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Audiovisual Overview: Journey of Healing: An Outpatient Therapy Group for War-Related PTSD
Theodore Nadelson, M.D.
Psychiatric Services 1999; doi:

Introduction by the column editor: Posttraumatic stress disorder (PTSD) has become a focus of increased clinical interest over the past decade, with the consequent development of a broader range of treatment modalities. Short- and long-range stressors, especially those related to war experiences, have been the focus of significant therapeutic effort. Fullerton and Ursano (1), editors of a comprehensive book on PTSD, note that this diagnosis has been the subject of much controversy ever since its introduction in DSM-III in 1980.The three-tape video series reviewed here is especially relevant because American veterans of three different wars—World War II, Vietnam, and the Persian Gulf—participated in the 20 two-and-a-half-hour group therapy sessions depicted. Rarely has this amount of detailed therapeutic process been available for study and reference. A detailed companion monograph about the videotapes and the therapy process is available to mental health providers.Although the focus of the tapes is on war-related PTSD and postwar sequelae, one can agree with coproducer Raymond M. Scurfield, D.S.W., that the dynamics and clinical interventions have considerable applicability for therapists interested in a much broader range of trauma exposure, such as survival of violent physical attacks, air crashes, or natural disasters. That relevance is due to the trauma-related commonality of the areas documented, such as responsibility-based guilt, memory loss, the dynamics of a perpetrator of trauma, the impact of PTSD on the family, and the relationship between childhood trauma and other traumatic experiences.The reviewer of this work is Dr. Theodore Nadelson, who was formerly chief of psychiatry at the Veterans Affairs Medical Center in Boston and is now vice-chair for education in the division of psychiatry at Boston University School of Medicine. He brings a special experience and expertise to the topic.

Abstract Teaser
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produced by the Pacific Islands Division of the VA National Center for PTSD, Raymond M. Scurfield, D.S.W., and Irene G. Powch, Ph.D. Three VHS videocassettes, almost 90 minutes each, 1997. Sixty-five-page monograph included. Free to mental health providers; contact Allan M. Perkal, M.A., Pacific Center for PTSD, 1132 Bishop Street, Suite 307, Honolulu, Hawaii 96813; phone, 805-566-1937; e-mail, allan.perkal@med. va.gov.

This unique document provides a record of an actual course of outpatient treatment with a group of dysfunctional men coping with combat PTSD. The three-tape record of 20 weekly sessions of therapy over a five-month period includes veterans of World War II, Vietnam, and the Gulf War. One aim of the video process was to be honest, yet experiential, and in this the producers have succeeded.

Journey of Healing is not meant to be a slick production: there are gaps, hesitations, and pauses, and the therapy presented does not flow to a smooth Hollywood finish. The producers certainly make no claim of universal success for the therapy. All therapists know that what patients express about therapy, and about others in the room, may be transient even when stated as enduring fact: "I feel better, lighter… . I can, must give up my hate."

These tapes present a gestalt-based form of trauma-specific therapy, but the producers candidly disavow the idea that this form of therapy is the only useful approach for PTSD. Moreover, they are aware of the current professional criticism about the efficacy of trauma-specific therapy as a method.

The video vividly presents the experience of therapy over five months, and it highlights the continuing suffering of veterans long after their wars are over. In one long, compelling section, Ben, a Chinese-American Department of Defense employee captured by the Japanese on Wake Island in 1941, describes in detail his capture and his brutal treatment during years of internment in Shanghai. He describes his continuing suffering from his inability to love even his daughters. He talks of his struggles with alcohol, isolation, and continuing hate.

There are many other gripping presentations. Fred drove convoy trucks in Vietnam and is now homeless, living in his truck in Waikiki. He is disaffected and looks fiercely at the therapists and other patients. He expresses guilt and anger for running over and killing civilians when he had to race his truck through a dangerous area that was congested with Vietnamese civilians.

Ed, a demolition expert, distances himself from feelings of guilt by avoiding any feeling. Chuck, a World War II combat veteran, who walked point with a Browning automatic rifle in Europe, is a reflective old man whose memories of long-past combat emerge freshly as he speaks of them. He talks of his failure to protect friends against the impossible; he speaks of continuing grief over the deaths he caused. He remembers, still as an echo in his memory, a German soldier calling for his mother: "Mutti … Mutti."

Mario, a helicopter gunner in Vietnam, reflects on his excitement and enthrallment with killing and with the memories of it. He is not reachable in his rage, remaining unhealed. He has suffered a stroke and has severe motor dysfunction. The veterans feel at one with him, despite his constant distancing from them.

But all of these men agonize about not having met the test, not having been able to "do it right" in the very midst of war's chaos. These shattered men believe that they failed friends and neglected moral meaning when the chips were down, and they blame themselves. They are welded to their guilt, using the remainder of their lives to expiate their past sins.

The therapists compassionately press for the participants to honestly own up to feelings of suffering, of sadness, and of remorse for what they have inflicted on others so that they forgive themselves at the same time as they accept their shared humanity. These videotapes are a "witnessing" as a way of marking and remembering human grief.

The viewer sits through long, often detailed recitations in which participants attempt to answer questions about military duties as the therapists try to bring an immediacy to memories. The viewer may be impatient with this process, but those who stay with it will be rewarded by a deep understanding of the commonality of the grief and the demonstration of a therapeutic process that offers help. Within this approximately four and a half hours of videotape are revelations of the brutality that war can impose on decent men, and consequently the suffering that is a large part of their lives.

Therapists Raymond Scurfield and Irene Powch are often directive, then silent for long periods of time during a flow of narrative. Intermittently, one of 32 "stop code" numbers appears in a corner of the video screen; the codes are keyed to an explanation of the clinical process in the accompanying monograph, and the video may be stopped at that point so the viewer can read an explanation of the clinical process. This device provides a more complete understanding of where the therapists are taking the process.

The therapy process has two conceptually separate formats: a workshop format for processing an individual participant's identified traumatic war event and a thematic or discussion format in which participants are all asked to discuss how their war experiences are expressed in their current peacetime lives. Even for those who have talked with veterans, it is striking to realize how vivid the memories are after 50 years. Patients are helped by the therapists and by the other participants to uncover the submerged affects that bind them to old patterns, developed in war for psychological survival.

Excerpts from briefing sessions in which the therapists identify and discuss the salient content of the sessions are also included. In addition, moving scenes of the veterans and their one-on-one therapists viewing the tapes together are shown. This immediacy in therapeutic alliance is powerful and therapeutically valuable.

The tapes of Journey of Healing are recommended viewing for PTSD therapists of any therapeutic persuasion and at any stage in their careers. They will recognize similarities with their own clients and with the directions taken by the therapists. Some may disagree with the therapists' style or view the videotaping as destructive to any real representation. But the tapes display a commonality of the traumatic experience of the soldiers and the facilitating compassion of the therapists. They also reflect an abundance of genuine respect of one person for another, and in that human connectedness may reside much of the healing power of this treatment.

Dr. Nadelson is vice-chair for education in the division of psychiatry at Boston University School of Medicine, Dowling 7 South, 850 Harrison Avenue, Boston, Massachusetts 02118. Ian Alger, M.D., is editor of this column.

Fullerton CS, Ursano RJ (eds): Posttraumatic Stress Disorder: Acute and Long-Term Responses to Trauma and Disaster. Washington, DC, American Psychiatric Press, 1997
 
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References

Fullerton CS, Ursano RJ (eds): Posttraumatic Stress Disorder: Acute and Long-Term Responses to Trauma and Disaster. Washington, DC, American Psychiatric Press, 1997
 
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