A male patient, Sam Heath, age 33, is presented for treatment with health and relationship complaints tracing back to service in Operation Iraqi Freedom on two bi-annual tours in 2004 and 2006. Sam describes his first, the 2004 deployment, as “heavy combat with multiple deaths, causalities, and losses” to his unit. Mr. Heath took part in a several battles where he reports his unit lost his two best friends to enemy fire. The 2006 deployment was a “sustainment operation with a only a few guys taken out, and fewer face-to-face scuttles” with the enemy. Sam would not disclose if he was close to any of the causalities from 2006.
Although his unit deployed to Iraq again in 2008, Sam angrily reports that he has been transferred to a logistical support section where he would “not be required to deploy with his men,” but rather support them from a base here. He views this as a reflection of his inability to handle his personal life and a demotion of the honor of responsibility he once held (prior to the 2006 tour). Military business practices indicate that this is a normal rotation for a Non-Commissioned Officer (NCO), and that for a man still seeking an NCO position (those for ranks E7 through E9), this would actually be a promotion. Sam has failed to recognize the reality of the situation and continues to cast blame upon himself and his spouse for his perceived failure.
Sam is a married to Paula Heath; they have no children. After multiple failed attempts to conceive over their first five years of marriage, the Heaths stopped trying to have children. Sam admits to occasional consumption of alcohol, but not binge drinking; Paula, age 31, confirms this. Sam reports that he and Paula both come from non-abusive families. Both sets of parents are college educated and well employed. Paula is an only child. Sam’s only sibling, a brother, went to State College and is also well employed. Sam reports that neither his parents or bother have spoken to him since 2007 solely because he is poor.
Sam has a high school diploma and joined the Navy at age 18; he has been on active duty for 15 years as a Combat Constructionman (a “Seabee”) and has not made E7, a rank easily attainable by this tenure. As stated, he is working in a position for a Chief (E7) while his unit expects his promotion to be on the horizon. He refuses to see this reality or being “left behind” that way.
Paula quit high school to marry Sam and never finished. They live in base housing on Little Creek Amphibious Base, Virginia, where rent, utilities, and maintenance are provided for by the military. Previous to 2006, the Heaths owned their own home a suburb of Norfolk, Virginia. Their neighbors are now all military, all their friends are military, and all their extracurricular activities are in some way related to the military.
Sam’s medical records include multiple visits since fall, 2006 for complaints of headaches, sleep disruption, and extreme fatigue with no physical diagnosis given. Two years ago, Sam was diagnosed with high blood pressure and then was put on an exercise and diet regiment by a cardiologist. Hidden or repressed “anger can cause physical-health problems [like] headaches, high blood pressure, sleep disturbances, [and] heart problems when it is not handles effectively” (Fenell & Fenell, 2003, p. 7). Sam reports that he followed treatment for the first six-months but then refused to continue because it was interfering with his work schedule.
Sam’s court records reflect no criminal record until spring, 2007 when multiple reports of domestic violence calls lead to arrests, but no convictions. There is no military record of these actions; Sam claims that his chain of command erased all records of the incidents because they were not true. Sam denies domestic violence and Paula confers. The referring physician indicates that she suspects actual spousal abuse followed by the refusal of Paula to testify thus the consistent dropping of charges in the record. Sam acknowledges bouts of irritability, short-temperedness, hyper-vigilance in traffic and loud crowds, and that he harbors an angry suspicion of infidelity by Paula during the 2006 Iraq deployment. In Paula’s pre-therapy interview, she appeared to be unaware of Sam’s suspicions, but concurred with his short temper and uncontrollable mood swings.
The Heaths’ financial statements show them on-track for a 20-year retirement until after Sam’s second Middle-East deployment, in 2006, where a house fire, caused by Paula’s smoking in bed, depleted all their savings and led to their filing bankruptcy. Due to the fact that his command required all spouses to be given General Power of Attorneys during deployments, Sam was not allowed to return home for the insurance and legal issues associated with the fire. Sam reports that he never knew his spouse smoked, and that the bankruptcy could have been avoided if his unit had allowed him to return home after the fire. Sam also reports that he may never be able to retire now and will likely die at work. The Heaths lost their house, one of their two cars, and the small savings they had accumulated.
PTSD and combat stress assumption in regard to this case
Recent studies have shown that anger and the repression of anger can be trademarks of Post-Traumatic Stress Disorder (PTSD) (Fenell & Fenell, 2003; Sherman, Zanotti, & Jones, 2005). PTSD can have both physical and psychological effects on the service member and his or her family, extended family, career relationships, and even community (Grossman, 2009; Hall, 2008; Johnson, 2005).
The Heaths both bring the initial ingredients of PTSD to their relationship. The trouble appears to be set in their inability to communicate in a more productive way. For Paula, this may be the house fire, the guilt associated with it, its cause, and angering revelation that, during this stressful time, neither Sam, nor the Navy, were there for her when Paula had perceived they promised they always would be. This betrayal of a central promise may be causing resentment of Sam, the Navy, and ultimately herself for trusting them. For Sam there are the horrors of front-line combat, the revelation that the last 15 years of service have amounted, financially and rank-wise, to nothing, and the stinging re-assignment to a rear-echelon unit while his men deploy to war without him. One could even surmise that Paula’s being barren may be causing hidden anger in Sam and guilt for Paula. All of these, or a combination of any, may be contributing factors in his stress and anger management issues.
Systems theory perspective
For the case in question, systems theory hopes to motivate the Heaths to reach a new understanding of normalcy based on the current situation without the baggage associated with constant re-construction of the past (Bevcar & Bevcar, 2000). A negative comparison to their previous financial state or a judgmental characterization of their lives and goals compared to their extended families proves unhelpful when dealing with reality. While both parties may appear to have played either an active or passive role in their current situation, systemic theory is noncasual in nature (Bevcar & Becvar, 2000) and therefore recognizes the best step forward is made by recognizing and admitting that the present is what must be dealt with more actively than the past.
Often, the actions taken by an individual to deal with unrecognized or undesired anger can lead to more protracted negative affects of those feelings (Fellen & Fellen, 2003). When combat veterans move from a fast-paced, high-energy environment back into the lackadaisical, slower-paced civilian world, confusion can set in (Hall, 2008). Everyday functioning, especially with PTSD, demands an outlet for these frustrations. The benefits of these outlets and communication can be repressed by difficulties veterans have communicating with friends and family who they perceive as either completely self-absorbed, disinterested, or simply unable to understand their feelings and internal conflicts related to the war experience (Hall, 2008; Paulson & Krippner, 2007). A systematic approach must take into account all factors in play, and work to rectify their conflict in a way that casts no blame. Therapy must only highlight the actions and reactions, and then explore positive ways to understand and deal with them.
The focus of therapy must be on what is happening, as opposed to why. Who are the affected parties in the relationship? What roles do each play and in which way can awareness of these roles aid in understanding their unique attitudes and affectations? Boundaries for the affected relationship must be defined. Are these relationship consciously acknowledged, how well are the lines of communication and resolution defined? Systematic theory is not completely disinterested in looking at the past, but its primary concentration is and acknowledgement and appreciation of “the present, on the here-and-now rather than on the past (Bevcar & Bevcar, 2000, p. 65).
Considerations for the treatment plan
“Research has clearly documented adverse effects of PTSD on intimate relationships. Combat veterans experience a high rate of marital instability, and veterans with PTSD describes their martial issues with more severity than do veterans without PTSD” (Sherman, Zanotti, & Jones, 2005, p. 627). Treatment began as soon as Sam Heath was interviewed by providing a trusted outlet to express the concerns both he and Paula felt were causal factors during the initial interview process. They couple was interviewed separately and given a written statement explaining the rights each had to expect privacy from their community, employer, and each other barring illegal or life-threatening activity or intentions.
The complex relationship between PTSD’s affectations and the resultant changing needs of the patient combat themselves. This can amplify symptoms and minimize the effectiveness of treatment (Johnson, 2005). PTSD and its symptoms are not just the combat-related questions of guilt or mortality. It is not simply a veteran’s struggle with haunting memories of lost comrades or the faces of enemy killed. These factors play a central role, but as systems theory appreciates, for all actions and reactions there is a network of factors to be considered and explored. Therapeutic planning therefore will include financial, marital, and life-career counseling. Multiple venues and resources should be utilized to include life-skills, stress management workshops, intrapersonal relationship characteristics exercises, and the free Couples’ Retreats offered by Fleet and Family Service Center (FFSC).
“Increased stress in the family (especially tension and hostility) can trigger the veteran’s PTSD symptoms” (Sherman, Zanotti, & Jones, 2005). It is evident from the opening interviews that Sam’s symptoms of PTSD first manifested themselves as troublesome after the 2006 deployment, not necessarily the 2004 tour where combat operations were more substantial. The financial trouble during the 2006 deployment, subsequent legal and work issues, as well as Sam’s admittance to no longer feeling completely at ease in potentially stressful situations like heavy or fast traffic and in loud crowds, substantiate this timeline.
A systematic approach dealing with current reality verses past affectations should address Sam’s anger management issues as well as budget and retirement planning. In joint sessions the couple should be educated about non-judgmental techniques for communicating their concerns. Homework assignments such as listing triggers for anger or researching career opportunities will assist with the bi-monthly sessions’ success. Group interactions on this subject, such as the Building Effective Anger Management Skills (BEAMS) classes offered by FFSC, can not only be effective methodologies to teach new skills, but also a means by which the couple can see that they are not alone in their problems. In several studies, isolation from peers and family, through the unhealthy thinking that one was alone in his or her troubles was considered a contributing factor in the longevity of PTSD and related family problems (Hall, 2008).
Worse, friends and family members who are adversely affected by the anger and attitudes of a veteran suffering from PTSD are apt to be unforthcoming in providing the exact kind of support the veteran unknowingly needs and is pushing away (Sherman, Zanotti, & Jones, 2005). A systematic approach, oriented to guide the relationship to deal with the current reality, rather than continually depress itself with the past, will solidify the strengths of the couple’s past, and nullify the temporary weakness that may appear permanent in the unexamined present.
Finally, if able, the therapist should approach the underlying resonance of the infertility concern. If the pattern of anger and guilt appears to be from this aged issue, alternative parenting techniques and counseling should be offered exploring adoption, foster care, or other avenues the couple feels might fill this (perceived) void. The importance is not the solution in so much as it allowing a safe environment for the couple to communicate and deal with the reality of this concern. Neither party admitted during the initial interviews that they had ever spoken at length about this discovery.
Goals of therapy
Intervention through a systematic approach can help the Heaths manage their new definition of normalcy (absent of blame for their mutual and individual difficulties), manage stress, and experience greater martial satisfaction (Bevcar & Bevcar, 2000; Hall, 2008; Sherman, Zanotti, & Jones, 2005). Group venues, such as those offered by FFSC, will contribute to the maturation of their understanding that their concerns are a normal product of life and not necessarily the result of a specific, blame-worthy event. This systemic revelation is important for Sam’s success at work, his and Paula’s intimacy, and perhaps a rekindled relationship with both of their extended families.
The sessions and their termination process
All therapeutic plans must plan for a beginning, a mediation or interaction of some sort, a specific stopping point, and a method for follow-up to ensure success for the patient or patients (Corey, Corey, & Callanan, 2007). For the Heath’s relationship therapy, the success of the process will be measured in years, not sessions. Yet the plan for therapeutic sessions is a short one. Three individual sessions per spouse will be followed by three to four joint sessions in which revelations from the previous meetings are explored insofar as they are germane to improving the handling of the current reality. Past issues that present roadblocks to maturation will be touched upon in order to recognize their place in the relationship as unhealthy manifestations of feelings toward events that cannot be changed, but must be understood. Further, group sessions with BEAM, educational counseling for the patient’s spouse toward attainment of her high school equivalency, career guidance if desired, and financial classes through FFSC will be highly recommended between sessions. A calendar of these events is available for free through a publication called Signals for the Hampton Roads area; participation in these events is not reported to active-duty commands, so Sam’s fear of work-related stigma will be avoided.
The couple will be asked to check back six months after treatment and again at 12 months out to refresh management lessons, update progress, and be given more information, if needed, on FFSC or other opportunities for personal and professional growth classes.
Personal reflection on case
Sam Heath was not self-referred; instead problems with his command led his immediate supervisor to make the first appointment. The concept of seeking support can be analogous to admitting weakness; this is a foreign and unwelcomed concept to many military members (Hall, 2008). “The concept of ‘finding support’ suggests that they are incapable of handling their life” (p. 19). It is this initial attitude that needs to be overcome before any hope of healing and growth can begin. A patient unwilling to own the current reality is already behind when it comes to learning how to work within it.
Regardless, there are multiple factors that need to be understood on a systematic level in this case. The latent resentment or guilt associated with the perceived failure to produce children may have calcified over the years into a roadblock for the mutual respect needed for effective communication. The fear of mortality experienced by both spouses during the dangerous 2004 Iraq deployment likely led to increased fear and anxiety during the 2006 deployment. These fears would certainly have shaped the coping strategies for both martial partners during that separation and upon return. The house fire on 2006 has nefarious origins to the patient who suspects infidelity in relation to its cause. The failure of the patient to achieve the next professional advancement in a timely manor has definitely challenged his self-concept, regardless of whether or not it is related to actual performance.
In all, a sinking self-concept, challenged by his perception of a failure to keep and satisfy his wife, remain financially solvent, succeed in his career, protect his men (while they deploy without him), and the loss of self-concept from not being validated as a man (becoming a father), has led the patient to dangerously suppress the anger and fear associated with his combat-related PTSD leading to a manifestation of this repression in both health and psychological problems. The need to suppress this anger could be a control mechanism where veterans try, at the very least, to control something in a life of uncontrollable tribulations (Grossman, 2009; Hall, 2008; Sherman, Zanotti, & Jones, 2005). It is the job of the skilled therapist to not only understand these concerns, but to help the patient and his or her family understand them and to advance from that revelation in healthy ways.
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