Contemp Fam Ther (2018) 40:266–275

DOI 10.1007/s10591-017-9424-z

ORIGINAL PAPER

Using Internal Family Systems Theory in the Treatment

of Combat Veterans with Post-Traumatic Stress Disorder
and Their Families
Rebecca Lucero1 · Adam C. Jones1 · Jacob C. Hunsaker2

Published online: 18 August 2017

© Springer Science+Business Media, LLC 2017

Abstract As many as one-third of all combat veterans Keywords Internal Family Systems theory · Post-
experience symptoms of post-traumatic stress disorder fol- traumatic stress disorder · Combat veterans · Systemic
lowing their service to the military (United States Depart- therapy · Military families
ment of Veterans Affairs 2016). Despite government efforts
to provide care for those suffering from PTSD symptoms,
veterans still struggle to receive appropriate and effective Introduction
treatments. Inadequate care often has devastating effects on
the veteran and his or her family. Currently, veterans typi- At least 11–30% of combat veterans experience post-trau-
cally receive individual treatments such as cognitive behav- matic stress disorder (PTSD) following their service to the
ioral therapy, exposure therapy, or eye movement desensiti- military (United States Department of Veterans Affairs
zation and reprocessing. While the United States Department [USDVA] 2016a, b). Although the prevalence of this disor-
of Veterans Affairs provides individually focused evidenced der has made it necessary that the U.S. government provide
based treatments, they do not currently endorse any par- more funding for treatment of veterans, veterans and their
ticular model of family systems therapy for the treatment families still struggle to receive appropriate and effective
of PTSD in veterans or their families. The present article treatments (Vogt et al. 2014). Currently, veterans are typi-
aims to demonstrate that Internal Family Systems (IFS), a cally receiving individually based treatments such as trauma-
systemic form of therapy, provides an effective treatment for focused cognitive behavioral therapy, exposure therapy, or
combat veterans who suffer from PTSD. We propose that eye movement desensitization and reprocessing (EMDR)
IFS’s collaborative approach, less-pathologizing stance, and (USDVA 2016a, b). While the Department of Veterans
simple language will resonate with military populations. We Affairs provides individually focused evidenced-based treat-
also argue that IFS provides a seamless transition between ments, they do not currently endorse any particular model of
individual and family therapy allowing the therapist to family systems therapy for the treatment of PTSD in veterans
address both the individual and relational effects of PTSD. (Mansfield et al. 2010; USDVA 2016a, b).
The potentially traumatic nature of military combat does
not only impact veterans, but also their families, often in dif-
ferent ways (Monson et al. 2009). While individual forms of
treatment may benefit the combat veteran with PTSD symp-
Jacob C. Hunsaker was deployed in Afghanistan, Operation
Enduring Freedom 2010–2011. toms, these treatments may ignore the family experience and
overlook the potential usefulness of family integration in
* Rebecca Lucero therapy (Mansfield et al. 2010). Also, combat veterans dif-
[email protected]
fer from other populations in their experiences with PTSD
1
Marriage and Family Therapy, Texas Tech University, P.O. due to the complexity of their trauma. Due to the prevalence
Box 41250, Lubbock, TX 79409, USA of PTSD symptoms within this population and the lack of
2
Marriage and Family Therapy, Bear Lake Community Health available treatment services, we present the case that more
Centers, Logan, UT, USA

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Contemp Fam Ther (2018) 40:266–275 267

systemic approaches and resources should be available to have examined why veterans fail to receive services pro-
this population. vided by the Department of Veteran Affairs, there are still
Our study aims to demonstrate that Internal Family Sys- unknown factors that may contribute to why veterans do
tems, a systemic form of therapy, can provide an effective not access care (Ouimette et al. 2011). Veterans who access
treatment model for the unique challenges of combat veter- services report that individual and/or family therapy services
ans with PTSD, as well as their families (Schwartz 1994). provide the greatest reduction of PTSD symptoms (Toscano
Within this article, we also provide a working guide to IFS and Roberts 2014). However, only individually based forms
treatment and the rationale to use IFS with this population. of therapy have been verified as evidenced-based treatments
To conclude, we use a case study to demonstrate how thera- (i.e., EMDR, Exposure Therapy, Trauma-Focused CBT)
pists may use IFS in the treatment of combat veterans. available for the treatment of PTSD in combat veterans
(USDVA 2016a, b). While these disturbances are experi-
enced personally by the combat veteran, their impact is felt
Review of Literature within the entire family system. These individual treatments
may overlook the secondary impact that family members
A significant portion of veterans with PTSD report that have on the veteran’s recovery (Mansfield et al. 2010).
their symptoms cause a number of disruptions to their lives, Combat veterans with PTSD and their partners report
including problems both on a personal level and in their greater levels of marital and parenting problems as well as
familial relationships (Warner et al. 2009). Veterans who problems with family adjustment (Jordan et al. 1992). Such
are diagnosed with PTSD may suffer from a number of problems include higher rates of behavioral problems in
symptoms including nightmares, dissociation, hyper-vigi- children and violence by either the partner or the veteran
lance, overreaction to stimuli, marked physiological reac- (Jordan et al. 1992). As a result of both increased personal
tions, flashbacks, persistent avoidance, exaggerated negative and relationship problems, many veterans cope with these
beliefs, distorted cognitions, arousal, angry outbursts, prob- challenges by resorting to substance use, disconnecting from
lems with concentration, sleep disturbances, depersonaliza- loved ones, and even suicide (Miles et al. 2015; Vogt et al.
tion, and derealization (American Psychiatric Association 2014). One study found that more than one-third of mili-
[APA] 2013). tary partners or spouses met criteria for at least one mental
Furthermore, military veterans may display symptoms of health diagnosis (Gorman et al. 2011). Family members may
complex PTSD more often due to prolonged exposure and also experience secondary, or vicarious, symptoms of PTSD
repeated trauma inherent in combat (Herman 1992). The while trying to support their veteran family member upon
most common stressors reported by soldiers and marines returning home (Monson et al. 2009). Family members and
include experiences such as roadside bombs, handling partners may not seek mental health treatments for the same
human remains, killing an enemy, inability to stop violence, reasons as combat veterans (i.e., fears of stigma or nega-
and seeing dead or injured fellow soldiers (Hoge et al. 2004). tively effecting their career) (Gorman et al. 2011).
Soldiers often face these scenarios and other traumatic situa- Although family members of veterans experience prob-
tions multiple times over the course of one or more deploy- lems due to their loved one’s PTSD symptoms, there are
ments. Notwithstanding training and preparation, many few professionals employed by the Department of Veterans
soldiers still suffer PTSD symptoms due to the complex and Affairs who are specifically trained to treat veterans with
repeated nature of these traumatic situations. their families. Marriage and family therapists comprise only
Despite the severity of distress caused by PTSD, many 0.7% of the 21,000 mental-health professionals employed
veterans do not seek out mental health services, or they by the Veterans Affairs Department (American Association
report that these services have not been helpful (Ouimette for Marriage and Family Therapy [AAMFT] 2017). With so
et al. 2011; Vogt et al. 2014). Many veterans fail to access few professionals trained to treat families, veterans and their
care due to the social stigma related to seeking help (Gor- families fail to obtain services beyond individual therapy for
man et al. 2011; Ouimette et al. 2011). Though less likely, the veteran.
some veterans suffering from PTSD have trouble obtaining Furthermore, the difficulty in integrating warring and
assistance due to logistical barriers such as “fit” into the VA civilian identities is a major contributor to familial and indi-
health care system, scheduling issues, lack of transportation, vidual distress experienced by military veterans. The mili-
cost of travel to obtain services, and perceived skill of clini- tary identity demands obedience, chain-of-command, and
cians (Ouimette et al. 2011). dissociation while the civilian identity demands self-advo-
Moreover, treating and helping military veterans with cacy, autonomy, and relationships (Smith and True 2014).
PTSD remains a continual challenge for clinicians as vet- The stark contrast between these identities increases sus-
erans tend to only access services that they perceive to be ceptibility for mental health disorders and relational prob-
helpful (Toscano and Roberts 2014). Though several studies lems (Smith and True 2014). Blending these two identities is

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difficult for the veteran alone. However, families often deal shock (Schwartz and Sparks 2014). In the face of attach-
with residual effects of these dueling identities as well (Gor- ment injuries or traumatic events, exiles are often left to
man et al. 2011). As the veteran struggles to create a cohe- shoulder the burden of the immense pain associated with
sive identity, the family is also in a constant state of flux. the event. Upon severe injury or hardship, many hide the
Balancing systemic and individual effects of PTSD can be exile away and no longer wish to acknowledge the pain.
especially challenging for both clinicians and their clients. Unable to process their pain, exiles are often suppressed
The Department of Veteran Affairs (2016a, b), recom- until further distressing events occur, which often results
mends family therapy as an additional form of treatment in a consuming emotion of depression or hopelessness
and recognizes that PTSD affects the whole family. While (Schwartz et al. 2009).
veterans have identified that family therapy is a useful form Combat veterans are confronted with the moral dilem-
of treatment (Toscano and Roberts 2014), there is currently mas inherent in war. The traumatic exposure to violence or
no endorsed, evidence-based family therapy model for the death may not be fully processed during deployment. Upon
treatment of PTSD in combat veterans and their families. their return, combat veterans are often confronted with the
We propose that Internal Family Systems (IFS) provides an realities of war as they try to reintegrate into civilian life
approach that can both address the complex nature of PTSD (Smith and True 2014). Furthermore, the constant possi-
in military veterans and operate from a systemic model that bility of re-deployment may motivate some to continually
allows for integration of relational therapy. repress the exile in order to ensure future survival. Combat
veterans may hesitate to discuss their exiled parts, due to
the severity of the trauma and the risk of exposing others
Internal Family Systems to their traumatic experiences.

Over the past two decades, IFS has become an increasingly

more popular approach to individual and family treatment. Managers
The IFS approach centers around understanding how inter-
nal parts, or psychic multiplicity, interferes with a person’s In response to injury and pain, other parts work to move
internal and mindful Self (Schwartz 1994). Schwartz’s the Self to a place of safety. One of these parts is com-
(1995) development of the model came from the idea that monly referred to as a manager. In its role as protector,
individuals’ internal workings often function much like a these managers work to identify and mitigate anything at
larger family system operates. IFS developed by utilizing risk of upsetting the exile. These parts also strive to accel-
systemic approaches to treat each individual as his or her erate an individual’s appearance, performance, and rela-
own internal family system (Schwartz 1995). tionships (Schwartz et al. 2009). This awareness of others’
The IFS approach assumes, that like a larger family sys- perceptions is also what contributes to managers being the
tem, each internal part has good intentions and immense largest critics. Often these managers can become so criti-
value (Schwartz and Sparks 2014). These internal parts take cal as to squander function and lead to self-destruction.
on characteristic roles that harbor pain (exiles), maintain The role of the manager manifests itself in the combat
normal functionality (managers), or respond to imminent veteran when the veteran asserts that he or she is well or
threats (firefighters) (Twornbly and Schwartz 2008). Simi- able to move forward without addressing the pain. Both
lar to family therapy approaches, individual improvement is among civilians and fellow military personnel, veterans
achieved not when a dysfunctional part is removed, but after may feel pressure to perpetuate an image of stoicism and
each part has been seen and valued (Green 2008). When strength. Society often views soldiers as examples of hero-
these parts do not dominate the person’s behavior, an indi- ism, bravery, strength, and courage. Often managers seek
vidual is better able to mindfully and calmly approach situ- to give the impression that everything is okay and that the
ations, what Schwartz (2004) calls leading with the Self. veteran is adjusting to civilian life. For example, Hoge
et al. (2004) found that in soldiers and marines diagnosed
with mental health problems, only 38–45% indicated
Parts Explained an interest in receiving help. A year later only 23–40%
reported actually receiving help. Those with mental health
Exiles problems were twice as likely to report fear of stigmatiza-
tion in receiving help as those without mental health prob-
The exile often represents the most innocent, sensitive, lems. Often the desire to show that “everything is okay”
spontaneous, and child-like part of an individual. While conflicts with the exile’s need to process the pain, which
these parts may be the most trusting and vulnerable, they often leads to the manifestation of firefighters.
often are more susceptible to feelings of hurt, betrayal, or

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Firefighters creativity, and connectedness (Schwartz et al. 2009). Once

parts are identified, clients are encouraged to speak for a
Managers may often overwhelm an individual’s sense of him part, rather than speaking from that part and allowing it to
or herself. Also, exiles may deal with such great pain that it dominate the Self (Lavergne 2004). For example, a clinician
overwhelms the function of the manager. In these instances, might recognize self-leadership when a client can recognize
there is another part that looks to protect the Self from deal- and communicate when they are feeling overwhelmed or
ing with the pain carried within the exile. These firefighters threatened by a situation, and identify which part is want-
often take drastic measures in order to numb or escape the ing to dominate the Self. This allows clients to mindfully
pain of the exile (Schwartz 1995). If the pain carried by acknowledge the needs of each part while not being con-
the exile is immense, firefighters often turn to binging on trolled by it.
alcohol, drugs, sex, or food in order to flee the scene imme-
diately. This movement is often for the purpose of distracting
the Self from addressing the pain until the present threat has IFS and Trauma
dissipated (Schwartz 1994).
Veterans who have faced combat and experience PTSD The IFS model has recently been acknowledged by the
symptoms often become overwhelmed by the pain that the National Registry of Evidence-based Programs and Prac-
exile holds. The firefighter is activated in an attempt to tices (NREPP) as an evidence-based treatment for effec-
help the veteran escape by resorting to extreme but effec- tively improving phobia, panic and generalized anxiety dis-
tive ways of avoiding that pain. Within military veterans, order, physical health conditions, and depressive symptoms
these attempts are often categorized as externalized behav- (Matheson 2015). IFS has also been commonly used in the
iors, such as substance abuse and violence, and internalized treatment of trauma. Schwartz himself, along with numer-
behaviors, such as depression, suicidal ideation, and disso- ous other trauma experts have endorsed IFS as a beneficial
ciation. Veterans who return from deployment are at greater approach (Twornbly and Schwartz 2008; Schwartz et al.
risk for alcohol and drug abuse (Eisen et al. 2012). This 2009; Schwartz and Sparks 2014). However, while IFS is
increased risk is due to the unrelenting pain that accompa- widely used to treat trauma, effectiveness studies of IFS
nies PTSD symptoms. While veterans may hope to only use treatments of trauma have not yet been conducted. Further-
their firefighters until the present threat dissipates, they often more, no current research addresses how to apply IFS to the
resort to more extreme behaviors, such as suicide, when the unique challenges of combat veterans.
pain does not disappear or lessen with time. Recognizing the unique culture and nature of military
service may change how we treat veterans in comparison to
Self others who experience different types of trauma. We argue
that combat PTSD may be different in its complexity due to
Schwartz (1995) identified that while individuals often speak increased exposure of trauma which realigns parts in order to
from various parts there is always a true or core Self that form a unique identity around the traumatic experience. The
knows what each part is needing. This Self is often mani- parts may be polarized to extremes when confronted with
fest when the person is in a curious or compassionate state new and traumatic experiences. However, upon returning
of mind, appropriate to lead the other parts with balance from deployment, the difficulty in integrating civilian and
and harmony. This Self is not a passive, nonjudgmental military identities is manifest in symptoms of PTSD (Smith
observer, but rather an active, compassionate leader. Those and True 2014).
who feel connected to the Self feel that they are centered,
light-hearted, confident, and free, without a sense of dis-
sociation or separateness from their other parts (Schwartz IFS and Combat Veterans with PTSD
and Sparks 2014).
Although individual treatments have been identified as use-
Self‑Leadership ful for treating PTSD in combat veterans, IFS offers a num-
ber of unique philosophical differences in its approach that
Developing competency in embodying qualities of Self- may resonate with military culture and potentially produce
leadership is the most important concept in IFS. IFS thera- better treatment outcomes for this population. Many of the
pists commonly spend the majority of their sessions helping currently-used, directive models of treatment focus on the
clients identify their parts and from which parts they speak. eradication of symptoms and may pathologize a population
The Self is usually identified when the client attitude toward that is resistant to the stigma of being diagnosed with a men-
different parts is characterized by one of the eight C’s: calm- tal health disorder (Hoge et al. 2004). In contrast, IFS is an
ness, clarity, curiosity, compassion, confidence, courage, integrative treatment approach that draws from both modern

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and post-modern theories. IFS incorporates post-modernism constantly adjusting to create a new homeostasis when the
by employing a collaborative effort between the client and veteran returns. The language within IFS focuses on internal
clinician in identifying treatment goals and content of thera- parts that can be applied to the internal system as well as
peutic sessions. Within this paradigm, the therapist views the to the parts of other individuals within the family system
client as an equal who brings both resources and strengths as (Goff and Smith 2005). Using IFS, clinicians easily integrate
they work together to find solutions. In this way, the client is family therapy at any point during the therapeutic process.
free to determine what symptoms are problematic rather than Rather than receiving psycho-education or skills training,
the therapist assessing and diagnosing a disorder. Veterans family members are encouraged to identify their own parts
are commonly aware of the difficulties they face in adjust- and respectfully honor each person’s voice in therapy.
ing to civilian life but they do not want to be perceived as
being mentally weak or incompetent (Pietrzak et al. 2009).
The less-pathologizing approach of IFS honors veterans’
sacrifices and bravery to enter potentially traumatizing situ- IFS Treatment Suggestions for Combat Veterans
ations by acknowledging and giving space to define what with PTSD
post-deployment life looks like, rather than being focused
on returning to “normal” civilian functioning. Assessment and Diagnosis
Many trauma treatments may view the existence of men-
tal multiplicities as a sign of pathology (Forgash and Knipe Combat veterans who deal with symptoms of PTSD often
2008). However, the IFS model sees all parts as essential receive more than one diagnosis before seeking treatment
components toward healthy functioning (Schwartz and (Holowka et al. 2014). They often seek out services through
Sparks 2014). This paradigm may change the way clinicians the Department of Veterans Affairs where they might be
treat symptoms such as depersonalization or de-realization diagnosed by a psychiatrist or other mental health profes-
(Twornbly 2013). Many veterans may struggle in other treat- sional. It is possible that a veteran will contact a therapist
ments when they feel the treatment aim is to diminish the prior to receiving a diagnosis. If there is no previous diag-
identity formed in combat and to return to a civilian iden- nosis, it is important for the clinician to assess and diagnosis
tity. Combat veterans may especially resonate with IFS’s accurately. Clinicians should be aware of all previous diag-
language of parts as they often face difficulty in integrat- noses and reported symptoms in order to understand how the
ing these two identities (Smith and True 2014). This com- client views his or her diagnosis. In determining a diagnosis,
mon struggle for a combat veteran is easily conceptualized we recommend collaborating with all other health profes-
within IFS’s approach to self-leadership (Schwartz et al. sionals that are treating the veteran. Collaboration allows
2009). This parts language in IFS is simple and intuitive for therapy sessions to focus on the client’s goals rather than
clients in treatment and does not require extensive psycho- determining a diagnosis.
education or skills training. Military veterans may feel that PTSD is commonly over-
As the therapist and client identify how the parts inter- diagnosed and does not fully represent their individual
act with one another, the clients become more aware of experiences following combat service (Pietrzak et al. 2009).
their own internal struggle that contributes to problematic Allowing veterans to define what is most problematic for
behaviors. For veterans with PTSD, hyper-vigilance to them provides direction for the IFS therapist. On the con-
potential triggers feels automatic and necessary. Mindful- trary, there may be some veterans that are relieved when they
ness approaches are commonly employed to help veterans receive a diagnosis which characterizes their experience.
slow-down these automatic reactions to stimuli (Schwartz Whatever the case, rapport is built as the therapist and client
and Sparks 2014). These mindfulness approaches are often work together to define goals of therapy (Schwartz 1995).
met with resistance from combat veterans. From the para- The less-pathologizing stance of IFS allows the therapist to
digm of IFS, this “backlash” is often the result of a lack of see the client as the client sees himself or herself, enhanc-
knowledge about how client’s parts interact rather than the ing the level of trust that the client places in the therapeutic
client’s unwillingness (Twornbly and Schwartz 2008). IFS relationship.
clinicians often utilize mindfulness techniques and apply When using IFS, the first few sessions will focus on
them sensitively in order to help the client connect with the assessing the individual’s internal system. In these sessions
Self and identify how their parts interact. the therapist and client work together to intently listen to
IFS also differs from current treatment approaches due to the problems experienced by the client and identify differ-
its natural ability to seamlessly transition between individual ent parts within the client that are acting in conflict. It is
and family treatment (Green 2008). As mentioned previ- important to allow clients to use their own vocabulary as
ously, combat veterans experience personal conflict integrat- they identify their different parts (Schwartz 1995). These
ing military and civilian life; however, family systems are conversations should continue until both the therapist and

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client have a vivid description of how each part functions in PTSD suggest that mindful awareness of these effects is
the system, sometimes even naming the various parts. essential to promoting proper cognitive functioning (Lang
As the therapist and client explore these different parts et al. 2012; King et al. 2016). Mindfulness approaches help
they will gain a greater understanding of how various PTSD reduce the tendency to avoid negative symptoms (which
symptoms have emerged and maintain themselves within often tends to exacerbate outcomes), but rather allow dif-
the individual’s internal family system. Combat veterans ficult emotions to be observed and acknowledged, which in
commonly experience a brand of PTSD where the interac- turn helps clients to recognize other potential responses to
tion between parts is very rigid; some parts being grossly stimuli (Lang et al. 2012; Schwartz and Sparks 2014). IFS
dominant while others may be wholly neglected (Herman treatment looks similar to other mindfulness approaches
1992). It is important for clinicians to recognize that the pro- by allowing veterans to acknowledge the needs of differ-
gress of treatment may be significantly slowed due to these ent parts and promote harmony between them (Schwartz
polarized dynamics. While therapists are encouraged to ask 2004).
questions concerning the interaction of each part, we recom- Because some symptoms of PTSD can be intrusive and
mend therapists resist the urge to directly access parts that debilitating (i.e., nightmares, hyper-vigilance, dissocia-
are particularly distressing, until the veteran demonstrates tion, flashbacks), veterans often come to treatment desper-
that he or she can appropriately Self-lead and maintain har- ate to eradicate all symptoms. They may grow impatient
mony between other parts (Schwartz 1995). trying to connect an internal conflict to these events. We
recommend externalizing these intrusive symptoms and
Family Assessment and Diagnosis integrating parts language to understand how the various
parts make sense of the symptoms. It is important not to
As mentioned previously, one of the potential benefits of attach symptoms to any particular part (Schwartz 1995).
using IFS to treat PTSD is the model’s systemic tenants, Therapists should help the client gain an understanding
which make it appropriate for family therapy as well. of how parts recognize and respond to the various symp-
Because military service often creates a new identity for toms. This process may be similar to externalizing a fam-
the combat veteran, upon his or her return, the family system ily member’s mental illness to recognize its effect on the
must adjust to a new homeostasis to account for the change entire family system. Miller et al. (2007) provide a useful
(Smith and True 2014). When treating individuals with reference for integrating narrative and IFS practices in
PTSD, we recommend meeting with other family members therapy. As clients separate their symptoms from them-
in order to gain greater contextual insight as to how the indi- selves and their parts, we recognize that they become less
vidual’s symptoms impact the larger family system. It may focused on eradicating the symptoms, but rather focus on
also be important to assess if family members experience managing the effects of the PTSD and find an appropriate
secondary PTSD, and whether that has reciprocal effects balance between parts (Miller et al. 2007).
on the veteran (Goff and Smith 2005). After assessing for Due to the polarizing effect that PTSD symptoms can
contextual factors, the clinician should work with the family have on an individual’s parts, sessions might focus on zero-
to determine an appropriate integration of treatment for both ing-in on one particular part with the goal of understanding
the individual and family. that part’s needs and addressing those needs from the Self.
When using IFS with families, the therapist adds another This allows the client to reconnect with the part of them that
level of analysis to the typical analysis and diagnosis of fam- wants to give a “fight or flight” response. The therapist may
ily dynamics. In IFS treatment, the unit of analysis includes first identify reactions to present or recent triggers and ask
each individual’s internal system and his or her influence him or her to track the event’s physiological effects. Thera-
on the family system. Family dysfunction is viewed as the pists should help the client identify which part is influenc-
imbalance within and among family members. When the ing them and then ask the client’s Self how they feel toward
whole family system is not functioning properly, the internal that part. Sometimes the client may resist leading with the
systems of family members will also be dysfunctional with Self and may respond from another part (i.e., “I feel pissed
the reverse also being true. that I feel helpless”), in which case the therapist may ask
that other part to step aside and provide space for the Self
Treatment to lead. The clinician and client can identify self-leadership
when any of the 8 C’s are present (Schwartz et al. 2009).
A large number of PTSD symptoms have physiologi- Once self-leadership has been identified, the therapist may
cal effects on the individual. IFS’s approach to building then invite the client to extend any of those 8 C’s to other
awareness of parts and their physiological effects has been parts. Before moving on to another part, it is always impor-
suggested as an important integration for treating trauma tant to ask the client if that part has any other salient needs
(Schwartz and Sparks 2014). Most approaches for treating (Schwartz 1995).

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Role of the Therapist For a few months before our appointment he had increased
his drinking in order to help him fall asleep at night, but as
Providing effective IFS therapy for veterans with PTSD the nightmares failed to cease, he came to the conclusion
requires a deep commitment to the collaborative paradigm that he needed help.
upon which the theory is built (Schwartz and Sparks 2014). Kylie’s description of Rex’s behaviors provided an alarm-
For example, from this paradigm, what might be typically ing insight into Rex’s symptoms. Kylie’s account shed light
viewed as resistance from the client, is seen simply as addi- on the effect Rex’s symptoms had on the family as a whole.
tional information. As the IFS therapist commits to their Kylie reported that she was feeling increasingly distant from
own self-leadership, they will respond to resistance with Rex. Kylie indicated a number of instances when Rex had
curiosity and utilize the resistance to understand more about “lost his temper.” The most recent incident, in which Rex
the client’s parts (Schwartz 2004). had knocked down a bookcase, was the first time Kylie felt
Goal setting in IFS is a collaborative process, rather than physically threatened. Kylie also described one instance in
being client- or therapist-directed. As part of this goal set- which Rex was driving the car and swerved to miss trash in
ting process, it is important for clinicians to be aware of the road thinking it was a possible IED. She said that when
their own agendas for the client. Therapists can observe the this happens he gets shaky and breathes heavily for a long
reactions of their own parts and recognize self-leadership period of time afterward. She also reported that Rex was
when they are using the eight C’s. Therapists who continu- rarely sleeping, and she would often have to wake to him in
ally work to lead from the Self and emphasize transparency distress following a nightmare. As time went on, Rex was
about their parts’ reactions model effective self-leadership isolating himself more and more. With Rex being gone for
for the client. so long due to his deployment and recovery, and because
Additionally, due to the difficult nature of treating PTSD of his more recent withdrawal from the family, Kylie had
symptoms, it may be important that clinicians continually noticed that their daughters had been making little effort to
seek collaborative efforts with other health professionals connect with their father. She herself had even started to ask
(Zeiss et al. 2012). Veterans with PTSD often receive other her oldest daughter, Sarah, for help with the other two girls
medical or psychiatric services. Effectively managing open instead of asking her husband. She felt guilty about this but
communication with these professionals can increase the said that it was simply easier. According to Kylie, Rex had
likelihood of treatment success. been given a few medications to help with anxiety and sleep,
but indicated that he had not been taking them.

Clinical Illustration Individual Sessions

Rex initially sought treatment at the VA hospital for ser- Following the initial assessment, I determined with the cli-
vices related to sleep disturbances. After meeting with a ents that I would meet individually with Rex for a few ses-
psychiatrist and a social worker, he was diagnosed with sions before bringing Kylie and their children into treatment.
post-traumatic stress disorder. Due to high volumes, he was Over the course of our first few sessions, Rex identified some
referred to my clinic for treatment of his PTSD symptoms. of the most salient problems in his life that he wanted to
After consulting with Rex over the phone, I asked that he address in treatment. He wanted to stop having nightmares,
also bring his wife in for the initial assessment. The initial feel more connected to reality, feel less agitated, and have a
assessment confirmed the previous diagnosis of PTSD. better relationship with his family. Rex also mentioned that
In the initial session, I met individually with both Rex his wife had a problem with how much he drank and that he
and his wife, Kylie. Rex reported that he and Kylie had been once had an outburst that alarmed both his wife and himself
married for 13 years and have three daughters ages 6, 8, (referring to the bookcase).
and 12. Rex had returned from deployment 18 months prior Throughout this discussion, I integrated parts language
due to a leg injury sustained when an improvised explosive highlighting that there were parts of Rex that had conflicting
device (IED) struck his team’s vehicle. Following his recov- goals. As Rex identified some of the feelings that he was cur-
ery, Rex had a difficult time adjusting to civilian life. He was rently having in session, he said that he felt “pissed that [he
dealing with increased agitation and feeling constantly “on couldn’t] fix” these issues on his own. We explored this part
edge.” He was having frequent nightmares and mentioned and identified it as a manager. Rex decided to name the part
sometimes feeling as if he were in a dream during the day- of him that tries to “fix” things and create order in his life,
time. He had concerns that his relationship with his wife “Hamilton,” after one of his former first sergeants.
was becoming strained. His children had started to become The next couple of sessions focused on understanding the
more defiant toward him and on several occasions his oldest, influence that Hamilton had on other parts and differentiat-
Sarah, had told him that life was better when he was gone. ing the Self. At first, Rex had significant trouble separating

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Hamilton from the Self. Rex indicated that his unstable fam- coaching), I would invite them to make a U-turn. Rex and
ily background also contributed to Hamilton taking control Kylie would momentarily turn their focus away from one
of other parts. Rex talked about how he has mixed feelings another and toward themselves. As each partner connected
toward Hamilton, because this part of him helped him to with the Self, they were able calm themselves and ask domi-
excel despite his chaotic childhood, but this part can also be nating parts to step aside. With their managers and firefight-
“demanding.” Using a visualization activity, Rex was able ers calmed, they were each able to speak from a Self-led
to identify areas in his body that reacted to Hamilton when position. I then invited them to “re-turn” to their spouse and
he was demanding. Rex reported that it felt like a “huge re-engage in the conversation.
weight on [his] shoulders.” I encouraged him to approach Over the course of treatment, the couple became more
this weight with curiosity to discover if he wanted to keep mindful of how their different parts triggered parts in the
it or take it off. He responded that he did not know how to other individual. They became skilled at speaking to one
take off the weight but that he wished he could take it off another from a Self-led position. During this phase of treat-
sometimes. He then spoke about how drinking used to work ment, Rex made a comment that I thought was very mean-
to take off the weight, but wasn’t presently working. ingful. He stated “I feel like for the first time in years, I am
While we discussed Hamilton’s role and Rex’s feelings having a conversation with the real Kylie and my wife is hav-
toward Hamilton, we examined each of Rex’s responses to ing a conversation with the real me.” With this new feeling
Hamilton and compared them to the 8 C’s. As we did this, of connection, Kylie and Rex were able to develop practical
there were times when Rex’s responses didn’t match the ways to manage Rex’s PTSD symptoms by leading with the
eight C’s and indicated to me that he was speaking from Self when responding to triggers. Once Rex and Kylie felt
another part rather than speaking from the Self. Through this that they were working together as a team, we decided it was
process, we identified two other parts that he identified as time to invite their children to therapy.
“Bud” (a firefighter focused on isolating) and “Monster” (a
firefighter focused on fighting). After sessions that explored
how Bud and Monster interact with Hamilton, Rex also iden- Family Sessions
tified that all of these parts work together to protect “Junior”
(the exile). When I asked Rex about how the other parts During the first session with the children present, I asked
felt toward Junior, he responded that Hamilton was embar- each of them to describe what changes they had noticed
rassed of Junior. We also discussed that at times it seemed over the last few weeks. All three children agreed that their
like Hamilton, Bud, and Monster felt like they had to work father had been around more and was getting mad less often.
extra hard to protect Junior because they believed that Rex’s However, they were unconvinced that these changes were
core-self was incapable of managing the stress. going to be permanent. I worked to normalize the family’s
fears that these changes might not be permanent. In a later
Couple Sessions session both Rex and Kylie brought up their concerns that
Sarah was still trying to act like a parent to her younger
Through this process, Rex began to be more aware of the siblings. Reminding Rex and Kylie of our previous parts
interactions between his parts in session. Once Rex began discussions, I was able to help the couple see that similar to
to be more comfortable acknowledging the exile, we invited how Rex’s fix-it part would “take over” his internal family,
Kylie back to integrate IFS couple’s therapy into Rex’s treat- Sarah felt the need to take over her external family. Both
ment. During this session, I asked Rex to give an overview Hamilton (Rex’s “fix-it” part) and Sarah had lost faith that
of his progress and we assessed for the couple’s goals. In Rex was capable of caring for the family (on separate inter-
following sessions we identified Kylie’s parts and how they nal and external levels) and so, they needed to intervene. It
interact with Rex’s various parts. In the first few sessions of became clear to Rex and Kylie that Sarah was operating as
marital counseling, I noticed that Rex would address Kylie a parentified child and she would need help to step down
from the voice of his manager or firefighter. In return, Kylie from that role.
would speak to Rex by using one of her managers. These Our next family session focused on identifying the
conversations quickly escalated and tensions became high. interactions between Sarah and her parents’ parts. As
I was able to observe during these encounters that Kylie’s we discussed their family process, Sarah identified that
firefighter part was trying to solve marital problems by argu- a managing part of her became activated when Rex felt
ing with Rex’s exile. This of course was ineffective. In these overwhelmed. Sarah explained that when Rex is more
situations, I used IFS techniques known as U-turns and re- present and involved with the family, she felt more “like
turns. Once one or both of the spouses had noticed that they a kid.” We highlighted that as Rex felt more connected
were speaking from a part-led position and not a Self-led to his Self that Sarah felt less responsible for her younger
position (with Rex and Kylie this often took a bit of therapist siblings. This allowed Sarah to feel less stressed and

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better able to focus on more age appropriate things like Conclusion

playing with her siblings, school, and dance.
After a few more sessions, the family reported a sig- Internal Family Systems theory provides a unique philo-
nificant decrease in the frequency and severity of Rex’s sophical lens for the treatment of combat veterans with
symptoms including nightmares, anger, and drink- PTSD. This approach recognizes the complexity of PTSD
ing. They also indicated marked improvement in their for those who have seen combat and allows for the inte-
responses to Rex’s PTSD symptoms. Kylie no longer felt gration of individual and family therapies. Moreover, the
threatened and felt competent in her ability to provide Rex collaborative nature of IFS, its less-pathologizing stance,
with the support he needed in managing any remaining and simplistic language provide great benefits that might
symptoms. The parents also noted that Sarah was better help reduce the stigma associated with receiving mental
able to “let go” of feeling responsible for her siblings. health treatment. Following our examination of using IFS
All the children felt connected to their dad and reported with combat veterans and their families to treat PTSD, we
being more comfortable at home. Each family member encourage researchers to broaden the evidenced-base treat-
further reported a greater ability to lead with the Self and ments of trauma by testing the effectiveness of IFS with
felt more confident in responding to future triggers. It was this population. We also urge clinicians who treat veter-
after acknowledging the family’s progress that Rex and ans to expand their practice to include the IFS approach.
Kylie decided to terminate therapy. Furthermore, we recommend that all mental health pro-
Overall, this fictional case illustration aimed to high- fessionals who treat combat veterans not only collaborate
light the IFS approach to treating PTSD in combat vet- with other medical and mental health professionals, but
erans at individual, dyadic, and family levels. First the also collaborate with veterans and their families to provide
therapist assessed for PTSD symptoms and confirmed the the best care for this unique population.
previous diagnosis. The therapist and client collabora-
tively identified individual parts through the assessment
process and set goals for treatment. The interventions var-
ied between individual, partner, and family sessions, but References
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