Theory

Dissociation is one mechanism that is used by the ego as a way to maintain its integrity for survival, and is a response to severe trauma (Gabbard, 1994). Research suggests that childhood physical abuse may be an antecedent to the development of combat-related posttraumatic stress disorder (PTSD) (Bremner, Southwick, Johnson, Yehuda, & Charney, 1993).When doing group therapy with a veteran who is known to dissociate it can present a number of challenges for the group therapist. In particular, it is important for the therapist to be able to hold the patient's unbearable mental states of mind in mind for the patient (Hinshelwood, 1994). Having worked with war veterans for eight years, a case will be presented as a descriptor of the dissociât ve experience.

Freud's theory of repression and memory disturbance provides the therapist with valuable insights for working with these patients (Freud, 1896). In addition, Klein (1975) uses the clinical approach of working with the leading anxieties, and Bion's concept of "container" provides essential knowledge for this work (Bion, 1961). "Bion's Experiences in Groups served as a mandate to investigate primitive affects and object relations in groups" (Schermer, 1994 p. 15).

DESCRIPTION OF THE GROUP

In the earlier years, the groups were residential in the hospital for the first four weeks. The program was intense, providing both psy-choeducational groups, individual therapy, and group psychotherapy. Attendance was daily with home visitations for the weekends. After the four-week intensive phase, the men then came one day weekly for eight weeks.

Although the program has changed over time, with the shift being toward non-residential programs it still remains a time limited one of twelve weeks with a maximum number of eight members in the group.

THE INTERVENTIONS Brief Case Example with Concomitant Intervention Procedures

One day during the group process, there was a sudden loud banging noise in the ceiling and workmen shouting information to each other. This was a sudden unexpected event for all of us. Our dissociative patient leaped up from his chair, his eyes looking around wildly with terror; he could not decide whether to go up into the ceiling and attack the workers or run away. I took the entire group down the hallway to the kitchen where we continued with the work over a cup of tea, talking about the effects this sudden intrusion had upon all of them. By providing structure and containment (being in a smaller safer space with the whole group together) this man began to calm down and stayed until the group time came to an end.

Dissociative Patient As Barometer of Group Anxiety and Necessary Intervention

I use the patient who is clinically diagnosed with a dissociative disorder as a barometer for measuring the level of anxiety in the group.

To reduce the increased levels of anxiety, greater structure is implemented, through a number of options, within the group. The therapy moves according to the level of anxiety manifested by this patient. When the level of anxiety escalates to the degree that the risk of

Diminishing Dissociative Experiences for War Veterans in Group Therapy 219

dissociation becomes prevalent with the concomitant possibility of a "flight or fight" response—structure needs to be implemented.

When the patient took "flight" out the door, I held him verbally, and took the group to the kitchen down the hall, on this occasion, to provide the necessary structure and containment and change away from the immediate environment.

Another measurement of anxiety with this man was the rate with which his memory began returning. Initially, he had almost no memory of things having occurred in his past. As his memory began to return, he described it as being like a board, with "pegs" popping up on it. This is exactly what we wish to occur. The reliving of the traumatic event(s) as a cathartic release for this patient's journey into recovery.

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