Peter is a sixty-four year old man who was referred for treatment of mood complaints. He was a field professional at different non-governmental organisations (NGO's), and led many missions, such as to war-torn Bosnia and Cambodia, and in the aftermath of the Tsunami in Thailand in 2004. In his professional career he experienced several life-threatening situations and was confronted with death in different forms. He lost colleagues due to accidents, murder and suicide. However, at the start of the therapy Peter does not report being burdened by these experiences and losses. First and foremost, he describes his anguish over bureaucracy and courses of action that he did not agree with, and that were taken at the time he was in the field. He preferred working intuitively, and from the view of trying to understand a crisis situation from a local perspective, a method that proved to be conducive. He felt a strong connection with his team members, but ran into conflict with his superiors about everlasting bureaucracy and, in his opinion, wasting of funds. As the years went by, bureaucracy got worse instead of better and Peter found it increasingly difficult to find his place in the organization. He stopped working three years before the start of the treatment. Since then he follows the news about NGO's fervently and still gets angry about how crises all over the world are tackled by them. At the same time, a mixture of positive and negative memories related to his working past are triggered. This confuses him and makes him sad. He also misses the meaningfulness of his professional life.
Peter suffers from mood swings and anhedonia already for half a year, he is often at home, and has trouble absorbing the daily routine. However, he still enjoys spending time with his grandchildren. His appetite is normal, and he does not report having sleeping problems. In his whole life he has never experienced nightmares or flashbacks related to the missions and the threatening life events he has faced. Sometimes he suffers from irritability and can have an outburst of anger, mostly when he perceives that injustice is done.
In the first sessions Peter was diagnosed with a persistent depressive disorder arising from excessive thinking and worrying about the predicaments linked to his professional career. He was, in particular, wrestling with many questions and moral dilemmas connected to his work at the NGO's. These can be framed within the moral injury concept, defined as "the enduring psychological, biological, spiritual, behavioural and social consequences of perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations" (, p. 697).
In the following sessions, more attention was paid to Peter's early psychosocial development in which no irregularities were found. Peter inherited a strong sense of justice from his upbringing. This brought him already at a young age into conflict with teachers and other authorities. However, this oppositional behaviour was not pathological to the extent that it would have met criteria for a personality disorder. Rather, it seems to be a character trait which causes that Peter is not always liked by others because of his criticism, but it does not appear to play a negative role in his family life and in relation to close friends. While recalling certain events linked to the missions, it was noticed that Peter would sometimes show strong emotions, mostly sadness and tears. However, these emotions would dissolve within seconds, morphing into expressing his anger about certain bureaucracy issues surrounding these events. This formed an indicator that "hidden" problems were present and they did surface later on in the treatment. Peter inclines to ignore and suppress his emotions in contact with people, mostly by moving a discussion to another topic, a phenomenon that often occurred in the sessions. Afterwards when he is alone, he rethinks the topics of a conversation, and only then he starts experiencing the corresponding feelings often resulting in rumination and a depressed mood.
Further in the treatment, his thoughts and ideas about certain events during the missions were explored more in-depth. Through this process, it became apparent that Peter suffered both from moral issues regarding politically motivated decisions and acting of his superiors which were not always in the interest of the local population, and from the shocking events which he had personally experienced. In this probing process Peter also began to realize that his way of coping showed similarities with the coping mechanisms of the people he reached out to as the NGO professional, survivors that showed no emotions in the middle of a catastrophe and just went about their daily business. Peter came to realize that his work confronted him with seriously impacting life events. He dealt with the impact of these events by comparing himself to the victims and labelling his own experiences as insignificant in comparison with theirs. When Peter came to full realisation of this defence mechanism, he unexpectedly developed sleeping problems, nightmares and re-experiencing of the work related events (PTEs). At that point in the treatment, Peter underwent for the first time emotions related to the events experienced in the past. It was an enlightening and cathartic experience for him. Nevertheless, it also made him upset because he realised that he was about to develop a full blown PTSD, a condition which he thought he will never suffer from.
Peter experienced numerous PTEs. The loss of several colleagues seemed to have had the strongest impact on him as many of them became close friends over the years. The knowledge that the suicides of his colleagues were a result of their inability to cope with constant horrors, was something Peter didn't want to face or think about until he was confronted with his avoidance in the therapy. He came to acknowledge that this fear came too close to his own anxiety related to losing control and committing suicide. Realizing that his own emotions were genuine and authentic responses to extreme experiences he had faced, helped Peter to find balance again. The depressive feelings were reduced to a great extent. Further, psycho education regarding the moral injury concept helped him realize that his anger, originating from the moral injuries, protected him from strong emotions linked to many personal losses over the last decades. Engaging into fights and disputes with his superiors was, even though justified in terms of content, an emotionally inadequate way of coping with the horrifying experiences and losses. The PTSD symptoms which emerged in a course of the therapy were successfully treated with EMDR.
Peter is an example of the delayed type of trajectory, where a lack of giving meaning to experiences, in combination with maladaptive emotional coping and withdrawal from active work, led to evolving depressive symptomatology and, temporarily, to a full-blown PTSD. Moral issues played a significant role in the emergence of Peter's mood complaints, as he was coping with consequences of political decisions impacting his daily work, and with feelings of powerlessness to influence them. However, frustration about the moral dilemmas also acted as a camouflage for authentic and painful emotions arising from multiple life threatening experiences he had accumulated over time.
Peter did not develop a PTSD earlier in life, even though he was confronted with many PTE's. PTSD symptoms developed only when Peter became aware of his emotional coping style. It remains an open question whether Peter would have developed PTSD at a later stage in his life without being triggered by the treatment? However, it remains the fact that Peter got referred because of suffering from mood complaints and a poor quality of life, something that changed significantly for the better at the end of the therapy.