International Journal of Group Psychotherapy
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20
Analytic Group Psychotherapy of Post-Traumatic Psychoses Gottfried R. Bloch & Noretta Haas Bloch To cite this article: Gottfried R. Bloch & Noretta Haas Bloch (1976) Analytic Group Psychotherapy of Post-Traumatic Psychoses, International Journal of Group Psychotherapy, 26:1, 49-57, DOI: 10.1080/00207284.1976.11491316 To link to this article: https://doi.org/10.1080/00207284.1976.11491316
Published online: 29 Oct 2015.
Submit your article to this journal
Article views: 2
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ujgp20
Analytic Group Psychotherapy of Post-Traumatic Psychoses
GOTTFRIED R. BLOCH, M.D., and NORETT A HAAS BLOCH
Lns
on a clinical project extending over several years and concerned with the diagnostic evaluation and treatment of patients with varied post-traumatic psychopathology following industrial injuries and prolonged stress situations (Bloch and Bloch, 1972). The main focus of the project was the study of developmental processes in adult life, namely, beyond the maturational stages of infancy and early childhood. Early stages of development were by no means ignored , however, since they were observable in recurring regressive phenomena. PAPER IS BASED
DEFENSE AND COPING PROCESSES Early developmental processes, genetic factors, and environmental vicissitudes are decisive for disposition, potential, and vulnerabilities characteristic of the personality. As the growing individual passes through the early developmental stages, he acquires means of "coping" with the "average expected" (Hartmann, 1958) hurdles of life . The way in which he copes expresses his character; the degree to which he succeeds shows the level of his effectiveness. Dr. and Mrs. Bloch are in private practice.
49
50
Gottfried R . Bloch-Noretta Haas Blo ch
Each person's coping potential, that is , his latent equipment fo r dealing with disturbing events, depends on the relative degree of ego strength available at the cri tical time . Hartmann (1950), in defining ego strength, specifies as one of its essential elements the ability of the autonomous functions of the ego "to withstand impairmen t through the processes of defense. " Ego resilience, as defined by Loewald (1952) and applied by Greenson (1967), is another important feature of the coping potential. While defense mechanism s deal intrapsychicall y with a disturbing experience, coping mechanisms are means of mastering external, potentially pathogenic events . Post-traumatic emotional disturbances occur when coping mechanisms are not sufficiently developed and available at the critical time or have been impaired . When adequate responses to trauma are lacking , a variety of pathological reactions may occur. T hese have been variously described as: traumatic reaction, traumatic syndrome, acute tr aumatic neu· rosis , post-traumatic neurosis , post-traumatic character neurosis, or post -traumatic psychosis. POS T -TRAUMATIC PSYCHOSIS Each of the d ifferent degrees of post-traumatic psychopathology carries with it the danger of decompensation which may lead to th e border of psychosis and beyond . The central issue in a psychotic devel opment is a regression to earlier stages of ego organization and a detachment from reality. We often see intense acting-out behavior as an attempt to restore the narcissistic equilib rium and to preven t a further -psychotic de terioration. T h e narcissistic injury may have impaired the ability to cope accord ing to the reality principle and internal conflicts are externalized Qacobson , 1967). The effort to change the situation by alloplastic endeavors without autoplastic al teration frequentl y leads to confl icts and cl ashes . Most patients di sc ussed in this paper came for psychiatric evalu a · tion qu ite some time after the tr auma tic event and sub sequen t medical and surgi cal interventions. When it ha d become evident that these patients were unable to cope with their existing condition , psychiatric opinion was requested . Followi ng a thorough exploration by way of interviews and psychological testing , these patients were p laced in groups set up for specific, m o dified treatmen t of post- traumatic dis·
Treatment of Post- Traumatic Psychoses
51
orders. In the most severe cases, particularly in acute psychotic conditions, treatment was started in individual sessions and was combined with chemotherapy and, where necessary, short-term hospitalization. The patients' personality structure and degree of disturbance varied considerably but all had experienced a traumatic event in adulthood which was the common factor in the origin of their psychopathology.
GROUP THERAPY OF POST-TRAUMATIC CONDITIONS
The First Phase The opening phase in such a therapeutic group is dominated by expression of enormous anger radiating in many directions. The anger is caused by frustration, deprivation, a nd narcissistic injury. When the patients describe the circumstances surrounding their injuries, they usually look for objects to blame for their misfortune. They seem incredulous th at "it could happen to me," and they react with rage whenever they are reminded of the original incident. With the emergence of group cohesion , however, the feeling of isolation and of· being singled out by fate lessens. Whenever a new patient enters an existing group, the group as a whole regresses to the angry behavior that was characteristic of the opening phase and is seemingly oblivious of the state of therapeutic development already reached. This regressive phenomenon is attributable to the group's attempt to include the new member by revealing universal distress, but there is also some hostility directed at the newcomer who reawakens and reinforces painful memories. Competitive traits enter the process, and confrontation becomes belligerent at times. In addition, the recall of earlier group experiences encourages repetition of the tragedy which for each meant a break in his mode of living. The unending need for such repetition is not only reflected in the group dynamics but also in anxiety-charged, post-traumatic dreams. The co -therapists of such a group become the object of different transferences and projections . The patients obviously feel great comfort in having two therapists listen to all the details of their condition (Wahl, 1972), particularly since they experience their environment as cold, rejecting, and unconcerned . The outer world has injured them,
52
Gottfried R. Bloch-Noretta Haas Bloch
they believe, and it should, without delay or further questions, be responsible for repair and compensation. The therapists are expected to have magic power with which to close the gap that exists between the patients and those involved in their treatment and rehabilitation. Whenever one of the therapists is suspected of calling for more realistic expectations, he will become the target for sudden aggressivity, while, at the same time, the patients will appeJ.l to the co-therapist for support and understanding. Due to their physical injuries, these patients have to face physicians of vari ous specialities, legal counselors, insurance agents, and representatives of other institutions. They soon begin to suspect that those in authority approach them with doubt and mistrust, and their attitude becomes hostile and defiant. The therapists find themselves being used as screens for projections and as objects of diverse transferences . Since the therapeutic situation promotes uninhibited expression of impulsive and regressive tendencies, the patients often test how far their demands and complaints will be tolerated before "parental disciplining" will occur. It is in this area that differences in degree of psychopathology become most noticeable. PSYCHOTIC ACTING OUT IN THE GROUP In borderline states and psychoses, poorly controlled reactions and ac ting out can be expected. Julia was a patient who had had to leave her job after many years of satisfying work. During several months of group therapy, whenever she recalled the circumstances and disappointments leading to her total disability, she was overcome with rage. Her anger would mount until it was so overwhelming that she stormed out of the room and pounded on the door with her fists until the tantrum ended in helpless, childlike sobbing. In some sessions Julia hinted at harboring murderous thoughts toward those she blamed for her condition and spoke of her impulse to torture and mutil a te the "enemies" in her paranoid world. Some of her complaints of neglect and rejection by those instrumental in the management of her illness were not totally unrealistic. It is characteristic for these cases that the borders between realistic and delusional perception and judgment are fluid, leaving the possibility for fusion and further regression.
Treatment of Post- Traumatic Psychoses
53
Another patient, Thomas, had led a totally unstructured existence for some years. When he finally accepted work in a factory, his right hand got caught in a machine and he lost four fingers. Following a series of surgical interventions he joined the therapeutic group in a severe depression. Withdrawn and isolated, he hardly left his room except to attend therapy. His appearance showed self-neglect; he lived without hope and was suicidal. At the start of his therapy Thomas appeared to be a heavy burden on the group. His physical and emotional traumata seemed to overpower the others. He was mute and the group was reluctant to approach him. The usual anger reaction precipitated by a new patient joining the group was absent; instead, anxiety was the nuclear affect . It took a number of sessions before some group members were able to encourage Thomas to "open up." Instead of words he used action. With an abrupt gesture he removed a cloth from his mutilated hand, exposing it to the group, and he repeated this provocative, threatening gesture in later sessions whenever he felt too overwhelmed for words. The degree of his depression and lack of hope were obviously quite different from the depressive discontent expressed by neurotic patients. The group gained some insight and an appreciation of their own resources from him, and Thomas, for his part, found some direction via identification with less disturbed patients in the group. THE SECOND PHASE
Group Integration of the Psychotic Patient The pyschotic patient, due to enormous inner threats and tensions, may attempt to monopolize the group situation. Sylvia, a patient in her thirties who had been an effective secretary , was forced to terminate work because of a disabling back injury. During the first part of her medical treatment she became acutely agitated and suicidal. After brief hospitalization in the psychiatric ward she entered the group as an outpatient. When she started to talk about her condition, her associations would become increasingly "loose" and tangential and signs of mounting agitation would occur. The therapists' attempts at making her aware of this behavior would meet with strong, angry responses, accompanied by abrupt body movements and gestures of lashing out. When the therapists suggested indignation as the meaning of her
54
Gottfried R. Bloch-Noretta Haas Bloch reaction , Sylvia, with the help of the group, began to work through to an understanding of her intense outbursts as the repetition of vindictive feelings she had toward some persons related to her accident.
Whenever the group is presented with an interpretation that , besides explaining the strange behavior of a psychotic patient, gives insight into the psychopathology of other group participants , the disturb ing patient will be more easily tolerated. Psychotic and borderline patients remain somewhat separated from the rest of the group at the beginning of treatment. However, mutual concern and therapeutic gain (Balint, 1972) seem to lessen the distance and allow integration of these patients into a predominantly neurotic group during the second phase of treatment in which the pretraumatic personality and the earlier history of the patients become subjects of communication and interaction.
Post- Traumatic Dreams and Reality Testing In the second phase of therapy a variety of group interactions are observable . Verbal associations, while not quite as free as those we hear in psychoanalysis, play an important role in the therapeutic process . The group 's associative responses to both the verbal and nonverbal expressions of a patient include an element of creativity (group creations) directed toward the finding of new coping methods . Some exchanges of thoughts and feelings among patients are recognizable as expressions of resistance. Resistances of individuals , of subgroups of patients , or of the whole group have to be worked through , a laborious process which may cover numbers of sessions and may require repetition as well as variations on similar themes . Poorly controlled anger in the psychotic patient may become a vehicle for resistance and may lead to destructive acting out (Bloch and Bloch , 1971 ) . Freud (1932) pointed to the importance of the post-traumatic dream , which he reformulated as being an attempt at wish fulfillment (1935 ), the wish being to master the traumatic event and its consequences. Schur (1966), on the other hand, sees in this repetition of the traumatic event in dreams "the ego's unconscious wish to undo the traumatic situation ." Fisher (1970) characterizes the post-traumatic dream as an expression of ego failure to cope with anxiety.
Treatment of Post -Traumatic Psychoses
55
The typical post-traumatic nightmare, especially in psychotic and borderline patients, often depicts frightful scenes of life-threatening dangers building up to paranoid panic. When the patient's paranoid associations go beyond the report of dream content and he adds his distorted ideation, crossing the border between the worlds of reality and delusional fan tasy, intervention by the therapist is necessary to help the patient toward a more realistic perception . Often, the other group members steadily support this process. James, a 32-year-old factory worker, had suffered a concussion and some local injuries in a job accident . After release from medical treatment he returned to work, but his increasing complaints of headaches and dizziness created difficulties and he was declared temporarily disabled. When he entered the group, he displayed his feelings of helplessness in a histrionic pattern of whimpering and whining. The other group members were vocal in their annoyance. James became more demanding and suspicious. At times his anger would grow to a rambling rage in which he loudly accused persons and institutions he thought responsible for his condition. His tirades and acting out were tiresome and repetitious. Being aware that James' treatment would be discontinued as soon as he was able to return to work, the therapists focused on reducing the complex psychopathology of the paranoid patient to the focal conflict around his accident. The steady cooperation of the group aided the therapists in their effort to guide the patient through his delusional ideation to more realistic perceptions. TERMINATION OF TREATMENT The unstable life situation of disabled patients often interferes with structuring the third phase , which is the process of termination. Members of the group in various stages of therapeutic progress display a wide range of responses each time a member leaves the group . Anger, envy, mistrust of the effectiveness of the treatment program as well as relief and reassurance permeate and punctuate the specific group sessions. Less than half the patients have the advantage of an orderly conclusion of therapy. In many cases termination is caused by environmental pressures beyond their control. The complicated system of medical, legal, and social processes that enmeshes the disabled gives
56
Gottfried R . Bloch-Noretta Haas Bloch
only limited recognition to psychotherapeutic rehabilitation. Reality factors frequently counteract efforts toward a satisfying resolution of treatment . Anticipating the possible interruption of treatment , we concentrate on uncovering regressive defenses and strengthening coping mechanisms to deal with the traumatic event. This may lead to selective neglect of pretraumatic psychopathology, and at times the patient, unable to cope with the outside world, needs to resume treatment. When James realized that he must terminate treatment and resume work as no further financial support was forthcoming, he experienced a new emotional crisis. During the long post-traumatic period he had regressed to dependent, helpless behavior. Responding to the unsettling development, the therapists accelerated interventions toward more competent coping (Hamburg, 1974) . The healthier part of the group (Ammon, 1970) encouraged the return to independent functioning. The more disturbed patients in the group mirrored James's doubts and fears. When James left , it was questionable whether he would be able to sustain a reasonable balance that would allow him to function and compete in the open labor market; his paranoid inclinations precipitated by the accident were still a substantial handicap . On his departure the group climate reflected futility and frustration. SUMMARY Part of a clinical project has been described which deals with posttraumatic psychopathology. The main emphasis is given to psychotic decompensation following a traumatic experience. Post-traumatic psychoses are the consequence of a breakdown in the coping process. Coping mechanisms are crucial for dealing with the emotional injury accompanying physical impairment and stress situations . In contrast to defense mechanisms which protect the ego mainly by avoidance of confrontation, these ego functions promote realistic perception and judgment. Coping mechanisms eventually replace defenses and assist in compensating fo r loss or restriction of functioning. In this project, patients suffering from post-traumatic illnesses were treated in analytic group therapy with emphasis on support and the creation of coping mechanisms. These were instrumental in the patients' social and occupational rehabilitation.
Treatment of Post- Traumatic Psychoses
57
REFERENCES Ammon , G. (1970), Gruppendynamik Der Aggression. Berlin: Pinel. Balint, E. (1972), Fair Shares and Mutual Concern. Internal. J. Psycho -Anal., 53: 61 -65. Bloch , G., and Bloch, N. (1971), The Handling of No in Analytic Group Therapy. Dynamic Psychiat., 4 :313 -332. ___ , and ___ (1972), Traumatic and Post Traumatic Neurosis . Industrial Med . & Surg. , 41:5-8. Fisher , C. (1970), Psychophysiological Study of Nightmares. J. Amer. Psychoanal. Assn., 18:474-782. Freud , S. (1932), Revision of the Theory of Dreams. Standard Edition, 22:46:7-30. London: Hogarth Press, 1964. _ _ _ (1935), An Autobiographical Study. Standard Edition , 20:1-70. London: Hogarth Press, 1959. Greenson , R . (1967) , The Technique and Practice of Psychoanalysis. New York: International Universities Press . Hamburg, D. (1974), Coping and Adaptation. New York: Basic Books. Hartmann, H. (1958), Ego Psychology and the Problem of Adaptation. New York: International Universities Press . _ __ (1950) , Essays on Ego Psychology. New York: International Universities Press. Jacobson, E. (1967), Psychotic Conflict and Reality. New York: International Universities Press . Loewald, H. W. (1952), The Problem of Defense and the Neurotic Interpretation of Reality. Internal. J. Psycho-Anal., 33:444-449 . Schur, M. (1966), The Id and the Regulatory Princzples of Mental Functioning. New York: International Universities Press . Wahl, C. W. (1972), The Technique of Brief Psychotherapy with Hospitalized Psychosomatic Patients. Internat. J. Psycho-Anal. Psychother., l :71.
Authors' address: 10921 Wilshire Boulevard Los Angeles, Calif 90024
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20
Analytic Group Psychotherapy of Post-Traumatic Psychoses Gottfried R. Bloch & Noretta Haas Bloch To cite this article: Gottfried R. Bloch & Noretta Haas Bloch (1976) Analytic Group Psychotherapy of Post-Traumatic Psychoses, International Journal of Group Psychotherapy, 26:1, 49-57, DOI: 10.1080/00207284.1976.11491316 To link to this article: https://doi.org/10.1080/00207284.1976.11491316
Published online: 29 Oct 2015.
Submit your article to this journal
Article views: 2
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ujgp20
Analytic Group Psychotherapy of Post-Traumatic Psychoses
GOTTFRIED R. BLOCH, M.D., and NORETT A HAAS BLOCH
Lns
on a clinical project extending over several years and concerned with the diagnostic evaluation and treatment of patients with varied post-traumatic psychopathology following industrial injuries and prolonged stress situations (Bloch and Bloch, 1972). The main focus of the project was the study of developmental processes in adult life, namely, beyond the maturational stages of infancy and early childhood. Early stages of development were by no means ignored , however, since they were observable in recurring regressive phenomena. PAPER IS BASED
DEFENSE AND COPING PROCESSES Early developmental processes, genetic factors, and environmental vicissitudes are decisive for disposition, potential, and vulnerabilities characteristic of the personality. As the growing individual passes through the early developmental stages, he acquires means of "coping" with the "average expected" (Hartmann, 1958) hurdles of life . The way in which he copes expresses his character; the degree to which he succeeds shows the level of his effectiveness. Dr. and Mrs. Bloch are in private practice.
49
50
Gottfried R . Bloch-Noretta Haas Blo ch
Each person's coping potential, that is , his latent equipment fo r dealing with disturbing events, depends on the relative degree of ego strength available at the cri tical time . Hartmann (1950), in defining ego strength, specifies as one of its essential elements the ability of the autonomous functions of the ego "to withstand impairmen t through the processes of defense. " Ego resilience, as defined by Loewald (1952) and applied by Greenson (1967), is another important feature of the coping potential. While defense mechanism s deal intrapsychicall y with a disturbing experience, coping mechanisms are means of mastering external, potentially pathogenic events . Post-traumatic emotional disturbances occur when coping mechanisms are not sufficiently developed and available at the critical time or have been impaired . When adequate responses to trauma are lacking , a variety of pathological reactions may occur. T hese have been variously described as: traumatic reaction, traumatic syndrome, acute tr aumatic neu· rosis , post-traumatic neurosis , post-traumatic character neurosis, or post -traumatic psychosis. POS T -TRAUMATIC PSYCHOSIS Each of the d ifferent degrees of post-traumatic psychopathology carries with it the danger of decompensation which may lead to th e border of psychosis and beyond . The central issue in a psychotic devel opment is a regression to earlier stages of ego organization and a detachment from reality. We often see intense acting-out behavior as an attempt to restore the narcissistic equilib rium and to preven t a further -psychotic de terioration. T h e narcissistic injury may have impaired the ability to cope accord ing to the reality principle and internal conflicts are externalized Qacobson , 1967). The effort to change the situation by alloplastic endeavors without autoplastic al teration frequentl y leads to confl icts and cl ashes . Most patients di sc ussed in this paper came for psychiatric evalu a · tion qu ite some time after the tr auma tic event and sub sequen t medical and surgi cal interventions. When it ha d become evident that these patients were unable to cope with their existing condition , psychiatric opinion was requested . Followi ng a thorough exploration by way of interviews and psychological testing , these patients were p laced in groups set up for specific, m o dified treatmen t of post- traumatic dis·
Treatment of Post- Traumatic Psychoses
51
orders. In the most severe cases, particularly in acute psychotic conditions, treatment was started in individual sessions and was combined with chemotherapy and, where necessary, short-term hospitalization. The patients' personality structure and degree of disturbance varied considerably but all had experienced a traumatic event in adulthood which was the common factor in the origin of their psychopathology.
GROUP THERAPY OF POST-TRAUMATIC CONDITIONS
The First Phase The opening phase in such a therapeutic group is dominated by expression of enormous anger radiating in many directions. The anger is caused by frustration, deprivation, a nd narcissistic injury. When the patients describe the circumstances surrounding their injuries, they usually look for objects to blame for their misfortune. They seem incredulous th at "it could happen to me," and they react with rage whenever they are reminded of the original incident. With the emergence of group cohesion , however, the feeling of isolation and of· being singled out by fate lessens. Whenever a new patient enters an existing group, the group as a whole regresses to the angry behavior that was characteristic of the opening phase and is seemingly oblivious of the state of therapeutic development already reached. This regressive phenomenon is attributable to the group's attempt to include the new member by revealing universal distress, but there is also some hostility directed at the newcomer who reawakens and reinforces painful memories. Competitive traits enter the process, and confrontation becomes belligerent at times. In addition, the recall of earlier group experiences encourages repetition of the tragedy which for each meant a break in his mode of living. The unending need for such repetition is not only reflected in the group dynamics but also in anxiety-charged, post-traumatic dreams. The co -therapists of such a group become the object of different transferences and projections . The patients obviously feel great comfort in having two therapists listen to all the details of their condition (Wahl, 1972), particularly since they experience their environment as cold, rejecting, and unconcerned . The outer world has injured them,
52
Gottfried R. Bloch-Noretta Haas Bloch
they believe, and it should, without delay or further questions, be responsible for repair and compensation. The therapists are expected to have magic power with which to close the gap that exists between the patients and those involved in their treatment and rehabilitation. Whenever one of the therapists is suspected of calling for more realistic expectations, he will become the target for sudden aggressivity, while, at the same time, the patients will appeJ.l to the co-therapist for support and understanding. Due to their physical injuries, these patients have to face physicians of vari ous specialities, legal counselors, insurance agents, and representatives of other institutions. They soon begin to suspect that those in authority approach them with doubt and mistrust, and their attitude becomes hostile and defiant. The therapists find themselves being used as screens for projections and as objects of diverse transferences . Since the therapeutic situation promotes uninhibited expression of impulsive and regressive tendencies, the patients often test how far their demands and complaints will be tolerated before "parental disciplining" will occur. It is in this area that differences in degree of psychopathology become most noticeable. PSYCHOTIC ACTING OUT IN THE GROUP In borderline states and psychoses, poorly controlled reactions and ac ting out can be expected. Julia was a patient who had had to leave her job after many years of satisfying work. During several months of group therapy, whenever she recalled the circumstances and disappointments leading to her total disability, she was overcome with rage. Her anger would mount until it was so overwhelming that she stormed out of the room and pounded on the door with her fists until the tantrum ended in helpless, childlike sobbing. In some sessions Julia hinted at harboring murderous thoughts toward those she blamed for her condition and spoke of her impulse to torture and mutil a te the "enemies" in her paranoid world. Some of her complaints of neglect and rejection by those instrumental in the management of her illness were not totally unrealistic. It is characteristic for these cases that the borders between realistic and delusional perception and judgment are fluid, leaving the possibility for fusion and further regression.
Treatment of Post- Traumatic Psychoses
53
Another patient, Thomas, had led a totally unstructured existence for some years. When he finally accepted work in a factory, his right hand got caught in a machine and he lost four fingers. Following a series of surgical interventions he joined the therapeutic group in a severe depression. Withdrawn and isolated, he hardly left his room except to attend therapy. His appearance showed self-neglect; he lived without hope and was suicidal. At the start of his therapy Thomas appeared to be a heavy burden on the group. His physical and emotional traumata seemed to overpower the others. He was mute and the group was reluctant to approach him. The usual anger reaction precipitated by a new patient joining the group was absent; instead, anxiety was the nuclear affect . It took a number of sessions before some group members were able to encourage Thomas to "open up." Instead of words he used action. With an abrupt gesture he removed a cloth from his mutilated hand, exposing it to the group, and he repeated this provocative, threatening gesture in later sessions whenever he felt too overwhelmed for words. The degree of his depression and lack of hope were obviously quite different from the depressive discontent expressed by neurotic patients. The group gained some insight and an appreciation of their own resources from him, and Thomas, for his part, found some direction via identification with less disturbed patients in the group. THE SECOND PHASE
Group Integration of the Psychotic Patient The pyschotic patient, due to enormous inner threats and tensions, may attempt to monopolize the group situation. Sylvia, a patient in her thirties who had been an effective secretary , was forced to terminate work because of a disabling back injury. During the first part of her medical treatment she became acutely agitated and suicidal. After brief hospitalization in the psychiatric ward she entered the group as an outpatient. When she started to talk about her condition, her associations would become increasingly "loose" and tangential and signs of mounting agitation would occur. The therapists' attempts at making her aware of this behavior would meet with strong, angry responses, accompanied by abrupt body movements and gestures of lashing out. When the therapists suggested indignation as the meaning of her
54
Gottfried R. Bloch-Noretta Haas Bloch reaction , Sylvia, with the help of the group, began to work through to an understanding of her intense outbursts as the repetition of vindictive feelings she had toward some persons related to her accident.
Whenever the group is presented with an interpretation that , besides explaining the strange behavior of a psychotic patient, gives insight into the psychopathology of other group participants , the disturb ing patient will be more easily tolerated. Psychotic and borderline patients remain somewhat separated from the rest of the group at the beginning of treatment. However, mutual concern and therapeutic gain (Balint, 1972) seem to lessen the distance and allow integration of these patients into a predominantly neurotic group during the second phase of treatment in which the pretraumatic personality and the earlier history of the patients become subjects of communication and interaction.
Post- Traumatic Dreams and Reality Testing In the second phase of therapy a variety of group interactions are observable . Verbal associations, while not quite as free as those we hear in psychoanalysis, play an important role in the therapeutic process . The group 's associative responses to both the verbal and nonverbal expressions of a patient include an element of creativity (group creations) directed toward the finding of new coping methods . Some exchanges of thoughts and feelings among patients are recognizable as expressions of resistance. Resistances of individuals , of subgroups of patients , or of the whole group have to be worked through , a laborious process which may cover numbers of sessions and may require repetition as well as variations on similar themes . Poorly controlled anger in the psychotic patient may become a vehicle for resistance and may lead to destructive acting out (Bloch and Bloch , 1971 ) . Freud (1932) pointed to the importance of the post-traumatic dream , which he reformulated as being an attempt at wish fulfillment (1935 ), the wish being to master the traumatic event and its consequences. Schur (1966), on the other hand, sees in this repetition of the traumatic event in dreams "the ego's unconscious wish to undo the traumatic situation ." Fisher (1970) characterizes the post-traumatic dream as an expression of ego failure to cope with anxiety.
Treatment of Post -Traumatic Psychoses
55
The typical post-traumatic nightmare, especially in psychotic and borderline patients, often depicts frightful scenes of life-threatening dangers building up to paranoid panic. When the patient's paranoid associations go beyond the report of dream content and he adds his distorted ideation, crossing the border between the worlds of reality and delusional fan tasy, intervention by the therapist is necessary to help the patient toward a more realistic perception . Often, the other group members steadily support this process. James, a 32-year-old factory worker, had suffered a concussion and some local injuries in a job accident . After release from medical treatment he returned to work, but his increasing complaints of headaches and dizziness created difficulties and he was declared temporarily disabled. When he entered the group, he displayed his feelings of helplessness in a histrionic pattern of whimpering and whining. The other group members were vocal in their annoyance. James became more demanding and suspicious. At times his anger would grow to a rambling rage in which he loudly accused persons and institutions he thought responsible for his condition. His tirades and acting out were tiresome and repetitious. Being aware that James' treatment would be discontinued as soon as he was able to return to work, the therapists focused on reducing the complex psychopathology of the paranoid patient to the focal conflict around his accident. The steady cooperation of the group aided the therapists in their effort to guide the patient through his delusional ideation to more realistic perceptions. TERMINATION OF TREATMENT The unstable life situation of disabled patients often interferes with structuring the third phase , which is the process of termination. Members of the group in various stages of therapeutic progress display a wide range of responses each time a member leaves the group . Anger, envy, mistrust of the effectiveness of the treatment program as well as relief and reassurance permeate and punctuate the specific group sessions. Less than half the patients have the advantage of an orderly conclusion of therapy. In many cases termination is caused by environmental pressures beyond their control. The complicated system of medical, legal, and social processes that enmeshes the disabled gives
56
Gottfried R . Bloch-Noretta Haas Bloch
only limited recognition to psychotherapeutic rehabilitation. Reality factors frequently counteract efforts toward a satisfying resolution of treatment . Anticipating the possible interruption of treatment , we concentrate on uncovering regressive defenses and strengthening coping mechanisms to deal with the traumatic event. This may lead to selective neglect of pretraumatic psychopathology, and at times the patient, unable to cope with the outside world, needs to resume treatment. When James realized that he must terminate treatment and resume work as no further financial support was forthcoming, he experienced a new emotional crisis. During the long post-traumatic period he had regressed to dependent, helpless behavior. Responding to the unsettling development, the therapists accelerated interventions toward more competent coping (Hamburg, 1974) . The healthier part of the group (Ammon, 1970) encouraged the return to independent functioning. The more disturbed patients in the group mirrored James's doubts and fears. When James left , it was questionable whether he would be able to sustain a reasonable balance that would allow him to function and compete in the open labor market; his paranoid inclinations precipitated by the accident were still a substantial handicap . On his departure the group climate reflected futility and frustration. SUMMARY Part of a clinical project has been described which deals with posttraumatic psychopathology. The main emphasis is given to psychotic decompensation following a traumatic experience. Post-traumatic psychoses are the consequence of a breakdown in the coping process. Coping mechanisms are crucial for dealing with the emotional injury accompanying physical impairment and stress situations . In contrast to defense mechanisms which protect the ego mainly by avoidance of confrontation, these ego functions promote realistic perception and judgment. Coping mechanisms eventually replace defenses and assist in compensating fo r loss or restriction of functioning. In this project, patients suffering from post-traumatic illnesses were treated in analytic group therapy with emphasis on support and the creation of coping mechanisms. These were instrumental in the patients' social and occupational rehabilitation.
Treatment of Post- Traumatic Psychoses
57
REFERENCES Ammon , G. (1970), Gruppendynamik Der Aggression. Berlin: Pinel. Balint, E. (1972), Fair Shares and Mutual Concern. Internal. J. Psycho -Anal., 53: 61 -65. Bloch , G., and Bloch, N. (1971), The Handling of No in Analytic Group Therapy. Dynamic Psychiat., 4 :313 -332. ___ , and ___ (1972), Traumatic and Post Traumatic Neurosis . Industrial Med . & Surg. , 41:5-8. Fisher , C. (1970), Psychophysiological Study of Nightmares. J. Amer. Psychoanal. Assn., 18:474-782. Freud , S. (1932), Revision of the Theory of Dreams. Standard Edition, 22:46:7-30. London: Hogarth Press, 1964. _ _ _ (1935), An Autobiographical Study. Standard Edition , 20:1-70. London: Hogarth Press, 1959. Greenson , R . (1967) , The Technique and Practice of Psychoanalysis. New York: International Universities Press . Hamburg, D. (1974), Coping and Adaptation. New York: Basic Books. Hartmann, H. (1958), Ego Psychology and the Problem of Adaptation. New York: International Universities Press . _ __ (1950) , Essays on Ego Psychology. New York: International Universities Press. Jacobson, E. (1967), Psychotic Conflict and Reality. New York: International Universities Press . Loewald, H. W. (1952), The Problem of Defense and the Neurotic Interpretation of Reality. Internal. J. Psycho-Anal., 33:444-449 . Schur, M. (1966), The Id and the Regulatory Princzples of Mental Functioning. New York: International Universities Press . Wahl, C. W. (1972), The Technique of Brief Psychotherapy with Hospitalized Psychosomatic Patients. Internat. J. Psycho-Anal. Psychother., l :71.
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