Process and content in a long-term PTSD therapy group for Vietnam veterans

Process and content were studied in four 16-session segments of a psychodynamically oriented therapy group for Vietnam veterans suffering from posttraumatic stress disorder (PTSD). On the Group Climate Questionnaire (GCQ-S), the group scored significantly higher in the Engaged dimension and significantly lower in the Avoiding and Conflict dimensions than contrasting samples of neurotic and psychotic groups. There was no evidence of group stages. Topics related to symptoms of PTSD were discussed most frequently (43.1%), followed by issues concerning relations with others (32.4%),general group therapy issues (13.7%), and other topics (10.8%). Clinical implications of these findings are discussed.The authors thank Tom Metzler, M.A., and Heidi Ronfeldt, B.S., for their assistance with the data analysis.Parts of this paper were presented at the American Group Psychotherapy Association Annual Meeting, February 15–20, 1993, San Diego, CA.     

Post-traumatic accelerated cohesion: Its recognition and management in group treatment of Vietnam veterans

Post-traumatic accelerated cohesion (p-TAC) is the name given to a frequently observed group phenomenon in the treatment of Vietnam veterans who suffer traumatic war neuroses. It is critical that this group dynamic be discussed, especially since group is widely regarded as the modality of choice in treating these veterans. Post-traumatic accelerated cohesion is the rapid, premature development of cohesion in a group of virtual strangers, and is here presented in terms of its harmful impact on the group and the impasses it creates. Suggestions are given to resolve p-TAC and move the group toward fulfilling its goals. Placed within the self psychology and object relations theoretical frameworks, the discussion addresses issues pertaining to developmental arrests and post-traumatic self disorders and their relationship to p-TAC dynamics.The views in this paper are the author's sole responsibility and do not necessarily reflect those of the Veterans Administration.     

Recovery from sexual assault: an innovative two-stage group therapy model

This article describes an innovative two-stage model of sexual assault therapy groups for women in a university setting. This model is recommended for use in various settings and includes a supportive therapy group and two specialized therapy groups, one for childhood sexual abuse survivors and the other for sexual assault (acquaintance rape and stranger rape) survivors. Theoretical underpinnings of the model are discussed in addition to practical aspects of group development such as elements of an effective group, screening of potential members, and marketing and recruitment techniques.     

Forgotten warriors: an evaluation of the emotional well-being of presently incarcerated Vietnam veterans

The emotional well-being of a group of incarcerated Vietnam veterans within the maximum security section of a state prison was assessed along with comparison groups of veterans and nonveterans. The Multiple Affect Adjective Check List (MAACL) (Zuckerman & Lubin, 1965), the Adjective Check List (ACL) (Gough & Heilbrun, 1983), and the Military Life Questionnaire (MLQ) (Panzarella, Mantell, & Bridenbaugh, 1978) were administered. Both the factors of incarceration and Vietnam experience proved significant on a number of MAACL, ACL, and MLQ measures, including depression, anxiety, hostility, and personal adjustment. The MLQ results also indicated that, compared to their nonincarcerated counterparts, the incarcerated veterans were more likely to be black, to have come from a less supportive family background, to have been assigned to an Army infantry combat unit, to have been injured in combat, and to have witnessed or been involved in the killing of enemy soldiers, prisoners, and civilians while in Vietnam. Many incarcerated veterans apparently began as poor prospects in terms of their social, economic, and interpersonal well-being. They went to Vietnam, bore the brunt of these experiences, and emerged as even poorer prospects, all the more at risk and prone to incarceration.     

The psychophysiology of combat-induced post-traumatic stress disorder in Vietnam veterans

The psychophysiological responses of heart rate (HR), systolic and diastolic blood pressure, skin conductance level and forehead electromyogram were compared during: rest, mental arithmetic and combat sounds of gradually increasing intensity for five groups of Ss: Vietnam veterans with post-traumatic stress disorder (PTSD); Vietnam veterans without PTSD but with comparable levels of combat experience; Vietnam veterans with other psychiatric disorders; Vietnam-era veterans; and nonveteran phobics. HR response to low-intensity combat sounds provided good discrimination between veterans with PTSD and the other groups and seems to resemble a conditioned emotional response.     

A crisis mental health intervention service: an innovative model for working intensively with young people on the edge of care

This paper describes the setting up and the first year of running of an innovative outreach service for adolescents on the edge of care that aimed at redressing family breakdown and preventing placements in the care system. It was a collaborative endeavour between social services and a child and adolescent mental health provision to facilitate the engagement of hard to reach young people and families that often presented high levels of risk. This article describes a distinctive model of applied psychoanalytic work with individuals, families and the networks of practitioners and agencies around the case. It focuses on the integration of two perspectives: the individual and the family on the one hand and the organisation on the other. Case examples illustrate how our psychoanalytic and developmental framework illuminated our understanding of frequently extreme acting out behaviour and parental difficulties in terms of underlying intergenerational trauma, which was often re-enacted. This framework also helped in understanding the difficulties that practitioners experienced and how these related to individual and family dynamics. The article describes the significance of containment in the treatment of adolescents and families in crisis as well as in supporting the professional network.     

The dream in group therapy: A reappraisal of unconscious processes in groups

Addressing the issue of the existence of a group unconscious, this paper views dreams as providing potential evidence on the question. Dream material presented by various members in each of three psychotherapy groups is considered. In each group, convergences were found in the material presented by separate individual dreamers. By integrating a conceptual model of neurological information processing during REM dream sleep with a variety of behavioral research, a conceptual model is offered for the development of a group disposition, which represents an overlap of both individual and shared group psychic content. Group phenomena of cohesion and dependency are derived from this conceptual model.     

The reparation of the self: Clinical and theoretical dimensions in the treatment of Vietnam combat veterans

This paper discusses a broad range of theoretical and clinical issues pertaining to a proposed approach to individual psychotherapy with Vietnam combat veterans. Called theself-reparative process, this approach features four phases, ranging in the first from anactive behavioral-cognitive approach to the fourth phase that utilizes a less active, psychoanalytic approach. This range of approaches is essential in order to adapt to the ongoing progressivespectrum-of-needs of the veterans, with the objective of increasing psychological control to resolving narcissistic rage and building a cohesive self.The views contained in this paper represent those of the author, who is solely responsible for its contents. As such, the views herein are not necessarily those of the Veterans Administration. Paper presented at a Queens Hospital Center (affiliation of Long Island Jewish-Hillside Medical Center) Department of Psychiatry, Grand Rounds in Jamaica, New York on April 10, 1981. The author acknowledges the gracious assistance of Doctors Scott Mykel and Robert Mednick of Queens Hospital Center during the first draft of this paper.     

Gestalt therapy in the treatment of Vietnam veterans experiencing PTSD symptomatology

In the author's clinical work with Vietnam veterans experiencing symptoms of PTSD, Gestalt theory and concepts have proven to be very helpful in (a) conceptualizing what sustains Vietnam as a deleterious problem in the lives of these veterans and (b) providing techniques which are effective in helping them overcome their Vietnam-related troubles. Although of great potential, the author feels that the effective application of Gestalt therapy techniques necessitates the kind of prudent clinical discretion which ordinarily requires a solid background in general psychotherapy and specialized training in Gestalt theory, concepts, and techniques.     

Projective identification and working through of the countertransference: A multiphase model

Referring to Melanie Klein's unpublished views on projective identification, Bion's theory of container/contained and Money‐Kyrle's understanding of countertransference as a process of transformation, the author develops a multiphase model of projective identification. He differentiates five subphases of (1) adhesion, (2) penetration, (3) linking of the projection with an internal object of the analyst, (4) transformation and (5) re‐projection. In the author's view the differentiation of overlapping subphases may be helpful to better localize problems of working through the countertransference. Some technical implications are illustrated by brief clinical vignettes. To conclude, the paper discusses typical impasses and options for interpretation.     

Divestment of pastoral authority: A model for healing

Traditionally the pastor has come to be responsible for the pastoral care needs of a congregation. This model suggests that by sharing this authority a pastor can empower the faith community and its members to bring about healing in a dynamic way. Healing is defined not in terms of physical rehabilitation but as the movement toward growth, wholeness, and maturity. The role of the pastor is redefined as one who leads the faith community to a new awareness of the mission of the church as a healing community.Reverend Lydic is Pastor of the Dixon Church of the Brethren, 215 N. Court Street, Dixon, Illinois 61201.     

The history of large group phenomena in relation to group analytic psychotherapy: The story of the median group

This paper presents a history of the large group approach in relation to Foulkesian group analytic psychotherapy, including the nature of this approach in relation to Foulkesian principles. Much of the theory reflects Foulkes's attitude, but there are also clear distinctions made, notably a new stance in our thinking about groups as a result of the increase in size (i.e., a membership of about 20), the introduction of the cultural dimension which this increase entails, and the question of what happens after the resolution of Kleinian, oedipal and familial conflicts has been achieved in psychoanalysis and small groups, no-tably what happens once “exile” has been achieved. The approach presented proposes to handle the frustration and hate that these conflicts engender in the form of negative or antilibidinal energies, and their transformation into psychic energy, through dialogue leading from hate to the establishment of koinonia, or impersonal fellowship, and of microcultural influences which promote rather than inhibit communication. Being neither small nor large, a group of about 20 members has become known as a “median” group.     

Distress in spouses of Vietnam veterans: associations with communication about deployment experiences

Emerging literature shows a consistent pattern of relationship and psychological distress in spouses or partners of combat veterans with symptoms of posttraumatic stress disorder (PTSD). One possible mechanism of partners' distress posited in clinical literature is that excessive discussion of traumatic events from deployment may have negative effects on partners. At the extreme, some partners are suggested to develop PTSD-like symptoms, or secondary traumatic stress. Despite these hypotheses, there have been few empirical tests of the effects of communicating about such events. In a sample of 465 combat veterans and their spouses who participated in the Family Interview Component of the National Vietnam Veterans Readjustment Study, we explored how the extent of couples' deployment-related communication was associated with partner relationships and psychological distress, and whether such associations were moderated by the severity of veterans' PTSD symptoms. Results showed that Vietnam-specific communication correlated negatively with relationship distress, but the effect was negligible after controlling for overall communication in the relationship. On the other hand, Vietnam-specific communication did not correlate with psychological distress, but the association was significantly moderated by veterans' PTSD symptom severity. Specifically, communication about Vietnam was increasingly and positively associated with partners' psychological distress as veterans' symptoms of PTSD rose into the clinical range, but nonsignificantly and negatively associated with such distress as PTSD symptoms decreased below this level. The findings support previous clinical recommendations that couples' discussions of potentially traumatic events be approached cautiously, and they suggest a need to attend to the content of couples' communications when conducting dyadic interventions for PTSD.     

Anxiety, signal anxiety, and unconscious anticipation: neuroscientific evidence for an unconscious signal function in humans

A central tenet of psychoanalysis, and arguably of any comprehensive theory of mind, is the existence of a psychological unconscious. Years of clinical investigation into the nature of unconscious processes have facilitated the development of psychoanalysis as a clinical method. Empirical investigations of unconscious mental processes, however, have lagged behind clinical inquiry. With few exceptions, attempts to understand unconscious processes using rigorous experimental controls have remained sequestered in scientific domains other than psychoanalysis, where they have proliferated recently. In view of this recent upsurge of research on unconscious processes outside of psychoanalysis, efforts to integrate such knowledge into general theories of psychopathology and clinical investigation are critical. In this paper, an interdisciplinary approach is taken to the study of one aspect of unconscious mental functioning--what Freud originally termed signal anxiety. Signal anxiety is examined using information from cognitive psychology and learning theory, psychophysiology, behavioral neuroscience, and psychoanalytic theory. Though the original concept of signal anxiety is supported by recent research, it is concluded that signal anxiety is probably best thought of not as the affect of anxiety but as a subset of unconscious mental processes that have a signal function of anticipating danger. Such unconscious anticipatory processes are a general feature of the mind that includes responses to both real and imagined (neurotic) appraisals of a situation. The neurophysiological structures and processes associated with unconscious anticipation in humans are just beginning to be understood.     

The Vietnam veteran and his preschool child: Child rearing as a delayed stress in combat veterans

Integral to a successful readjustment following his Vietnam combat experience, is the veteran's ability to make the transition from the reflex of combat aggressiveness, to adaptive, nondestructive aggression in his current life. Child rearing has been observed to stress the veteran's working through of this very necessary, though often difficult, transition. Specifically, the activity and agression of the terrible two's and the preschool child, particularly males, reawakens the painful affects of combat aggression and sadism. Attempts to control the aggressiveness in his children and himself may lead to maladaptive coping and symptom breakthrough in the veteran, his child and/or his family unit. Two case examples, one brief, one more detailed, illustrate this observation.Paper read at Symposium on War Babies: Delayed Effects of Warmaking, Disaster and Persecution on Children, Xth International Congress of Child and Adolescent Psychiatry, Dublin, July 26, 1982.