Saving Sal—A PTSD Case Study

I learned of the tragic story of Sal K. several years ago. At his worst, he was given to explosive anger and was even charged with attempted murder. Where did his volatile anger come from? Had he experienced some kind of traumatic event in the past that led him to treat an employee and even his son with such rage? What might we do to help him with such violent outbursts?

Sal’s story is more than a tale of personal struggle—it is a window into a critical question: How should we help someone like him? Two approaches dominate the counseling landscape: integrationism, which attempts to blend secular psychology with the Bible; and biblical counseling, which relies on the authoritative and sufficient Scripture. Sal’s journey, as we will see, reveals why the latter offers the best path to hope and help.

From Rags to Riches

Sal, a humble and hardworking man from a small town in rural Illinois, founded a pharmaceutical company that would eventually grow to be worth billions. Although he did not come from a background of wealth or status, Sal’s remarkable success took him and so many others by surprise. From the outset, he leaned on his faith, trusting God to guide the company’s growth. When challenges arose, he prayed to God for help and gave generously to his church, striving to follow God with integrity.

As the company flourished, Sal gained prominence in the pharmaceutical industry. He was celebrated as a visionary leader whose breakthroughs brought him wealth and influence. A few years after founding the company, Sal hired Dave, a brilliant young scientist who quickly formed a unique bond with him. While Sal’s occasional outbursts of anger left other employees rattled, Dave had a calming presence, always knowing the right words to help Sal regain perspective and focus on leading the company. Beyond his interpersonal skills, Dave was a committed believer, talented, and deeply dedicated to the company’s mission.

Within his first year, Dave’s work led to a groundbreaking treatment, earning him admiration among his colleagues. Yet, he remained humble, focusing on the team’s success rather than personal fame, and was steadfastly committed to building Sal’s vision.

From Riches to Rage

Sal was jealous of the acclaim that Dave was receiving. After all, he had hired him. Every time he saw another headline about Dave, he would grow in jealousy. He felt threatened, scared that Dave would challenge his leadership. Despite Dave’s loyalty, Sal saw him as a rival and sought to undermine him: reassigning him to lesser projects, making false claims about him, and even trying to frame him with embezzlement.

Once relying on God for every decision, Sal had pushed God to the background of his life. Sal began to cut corners with the reporting of his research. He made it his personal mission to reverse the community’s perception of Dave, often falsifying profit numbers to shareholders to make himself look better than Dave.

One night, Sal and his employees were pushing to meet a deadline, and they stopped for a quick dinner at the office. The conversation quickly led to talks about the latest breakthroughs. When one of the employees mentioned the impact that Dave had on those discoveries, Sal lunged at Dave and began to choke him. Some of the other employees intervened, wrestling Sal away. Everyone went home for the night. Dave did not press charges, and by the next morning, everyone was back to work, focusing on their mission of producing the best pharmaceutical drugs.

Sal’s obsession with Dave was taking a toll on him. He alienated himself from his employees, lost their trust, and damaged the company’s reputation. Sal was driven to despair. He could not imagine how he would ever get out of this funk. How could a guy who read his Bible every morning struggle with explosive rage?¹Why was he this way? Was it something that he did? Or was it something done to him? Years passed, and Sal became more and more detached from life. He felt emotionally numb. He struggled to evoke deep feelings. He started to experience nightmares, so intense that he would wake up choking his wife. He had to move to a hotel to avoid harming his wife and children. While at the hotel, he grew more and more anxious, and spent several nights unable to sleep, because he was afraid of what he might experience while sleeping.²

Did Sal’s Body Keeps the Score?

Sal’s downward spiral left him desperate for help. But what kind of help? Some help, rooted in Scripture, would see a deeper issue at play. Others would turn to psychology to unlock the past, and that is what Sal chose. A close friend referred Sal to a local psychologist and retired university professor, Ivan Benson, who specialized in traumatic stress. From the beginning, Dr. Benson believed that Sal had experienced some kind of childhood trauma. At the first session, he spent an hour and a half learning about Sal’s childhood and his sudden rise to wealth and fame. He learned of the setbacks and pressures related to owning a multibillion-dollar company. He listened as Sal recounted the heaping shame that he felt from his violent choices, particularly the attack of Dave in front of the others.

Confident that he could help, Dr. Benson assured Sal that he knew exactly what Sal was thinking and feeling.³ Dr. Benson took the bottom-up approach to therapy.⁴ He assured Sal that his problems were not the result of moral failings.⁵ Rather, he believed that people who have experienced trauma have alexithymia—not having words for feelings.⁶ Dr. Benson’s goal with Sal was not merely to cover his problems with psychotropic medication, but he believed that Sal’s central nervous system had been reorganized to make him believe that the entire world was a dangerous place.⁷. So, according to Dr. Benson, Sal’s problem was a psychological issue, not a spiritual one.

Dr. Benson did not try to explain why Sal felt so angry, guilty, and shut down. He knew that Sal already saw himself as damaged goods. If Sal was going to be helped with his misery and hurt, Dr. Benson would have to recruit Sal’s own strength and self-love, enabling him to heal himself. This meant focusing on his many inner resources. Benson knew that he could never provide him with the love and care that he missed so much throughout his life.⁸ While it was not recognized as a valid disorder in the DSM-5, Benson saw Sal’s condition as Complex PTSD (C-PTSD), a condition resulting from prolonged, repeated trauma, particularly during childhood, which effects the development of psychological and biological systems.⁹

The goal was to actually change Sal’s physiology, particularly his relationship to bodily sensations while he was reliving his past trauma.¹⁰ Sal needed to feel his body as the place where the psyche lived.¹¹

Benson knew that no psychologist could undo past trauma. Instead, Dr. Benson sought to deal with the imprints of the trauma on Sal’s body, soul, and mind. Trauma had robbed Sal of feeling in charge of himself. Dr. Benson’s challenge would be to help reestablish ownership of Sal’s self, which meant that Sal should feel free to know what he knows and feel what he feels without becoming overwhelmed, enraged, ashamed, or defeated.¹² “I had to help him find a way to survive,” Dr. Benson would say about him. And the only way that Sal could change the way he felt was by becoming aware of his inner experience and learning to befriend what was going on inside of himself.¹³ At the core of recovery had to be his own self-awareness.¹⁴

At the second visit, Dr. Benson introduced Eye Movement Desensitization and Reprocessing (EMDR). First, he asked Sal to go back in his mind and retrieve those images and sounds of his past trauma. Then, Sal was to follow Dr. Benson’s index finger as he rapidly moved it back and forth in front of his eye. Finally, whenever he would see that Sal would become unsettled, Dr. Benson would say, “Notice that.” He didn’t ask Sal to explain what he saw. He just asked him to recall past trauma and notice how his body was responding whenever he would relive those events.¹⁵. At the end of that second session, Sal was noticeably calmer and visibly relieved¹⁶.

After the third session, Sal realized that he had treated Dave like his father had treated him when he was a boy. After the fifth session, he was sleeping better and for the first time, Sal experienced feelings of peace.¹⁷

Dr. Benson’s method reflects the psychological approach. Yet, by framing Sal’s rage as a psychological issue—Complex PTSD from childhood trauma—he sidelined the moral and spiritual roots that Scripture reveals.

What if Sal’s Body Does Not Keep the Score?

I would have loved to meet Sal. He seems like an interesting, albeit deeply troubled, person. But could I really help someone like Sal? Critics of biblical counseling maintain that biblical counselors would only do damage to sufferers of trauma. They say that we ignore the physiological realities that trauma has on a person. After all, the body keeps the score, so they say, whereas biblical counselors focus on the soul. For cases of traumatic stress, these critics believe that should defer to professionals.

But what if the Word of God has the power to transform Sal? We know from Hebrews 4:12 that the Word of God is alive, sharper than any sword, able to pierce through the dividing asunder of Sal’s soul and is able to judge the thoughts and intentions of his heart. If I had an opportunity to meet with Sal, I would not use language about trauma being stored in the body. Trauma can serve as an excuse for Sal to pass the blame and to remove personal responsibility. Not knowing all of Sal’s past, I can still confidently say to him that his responses to his past trauma with explosive and sinful rage were wrong. That may not sound very caring, but if Sal could take personal responsibility for his explosive rage, then true change could happen through confession and repentance (1 John 1:9). Dr. Benson might look at Sal’s present explosive outbursts at Dave and suggest that those responses were understandable and even expected. But the Scriptures never give a person an excuse to sin, even if they experienced the worst kinds of suffering at the hands of others.

How would I deal with Sal if he came to me?

It is easy to play armchair quarterback, claiming that we would have done better if we had to care for Sal. But was EMDR what Sal really needed? Or could it be that Sal needed to deal with the hurts that he had experienced by looking to God for strength? Whether a person’s suffering is innocent or guilty, there is always a biblical response (cf. Joseph and Peter). Where Sal was guilty, he needed to own his sin, repent of it, and find mercy and compassion from God. He needed to turn from his jealousy. He needed to confess his sins and find forgiveness from God.

Unpacking all of his past experiences would not have been easy, but I would have been happy to listen to his story. The challenge for biblical counselors is to know how much impact past events have on a person’s current situation. A person’s past is certainly a factor in how they think, feel, and act. But it is never the cause. James 1:14 says that we are drawn away and enticed by our own evil desires. The devil has never forced anyone to do anything. We do not explode in rage because of our childhood or our present stressful environment or because of our biology. We do it because we choose to do it. It is when we choose in our hearts to please ourselves instead of God that we give in to our desires and act out in rage.

The lion share of my time with Sal would have been spent on a proper response to suffering and on his personal responsibility before God. What did God expect of him? What does the Bible require from a pharmaceutical company’s owner and president? Of course, the Bible has a lot to say about managing people, “Masters, grant to your slaves justice and fairness, knowing that you too have a Master in heaven” (Colossians 4:1). Ephesians 6:9 says,

“Masters, do the same things to them [i.e., treat your slaves with respect and honor as they are supposed to do to you, cf. vv. 6–8], and give up threatening, knowing that both their Master and yours is in heaven, and there is no partiality with Him.”

Regarding Sal’s jealousy, James 3:13–18 says,

“Who among you is wise and understanding? Let him show by his good behavior his deeds in the gentleness of wisdom. But if you have bitter jealousy and selfish ambition in your heart, do not be arrogant and so lie against the truth. This wisdom is not that which comes down from above, but is earthly, natural, demonic. For where jealousy and selfish ambition exist, there is disorder and every evil thing. But the wisdom from above is first pure, then peaceable, gentle, reasonable, full of mercy and good fruits, unwavering, without hypocrisy. And the seed whose fruit is righteousness is sown in peace by those who make peace.”

The Scriptures do not allow a person to use their suffering as a justification for jealousy and sinful rage. James makes it clear that whenever there is jealousy or selfish ambition, it is not caused by a person’s past experiences, nor is it because a person did not get enough yoga therapy, or that he did not have a psychologist conduct EMDR with him. It is because he is responding according to his own wisdom and understanding, a wisdom that is “earthly, natural, demonic.” And the pathway toward true change starts with humbly recognizing that he needs to take ownership of his personal sin and seek forgiveness from God.

Paul has much to say about dealing with the evils done to us. He writes in his letter to the Romans,

“Bless those who persecute you; bless and do not curse. Rejoice with those who rejoice, and weep with those who weep. Be of the same mind toward one another; do not be haughty in mind, but associate with the lowly. Do not be wise in your own estimation. Never pay back evil for evil to anyone. Respect what is right in the sight of all men. If possible, so far as it depends on you, be at peace with all men. Never take your own revenge, beloved, but leave room for the wrath of God” (Romans 12:14–19).

We are not to take vengeance or treat people with evil. We are to bless them and rejoice with them. We are to seek to live at peace with others, and then leave the rest to God.

A Modernized Story to Make a Point

The story of Sal is not what it appears. In fact, I modernized this true story in order to show how Bessel van der Kolk might have handled such a case and to show how clinicians (Christians or not) tend to overthink trauma and try to resolve the problems associated with trauma with God-excluded means. While there are physiological factors to a traumatic event, it is not primarily a bodily issue. It is a spiritual and relational issue. It has to do with how a person relates to God and others. It has to do with how a person looks at life and interprets things.

The story of Sal is actually a version of a real-life event from about 3,000 years ago. Sal’s character is based on King Saul, and Saul was not from rural Illinois. He was from Benjamin, the smallest tribe of Israel. He grew up in relative obscurity but rose to prominence quickly because of God’s providence. And early on, he did seek to obey God and give him the glory for the victories. But when David started to receive more recognition, Saul grew in jealousy, and began to explode in rage at David, trying to kill him on several occasions. He even threw a spear at his own son, because he hated David so much.

Dr. Ivan Benson is a fictional representation of the kind of approach that Dr. Bessel van der Kolk, famed psychiatrist and author of The Body Keeps the Score, might take with a person like Sal.¹⁸You will notice that in Dr. Benson’s approach to helping Sal, I have included endnotes to show van der Kolk’s approach from his book.¹⁹

This modernization was undertaken to make a point, that Christian integrated counseling is severely flawed as it is quick to implement psychological theories to treat what are ultimately spiritual issues. Dr. Benson might have diagnosed Saul with trauma, thinking that his trauma was stored in his body. But Scriptures show his rage stemmed from jealousy and disobedience—sins that only God’s Word, not EMDR, can free him from.

The Bible was never meant to be exhaustive. My point in this essay is to show the absurdity of being quick to assign psychiatric diagnoses to people. When we bring King Saul into modern times, we treat him very differently than we would have if we had just looked at the straightforward spiritual issues that needed to be addressed. The Bible explains his situation without a label, just like the Bible explains so many situations, because the Bible is the only way to truly understand the human condition. Well-meaning biblical counselors fall into a trap of reading modern psychiatric diagnoses, constructs, and labels into the Bible. In doing so, they end up assigning labels to people in the Bible that go beyond what the Scriptures intended. I think we do damage to the interpretation of Scripture when we force diagnoses on biblical characters (e.g., “Nebuchadnezzar must have had schizophrenia,” or “King Saul was definitely bipolar,” etc.).

One of the problems that David Powlison warned about was giving proof-texts or pat answers to complex problems.²⁰To be clear, I do not believe King Saul had PTSD. The point of connecting Saul with PTSD is to show how a modern-day clinician might diagnose him and seek to help him. Saul’s case exposes critical flaws in Christian psychology’s approach to trauma. Too often, it hastily dismisses sin as a potential factor in the persistent effects following a traumatic event while eagerly adopting secular diagnoses and theories as solutions. This does not imply that every individual grappling with trauma’s aftermath is living in sin, nor should we rush to assume that a person is acting sinfully. However, it demands that we carefully consider sin as a possible influence on how a person processes and responds to past trauma, ensuring a biblical approach that neither ignores spiritual realities nor oversimplifies complex struggles.

A War Veteran and Trauma

Louis Zamperini ran track in the 1936 Berlin Games. He enlisted in the US Army Air Forces (AAF) and served as a bombardier in the Pacific during World War II. His plane was shot down on May 27, 1943. Crashing into the ocean, he and two soldiers were left to survive on a life raft for a month and a half. The Japanese would then capture them and brutally torture them for two and a half years. They endured some of the most terrible kinds of suffering and despair. When the war was over, they were released.

Back in the States, Louis struggled with PTSD and alcoholism. He had night terrors nearly every night after the war. These vivid nightmares would often lead to violent outbursts. On one occasion, he woke up with his hands around his wife’s throat.²¹ She would consider divorcing him. He tried muting his trouble with alcohol, but it only made things worse. When he went for treatment from a psychologist, he was asked to recount his past trauma, which only incited his angers and fears even more. After three sessions, he discontinued treatment. He could find no relief until he heard the gospel preached in the winter of 1949. Under the weight of conviction, he remembered a promise he had made while on the raft, dying of thirst, “If you will save me, I will serve you forever.”²² He gave his life to Christ that night. He went home that same evening and removed the alcohol, cigarettes, and everything evil that was part of his ruined years. When he awoke the next morning, he realized that for the first time in five years, he had not dreamed about his torturers. Moreover, he would never have a night terror about his past trauma again.²³ This led him to consider the biblical concept of forgiveness. Zamperini finally came to a place where he could release his torturers from the sins that they had committed against him. Here was the letter he wrote to the chief torturer, known as “The Bird”:

To Matsuhiro Watanabe,

As a result of my prisoner of war experience under your unwarranted and unreasonable punishment, my post-war life became a nightmare. It was not so much due to the pain and suffering as it was a tension of stress and humiliation that caused me to hate with a vengeance.

Under your discipline, my rights, not only as a prisoner of war but also as a human being, were stripped from me. It was a struggle to maintain enough dignity and hope to live under the war’s end.

The post-war nightmares caused my life to crumble, but thanks to a confrontation with God through the evangelist Billy Graham, I committed my life to Christ. Love replaced the hate I had for you. Christ said, “Forgive your enemies and pray for them.”

As you probably know, I returned to Japan in 1952 and was graciously allowed to address all the Japanese war criminals at Sugamo Prison…I asked then about you, and was told that you probably had committed Hara Kiri, which I was sad to hear. At that moment, like the others, I also forgave you and now would hope that you would also become a Christian.²⁴

Like Saul, Zamperini suffered deeply—Saul from war and jealousy, Louis from torture and despair. Psychology failed Louis, just as it would have failed Saul. Only God through His Word can bring peace. I realize that the stories of Saul and Louis do not account for all the complexities of trauma, but they do illustrate how a straightforward, biblical approach to trauma can move to a solution. We were all created by God with the capacity to interpret our world, and that is what we do. When our interpretation excludes God, sin, a faithful response to human suffering, and personal responsibility, we are going to look for extrabiblical explanations for why we respond the ways that we do. However, our first stop for an answer must always be the Bible. And any other stops along the pathway toward an answer must have the Bible as the lens through which we evaluate those means of help. Of course, there could be some physical factors, and biblical counselors are quick to encourage counselees to inquire with a doctor about biological causes that may contribute to a particular response. But even when given a medical diagnosis, believers must interpret those results through the lens of Scripture.

Saul’s rage and Zamperini’s trauma show that suffering is real, but personal responsibility and forgiveness cannot be ignored. Integrationism may be quick to borrow from van der Kolk and others, and in them they may find partial fixes. But pain and guilt have to be tackled head-on, using principles from the Scriptures.

Biblical counseling’s approach to dealing with trauma may appear overly simplistic, but the sufficiency of Scripture is not a simplistic approach. It is complex and nuanced. And while the biblical counseling approach may sound too good to be true, it is not. God wrote the manual for how humans should relate with Him and with each other. If we are going to effectively set His Word aside and instead turn to theorists and clinicians who overlook the reality of the Creator and the existence of sin, we are misguided. It does not matter how intellectual, academic, or complex the theory is, we cannot disregard clear instruction from God on how to deal with suffering and our own sin. If we do so, we are ignoring God’s wisdom to our own detriment.