STEP 6

Process

Taking a Deeper Look

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The most important thing in life is to learn how to give out love, and to let it come in.

—Morrie Schwartz

Robert and Felicia, who we introduced in Step 2, had been growing apart over the past several years. The stress of deployments, combined with raising two teenage boys, had resulted in a growing friction and sense of dissatisfaction with each other. Although they had made significant progress in the previous sessions, Robert and Felicia still lacked the connection and communication that is necessary for a deeply fulfilling relationship. In our sessions, it became apparent that the couple did not openly share emotions or even let down their guard with one another.

Robert and Felicia had taken considerable steps to strengthen their family. They had worked to interact better with their sons. However, Robert and Felicia still struggled with being able to open up to each other. The closeness that this couple had years ago had eroded over time. They needed to learn how to change the hurtful and dysfunctional communication patterns that were driving them apart.

Setting the Stage

When service members like Robert and Felicia hold leadership positions, or are hoping to advance in their careers, they may feel a constant pressure on themselves to set an example for others. In the course of being “strong” role models, they can develop a tendency to be “in control” all of the time. When the couple has to cope with the effects of trauma, they can become disconnected from their emotions. Their relationship can suffer as a result of being unable to share with each other.

In Step 6, we work through the key issues of trust and unconditional acceptance with our military families. At this stage, returnees may be reluctant to open up about deployment or war-related experiences. Family members may have fears of rejection or abandonment. In this step, we help family members to let go of their need for control, so that they can reconnect with their loved ones.

While family members began to address intimate trust in Step 5, now we will take it to a deeper level. In Step 6, returnees will be able to share their painful or traumatic experiences, as their family members positively react by giving them unconditional love and acceptance. This step will further empower family members to overcome greater challenges as a family unit, with the knowledge that they are there for each other no matter what.

Why People Stuff Their Emotions

When family members stuff their emotions, including grief, this can create problems in the family. Returnees and their loved ones may have difficulties sharing their feelings and stuff them to protect themselves. Here are some common reasons why people stuff their emotions.

“They Can Handle It on Their Own”

Many people are raised with the idea that people simply shouldn’t talk about their problems or express negative emotions. Instead of talking about their problems, some individuals believe that they should handle problems on their own. In addition, certain cultures may hold beliefs that family members should restrain their emotions. Some individuals feel that sharing their feelings can burden or impose on others.

“It’s a Sign of Weakness”

As we mentioned in previous chapters, stigma related to mental health prevents many individuals from being willing to share their feelings or admit to having any psychological “weaknesses.” Many people believe that sharing their feelings or problems is a sign of weakness, so they stuff their emotions instead. Some family members may believe that when someone is struggling on an emotional level, they are “weak” or “crazy.” On a related note, many families hold to the belief that it brings shame to their family if a member discusses their family problems with outsiders.

“I Will Get Hurt if I Open Up”

Some individuals think that other people will not understand what they are going through. Some might fear that others will minimize their problems or feelings, whereas other people may fear being put down or criticized for feeling the way they do. Many individuals refuse to be vulnerable because they remember being hurt before when they shared with someone. As a result, they don’t share because they would rather not risk getting hurt again.

“I Wouldn’t Know Where to Begin”

Some people will not share because it feels uncomfortable to them. Also, some people might lack basic communication skills when it comes to talking about or listening to others’ sensitive feelings.

“They Will Make Fun of Me”

Like the individuals who don’t share because of their fears of being hurt, there are people who do not share because they are afraid others will make fun of them or laugh at them. Many people don’t know how to appropriately handle sensitive topics. For some, the only way that they know to react when someone is emotionally upset or crying is to giggle or laugh, or to make a joke out of that person’s experience. There may also be times when individuals might unintentionally laugh. The result of these reactions is that the person who was the brunt of a joke will be a lot less likely to share their feelings with people again in the future.

A Case in Point: Robert and Felicia

In the case of Robert and Felicia, I had noticed in previous sessions that they both had a tendency to make jokes and cutting remarks toward each other. In earlier exercises, they shared on an intellectual level, but they were still emotionally guarded with one another. As I checked in about their week, I probed deeper into their communication style and level of trust in each other.

THERAPIST: Felicia and Robert, tell me about your week.

FELICIA: It wasn’t bad. (looking at Robert) We went to our son, Robbie’s, baseball game on Saturday and went out to a retirement party on Sunday.

ROBERT (smiling): There was some good food there.

FELICIA (laughing): Yes, and we ate too much.

ROBERT: You ate too much.

FELICIA: You ate too much, Robert. Your doctor won’t like you eating all that cholesterol.

THERAPIST (interjecting): Tell me more about what it’s like going to parties together.

FELICIA: Well, I enjoy getting dressed up and going out. We wear uniforms to so many events that sometimes I forget what I look like in civilian clothes. I bought a new dress for the party and these great red shoes.

ROBERT: Yeah, Staff Sergeant White thought she was sexy.

FELICIA: What is that supposed to mean? Are you saying I’m not attractive?

ROBERT: Yeah, whipping Fobbits into place all day is what I call sexy. (“Fobbits” is a somewhat derogatory term for soldiers who never leave a forward operations base, or FOB.)

FELICIA: Well, I can say that Sergeants Young and Lopez told me how nice I looked. At least I know they are men!

ROBERT: You know what, Felicia, you are a Staff Sergeant, and you are a mother. You’re not supposed to look sexy.

FELICIA: You know what Robert? I’m a woman too. If you were more of a man, you would see that!

ROBERT: Oh God. What’s the use in all of this?

Discovering Patterns

I stopped this downhill conversation and pointed out to Felicia and Robert that they were making cutting and invalidating remarks to each other, and they admitted that this type of interaction was typical for them. Not surprisingly, Robert and Felicia also avoided sharing vulnerable emotions with each other. Although they had greatly improved in their abilities to listen to, validate, and positively reinforce their children, they needed to transfer these skills to communicating with one another.

I learned that neither Robert nor Felicia was brought up in a family where feelings like sadness or fear were shared. Robert was raised within a military family. His parents did not hug or openly show affection, and he said his parents would berate him if he made mistakes or showed vulnerability. Felicia was raised in a similar environment, where her family did not express their emotions. She came from a big family, which she described as being highly critical. Money was often tight, and her father was physically abusive.

As adults, the military reinforced Robert and Felicia’s need to maintain emotional control, but it was damaging their marriage. They needed to become aware of what their patterns were, where they came from, and to learn how to communicate with each other in a safer and more intimate way. And that is exactly where we headed in our first exercise with this family.

Making It Real: Changing Beliefs About Sharing Emotions

In this exercise, each partner answers questions about their beliefs and fears about sharing their innermost thoughts and feelings. The exercise will also help clinicians to identify the family members’ beliefs about sharing negative emotions.

Exercise Directions: Please use Family Handout Step 6.1.

Spend at least 15 minutes on this exercise, or more if needed. Have the couple or family write responses on their handouts. The rule is to be as unguarded and honest as possible. Then, open up a dialogue with the couple by having each partner share their responses out loud and discuss their reactions.

The first two questions in this exercise can help the couple understand how they normally share their emotions. When partners identify a person with whom they shared feelings of fear and/or sadness, take note of what that experience was like.

In most cases, sharing emotions is a positive experience associated with feelings of comfort, closeness, or validation. Discuss the importance of sharing such experiences as a couple. If a client had no one with whom to share vulnerable emotions, or had negative experiences when they shared with another person, take time to explore what that was like for the client.

The last question can help reveal whether a family member understands how to respond when someone else shares vulnerable information and communicates his or her needs. Overall, the question can help set the stage for family members to share any inner thoughts or feelings. As the clinician, you can educate the couple or family here about the value of emotional disclosure. Through observation and questioning, address any potential communication barriers. You may need to train family members to share and empathetically receive difficult content, and otherwise help them overcome trust issues and fears of rejection within the relationship. Here are the questions:

Talking Points

Robert and Felicia both went through negative experiences in the past after they shared their emotions with someone they had trusted. As a result of the pain they had experienced in the past, both Robert and Felicia believed that the other would betray their trust. They were both afraid to be vulnerable with each other. Take a look at Robert and Felicia’s responses to the questions.

Felicia’s Responses:

1. Yes, my older sister. It was reassuring to know that I wasn’t crazy.

2. Very difficult, but I could do it if he agreed not to tell anyone else.

3. By letting me know that he would never tell anyone else or otherwise use it against me.

Robert’s Responses:

1. Yes, my dog. Comforting.

2. Embarrassing.

3. Listening without speaking, nodding her head.

Robert’s Past Experiences With Sharing

Felicia felt that Robert just “doesn’t open up” to her at all anymore. Robert remembered times when he was ridiculed for being scared. For example, when Robert was a little boy, he was afraid that there were monsters hiding under his bed. His older brothers made fun of Robert because of his fears. Years later, when he was a little older and learned that his parents had been in a car accident, Robert told his brothers that he felt scared. Again, his brothers poked fun at him.

Because of these experiences he had growing up, Robert hesitated when it came to sharing his feelings with others. Felicia pointed out that Robert never cried during sad movies. When one of his friends from childhood and his grandmother died, Robert did not show any emotion at their funerals. Robert acknowledged that his early experiences kept him from sharing emotions and made it difficult for him to admit that he could “have a problem.” As a result of doing this exercise, Felicia learned why Robert had such a hard time sharing his feelings. This helped her understand why Robert didn’t open up to her about things.

Felicia’s Past Experiences With Sharing

When she was a child, Felicia used to share her feelings with her sister. Felicia felt comfortable sharing with her. But that all changed when Felicia found out her sister had betrayed her trust by telling her friends what she had shared in private. Because of this, Felicia came to believe that everyone would betray her trust if she shared her feelings. In their marriage, Felicia expected Robert to make light of her feelings or to put her down around her friends, so she kept a stiff upper lip and maintained control over her emotions.

Coming to Truce

In the session, Robert promised that if Felicia got upset, he would never share this with anyone else. Robert and Felicia also vowed that if either of them needed to vent about something, that the other would just listen. Through this exercise, Robert and Felicia understood each other better and learned how important it is for family members to be vulnerable with each other. Robert and Felicia could now see how they had slipped into some of the same communication patterns with which they were raised. They both agreed that they wanted their relationship to be a lot better than what their parents had. Also, Felicia expressed that she would appreciate it if Robert would be more openly affectionate toward her.

Opening Up About Traumatic Experiences

When they are deployed, service members go through powerful changes as a result of their experiences. Service members endure profound, life-altering events, such as being in danger, losing their buddies, being physically injured, and killing others. In a war zone, service members need to be able to ignore their emotions and focus only on surviving. They need to channel their anger into the battle so that they can survive. To get through their experiences, service members also need to ignore their feelings when they are involved in or witness grotesque deaths, atrocities, or severe human suffering.

When service members return from combat, they may still be ignoring and stuffing their emotions. They may try to forget about their trauma. It is common for service members to feel numb and like they are in automatic mode. Many service members maintain a tough soldier mentality that can be difficult to break.

For Your Information: Talking About Traumatic Events

For most people, talking about difficult experiences and expressing their emotions helps them feel better. When people do not disclose painful experiences, they can experience adverse physical and mental effects (Pennebaker, 1989; Pennebaker & Beall, 1986). People who do not feel that they can share their traumatic experiences have higher levels of PTSD symptoms over time (Cordova, Ruzek, Benoit, & Brunet, 2003). On the other hand, trauma survivors who disclose their traumatic experience(s) to people who support them have less distress, and they cope better compared to those who do not (Lepore et al., 1996; Pennebaker, 1993). Also, sharing traumatic experiences is linked to lower rates of PTSD in various groups, including veterans (Green, Grace, Lindy, Gleser, & Leonard, 1990).

Many scholars believe that processing potentially traumatic events with another person is necessary for overcoming PTSD (e.g., Foa & Kozak, 1986; Rimé, 2007; Stroebe, Hansson, Stroebe, & Shut, 2001). The term “trauma processing” refers to contemplating, confronting, and integrating a highly stressful event into a person’s view of himself and the world (Cordova et al., 2003; Foa & Kozak, 1986). In some theories about PTSD, the traumatic event becomes “stuck” as a memory (Monson et al., 2006; Resick & Schnicke, 1993). According to these researchers, talking about a traumatic event triggers the original memory so that it can become “unstuck,” and this can reduce a person’s psychological distress related to the event.

On the other hand, when trauma survivors share their experience and have someone react negatively to them (e.g., minimizing or invalidating their experience), this can result in greater levels of PTSD than those who had positive reactions from people (Cordova et al., 2003). As such, when a trauma survivor shares their traumatic experiences with a spouse or other family member, it is important that they listen and respond with empathy.

Another factor that makes it difficult for trauma survivors to share is avoidance. When people go through very traumatic events, the brain becomes overreactive to stress. Because certain things will trigger uncomfortable feelings or thoughts of their deployment, service members will instead avoid things that remind them of their experiences. And when they avoid thinking about, feeling, or talking about the war zone, this provides temporary relief from the reexperiencing and hyperarousal symptoms of PTSD. Unfortunately, continual avoidance actually drives or maintains the PTSD.

Avoidance can generalize to other life situations as well. For example, if a returnee feels uncomfortable in a shopping mall, he might avoid going there. If a returnee is triggered by seeing people who look like the enemy, she may begin to avoid being around similar-looking types of people. Some people may start to isolate from others more and more, avoid talking about their traumatic experiences, or stop going to crowded places or events, but avoiding something does not make it go away. By the same token, until an individual stops avoiding the trauma, he or she will not emotionally heal. The PTSD will only continue to get worse. Sharing is essential to healing traumatic experiences.

Feeling Out of Place in the Family

We first met Michael and Lisa in Step 3. Michael was medically discharged from the Army following an injury in which he lost most of his ability to use his arm and hand. In Step 3, Michael mentioned that when he is with his buddies, he could be “himself.” He said that at home he feels out of place, “like I’m a trained soldier and cop in this soft, clean, perfect world.”

In the exercise earlier in this step, Michael told Lisa and I that when he was younger, he didn’t have anyone with whom to share his innermost thoughts and feelings. His father was a police officer and would say that cops are “tough” and “feelings were for sissies.” Michael learned to internalize his father’s beliefs. Earlier, he had scoffed at the second item in the exercise, where he was asked to share his feelings with Lisa. When we discussed it later on, Michael admitted that it “might be helpful for other guys” to share vulnerable feelings, but that he wouldn’t do it himself because of his pride.

Michael’s Sharing Process

Michael had previously alluded to seeing some “bad stuff” while he was deployed, including the event that led to his disabilities. In other sessions, Michael denied that he was feeling depressed or having any symptoms of PTSD. I had suspected that he had been downplaying his symptoms, but we made some progress in this session when Michael finally admitted that he felt sad about his assistant, Frank, getting injured in an IED attack. I asked to speak with him alone at the beginning of our next session. Here is an excerpt from our conversation.

THERAPIST: Michael, in the last session you said that it “might be helpful for other guys” to share vulnerable feelings, but that your pride kept you from sharing yourself.

MICHAEL: Yeah, it may be pride, but sometimes talking about the bad stuff is just not necessary.

THERAPIST: And so what is it about pride that tells you not to talk about the bad stuff?

MICHAEL: Well, men aren’t babies or sissies. They shouldn’t have to talk about that.

THERAPIST: Talking about vulnerable feelings equals being a baby, or a sissy?

MICHAEL: More or less.

THERAPIST: Do you know any men who have talked about feeling sad or scared in-country?

MICHAEL: Yeah, I guess so.

THERAPIST: Can you tell me about them?

MICHAEL: There were guys who broke down in the field. Some guys just become a mess. They can’t handle it.

THERAPIST: And how did the unit respond to those guys?

MICHAEL: We just left them alone for a while. Most of them got over it. We had to Medevac a few out, and we never saw them again.

THERAPIST: What about some of the guys who stayed? Did you see them as sissies?

MICHAEL: No, but I’m sure they were pretty ashamed at the time.

THERAPIST: What makes you think so?

MICHAEL: They broke down and cried. That’s pretty embarrassing.

THERAPIST: What happened to the guys after they broke down?

MICHAEL: They got over it. I saw my sergeant with his face in his hands bawling once. He got over it.

THERAPIST: And is he a sissy?

MICHAEL: No . . . he’s not . . . he was back in the field two hours later.

THERAPIST: Remember how I mentioned that holding in emotions is related to having more bad memories and other PTSD symptoms?

MICHAEL: Yeah.

THERAPIST: In addition to those short-term problems, holding in emotions is also related to chronic health problems. So, actually the guys who went ahead and cried are going to be healthier in the long run.

MICHAEL: Even if they looked like babies?

THERAPIST: Sometimes the strongest thing to do is realize that pride isn’t helping you, and it isn’t even making you look better. Sometimes the strong thing to do is realize you’re not fooling anyone. The strong soldiers purge the bad stuff.

The Turnaround Point for Michael

I told Michael that I could see that, on some level, things were not going as well for him as he let on. Michael admitted he had been denying symptoms, to himself as well as to his family and loved ones. He said he was dealing with reminders of what had happened during the IED incident. He was particularly troubled by images of his buddy Frank before he died. However, he didn’t want his family to know how bad his symptoms were.

We explored what was behind his need to conceal his symptoms. Michael didn’t want his family to worry about him. He also said he was concerned that, if he opened up about what happened and ended up being vulnerable, he might appear to be “less of a man” in Lisa’s eyes. But Michael wanted to save his marriage. I told him that I thought Lisa would actually think more of him for sharing something so important from his life.

Once Lisa came back into the room, the three of us discussed the fact that many service members have a natural tendency to try to ignore and forget about the “bad stuff” that they have seen. We talked about how family members who do not share their experiences with each other actually grow further apart. Lisa said she would really like to hear about Michael’s experiences. Michael, with some hesitancy, said he thought he was ready to talk about it.

For Your Information: Trauma-Related Thoughts and Emotions

The sudden and/or violent death of a significant other in combat is often shocking and horrifying and can be difficult to accept. Service members who go to combat are trained to watch out for their buddies or fellow unit members. They are able to fight because they know their buddy has their back. When service members lose a peer or subordinate they were supposed to look out for, they may feel a profound sense of failure.

It is also common for surviving service members to blame themselves for the loss. When returnees have killed or harmed others, they may feel disgust or guilt about their actions. Even if they had been following orders, they may blame themselves. Some may consider themselves to be an “animal” or, in one returnee’s words, “the devil.” Other times, service members will blame their unit leader for making a strategic error that led to the deaths. Finally, service members may experience survivor guilt. That is, they may strongly regret surviving because they feel like they don’t deserve to live as much as the person who died.

Service members’ guilt or blame (toward self or others) can essentially serve as a way to “undo” the events (Resick & Schnicke, 1993). When service members obsess about changing the events leading up to the loss, they avoid coming to terms with and grieving the loss. People suffering from traumatic grief may also feel that if they accept the trauma, or even stop suffering the effects of the trauma, it means they are no longer honoring a person who has died. It may even feel like a betrayal to let go of the event.

In general, trauma survivors who suffer from PTSD have persistent and exaggerated negative thoughts about one’s self, others, and/or the world. Here are some examples:

These beliefs prevent people from resolving their traumas and have been identified as risk factors for PTSD (Brewin, Andrews, & Valentine, 2000). When trauma survivors share their stories, you can help to identify and gently challenge maladaptive beliefs they might be having associated with fear, guilt, anger, and sadness. For example, a returnee shared that having killed an enemy soldier in a battle now makes him a “murderer.” In this case, the clinician might highlight the differences between killing in war and murder. When the trauma survivor shares their experience and is loved and accepted by others, this will help the person have more accurate interpretations of what happened. In essence, they will consider different ways of looking at the trauma (Lepore et al., 1996).

The Need to Grieve

When service members continue to suffer in silence, it can be very therapeutic for them to share their experience and grieve with their loved ones. As the clinician, you can assist in two very important ways during the sharing process. First, you can encourage family members to be unconditionally loving and supportive. Second, you can guide the service member to stay in the moment and feel their emotional pain. With these two elements present, the returnee will be able to heal from these experiences, and it will bond family members closer together.

Some More Precautions Before Processing Trauma

As we have shared throughout this book, trauma processing is not something to be lightly treaded upon. As such, we would like to review a few very important points for you to consider as you proceed in this step with your military families.

Making It Real: Honoring the Loss

This exercise will help family members make sense of and begin their healing from trauma. It involves sharing the details of what happened and its impact on one’s family member(s) or spouse/partner.

Instructions: Please go to Family Handout Step 6.2.

We recommend first having the trauma survivor write out the event using the Step 6.2 handout “Honoring the Loss.” Any loss can be discussed, whether it’s an event, a particular person, a group of people, the loss of physical health, or of becoming disabled. However, we recommend that the loss be discrete enough to be able to discuss as one impression. For example, if a service member lost several unit members over the course of a year deployment, ask him to choose one person who he was particularly close to or who might particularly stand out to represent the rest. Please have the family member who has survived trauma respond to these questions.

1. What is it or who was it that you lost?

2. What was important to you about that person, thing, or event?

3. When did the loss occur?

4. How did the loss occur? What took place?

5. What were your thoughts when the loss occurred?

6. What are your thoughts now about the loss?

7. How exactly did having the person, place, or thing in your life change your life?

8. What can you do to honor the person, thing, or event?

Talking Points

With his family’s support, Michael was able to share about his loss, which he identified as “Losing Frank and being helpless to counterattack.” Michael shared some funny stories about when he first met Frank, and then told us about the day when his truck encountered an IED. He shared that, although he was hurt himself, it was even harder for him to see his close buddy Frank suffer from severe injuries and then die. He told Lisa that he thinks about the event several times a day. His thoughts focused on what he “should have done” and his belief that he was “responsible for” Frank’s death.

When I saw him grimacing and holding back tears, I gently reminded Michael to sit for a moment with his feelings and just breathe. Michael began to cry and exclaimed, “Damn it, Frank, damn it! Why’d you have to go?”

After Michael spent a few minutes experiencing his grief, I thanked Michael and let him know how much courage I thought he had to share his story with us. We discussed his difficulty accepting the loss of his buddy Frank. He said he had been obsessed with thoughts such as “I could have saved Frank” and “I should have known that we were going to hit an IED,” while he was at home watching TV or in bed at night. So we addressed these thoughts and briefly utilized cognitive processing therapy with Michael to address his guilt and self-blame for his friend’s death. Here is a little snapshot of this process.

THERAPIST: Michael, how do you know that you really could have saved Frank?

MICHAEL: “If I had acted more quickly, I may have been able to save Frank. It took me a few minutes to shake off the impact and move. By the time I put on the tourniquet, half of the blood was gone from his body.

THERAPIST: And so the IED should not have impacted you too?

MICHAEL: No.

THERAPIST: You were under attack and hit by an IED. How did the blast affect you?

MICHAEL: Well . . . my arm and hand were shattered, and I was bleeding from my face wounds (touching his injured arm with his other hand).

THERAPIST (gently): Michael, Frank’s death was not in your control. He was killed by the enemy. There was no way for you to prevent that from happening. Can you see that?

MICHAEL (looks at Lisa and me with new tears in his eyes): I just want that kid back.

After Michael allowed himself a few more minutes to grieve, I let him know that I thought Frank was lucky to have such a loyal and caring friend and leader. Lisa nodded in agreement and put her hand on Michael’s leg. He put his arm around Lisa and thanked her for “putting up with him.” Lisa told him that she actually felt relieved because now she understood what was going on with him, and she wished she had known earlier. Michael told Lisa that he was afraid of burdening her and Abby with his war experiences. She told him that sharing his deepest experiences with her was a gift, and thanked him for doing so.

A Load Off of His Shoulders

Sharing his experience in detail provided Michael with a chance to unload the weight he had been carrying around alone. Opening up about his military experiences to his wife also helped Lisa better understand and feel closer to Michael. Furthermore, Michael allowed himself to let down his guard and be vulnerable with Lisa. This experience helped strengthen the bond between the couple.

In later sessions, Michael seemed like a different man, without a heavy weight on his shoulders. Now, rather than feeling like a stranger or an imposter, Michael sees his home as a sanctuary away from his role as a soldier/cop. Michael can call on those roles if he chooses, but he can also “hang up that hat.”

Traumatic Grief

People suffering from trauma sometimes feel that if they accept the trauma, or even stop suffering the effects of the trauma, it means they are no longer respecting the person or event. It may even feel like a betrayal to let go of the loss. Helping your clients find meaning in their losses can help them let go in a healthy manner.

Sometimes a trauma survivor will need to undergo more intensive and specialized psychotherapy for PTSD before experiencing relief from their symptoms. If problems with PTSD symptoms persist, specialized treatment by an appropriately trained clinician with experience in prolonged exposure therapy (PE) and cognitive processing therapy (CPT) is recommended. Most of these, such as prolonged exposure and cognitive processing therapy (e.g., Monson et al., 2006), are individually based interventions, although cognitive processing for couples is also available.

In some treatments, clients are asked to write about the impact and content of the traumatic memory, and this is read aloud during the sessions. Such treatments directly target PTSD, as well as associated problems, such as depression, guilt, and anger. More information about these interventions is available on the National Center for PTSD website, http://www.ptsd.va.gov/professional/index.asp.

Making It Real: Meaning Making

This exercise focuses on helping trauma survivors honor the person, thing, or event that they lost through meaningful rituals or activities. You will help the trauma survivors to identify an activity or ritual that they can do with the support of their spouse or other family members.

Instructions: Please go to Family Handout Steps 6.3. and 6.4.

For Your Information: Traumatic Grief

Grief involves sad and painful emotions and other reactions to a major loss, such as the death of a loved one. Traumatic grief, however, is a different process that can interfere with the normal grieving process (Resick & Schnicke, 1993). Traumatic grief occurs when someone anguishes over a loss for an extended period. It often includes unwanted, invasive thoughts and a powerful need to reconnect to the person or object of the loss (Lichtenthal, Cruess, & Prigerson, 2004; Prigerson et al., 1995).

People suffering from traumatic grief may have:

Approximately 15% of people who are suffering from bereavement related to the loss of a loved one experience prolonged traumatic grief following the loss (Prigerson et al., 1999).

Talking Points

When we did this exercise, Michael immediately thought of an activity to honor his friend. Frank had often talked about his younger brother, who was mentally disabled. Because Frank was no longer around to support his brother, Michael decided to devote time volunteering with the Special Olympics. Due to the distance, Michael was unable to physically be there for Frank’s brother; however, he could support Frank by supporting a cause that was meaningful to his lost friend. Michael also created a new ritual to do with his family. He and his family would attend the yearly Special Olympics meets.

Letting Love Come In

As human beings, we all need to give love and be loved. To love unconditionally means that we love someone regardless of their qualities or actions. Humanistic psychologists such as Drs. Alfred Adler and Abraham Maslow considered unconditional love to be essential to a person’s sense of well-being. They believed that all people, even the most stoic or jaded, longed for intimacy and closeness. All people have an innate need to be loved and accepted. When family members receive unconditional love, they can be vulnerable enough to present their real selves because they know their family members are on “their side.” This last Making It Real exercise for this step will help family members to give and receive unconditional love and acceptance.

Making It Real: Unconditional Support and Acceptance

This exercise can be done with couples or family members. In this exercise, family members take turns making commitments to give unconditional love, support, and acceptance toward their loved ones. Family members make vows to be there for each other no matter what and learn how to give out love and to let it come in.

Exercise directions: Please go to Family Handout Step 6.5.

Talking Points

This last exercise was a turning point for Michael and Lisa’s relationship. Here were Michael and Lisa’s vows to each other.

Michael’s Vows

“Lisa, I don’t know how you have put up with me since I got back. I know I am hard to handle. From this moment on, I vow to open myself up to you. I will trust you with my thoughts, feelings, and pain. I will share myself with you and stop shutting you out. I vow to do my best to get closer to you, and to stop driving you away. You are the most important person in my life. And I love you so much.”

Lisa’s Vows

“Michael, I didn’t realize everything that you went through. I didn’t understand where you were coming from. I want to be there for you like you have never known before. I vow to be there for you, to listen, validate, and support you in any way you need me to. I vow to love you with all of my heart, regardless of what you are thinking or feeling. You are my heart, and I vow to always be there for you.”

When Michael and Lisa held hands and exchanged their vows, they couldn’t contain their feelings. You could see and feel all of the love this couple had for each other. This exercise helped to deeply strengthen Michael and Lisa’s relationship. They both came to understand more about each other, and they unconditionally loved and accepted one another.

Final Thoughts

Michael and Lisa shared their flaws and mistakes with each other. Michael was able to share his traumatic war experiences with Lisa, who was able to support her husband. This helped both Michael and Lisa to feel a deep sense of trust that they hadn’t felt in awhile. By giving and letting love come in, this family has grown closer together.

In your work with military families, we can’t emphasize enough how important it is to foster this unconditional support among family members. When family members know that they can be who they are, and still be loved in return, this will promote a more loving, trusting, accepting home. The family will learn to feel more at peace and at home with themselves and with each other. Their relationship bonds will be tighter, and they will be ready to move forward in life, to set new goals and face challenges together as a fortified military family.

Keys to Family Wellness

Taking Action

Taking action will help rebuild the family. Please check off each step as the family accomplishes it.