
It seems strange that in the dictionary close to the word ‘terror’, is ‘terra’ (the Latin) or ground, because ‘ground’ as territory is often the source of war. Strangely, ‘felt ground’ becomes the source of healing.
In my work as a Gestalt psychotherapist I meet clients in the therapy room suffering with shock and numbness. I know the client can be in a place that is beyond words. In therapeutic contact such as the above, Melnick (1980) writes in exposition of “heuristic experiments” that lead to “further inquiry”, born out of “intuitive sense” that serve to “open up new lines of communication” (16). In my words, as therapist, rather than intending teaching the client, it is best to become the interested learner in the room.
In 2010, the Irish Gestalt Centre invited Prof. James Kepner to the Centre. In his book, Healing Tasks (1996: 8), he identifies four distinct phases of the healing process, namely:
3. Undoing, redoing and mourning
It’s important to note these phases are not linear. Rather, like a hologram, the phases coexist and the survivor goes back and forth into and out of the phases. Incidentally, writing this for Inside Out is facilitating completion of part four of my own healing task of reconsolidation while issues from my phases one, two and three also emerge as I write. It’s useful for the therapist to have Kepner’s insight to know how to support the client exploring their process.
Insight into human suffering is so competently summed up in Frankl (1945). What makes the difference is attitude to your suffering and choosing to focus on love.
Regarding the Zones of Awareness mentioned above:
In practice a healthy person shuttles back and forth between the zones throughout his daily life. When awareness becomes weighted in one particular zone, the effect is to unbalance functioning, with sometimes quite problematic results.
Molly focussed excessively on the outside world, and the opinions of others; she desensitized her own feelings and judgements. In therapy she said she never knew what to do or even what she wanted and that she relied on someone else to make the decisions for her (dominant outer zone). Hari was constantly in a state of worrying and obsessing about life (dominant middle zone) while Deanna was so overwhelmingly aware of her bodily affective states, almost to the exclusion of all else, that she frequently escalated into a wordless panic, which she was incapable of managing (dominant inner zone).
(Joyce & Sills, 2001: 32)
Healing in the community
As professional psychotherapists living in our communities, and as lay people, we can be agents of change.
I feel gratitude to my family and friends for feeling so well and even though these words are only words, they will hopefully tell you about the meaning of love with every line you read and every breath. I am delighted to be in my community in Athlone, Co. Westmeath, where as a lay person, I am in groups with people on the theme of self-acceptance in relationship with community.
I feel compassion for a community who suffered the shock of terror of what happened to its members. However unpopular it may be to say this, in the face of terror the healthy instinct and self-preservation is to pull away. One side effect of this is to re-traumatise the persons who suffered the traumatic events.
Communities who get together to play music, sing, explore the arts, poetry, story-telling and listening while facing one another are without doubt healing.
I am grateful to “those who came back alive” as they have taught us much about resolution of disturbance, how to get together differently and to love again.
Increasing the range of how I meet my environment today, still a little concerned “they may stop looking for me”, I want you to know that I welcome feedback on your experience of reading this article.
Jim FitzGibbon MIAHIP is a Gestalt psychotherapist and an accredited member of IAHIP. He works in private practice both at the Vista Primary Care Psychotherapy Centre, Ballymore Rd., Naas, Co Kildare and at 2 Garden Vale, Athlone, Co Westmeath. Jim can be contacted at mobile: 087 7555680 and email: firstname.lastname@example.org.
I wish to express a special gratitude to my wife, Concepta, and to my relationship with her, myself, my children Neil, Mark and Conor for our special loving, to my extended family, past and present and to my friends, to my former fellow hostages, to my psychotherapy and Defence Forces professional colleagues for our consistent support of one another in one another’s lives.
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