It became apparent in the early 1980s to the team leader (the first author) of the Seattle Veterans Readjustment Counseling Center—a Vet Center (1)—that African-American veterans with posttraumatic stress disorder (PTSD) were underrepresented in Veterans Administration (VA) treatment programs. As both a psychotherapist and an African-American Vietnam combat veteran, he recognized that the legacy of racism and cultural differences between African-Americans and Caucasians often created barriers that interfered with effective participation by African-American veterans in PTSD treatment programs in which Caucasians were in the majority. In response he developed a group therapy program for African-American veterans with PTSD.
One hundred fifty-three African-American veterans have participated for at least six months in the African-American PTSD treatment program in Seattle since its inception in 1984. In most cases PTSD resulted from combat trauma. In some instances it resulted from life-threatening racial abuse encountered in the military or a combination of combat trauma and racial abuse trauma. Three veterans have been active members of the program since its inception. Another 12 have been active members for at least five years. In 1998 the program had 38 active members (defined as attending at least 12 meetings during the year). The mean±SD number of members attending the group was 17±8 (range, 9 to 23).
The program has provided weekly group psychotherapy sessions since 1984. In 1995 the program expanded to include a second, geographically separate psychotherapy group for African-American veterans in Tacoma, Washington. This report describes only the format and experience of the Seattle group.
Inclusion criteria are a diagnosis of PTSD and self-identification as an African American. Exclusion criteria are schizophrenia, acute mania, or inability to maintain sobriety on the day of the weekly group meeting. Participants remain group members as long as they wish. Although regular group attendance is encouraged, it is not mandatory. A sense of continuity and connectedness with other group members is fostered by a group phone tree, a listing of all members' telephone numbers that is updated monthly. Members are encouraged to call one another whenever they feel the need for support or information. Supportive psychotherapy focusing on current problems is the major therapeutic approach. However, trauma-focused therapy and psychoeducation are employed as appropriate.
Three of the authors (LJ, DB, and MR), each of whom had been a group cotherapist for at least one year, determined by consensus which aspects of the program group members had consistently described as specifically helpful. They also reached consensus on which aspects of Caucasian-majority group therapy programs that members had frequently described as creating barriers to successful participation by African-American veterans.
Participants reported that both their verbal and nonverbal communications usually were accurately understood by other members of the African-American group, and that they were comfortable expressing honestly their thoughts, beliefs, and feelings in this setting. In contrast, in Caucasian-majority groups they frequently felt misunderstood. Linguistic style, speech structure, slang, metaphors, and nonverbal communication that were clearly understood among African Americans had often appeared incomprehensible to many Caucasians. African-American veterans participating in groups with a Caucasian majority found themselves "wearing the mask" (2) to keep private their inner thoughts, feelings, and beliefs.
Support for dealing with the intrapsychic pain caused by racism and developing more effective methods of coping with the social and economic consequences of racism were frequently cited as uniquely positive aspects of the African-American program. Most of the veterans in the Puget Sound program had been born and raised in the legally segregated and explicitly racist society that characterized the Southern United States until—and often after—passage of the Civil Rights Act of 1963.
Racism was problematic for veterans during and after military service. For African-American veterans of the officially segregated army of the World War II era, racism in the military was clear. Although the military was integrated in 1948, and in Korea and Vietnam racial tension tended to dissipate temporarily in combat, relations between African-American and Caucasian troops reflected racial tensions at home and were particularly strained in more secure rear-area base camps (3). The experience of being treated as second-class citizens at home after risking life and limb on a foreign battlefield produced additional anger and alienation.
Participants in the African-American group felt that in the group setting, sharing the anger and humiliation resulting from racism would be understood empathically and accepted as valid. In some instances feedback from other group members suggested that the veteran may have interpreted an event or interaction in daily life as racist when other interpretations were possible. Such feedback from another African American could be taken at face value but from a Caucasian would likely be taken as an insensitive affront.
In contrast, veterans in the African-American group rarely felt comfortable discussing racism in Caucasian-majority groups. Attempts to discuss racism in such groups had frequently elicited an embarrassed silence, a changing of the topic, or implications that the African-American veteran was paranoid or exaggerating.
Shared cultural identity also facilitated discussion of controversial issues within the African-American community, such as street violence, family instability, and children enmeshed in drug addiction. Although such issues are relevant to many veterans and nonveterans regardless of ethnic origin, African Americans often felt that discussing such issues in Caucasian-majority settings would reinforce negative stereotypes of African Americans and their community.
The African-American treatment program provided valuable information about PTSD and its treatment. Most participants had suffered symptoms of PTSD for decades—bewildering and distressing nightmares, flashbacks, hypervigilance, low anger threshold, emotional numbing, isolation, and other symptoms. The group program made clear that the participants were suffering from a treatable psychiatric illness and that behavioral and pharmacologic treatment modalities, as well as the group process itself, could help alleviate PTSD symptoms. Emotional numbing, isolation, avoidance, and low anger threshold appeared particularly responsive to the group process.
Decreasing social isolation
Many members had become isolated even within the African-American community before joining the group. Once a new member had attended several group sessions, he usually reported feeling more comfortable within the group than he had been in any social setting for many years. Being among veterans who understood combat trauma-induced PTSD and who also were African American created an atmosphere in which mutually supportive friendships could develop and carry over into daily life. Of course not all relationships within the group were equally positive. However, the group provided a safe setting in which participants could explore differences and conflicts between them.
This is the first description of a long-term group therapy program for African-American veterans with PTSD. The longevity, growth, and vitality of the program and the enthusiasm with which group members have promoted the program to other veterans in the African-American community provide face validity for efficacy. Many members reported that symptomatic exacerbations of PTSD that previously would have prompted inpatient hospitalization had been successfully managed on an outpatient basis with the help of the group.
That this program often was described as more beneficial than traditional PTSD treatment programs does not imply that African-American veterans do not have access to or do not obtain benefit from other VA medical center and Vet Center PTSD programs. In a quantitative analysis of mental health service use by minority Vietnam-era veterans (4), no differences were found among ethnocultural groups in overall use of VA mental health services. An outcome analysis of VA treatment programs for acute PTSD revealed no major effects of ethnic origin on treatment outcome (5). However, an analysis of effects of clinician-veteran racial pairing in VA treatment programs for PTSD demonstrated that African-American veterans had less satisfactory program participation than Caucasian veterans regardless of clinician ethnicity (6).
Participation in the African-American group appeared actually to enhance several members' ability to profit from participation in concomitant Caucasian-majority VA treatment programs as well as their ability to work within these programs to make them more responsive to the needs of minority veterans. The support of the African-American group appeared to enable these veterans to participate more openly and assertively in Caucasian-majority therapy groups and other treatment programs.
This program addresses many of the issues proposed by others as important for successful psychotherapy for African Americans in general and for African-American veterans with PTSD in particular (2,3,7,8,9). Providing a setting in which African-American veterans can interact openly and honestly and can develop group cohesiveness creates the type of milieu considered essential for long-term group psychotherapy to succeed (10).
The program provides a forum in which the intrapsychic and environmental effects of racism can be constructively addressed. Group members can relate to and empathize not only with each other's experiences as combat veterans but also with their experiences as African Americans growing up and living in an often hostile society. This African-American group therapy program appears to be a valuable treatment option for African-American veterans who have PTSD. Systematic evaluations are necessary to confirm the efficacy of this treatment approach.
Mr. Jones is a therapist and Ms. Brazel is a mental health nurse practitioner in the mental health service of the Veterans Affairs (VA) Puget Sound Health Care System in Seattle. Dr. Peskind is associate director and Dr. Raskind is executive director of the Northwest Network Mental Illness Research, Education, and Clinical Center of the VA Puget Sound Health Care System. Dr. Morelli is a staff psychiatrist at University of Hawaii in Honolulu. Send correspondence to Dr. Raskind, VA Puget Sound Healthcare System, Mental Health Service (S-116), 1660 South Columbian Way, Seattle, Washington 98108 (e-mail, email@example.com). A version of this paper was presented at the fourth African-American Conference on Posttraumatic Stress Disorder held September 13, 1999, in Washington, D.C.