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Section 1
Splitting in PTSD

Question 1 | Test | Table of Contents

Over the past 12 years, more than 2.6 million veterans have returned home from service. With these men and women returning to their lives after the experience of military life, how can we, as mental health professionals, help them adjust to civilian life?

Soldiers vs. Warriors
In writing this course, there appears to be an awkwardness in the terminology. If we use the term Soldier, traditionally that can refer to those serving in the Army, thus, excluding the other military branches. The most commonly used generic term for those having served in the military is warriors. Thus at times we will use the following words to mean all of those that served in the military: soldier, warrior, or soldier/warrior.

In the first portion of this course, we will discuss the transition from soldier to civilian. In the second portion of the course, we will focus on EMDR.

In this section, we will begin with the discussion about how your client can eliminate their black and white thinking and helping them decide what to share with their loved ones.

Sharing Experience- Eliminating Black and White Thinking:

Kyle, age 32, was a Guardsman who served in the transportation unit and went on multiple convoys, and he explained that he was constantly under threat of fire and bombings. He explained hesitantly, "The memories and flashbacks were so horrible and immediate, I would freeze with fright every time they came. It was exactly like it was happening all over again. Only. this time, it was evidently coming from inside my own head- although you couldn’t convince me while it was happening."

Kyle came to me when he began feeling concerned after returning home. He stated, "Since I didn’t know how to fit back in with my family and friends, I felt useless and out of place. I am having a hard time adjusting to civilian life and going back to the way things were."

When veteran clients are adjusting to civilian life I have found it helpful to discuss how black-and-white thinking can be unhelpful when trying to talk with loved ones about their experience. I stated to Kyle, "For one thing, you may feel as if you have to tell your family and friends all or nothing about your experience. Because the risk of sharing everything is so great, it would make sense with all or nothing thinking to not share anything. Secondly, you may think that only veterans would be able to understand what you went through and nobody else."

I then shared with Kyle how he can set the stage for sharing his experience through the following six steps:

1. Before going into your experience ask loved ones to describe what it was like during the time while you were away

2. Choose people with whom to share who you know you can trust and who are likely to understand.

3. Talk with them when you have enough time for the conversation and when you won’t be distracted.

4. Share with your loved one how you would like them to respond before you begin. For example, Katie requested that her family only listen and not interrupt her.

5. Avoid using black-or-white thinking and share only what you feel comfortable sharing. You don’t have to go chronologically and you don’t have to share only the bad or only the good parts of your experience.

6. Make time for a cool down to deescalate the conversation before going back to your daily routine. I stated to Kyle, "in other words, instead of rushing off to the movies, immediately leaving to visit a friend, when you have said everything you wish to say at this time, you might shift the conversation to something neutral and in the present. Thus this makes a transition between the discussion of the war experience and everyday life."

We will now transition to discussing how your client can decide what to share with their loved ones about their combat experience.

Deciding What to Share:

I have found it is also important and helpful to go over with your veteran client what they would want to share. Here are some basics that I shared with Kyle as he decided what he wanted to share with his family. As you will notice these are ranked regarding the level of intensity into two parts.

Part 1: General light sharing

1. General photos: Low general level of intensity: Share memorabilia such as photographs. For example, Kyle had photos showing where he lived.

2. Positive Journal Entries: Higher level of intensity: I suggested Kyle use post-it notes to mark selected pages of his journals while keeping in mind what may be a trigger and cause uncomfortable memories. He decided to share journaling he had done regarding positive connections with others in his unit.
3. Lessons Learned: Discuss a few of the people you served with and what you learned from them.

4. Different Environment: Recount what it was like to be immersed in a different environment and culture while at war. This information can be general regarding climate, dress, food, etc.

5. The Future: Talk about how your view of life and your hopes for the future have changed because of the war.

Part 2: Selective sharing of emotionally charged events:

I have found it best for my clients to save sharing these four types of emotional events only for those with whom the client has a high level of trust. To assess trust, I ask clients to list the names of those family or friends who were the most supportive of the client when he or she left. I also discuss what it means to be supportive. When I asked Kyle what supportive means to him, he responded, "To me, the people in my life who are supportive don’t ridicule, criticize, or second guess me, or react in disgust." Kyle had an older brother he felt particularly close to. He decided to select him first to share these more emotionally charged events.

1. Combat survival strategies currently used: I suggested to Kyle, "Mention to your family how you are trying to cope with your war experience by sharing survival strategies that you have found helpful and perhaps information they could use as well." For example, Kyle as he put it, "had a bad temper" before he was deployed. Now he is better at putting things in perspective after being involved in life and death situations.

2. Combat and Death: Share selected journaling entries regarding combat, death, and dismemberment.

3. Current combat reactions i.e. nightmares: Discuss reactions that you are currently having that are tied to your war experience. For Kyle, he wanted to explain the nightmares he was having about his deployment.
4. Specific Events: Share a specific event during your deployment or service that had a tremendous impact on you.

Do you have a soldier/warrior as a client who is struggling regarding sharing his or her experience with their loved ones?

In this section, we discussed the transition from soldier to civilian. We began with the discussion about how your client can eliminate their black and white thinking and help them decide what to share with their loved ones. When deciding what to share there are two levels of sharing. The five topics listed under level 1 sharing are General photos; Positive Journal Entries; Lessons Learned; Different Environment ; and the future. The four topics listed under level 2 sharing are reserved for individuals they can trust and that would be supportive. They are: Combat survival strategies currently used; Combat and Death; Current combat reactions i.e. nightmares; and Specific Events.

In the next section, we will discuss how returning soldiers/warriors can adjust to civilian life by learning to respond to dumb questions from civilians, talk about their war experience with supportive adults. Furthermore, we will discuss how they can relearn to communicate with and discipline their child.

Source: Armstrong
statistic source:
case study: Naparstek 95
Reviewed 2023

Shifting to Trauma-Informed Care in Inpatient Psychiatry: A Case Study of an Individual with Dissociative PTSD Undergoing EMDR Therapy

Winkler, O., Burback, L., Greenshaw, A. J., & Jin, J. (2023). Shifting to Trauma-Informed Care in Inpatient Psychiatry: A Case Study of an Individual with Dissociative PTSD Undergoing EMDR Therapy. Case reports in psychiatry, 2023, 8161010.

Peer-Reviewed Journal Article References:
Baker, F. A., Metcalf, O., Varker, T., & O'Donnell, M. (2018). A systematic review of the efficacy of creative arts therapies in the treatment of adults with PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, 10(6), 643–651.

Barr, N., Davis, J. P., Diguiseppi, G., Keeling, M., & Castro, C. (2019). Direct and indirect effects of mindfulness, PTSD, and depression on self-stigma of mental illness in OEF/OIF veterans. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.

Barr, N., Kintzle, S., Sullivan, K., & Castro, C. (2018). Suicidality and nonsuicidal high-risk behavior in military veterans: How does PTSD symptom presentation relate to behavioral risk? Traumatology, 24(1), 55–61.

Gagnon, J., Vintiloiu, A., & McDuff, P. (2016). Do splitting and identity diffusion have respective contributions to borderline impulsive behaviors? Input from Kernberg’s model of personality. Psychoanalytic Psychology, 33(3), 420–436.

Kramer, U., de Roten, Y., Perry, J. C., & Despland, J.-N. (2013). Beyond splitting: Observer-rated defense mechanisms in borderline personality disorder. Psychoanalytic Psychology, 30(1), 3–15. 

Marx, B. P., Engel-Rebitzer, E., Bovin, M. J., Parker-Guilbert, K. S., Moshier, S., Barretto, K., Szafranski, D., Gallagher, M. W., Holowka, D. W., Rosen, R. C., & Keane, T. M. (2017). The influence of veteran race and psychometric testing on veterans affairs posttraumatic stress disorder (PTSD) disability exam outcomes. Psychological Assessment, 29(6), 710–719. 

What are some examples of Level One sharing of deployment experiences reserved for individuals they can trust and that would be supportive? To select and enter your answer go to Test.

Section 2
Table of Contents