COMMENTARY
The Interpersonal Psychoanalytic Approach to Working with Veterans Andrew BERRY
In the earliest writings by Freud (1901/1960) on “war neurosis,” as it was then called, his first observations were those of a surviving soldier mourning the death of a brother-in-arms. Freud does not initially speak of Oedipal conflict, libido, or an interaction among id, ego, or superego in these seminal writings. He speaks instead of how one friend misses another. At its heart, this is an interpersonal perspective. I also am interested in the interpersonal aspect of working with veterans and the symptoms of war neurosis, known now as posttraumatic stress disorder (PTSD), and more often associated with fear or with biological dysfunction. I draw my theory from my training at the White Institute, and specifically from Harry Stack Sullivan (who was a veteran himself ), one of the Institute’s eminent founders, and his landmark work, The Interpersonal Theory of Psychiatry (1953). For Sullivan, pathology exists because of pathology in the patient’s relationships. No psyche exists in a vacuum. Even when alone, the totality of a patient’s existence comes from relationships with those living and dead. From the interpersonal perspective, the symptoms of PTSD, while certainly glaring and present, are not quite as monolithic as in other paradigms, and certainly not as reductive as a mere collection of symptoms to be medicated and nothing more. If we focus solely on symptomatic relief of PTSD symptoms, we are at risk for missing entirely the deeper psychological meaning of PTSD. This meaning can be found in relationships with others, and the deeper levels of healing cannot be attained without exploring these relationships. I would also submit that the interpersonal approach focuses on early relationships affecting current relationships; what’s past is prologue. This is of significance analytically, because a child’s first relationships with caregivers are their first relationships with people in positions of supreme authority, and relationships with authority figures are the bedrock upon which the military does or does not function. Jonathan Shay (1994) points out that the subtitle to the Iliad is “The Rage of Achilles.” Achilles is incensed by the betrayal by his leadership of what is right. Shay points out that betrayal by a trusted military leader may be the most traumatic aspect of combat experience. I have often encountered veterans battling with PTSD symptoms who, concomitantly, are also reeling from years of deeply conflicted relationships with people
in positions of authority. And the interaction between the two phenomena can often be thought of as an extreme illustration of psychological potentiation, highly analogous to chemical potentiation, i.e., mixing alcohol and barbiturates and just how lethal this can be. Imagine a child playing on the playground and skinning his knee. At best, we can hope the child goes to a mother, or father, or nurse, or whomever, and the injury is not only attended to in a physical sense with disinfectant and a bandage, but also in a psychological sense, i.e., the authority figure making the child feel soothed, safe, and not needlessly blamed for the injury. Now, what if the same injury occurs and the child is afraid to turn to an authority figure, or otherwise has no authority figure to turn to? These children will bear not only physical scarring, but also the emotional scarring of such incidents in a cumulative sense. Through repeated, less than optimal experiences with authority figures, trust in self and the outside world is understandably eroded, if not obliterated. Now, what if this child grows up seeking a non-blood surrogate family because of coming from circumstances of abuse or of an unavailable parent? Or of not having parents or caregivers at all? Already, when the child, now an adolescent, signs on the dotted line, takes the oath, and enlists, he or she is at risk for having the emotional makeup of someone who could have a very hard time with taking orders from any kind of authority figure, no matter how capable. And what if the authority figure, in the form of either officer or enlisted superior, is either incompetent or abusive, especially during and after combat tours, where the seeds of PTSD are sewn? What if a combat veteran becomes increasingly symptomatic, as denoted by psychiatric criteria, while still on active duty? I submit that PTSD symptoms can be deeply aggravated by such incompetence, and doubly so by the feelings of betrayal mentioned above. This can lead to disciplinary problems and puts the veteran at risk for, in some cases, less than honorable discharges. I have had Herculean difficulty reaching many of the veterans who have suffered such fates while on active duty, and who have experienced childhoods replete with neglect or abuse, in my consulting room. As a psychologist and psychoanalyst, I am an authority figure, along with the active duty military and veterans affairs healthcare providers the veterans have en40
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countered before coming to see me. This illustrates how behaviors can repeat in terms of “What’s going on around here” and “You can’t not interact,” as Edgar Levenson points out in The Fallacy of Understanding & The Ambiguity of Change (2005). Often, it feels from the intake onward that I have been put on notice that I will have to go to great lengths to earn their trust. In such situations, I have found that PTSD symptomology per se decreases in size and importance, in a manner of speaking, while interpersonal issues regarding authority conversely increase, and markedly so. Veterans want to be heard and not judged. Unfortunately, many clinicians often do judge, and I have to work through additional damage from this as well when I work with patients who have already had experience with clinicians who simply do not understand what they are dealing with. This adds additional authority figures to an already long list of people perceived by the veteran as incapable or unwilling to help them in any other way than the path of least resistance via medication alone. Another phenomenon I have encountered along these lines is clinical experiences where there really has been no relationship other than being interviewed for 15 minutes, being tagged with a diagnosis, and being prescribed medication. This process usually involves little to no eye contact, and I find there is no difference between this unfortunate occurrence and receiving inadequate attention to a skinned knee. In both scenarios, hope for a successful outcome is left wanting, and being somehow further damaged is often understandably anticipated: some patients may even provoke it—perhaps as a test of their clinician (or of themselves). I have often heard from veterans who have been on active duty for long periods of time, sometimes for decades, that part of them still feels the same age as they went in, which offers us the idea of a psyche which retains aspects of being an emotionally immature 17-year-old, combined with another aspect of being thousands of years old, in the cases of combat veterans who have seen enough blood, gore, and death to last a thousand lifetimes. To this end, Hans Loewald’s idea of re-pare (1960) as what constitutes therapeutic action in analysis comes to mind. In addition to attempting to heal the profound levels of trauma and loss from childhood through combat, we are faced with veterans dealing with some emotional coping mechanisms on the same
FALL 2018
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