Prolonged exposure therapy for combat-related posttraumatic stress disorder: comparing outcomes for veterans of different wars

There is significant support for exposure therapy as an effective treatment for posttraumatic stress disorder (PTSD) across a variety of populations, including veterans; however, there is little empirical information regarding how veterans of different war theaters respond to exposure therapy. Accordingly, questions remain regarding therapy effectiveness for treatment of PTSD for veterans of different eras. Such questions have important implications for the dissemination of evidence based treatments, treatment development, and policy. The current study compared treatment outcomes across 112 veterans of the Vietnam War, the first Persian Gulf War, and the wars in Afghanistan and Iraq. All subjects were diagnosed with PTSD and enrolled in prolonged exposure (PE) treatment. Veterans from all three groups showed significant improvement in PTSD symptoms, with veterans from Vietnam and Afghanistan/Iraq responding similarly to treatment. Persian Gulf veterans did not respond to treatment at the same rate or to the same degree as veterans from the other two eras. Questions and issues regarding the effectiveness of evidence based treatment for veterans from different eras are discussed.     

Adolescents' views on war and peace in the early phases of the Iraq conflict

Adolescents' views of war and peace were assessed among 209 children aged 10-14 who attended a parochial school or its after-school religious program located in a predominantly middle-class, suburban area within commuting distance of New York City. Findings were compared to those of youth surveyed during other armed conflicts, specifically the Vietnam War, the first Persian Gulf War, and the U.S. military involvement in Latin America. The study took place in early fall 2003, and results were interpreted in light of the social climate and complex realities of post 9/11 in New York State, the Catholic Church's initial opposition to the Iraq conflict, and popular opinion. In spite of differences between the Iraq War and other conflicts, findings are remarkably similar. Although the present group is highly preoccupied with terrorism and nuclear war, even in a time of war, participants show concern for what they perceived as affecting their lives directly, rather than with conventional war. While they believe that President Bush was honest about the war in Iraq and right in sending troops, they do not glorify war. On a theoretical level, they overwhelmingly believe that wars are bad and the majority is optimistic that world peace is possible, though they realize that wars are difficult to prevent, believe that they are sometimes needed, and will occur in the future. Unlike the Catholic group surveyed by Tolley during the Vietnam War, however, participants are not as ready to die for their country, although findings show that, overall, like past groups, more boys tend to be pro-war than are girls and participants' views tend to reflect contemporary public opinions.     

The Immigrant Analyst: A Journey From Double Consciousness Toward Hybridity

In this paper I utilize the concept of “double consciousness” as a framework for theorizing the subjectivity of the immigrant analyst. I invite the reader to journey with me as I deconstruct my experiences as an immigrant analyst in North America in order to depict how “double consciousness” shapes subjectivity. I show that I developed a binary, bifurcated analyst self, despite my wish to become a multicultural analyst who could “stand in the spaces.” This subtly clouded my clinical judgment causing me to side with the immigrant boyfriend of an American patient and to ignore significant differences between myself and a French patient because he too was an immigrant. When I named and processed my “double consciousness” I experienced resignification, my subjectivity was reconfigured, I was able to experience a panoply of selves, a hybrid “me-ness,” and I could recognize and address “double consciousness” in my immigrant patients.     

Political Attitudes and the Vietnam War: A Study of College-Educated Men of the Vietnam Generation1

Groups of Vietnam veterans (n= 52), Vietnam era veterans (n= 77), and nonveterans (n= 249), all of whom had graduated from an Ivy League university in 1966, were compared in terms of their retrospectively reported general political orientation in 1966 and their current orientation and specific political attitudes in 1990–1991. The Vietnam veterans rated themselves as being more conservative than the nonveterans on political orientation and on specific political issues in 1990–1991. The Vietnam-era veterans tended to take an intermediate position politically between the other two groups. Controlling for retrospective political orientation in 1966, intensity of military experience predicted more ideological conservatism and more support for the war against Iraq, as well as a more conservative position on a number of specific political issues of current interest. Results are consistent with the idea that critical experiences in young adulthood, namely military service in Vietnam, may affect political attitudes over many years.     

Silence as the Voice of Trauma

Silence is a key to the unspoken world of the patient. Rather than interpreting silence as a defensive maneuver, the analyst may understand this disruption as a royal road to the patient’s traumatic experiences. The author proposes to recognize traumatic silences in the analytic process and the transference as a re-experiencing of past, unpredictable traumatic affective states and memories. Silences in this context are both a repeat of a disconnecting experience as well as a manifestation of a silencing identification with the original silencer. The clinical material illustrates effects of a German mother’s World War II (WWII) personal traumata and collective shame-based silence on her daughter’s self and good object development. In the daughter’s analysis, the patient and the analyst, who herself experienced similar WWII traumata, face the pain of trauma recovery and un-silencing. The author suggests that the deadening effect of past traumata may be reversed by an analytic process of re-membering and re-speaking for both the patient and analyst. This allows for a more transparent, subjective experience in the transference and a verbal integration of ego functions.     

Immigration: The “Illegal Alien” Problem

ABSTRACT

The present paper explores the “immigration crisis” both in the United States and in countries around the world. Consideration is given to what is typically absent in public discourse—that is, that immigration is inflected with race, class, ethnicity, religion, and language. Drawing on the work of several leading scholars in philosophy and linguistics, with particular attention to how metaphor shapes thinking, the “immigration problem” is unpacked to examine the issues embedded within its characterization as a “crisis” and for whom that might be so. Examined as well are the larger sociopolitical issues beyond the worldwide public outcry about securing borders. The paper rests analysis of both how the immigrant “other” is characterized and the larger sociopsychological significance of that characterization within the idea of the social unconscious. Finally, the paper explores the role of the group analyst as “citizen therapist” in expanding empathic engagement among groups affected by the huge migration flows. Included are recommendations for the role the group analyst may play in addressing the issue of immigration in our groups and communities.     

Fear and Shame in an Israeli Psychoanalyst and His Patient: Lessons Learned in Times of War

Living in the midst of a war presents unique challenges to ongoing psychotherapeutic treatment. This paper focuses on the ever-present threat of fracture to the analytic frame and the limited ability of the therapist to create a safe, insulated environment— a reliable container—in which to work, while coping with a violent external reality. Using an intrapsychic lens, as well as an interpersonal one, the dynamics of both the analyst's and the patient's fear and shame are brought into focus. This delicate balance is illustrated through two cases: one occurring during the First Gulf War (1991) and the second taking place during the Second Lebanon War (2006). In both cases, fear and shame cause a stalemate in the psychotherapeutic process. The analyst recalls his active duty as a soldier during the Yom Kippur War (1973). These memories and their attendant acknowledgement of fear and shame by the analyst, as well as his analysand's “supervisory” comments, gradually dissolve the knot and repair the rupture in the analytic process. The ability to fully experience fear, shame, and helplessness is at the core of psychic health, a health once destroyed by dissociation and denial of these feelings. This ability to experience fear and shame is the psyche's antidote to mental breakdown. Following discussion of the two case studies, this paper seeks to illustrate how the very structure of a society, in this case Israel, can codify societal defense mechanisms against emotions like fear and shame, exacerbating the very problems it seeks to assuage.     

Legacies of War: Asian American Women and War Trauma

ABSTRACT

Although Asian Americans are diverse in many ways, such as language, culture, ethnicity, religion, generational status, and more, many share a common experience: that of having experienced war first hand or being progeny of war survivors. World War II, the Korean War, the Vietnam War, the Cambodian genocide, along with centuries of oppressive and authoritarian rule, have brought experiences of trauma, directly and historically, to the lives of many Asians. Subsequent experiences of migration and resettlement, as well as life in the United States as an ethnic minority, have also compounded the layers of oppression for many Asian Americans. Sexism in our cultures of origin, as well as sexism in the U.S., represents additional realities and traumas faced by Asian American women. In this article, we explore the experiences of war and subsequent traumas in the lives of Asian American women. We present a brief review of the current state of mental health as it relates to the experiences of war trauma, with the goal of providing a crucial contextual backdrop for our review of the best practices in mental health services to Asian American women. We review some of the best practices and conclude with a narrative reflection based on our own involvement in a small professional women’s group that yielded insights, discoveries, healing, and empowerment from the legacy of war trauma.     

The analytic third: implications for psychoanalytic theory and technique

The author views the analytic enterprise as centrally involving an effort on the part of the analyst to track the dialectical movement of individual subjectivity (of analyst and analysand) and intersubjectivity (the jointly created unconscious life of the analytic pair--the analytic third). In Part I of this paper, the author discusses clinical material in which he relies heavily on his reverie experiences to recognize and verbally symbolize what is occurring in the analytic relationship at an unconscious level. In Part II, the author conceives of projective identification as a form of the analytic third in which the individual subjectivities of analyst and analysand are subjugated to a co-created third subject of analysis. Successful analytic work involves a superseding of the subjugating third by means of mutual recognition of analyst and analysand as separate subjects and a reap-propriation of their (transformed) individual subjectivities.     

Embodying analysis: the body and the therapeutic process

This paper considers the transfer of somatic effects from patient to analyst, which gives rise to embodied countertransference, functioning as an organ of primitive communication. By means of processes of projective identification, the analyst experiences somatic disturbances within himself or herself that are connected to the split‐off complexes of the analysand. The analysty’s own attempt at mind‐body integration ushers the patient towards a progressive understanding and acceptance of his or her inner suffering. Such experiences of psychic contagion between patient and analyst are related to Jung’s ‘psychology of the transference’ and the idea of the ‘subtle body’ as an unconscious shared area. The re‐attribution of meaning to pre‐verbal psychic experiences within the ‘embodied reverie’ of the analyst enables the analytic dyad to reach the archetypal energies and structuring power of the collective unconscious. A detailed case example is presented of how the emergence of the vitalizing connection between the psyche and the soma, severed through traumatic early relations with parents or carers, allows the instinctual impulse of the Self to manifest, thereby reactivating the process of individuation.     

External and internal reality: The impact of the current socio‐economic crisis on the analytic dyad

This paper addresses the impact of the current economic crisis on the psychic functioning of the patient and the analyst, their relationship and collaboration. This intrusion of ‘external reality’ is multidimensional, and thus with multiple meanings. The critical role of the economic factor brings various dimensions of money into play, such as self‐preservation, power as well as aspects of psychosexual development. In addition, the crisis involves symbolic loss of basic ideals such as honesty and social responsibility. Patient and analyst are affected in similar and different ways in their respective roles as well as according to the specific intrapsychic functioning of each. Moreover, unique characteristics of the crisis often create a crisis in the analysis. In order to avoid deformation of the analytic relationship, the analytic dyad must examine and work through the multiple meanings of the crisis as well as the meaning of the impact of the crisis on the analytic relationship for both patient and analyst. This complex transference‐ countertransference interplay poses specific challenges to the analyst. After discussion of these issues, clinical material is presented that demonstrates how they appear in analytic practice today.     

Creating analysts, creating analytic patients

This paper applies a contemporary, 'two-track'- transformational as well as archaeological - perspective on psychoanalytic process to clinical issues in the creation of analytic patients: case finding, recommending analysis, and recommending and negotiating the intensification of frequency of sessions in analytic psychotherapy. Central importance is assigned to the role of the mind and analytic identity of the analyst, including the analyst's capacity to maintain an internal analytic frame and analyzing attitude from the very first contact with the patient and throughout the treatment, the analyst's confidence in and conviction about the usefulness of analysis for a given analytic dyad and the role of the analyst's theory, which must be broad and consistent enough to allow the analyst to feel that he or she is operating analytically when addressing non-neurotic (unrepresented and weakly represented mental states) as well as neurotic structures.     

Dreams and the holistic nature of interpersonal psychoanalytic experience

Patients’ dreams and analysts’ dreams about patients are assumed to reflect each analytic participant's attitude and psychic conduct toward the other, and an unconscious overlapping of psychic issues and struggles between them as well. This makes it possible to deal with dreams from one‐person and two‐person models of psychological functioning, as well as from an additional psychic dimension that is assumed to be a creation of the analysis itself. As a source of freely moving experience within both participants, one that is assumed to have a life and direction of its own, this latter dimension of analysis permits patient and analyst to undergo more freely the actual experience of the treatment as a modality that is separate from and prior to positivistically grounded determinations that can be made about either the patient or analyst individually, or about the two of them jointly.

This dimension of analysis is said also to reflect a holism that characterizes conscious and unconscious psychoanalytic experience. Dreams and unconsciously generated dreamlike clinical phenomena are presented to try to illustrate this holistic character of analytic work, and to show how either participant's psychic productions maybe used to evoke significant experiences and further clinical knowledge.     

‘I'm not a war monger but…’: Discourse Analysis and Social Psychological Peace Research

The present paper argues for a discourse analytic approach to social psychological peace research and demonstrates the potential of such an approach through a re‐specification of the concept of attitudes to war. This is illustrated through an analysis of a series of televised debates broadcast in the UK in February–March 2003 in the build‐up to the formal outbreak of the Iraq War. Analysis draws attention to the importance of rhetorical context and function, the inseparability of attitude object and evaluation and the formulation of evaluations as specific or general. Findings are discussed in the context of recent calls for methodological pluralism in social psychological peace research with a suggestion that matters of epistemology stand prior to methodology. Copyright © 2011 John Wiley & Sons, Ltd.     

Performative and enactive features of psychoanalytic witnessing: The transference as the scene of address

This paper will attempt to broaden the conception of witnessing in analytic work with traumatized patients by extending the idea to incorporate the patient’s developing and varied capacity for witnessing, as well as a witnessing that occurs within the analytic relationship itself. Actions occuring as part of traumatic repetition are understood to represent memory phenomena and are distinguised from dissociated self‐state experience. These experiences are not therapeutically intended to be symbolized, but rather lived‐through with the analyst, thus transforming the patient’s own relation to the experience. I suggest that the scene in which this living‐through takes place is the transference–countertransference matrix, and that it is the analytic encounter that allows traumatic repetition to take on the quality of a communication, an address to another, rather than remain meaningless reproduction. A clinical vignette illustrates the turning of trauma’s imperative for witnessing into an address in the analytic encounter.     

Immigration as a Vessel for Transformation

French cultural complexes revolve around competitively affirming superiority of culture, including language, competing with American complexes of supremacy and heroism. Immigration often resonates with personal histories of separation. Through the lens of my personal experiences as a French immigrant and my clinical experiences working with immigrants, I explore the interplay of personal and cultural complexes in the analytic field through transference and countertransference, and the meaning of immigration and distance for the development of the personality. Leaving enables the immigrant to safely explore relationships. As a self-imposed rite of passage, immigration prunes branches for growth. Idealization of the transference and the risks of the polarization of cultures and of the feeling of “us and them” are the main ethnocultural elements coloring transference and countertransference reactions with this population. Immigration, a symbol of separation and often a striving for wholeness, has the power to shape one's cultural and personal identity and ferment individuation, with personal and cultural histories cross-fertilizing each other.     

At Death's Door: Therapists and Patients as Agents

This paper explores the interrelationship between patients' exercise of will to make advances in an analysis and their readiness to forgive their analysts for their human limitations. There is a thin line between idealization of the analyst, probably a necessary component of the process, and resentment of the analyst for his or her privileged position in the world and in the analytic situation itself. The patient's “progress” emerges as a kind of reparative gift, one that implicitly overcomes the patient's tendency to withhold such change out a sense of chronic, malignant envy. Particularly poignant in terms of its potential to elicit the patient's reparative concern is the situation in which the analyst is struggling with his or her mortality because of aging or life-threatening illness. In this essay two clinical vignettes are presented to illustrate some of the issues that this situation poses. One begins with an elderly patient appearing at the door of the analyst's (the author's) home the day of his return from the hospital after coronary bypass surgery. The other begins with an analyst who is terminally ill appearing at the door of a patient who is threatening suicide. The two stories are compared in terms of their implications for human agency, the exercise of will, and the coconstruction of meaning in the face of mortality in the analytic process.     

Ordinary Sadism in the Consulting Room

The analyst’s retaliatory sadism can be construed as a perversion of the wish to penetrate, just as masochism can be viewed as a degradation of the desire to surrender. When a patient refuses to speak any other language but that of domination and submission, ordinary attempts for communication and recognition fail. In her attempt to reach the patient, to reinstate herself as an active agent and subject, and also to dislodge the patient from a rut of despair, passivity, or malignity, the analyst may escalate to a sadistic response, even if she suspects that this might cause the patient pain. This type of sadomasochistic enactment can gather strength when disowned self-states of analyst and analysand are activated. In this process, an analytic interpretation, seemingly legitimate, can be used as a knife, a weapon, an instrument of retaliation and sadistic control. The disastrous potential of the analyst’s sadism is easy to imagine. Through a couple of clinical vignettes I will demonstrate that even something as lamentable as the analyst’s sadistic retaliation can lead to growth as long as such sadism can enter the analytic dialogue and the patient is allowed to perceive and reflect upon the analytic misbehavior, and the analyst is willing to join the patient in the quest to understand their co-created predicament.