Crossing the Rivers of the Tartarus: The Grief Process among Combat-Related PTSD Patients

Abstract

The third stage of Pierre Janet’s model of trauma-focused treatment focuses on personality reintegration and rehabilitation and includes psychoeducation and hypnosis. According to the Jungian conceptualization presented herein, therapeutic work with combat posttraumatic stress disorder (PTSD) patients at this stage involves the completion of the grief process, during which there is a metaphoric descent to the underworld and a crossing of the rivers of the underworld, which represent complex emotional states. During the treatment of these patients, the therapist embodies, or personifies, the ancient Greek god Hermes, a psychopomp and mediator between different worlds who facilitates the healing process.

Odysseus awoke out of his sleep in his native land. Yet he knew it not after his long absence, for about him the goddess had shed a mist. –The Odyssey (Homer, 1946, p. 15)

Evidence-based treatments for posttraumatic stress disorder (PTSD) in general, and combat-related PTSD in particular, rely on protocols (Watkins et al., 2018; Wilson et al., 2018) that target invasive and avoidance symptoms (Foa, 2011; Shapiro, 2017). Despite robust empirical support, these treatments have significant dropout rates (Doran & DeViva, 2018; Varker et al., 2021), as patients can experience mounting distress (Cook et al., 2014) or can refuse outright to engage in interventions such as imaginal exposure (Schottenbauer et al., 2008). Researchers recommend tailoring evidence-based treatments to individual patients (Varker et al., 2021) using strategies that address engagement and therapeutic rapport (Hoge et al., 2014) and meeting veterans where they are (Hoge, 2011). In other words, psychotherapeutic methods that prioritize the individual and the therapeutic relationship rather than symptom reduction may prove beneficial in the treatment of combat PTSD patients.

Ann McCoy, The Death of the King, 1998. Pencil on paper on canvas, 9 × 14 ft. Courtesy of the artist.

Although Jung himself rarely addressed PTSD (Wilson, 2004), Jungian analysts and scholars have written extensively on the treatment of combat-related PTSD (Decker, 2014; Early, 1993; Shay, 1995; Tick, 2005). Their work has led me to posit that the integration of Jung’s archetypal approach with evidence-based treatment for combat-related PTSD has many beneficial effects. First, it may enable us to understand that patients suffer not only from PTSD symptoms, but also from moral and spiritual injuries arising from the commission of various acts during armed conflict, and from the transgression of deeply held moral beliefs and expectations (Litz et al., 2009; Shay, 1995). Second, the Jungian approach has added value because of its focus on the present and on the meaning of symptoms (Brooke, 2017). Third, the Jungian approach helps us to understand that the mental wounds of war are a universal human experience and that common processes of healing can be found within traditional warrior cultures (Brooke, 2012).

I addressed this issue in a recent article (Potik, 2022), in which I presented a depth psychological conceptualization of trauma-focused treatment for patients with combat-related PTSD that corresponds with Pierre Janet’s three-phase model of treatment for post-traumatic stress (Janet, 1919/1925). More specifically, I described the first two stages of the model and suggested that the psychotherapy of combat-related PTSD patients involves a symbolic journey of recovery, wherein the psychotherapist is the personification of Hermes.

In this article, I will describe a depth psychological conceptualization of the third phase of Pierre Janet’s trauma-focused treatment involving personality reintegration and rehabilitation and delineate the processes that veteran patients undergo during treatment. My first assertion is that, for many patients, this final stage is a grieving process, which may be viewed as a symbolic journey across the different rivers flowing through the mythological Greek underworld. My second assertion is that, during this stage, the therapist constitutes the personification of Hermes, the psychopomp who helps the patient to complete the grieving process and establish a renewed relationship with life and humanity, as well as to carve out a new place within the communal order.

Phase Three of Trauma-Focused Treatment: Personality Reintegration and Rehabilitation

In the latter part of the 19th century, Pierre Janet (1904, 1911) laid a firm foundation for the future of all psychological treatment of mental trauma. He presented a systemic therapeutic approach to post-traumatic stress syndromes and dissociative disorders, which became the bedrock of major therapeutic approaches to treating complex PTSD (Herman, 1992), and has also informed the guidelines for treating dissociative identity disorder in adults (International Society for the Study of Trauma & Dissociation, 2011). Janet’s model relates to the patient’s treatment needs at different stages in the evolution of post-traumatic stress reactions (van der Hart et al., 1989).

A myth persists among some patients and clinicians that remembering the traumatic experience is sufficient for healing (Steele et al., 2005). In other words, many professionals believe the reduction of PTSD symptomatology following the administration of evidence-based protocols constitutes the essence of trauma-focused treatment. Yet, while the processing of traumatic memories is necessary, it is inadequate for the complete resolution of post-traumatic stress, not least because there are considerably more clinical issues that remain to be addressed (van der Hart et al., 1989).

According to Janet (1911), the third phase of trauma-focused treatment—personality reintegration and rehabilitation—focuses on the prevention of relapse and the management of residual symptoms through education, excitation, and hypnosis. He noted that, at this phase, patients are likely to experience apathy, boredom, depression, constricted affect, hypochondria, and difficulties in initiation, and his therapeutic interventions included education, stimulation, and moral guidance (van der Hart et al., 1989). These interventions correspond quite well with cognitive behavioral treatment, which focuses on techniques aimed at contemporary thought-stopping, skills training, and encouraging patients to become more active.

The professional literature on the three-phase trauma treatment model focuses primarily on child abuse victimology, and addresses issues related to traumatic developmental experiences (Steele et al., 2005). According to Herman (1992), the third phase deals with meaning and reconnection as patients confront existential questions and begin to think about establishing new relationships. Based on my experience, during this phase, patients are less haunted by intrusive memories and less threatened by sudden noises. They report feeling emptiness and futility, and tend to be preoccupied with conducting a moral inventory: examining their lives in the present and wondering about their future. On one hand, they are no longer army soldiers wearing the uniform and insignia that identified them as warriors; and, on the other hand, they are not civilians who work and have a family life. They remember their dead comrades, all the while wondering whether they can fit into the world. They feel estranged and usually do not share their emotions and thoughts with others. In fact, the mental state of such veterans has been described in legends and myths for centuries.

Issues of Personality Reintegration and Rehabilitation among Veterans in Mythology and Literature

In The Spirit in Man, Art and Literature, Jung (1971) presented archetypes as mythological motives: innate, universal prototypes for ideas that may be used to interpret observations in a world that is governed by the principle of “eternal rotation” (p. 204). In his writings, Jung used clinical material but mostly examined the role of archetypes in mythological, religious, and literary texts, because these primordial images were more readily available for study in such texts (Leigh, 2011).

One of the most famous archetypes is the “warrior,” who is characterized by courage, aggressiveness, purposefulness, mindfulness, decisiveness, loyalty, and self-discipline (Moore & Gillette, 1991). Prominent examples of the embodiment of this archetype include the ancient Spartan warriors; the Japanese samurais; and the gladiators. In the monomyth of many cultures, the hero or warrior undergoes mysterious adventures, returning to his village victorious and brandishing a boon (Campbell, 1949). In contrast, combat PTSD patients and veterans suffering from various mental malaises are heroes—but ones whose monomyth was suddenly aborted, leaving them living in limbo, suffering from psychic and spiritual wounds (Potik, 2022).

The veteran, or returning soldier, is an archetype that has featured in mythology and literature for eons. Protagonists of various myths and legends often surfaced themes associated with returning home from war or military service and needing to reintegrate into the community. Nostos (“homecoming” in ancient Greek) is a central theme in The Odyssey (Bonifazi, 2009), which depicts the veteran’s adventures and vicissitudes on his journey to Ithaca. In a seminal book, Shay (2002) references The Odyssey to explore the issue of veterans’ reintegration into civilian life and offers compelling insights into their experiences. Shay focuses on Greek mythology, but other legends likewise offer valuable contributions to clinicians who treat veterans.

The fairy tale “Bearskin” tells the story of a soldier who returns from war only to find his parents have died and his brothers have no room for him (Grimm & Grimm, 1975). The despondent soldier meets the devil, who offers to make him rich if he promises not to bathe, cut his hair, clip his nails, or pray, and to wear the coat and cloak he will give him for seven years. If the soldier succeeds, his boon will be wealth and freedom, but if he fails, the devil will have him (Grimm & Grimm, 1975).

This fairy tale deals with a number of significant issues associated with the nostos of veterans. First, the brothers’ response corresponds with the “cold shoulder” society gives to returning veterans (Marlantes, 2011). Second, according to Stephenson (2015), this story deals with identity transformation as the protagonist becomes a soldier by killing a totemic animal (warfare skills), thereby forming the soldiering identity that will alienate him from the human society he fearlessly serves. Third, the soldier’s alienation from human society and encounter with the devil, who offers a tempting solution to his feelings of isolation, are prominent elements in a veteran’s universal experience.

Since the beginning of history, warlords have sought professional personnel with military experience; the use of mercenaries is probably as old as war itself (Dodenhoff, 1969). In the current era, these elements are embodied in TV series like Barry (Berg et al., 2018) and Quarry (Yaitanes et al., 2016), which depict disillusioned and estranged veterans who become hired hit men. In this context, Early (2003), a psychologist who treated veterans for many years, also demonstrated the embodiment of the veteran archetype in films.

The tale of “Bearskin” also addresses another major issue concerning the veteran’s return: grief. In fact, it emphasizes the essential nature of a grief process in self-integration and reintegration into society. In the story, the devil’s condition of avoiding any self-care for seven years is parallel to the mourning rituals of some religions. For example, in Judaism, Shiva (literally, the number seven in Hebrew) is a week-long period of ritual mourning that commences immediately after the burial of the deceased. During this week, the mourner is relieved of all daily responsibilities; he/she is instructed not to bathe, change clothing, use cosmetics, cut his/her hair, or engage in sexual contact (Lamm, 1969; Slochower, 1993), and is directed to devote his/her energies to lamenting and remembrance.

In discussing recovery from trauma, Herman (1992) noted that such “lamenting”—that is, the (re)telling of the traumatic experience—inevitably plunges the patient into profound grief, even as many of his or her losses remain invisible or unrecognized. The descent into mourning is simultaneously a necessary and dreaded task, which patients often fear and conceive of as insurmountable (Herman, 1992). Van der Hart et al. (1989) assert that the third phase of trauma-focused treatment may contain some of the most difficult work, including the painful grief work that is necessary for deepening understanding.

Combat-related PTSD patients stand at a complex crossroads after processing their traumatic memories should they continue to feel empty and detached from society. On one hand, they cannot step onto Charon’s skiff because they are not physically dead like some of their comrades. On the other hand, many of them report an inability to identify their place in the community because of feelings of psychic and spiritual deadness. In order to find their place in the communal order, they have to complete a grief process quite similar to the mythical descent into (and ascent from) the underworld.

Katabasis and Anabasis in Greek Mythology

Jesus, Gilgamesh, Ishtar, Osiris, Indra, King Geasr, and Phra Malai are examples of real and mythical characters that had encounters with the underworld (Alai, 2015; Bodewitz, 2019; Brereton, 1995; George et al., 2003; Roberson, 2013; Rouwhorst, 2018; Stephany, 2015). In fact, myths about human and superhuman beings who journey to the underworld prevail in many cultures and religions, so it is no wonder this intriguing motif has received diverse representations and interpretations in writings and artistic works (Alighieri, 2009; Aristophanes, 1996).

Katabasis (or catabasis) is a Greek term with multiple related meanings in poetry and rhetoric, such as “to retreat,” “to move downhill,” or “to descend or journey into the underworld.” The mytheme of a trip to the underworld had various significations for the ancient Greeks; it allowed them to understand the changing of the seasons (e.g., Persephone’s kidnapping), and to teach that selfishness ends badly (e.g., Tantalus’s punishment). Additional interpretations of the katabasis explained matters such as cosmic order and the relationship between gods and humans (Allan, 2006). Perhaps more than any other mytheme, the descent into the underworld depicts humanity’s limitations and the necessity of accepting how death is an integral part of our lives (see the story of Orpheus and Eurydice).

Another significant motif in Greek mythology is anabasis, a term that means marching up or gradually ascending. This word is best known from a book by Xenophon about 10,000 Greek mercenaries who fled from Babylon after their commanding officers were deviously led into a trap and killed by the Persians (Xenophon, 1922). In Greco-Roman mythology, the ability to descend to Tartarus and ascend again was given by the gods to heroes (Hercules, Theseus) and soldiers (veterans) such as Odysseus and Aeneas. Odysseus, in fact, does not descend into the underworld but engages in a nekyia, a rite by which ghosts would be called up (Clark, 1979).

Aeneas, on the other hand, with the guidance of the Cumaean Sibyl, descended into the underworld. In discussing similarities between Odysseus and Aeneas, Payne (2017) writes that death is a present thought in each of their minds, and they must engage with it in order to consciously decide to continue living rather than merely existing in a grief state that keeps them detached from the rest of civilization. Relying on these ideas and my own clinical experience, I believe the grief process of veterans includes not only katabasis and anabasis but also (and perhaps mainly) the crossing over of the various rivers of the underworld.

Crossing the Rivers of the Underworld to Complete a Grief Process

Greco-Roman mythology depicted the underworld as replete with deities: Achlys, the goddess who symbolized the mist of death and personified misery and sadness; Erebus, the primordial god of darkness; the Erinyes, chthonic deities of vengeance; the Keres, goddesses of violent death; and Oizys, the goddess of misery, to name only a few (Mackin Roberts, 2020). In Norse mythology, Niflheim, the world of the dead, was associated with the goddesses Hel and Freyja (McCoy, 2016). Artistic depictions of the underworld described it as a dark and shadowy place with extremes of heat and cold (Albinus, 2000). The deities who personify death are portrayed as powerful figures who inflict various forms of pain and suffering on the dead.

The renditions of the underworld in both the Norse and Greco-Roman mythologies include rivers. The Greek underworld includes five main rivers: Acheron, Styx, Lethe, Phlegethon, and Cocytus. Each river possesses unique features and reflects an emotion or deity associated with death. The Acheron was perceived as a physical barrier between Hades and the mortal world, for mortals could not cross it to enter the land of the dead, and the dead could not escape to the land of the living (Mackin Roberts, 2020). The more well-known river Styx is also often considered the main boundary separating the living from the dead (Felton, 2010). The third river, the Lethe, was said to flow across the plain of Lethe and pass the cave of Hypnos, the god and personification of sleep (Mackin Roberts, 2020). The river Phlegethon was a river of fire associated with punishment in the Tartarus (Morford et al., 2013). The Cocytus, the river of wailing, flowed into the Acheron (Grimal, 1996).

The ancient Greeks believed the journey of the dead through the underworld followed a clear path, and that Hermes, the psychopomp, gathered the souls of the dead and led them down to the river banks of the underworld, where they awaited the ferryman to transport them across the waters to Hades. After being paid an obol apiece, Charon conveyed the souls across the Acheron and the Styx. All of the spirits who entered the underworld drank from the river Lethe, whose waters had the power to cause them to lose all memory of their lives (Plato, 1968). The wicked were destined to suffer eternal torture and therefore found themselves on the Phlegethon, which ran into the Tartarus. According to Plato (1968), the Cocytus also emptied into the Tartarus; it was associated with the punishment of murderers. Blessed people and heroes arrived at the fields of Elysium (Grimal, 1996).

Psychotherapy with veterans involves not only a descent into the underworld but also a crossing of the rivers of the underworld in order to resolve a grief process. Combat-related PTSD patients suffer from a significant split in their psyche; they can neither step into Charon’s skiff (because they are not physically dead), nor can they find their place within the world of the living. Although they may no longer suffer from intrusive memories once these have been processed, they do both think and dream of their dead brothers-in-arms. Their feelings of spiritual and mental deadness prevent them from taking an active part in the lives of their loved ones or from expressing positive emotions.

Authors, poets, and clinicians have been documenting the mental pain associated with the loss of comrades since Gilgamesh’s grief over the death of Enkidu (Crocq & Crocq, 2000). The sources of grief for combat-related PTSD patients vary, and may include physical handicap, loss of innocence, and loss of comrades (Brooke, 2012; Shay, 2002). Empirical studies have convinced skeptics that this unique phenomenon is more akin to the reaction of a bereaved individual who has experienced significant loss than to psychopathology (Papa et al., 2008; Pivar & Field, 2004). In this context, one of the amazing findings of Pivar and Field (2004) was that approximately 30 years after combat losses, the level of prolonged grief of veterans was comparable to that of a bereaved individual whose spouse had recently died; this suggests the loss of comrades plays a momentous role in the distress suffered by combat veterans (Pivar & Field, 2004).

In light of these findings, perhaps it is no surprise that in Greek mythology, Penthos, the god of mourning, is described as wearing torn and bloody clothes and as being related to the spirits of sorrow and suffering (Sadak & Weiser, 2017). Sadak and Weiser (2017) eloquently describe grief as a soul-aching experience that changes the individual from the inside out. Unresolved grief signifies the patient is caught in Penthos’ grip, or, to paraphrase Freud’s (1917) famous saying: the shadow of Penthos fell upon their ego. I believe the combat veteran’s healing journey should include a katabasis and anabasis in order to properly facilitate separation from the dead and foster an understanding that their time has not yet come. This journey of grief processing can take place when the therapist understands their role in such a journey.

In addition to helping heroes with various quests upon the earth, one of Hermes’ most well-known roles was that of leading souls of the dead to the realm of Hades (Grimal, 1996). Hermes is a psychopomp who can cross boundaries and dimensions, navigating between humans and the divine, and between the personal and collective unconscious (Edinger, 1994; Stromer, n.d.). I believe the therapist is a personification of this mythical figure who helps the hero in his healing journey in the underworld. The therapist’s presence, guidance, and ability to process dark materials all enable the hero to traverse the different emotional states represented by the rivers of the underworld. In the following section, I will illustrate these ideas through several clinical vignettes.

Crossing the River of Hate

Styx was the name of a Greek goddess of the underworld—the same name as that of the river separating the underworld from earth (Grimal, 1996). After death, the soul left the body and journeyed, with the guidance of Hermes, to the banks of the Styx, where it waited with other souls to enter Hades (Tatlock, 1917). In a powerful memoir written after a great loss, Joan Didion (2005) wrote:

I seemed to have crossed one of those legendary rivers that divide the living from the dead, entered a place in which I could be seen only by those who were themselves recently bereaved. I understood for the first time the power in the image of the rivers, the Styx, the Lethe, the cloaked ferryman with his pole. (p. 75)

The Styx is also known as the “river of hate” (Morford et al., 2013), and in a study that assessed hatred and revenge levels among Kosovo war veterans with PTSD (Halimi & Halimi, 2015), more than 40% reported feeling some level of hatred and having fantasies of revenge, and nearly 85% of them reported a willingness to act upon such feelings. Veterans with murdered or missing family members were shown to be more predisposed toward hatred and revenge (Halimi & Halimi, 2015). Considering this finding, it is quite understandable why the ancient Greeks believed the Styx “circled the Greek underworld seven times,” separating it from the land of the living (Leeming, 2005, p. 366).

Hate among veterans is also associated with contempt, disgust, criticism, suspicion, blame, and revenge (Reyes & Hicklin, 2005; Shay, 2002). I have described elsewhere the manifestations of such emotional states in an integrated treatment of a war veteran (Potik, 2016). That treatment included a behavioral intervention that involved in vivo exposure to public places near the clinic, which was meant to reduce the patient’s avoidant behavior of situations, activities, and objects that caused him distress but were not inherently dangerous (see Foa et al., 2007). During a walk in a quiet urban neighborhood, the patient saw a man with “a Middle Eastern appearance” emerge from one of the buildings carrying a sack on his back. Suddenly, the veteran aggressively grabbed the man and demanded to see the sack’s contents. Later, he explained that his unit stood guard at checkpoints where civilians would pass carrying handbags or sacks. Occasionally, one of the civilians who approached the checkpoint would try to stab a soldier. Ever since, the veteran had viewed every man with “a Middle Eastern appearance” as a terrorist until proven otherwise.

This example demonstrates how joining patients on their recovery journey enables the therapist to understand complex “triggering” situations in the present that prevent their successful social reintegration. It also demonstrates how psychotherapy for combat-related PTSD can integrate diverse approaches. Although I previously noted that this treatment included psychoanalytic psychotherapy with behavioral components, it seems it also corresponded with Jungian ideas on many levels.

First, therapists who use behavioral interventions usually rely on students or assistants for in vivo exposures outside the clinic (Hunt & Fenton, 2007). The decision to join the patient in a complex situation corresponds with that of Hermes escorting various heroes in Greek mythology. Second, according to Hesiod’s (2006) description in Theogony, Mavronéri is a river equated with the river Styx of Greek mythology. The meaning of the word Mavronéri in Greek is “black water,” and it seems that in this black water, or in the nigredo, the patient encounters his shadow.

The nigredo, according to Jung (1956/1969), “brought decay, suffering, death, and the torments of hell visibly before the eyes of the alchemist” (para. 493). The dark water of the Styx includes the veterans’ memory shades of life-threatening situations alongside their mental disorientation in the past and the present. Jung (1975) wrote: “Everyone carries a shadow, and the less it is embodied in the individual’s conscious life, the blacker and denser it is” (para. 131). In this clinical vignette, only after the patient’s encounter with the man carrying the sack on his back (and with his own aggression) could he describe his fear, suspicion, guilt, and shame (Potik, 2016). In other words, the crossing of the Styx requires immersion in the dark water; only when the therapist helps the patient to process emotions of guilt, shame, anger, and hate is there internal movement in the patient’s psyche toward integration and self-acceptance.

Crossing the Lethe: Moving from Oblivion to Remembrance

The river of forgetfulness, Lethe, was likewise associated with a deity with the same name (Grimal, 1996) who was the personification of forgetfulness and oblivion. In classical Greek, the word lethe literally means “oblivion, forgetfulness, or concealment” (Detienne, 1996). A common saying of combat-related PTSD patients is that they wish they could forget dreadful memories or images; metaphorically, they would like to drink from the Lethe’s waters. However, the word lethe is also related to the Greek word aletheia, which means “truth” (Christodoulidis & Veitch, 2001). Heidegger (1998) interpreted this term as referring to the disclosure of that which is hidden and concealed. Issues of forgetfulness and remembrance appear in different forms during the third stage of trauma-focused treatment, and unresolved grief stems from the stagnation of the patient’s psyche between lethe (forgetfulness) and aletheia (unconcealment).

The word aletheia appears in The Iliad and The Odyssey some 17 times in relation to reliability, openness, and trustworthiness (Peters, 2021). It is also related to the recovery of an old memory or to the pushing back of the borders of oblivion (Christodoulidis & Veitch, 2001). Odysseus’s visit to the underworld well illustrates this critical point. In The Odyssey, Odysseus meets the spirit of Elpenor, one of his dead soldiers. Elpenor did not die in battle but lost his life accidentally when he fell from the roof of Circe’s abode (Homer, 1966, p. 385). Odysseus and his men had been eager to leave Circe’s island after their stay of a year and did not check to see whether they had left anyone behind. In the underworld, Elpenor asks Odysseus to return to Circe’s island and give his body a proper burial.

Elpenor is the personification of soldiers who died under various circumstances and not in battle. He is also the personification of soldiers who are missing in action; his story underlines the Greek dictum of honoring the dead by not forgetting them and establishing a memorial monument (Alock, 2002). A similar story is told in The Iliad about the appearance of Patroclus’s soul to Achilles, who seems to have endured prolonged grief. Patroclus pleads for Achilles to bury him so he can pass through the gates of Hades.

In both cases, proper burial ceremonies and commemoration rituals honor the memory of the dead and save them from forgetfulness (oblivion). The heroes’ actions enable them to continue on their journey. Therapists who treat veterans with unresolved grief can learn from such myths that grief processing should include an encounter with the dead and the conducting of memorial rituals and ceremonies that will save the dead from oblivion and permit the living to continue with their lives.

In the following lines, I will provide an example of such a therapeutic intervention for resolving complicated grief. Ron (a pseudonym) is an Israeli war veteran who fought in the 1982 Lebanon war. He came for treatment at a psychiatric daycare department 30 years after the war because of intrusive memories, sleep disturbances, difficulty holding down a steady job, and angry outbursts toward his family. The processing of Ron’s traumatic experiences lasted several months. Following his sessions, he looked gloomy. As the therapeutic alliance strengthened, he revealed that every day for the past 30 years he had been thinking about a brother-in-arms who served with him and died during their service. He added that he had not been the same since his comrade’s death. Although he did get married and have children, he felt a constant sadness that prevented him from rejoicing. Ron shared these emotions with his wife, who often told him she understood that his sadness and avoidant behavior resulted from grief over his comrade. She added that she had acted the same way after her parents died, “but life goes on,” and he should continue with his life.

In therapy, Ron elaborated on the special bond between him and his comrade and how they had asked to participate in every military activity together. Many of Ron’s memories included joint recreational activities with his wife and the dead comrade’s wife. Ron had not seen the latter for many years since the army had not released him to attend his friend’s funeral because of the ongoing war, and although he had wanted to see her following the war, he simply could not go through with it. He disclosed that since the war he had dreamt about his dead friend; he felt there was a connection between his not attending the funeral and his recurrent dreams.

Ron’s psychiatrist and I discussed the option of arranging a meeting between Ron and the dead comrade’s widow in order to allow Ron to complete his grieving process. I asked Ron about the option of arranging such a meeting, and Ron replied that he had been thinking about it for many years but had never “found the courage” to do it. He was ambivalent, as he wanted to see his dead comrade’s widow and apologize for his absence from the funeral, but at the same time he was afraid she would be angry at him for not trying to contact her for all these years. All of these considerations were the focus of our sessions until Ron stated he had decided to meet her and asked me to join him.

The following week, after about a year of treatment at the psychiatric day department, Ron reported he had called the widow, who was happy to hear from him, and set up a meeting. I joined Ron in an emotional encounter with the comrade’s widow. Ron apologized for not attending his comrade’s funeral and not calling her for all these years. He explained how he had wanted to see her, comfort her, and talk about their joint experiences with the deceased but could not bring himself to do it. The widow responded that she had also yearned for a meeting with him since her late husband had talked constantly about his unique friendship with Ron.

The widow noted that she completely understood his detachment from life and said she too had undergone therapy over the years. She added that she was very happy that Ron had also turned to therapy. One of the most significant and emotional moments in this meeting was the widow saying that, following her husband’s sudden death, she had experienced difficult years but decided to continue living her life despite everything. They shared stories about their experiences over the years and showed each other photos of their lives and their new families.

As noted above, Shiva is a week-long period of ritual mourning beginning after the burial of the deceased, during which family members sit together and grieve their loss (Lamm, 1969). During this period, people who knew the deceased and the mourners visit the house of mourning to extend their condolences and offer comfort and support. Those who knew the deceased often talk about shared experiences and events of the past and express their own feelings of loss (Slochower, 1993). For the entire week of the Shiva, the mourner is relieved of all daily responsibilities and his or her time is dedicated to lamenting and remembrance. Rubin (2015) notes: “The Shiva period provides a strong and familiar framework, allowing the bereaved the opportunity to experience the impact of their loss, and the significance as well as pain of separation from the departed” (p. 90).

In Ron’s case, the meeting with his comrade’s widow enabled the two people closest to the deceased to share memories and find comfort in each other. One of the Shiva’s main characteristics is that it provides time and space for those grieving to deal with their loss (Rubin, 2015). Ron attended neither the funeral nor the Shiva for his comrade because of the ongoing war. Consequently, he never had an opportunity to properly grieve a friend who had been like a family member and whose loss left him feeling profound sorrow. Paying a condolence call during the Shiva relieves the mourner’s unbearably intense loneliness and symbolizes the community’s acknowledgement of the experienced grief (Lamm, 1969).

The Shiva is a spiritual quarantine (Dreyfus, 2020), after which the mourner rises and slowly reenters society. In Judaism, the observance of religious rituals during a year of mourning (such as daily prayers at the synagogue and refraining from attending celebrations) offers the bereaved support and a framework for processing their loss and buffering the pain (Rubin, 2015). In the absence of any time or space devoted to proper grieving, Ron’s spiritual quarantine lasted for years. His avoidant behaviors were not necessarily PTSD symptoms but rather an expression of his unresolved grief. In his ensuing sessions, Ron thanked the staff for helping him carry out a meeting he had longed to have for the past 30 years. He observed that he did not think he could have done it without my presence and encouragement. He was surprised to discover he did not dream about his dead comrade anymore, and he added how he thought a great deal about how his comrade’s widow had carried on with her life despite her loss.

In this context, in a recently-published article that also dealt with the treatment of veterans (Potik et al., 2022), my colleagues and I demonstrated how engagement in a formal mourning process (a visit to a dead comrade’s grave and the lighting of a yahrzeit, a memorial candle) could unblock previously blocked mourning, with a marked resolution of symptoms. Plakun (as cited in Potik et al., 2022) noted that when a mourning process is incomplete or blocked, symptoms may arise that encode the loss that has been blocked from mourning. He explained that culturally congruent, shared processes may help individuals unblock previously blocked mourning.

One of the reasons for unresolved grief among veterans is a misconception that not thinking about dead comrades every day means forgetting them or dishonoring them. Significant progress in therapy occurs when a willingness and readiness to bury the dead arises. In fact, only when veterans let go of their dead do they discover the dead will let go of them. In The Iliad, the grieving Achilles gradually begins to eat, but he refuses to wash until he has buried Patroclus. He agrees to do so only after the latter’s ghost appears to him in a dream and asks him to hold a funeral. In The Odyssey, Elpenor’s ghost asks for an honorable funeral. In both cases, the ghosts cease to haunt the heroes once the dead receive a proper funeral ceremony, leaving the heroes to continue on their journey.

The katabasis with the patient to the underworld may take the form of performing a memorial ceremony, building a memorial monument, or meeting with a dead comrade’s family members. Following such interventions, the veteran can cross, accompanied by the therapist, the Cocytus—the river of wailing, cries, and lamentation. Charon can now ferry the souls of the dead to their destination because they have received a proper burial, and the patient and therapist can start the anabasis, which will enable the patient to find his place in the communal order.

Concluding Remarks

The essence of the third phase of trauma-focused treatment is the resolution of a grief process that enables veterans to feel some peace of mind, and to try and identify their place in the communal order. In ancient cultures, a shaman assisted veterans, as he had access to the spirits of the dead and was therefore a psychopomp (Kowalewski, 2015). In Greek mythology, Hermes performed this shamanic function, and, in our era, therapists fulfill this function by bridging the past, the present, and the future in a patient’s narrative. The therapeutic journey through disavowed mental territories resembles a descent into hell, in which the most dissociated selves are gradually engaged and the most profoundly concealed feelings arise (Hammer, 1973).

Depth psychology therapeutic principles, such as trying to understand the subjective experience of the patient, seeking the meaning of symptoms, and displaying a readiness to delve into unconscious psychic territory, are essential during such healing processes. The Jungian perspective stresses the personal over the technical (Sedgwick, 2001) and encourages the therapist to find the mercurial elements required for an alchemical process of transformation. Within this context, Hammer (1973), a physician, psychoanalyst, and acupuncturist who has addressed diverse facets of healing, wrote:

The medium for new experience and for human growth is the heat, light, and energy of a searing and powerful direct involvement between two members of the human species. In a profound way, each person knows that the experience of being himself can change only when his most hidden selves live again in this intense way with another person, one who will relate to these selves differently from those who bore the original responsibility for labeling his psyche. (p. 391)

Additional information

Notes on contributors

David Potik

David Potik is a clinical criminologist and PhD candidate at the Department of Criminology at Bar-Ilan University, Israel. He works in the Dr. Miriam and Sheldon G. Adelson Clinic for Drug Abuse Research and Treatment at the Tel-Aviv Sourasky Medical Center, Israel. David’s research interests include psychotherapy, psychopathology, addictions, Eastern philosophy, and Haruki Murakami’s writing. He authored a book entitled Psychodynamic Approaches for Treatment of Drug Abuse and Addiction in 2020.