Plenary 2:
Psychoanalysis and Combat Trauma: The Analysis of a War-Torn Soldier

My plenary address illustrates treatment of combat-related PTSD through an intersubjective lens. It applies Robert Stolorow's ideas on trauma, largely found in his recent book Trauma and Human Existence. I describe fifteen months of twice-weekly therapy with MAJ B. As part of the intersubjective approach, I also describe what I brought to our work together as a Navy psychiatrist, and how our sessions impacted me.

My thesis is that Stolorow's phenomenologic, contextualist approach to trauma provides an understanding of combat-related PTSD, a form of adult-onset trauma. I had searched for understanding of combat trauma since I first started seeing military patients with PTSD after the campaigns in Iraq and Afghanistan began in late 2001. My search became personal when I deployed to Iraq in 2008. While in Iraq, I discovered Trauma and Human Existence, which immediately fit my work. It also became a relational home for me, as I struggled to endure the isolating effects of a combat zone.

I describe MAJ B's history, focusing on his experiences in the military. By the time I met him, he was hospitalized on a psychiatric ward for suicidal ideation. He had been in the military for about ten years, serving mostly as a B-52 pilot. He volunteered to deploy to Afghanistan as a Forward Air Controller with Special Forces units. In that role, he went on missions with Special Forces teams and called in air strikes for them. He estimated that he killed over one hundred people in that role, and often had to count their bodies after the fights were over. He noticed problems right away after that deployment, including isolation from his pilot peers in the Air Force and his wife. He then sought a return to Southwest Asia, this time as a military attaché in Pakistan. However, his problems only worsened there, and he was returned to America for medical retirement for PTSD. When I met him, he had been waiting over nine months for medical retirement, only to learn that his doctors had never submitted the required paperwork for it. With a plan to drive his car into an embankment at high speed, he decided at the last minute to seek help. Following his hospitalization, I became his psychiatrist.

Like many traumatized combat veterans, MAJ B described a devastating combination of shame and guilt from events in Afghanistan. We explored one of his most difficult experiences in Afghanistan through a recurring nightmare. MAJ B then described hearing the screams of a group of young Taliban conscripts just before the bombs he directed fell on them. His account was very disturbing to me, and evoked for both of us the uncanniness that Stolorow describes as Being-towards-death. Unlike MAJ B, I was eventually able to re-engage in my daily life. MAJ B remained in his shattered experiential world. When someone cannot find words and a relational home to bear these feelings, they become dissociated and lead to what Stolorow calls an ontologic unconscious state.

MAJ B's shame stemmed mainly from two sources: his inability to deal with his experiences and what he feared he had become after combat. He felt tremendous shame that he could not maintain a stoic John Wayne persona after combat. He also feared that he had become a "killing machine that could not be turned off." Because MAJ B's pilot peers could not tolerate his emotional experience of combat and he could find no other relational home, he remained in his ontologic unconscious state. His heavy drinking and job in Pakistan can be seen as attempts to find antidotes to his unbearable emotional state of deadness. I then illustrate MAJ B's sense of guilt and shame through segments of two consecutive sessions. We explored a series of dreams. It was clear that MAJ B felt he should be punished for his actions in Afghanistan and felt ambivalent about his connections with others.

At this point, I describe how our sessions impacted me. I often found myself slipping back in our sessions to my own experiences in Iraq, or to traumatizing scenes that any one of my former patients with combat-related PTSD described to me. In my sessions with MAJ B, I was joining him in our shared darkness of similar traumatic emotional experiences. I was giving and receiving twinship with him so that he could bear and process his emotional experiences. I discuss how Stolorow describes trauma and the indefiniteness of our shared mortality as ubiquitous.

I then summarized the course of our remaining work with MAJ B. He remained ambivalent about his relationship with his wife and about re-engaging with the present. He eventually revealed that he wanted to keep his options open for suicide in the future if he chose to end his struggles. At times, I feared that I could not save him. However, I remained with him and we gradually processed his emotional trauma. Over time, he gained a sense of what Stolorow calls authentic resoluteness. He undertook a leadership role with the Wounded Warrior organization within the Air Force, and had less intense experiences of deadness in his life. After almost a year of work together, MAJ B was medically retired from the Air Force. He has continued to develop a better sense of self constancy.

I concluded my presentation with a description of what I felt constituted therapeutic action of our work together. I also described how our work helped me process my own traumatic emotional experiences and reinforce an authentic resoluteness toward the work I do in military mental health.

My presentation ended with a brief video-taped message from MAJ B himself. He had asked to address the audience. He explained what he feels have been the most important aspects of our work together: me allowing him to guide the direction of therapy and my focus on our relationship.