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The role of self-continuity in Vietnam combat veterans’ recovery from traum a Cohen, Robert Paul, Ph.D. The University of Michigan, 1992
C opyright © 1992 b y C ohen, R obert P au l. A ll rightB reserved.
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THE ROLE OF SELF-CONTINUITY IN VIETNAM COMBAT VETERANS' RECOVERY FROM TRAUMA
by Robert Paul Cohen A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy (Psychology) in The University of Michigan 1992
Doctoral Committee: Professor Professor Assistant Professor
George Rosenwald, Chairman Gerald Linderman Professor Naomi E. Lohr Christopher Peterson
RULES REGARDING THE USE OF MICROFILMED DISSERTATIONS
Microfilmed or bound copies of doctoral dissertations sub mitted to The University of Michigan and made available through University Microfilms International or The University of Michigan are open for inspection, but they are to be used only with due regard for the rights of the author. Extensive copying of the dissertation or publication of material in excess of standard copyright limits, whether or not the dissertation has been copyrighted, must have been approved by the author as well as by the Dean of the Graduate School. Proper credit must be given to the author if any material from the dissertation is used in subsequent written or published work.
Robert Paul Cohen
All Rights Reserved
1992
"History is said to be a series of messes.
Only a feeling
of personal identity (more or less continuing) can bring to the mess of one's past an impression of unity." --Leonard Shengold
ACKNOWLEDGEMENTS I would like to thank the institutions and people who helped transform this project from a whimsical idea into a reality.
First, I would like to thank George Rosenwald, my
dissertation committee chairman, who showed faith in the project when it was merely a set of hazy speculations. Professor Rosenwald has been an ideal mentor:
a scholar of
integrity, humanism, and, always at the right moment, exceptional wit.
Chris Peterson ably tolerated my confusion
and ceaseless inquiries about the study design and methods, and has encouraged me throughout my graduate training. Naomi Lohr has offered wise guidance since I arrived in Ann Arbor six years ago to begin graduate school. my abilities has been unwavering.
Her belief in
I have especially
appreciated her interest in this project and her contributions towards its completion.
Gerald Linderman,
professor of history, agreed to serve as the outside reader. His insights about the Vietnam conflict helped me better understand the experiences of my subjects. Without the help of several funding sources, this project would never have been completed.
The Horace Rackham
School of Graduate Studies provided a thesis grant and a contribution from the Rackham Discretionary Fund. iii
Psychology Chairwoman Pat Gurin provided generous support from the psychology department which made it possible to hire the coders who listened to the tapes.
Ken Silk also
helped by providing money for coding from the Personality Disorders Program of the Department of Psychiatry. Michael Davis, Michael Hoexter, and Adrienne Storm patiently listened to all sixty of the interviews to code them for Recovery Style.
I appreciated their careful
judgments and enjoyed our stimulating discussions of the coding.
I also want to thank Adrienne for preparing the
portraits of three veterans that appear in Appendix D. Sean Gargan and Matt Cruger helped by volunteering many hours to conduct difficult-to-schedule interviews with the subjects.
Matt was also willing to take on a number of
thankless tasks for which I am nonetheless thankful.
Cathy
Schleif did an expert job of preparing some of the more complicated tables.
A number of undergraduate students
provided important contributions to the project, usually settling for research experience as their only compensation. I hope when they do their dissertations, they will be as fortunate as I was to be helped by people like them. Michelle Brancheau and Wendy Stevens made major contributions to the project.
I am also thankful for the
assistance of Becky Gastman, Susan Gold, David Goldberg, and Helene Golden. Two persons at the Ann Arbor Veterans Administration Medical Center deserve special mention. iv
Ken Chamberlain
provided useful suggestions, as well as help in recruiting subjects. Jean Tweedie arranged for me to obtain clinical experience working with veterans who were suffering from Post-traumatic Stress Disorder.
This experience shaped my
ideas about the disorder and influenced the project in many important ways.
Dr. Tweedie also arranged pilot interviews
with veterans for me, and provided generously her own time to help me understand PTSD. I also want to thank the sixty Vietnam veterans who participated in the study, often traveling long distances and devoting many hours to the project.
They showed
admirable courage in their willingness to trust a stranger and speak with me about many private and difficult experiences. I would like to mention several individuals and institutions who contributed greatly to my graduate training.
I learned a great deal about research from Drew
Westen and Ken Silk and value their support and encouragement. Many excellent supervisors contributed enormously to my identity as a clinical psychologist.
My
training at the Psychological Clinic was an invaluable educational experience.
I have valued University of
Michigan Clinical Psychology Program for its high standards, respect for academic excellence, and dedication to training of students in depth psychology.
I feel fortunate to have
attended the program and have grown immensely both personally and professionally as a result.
Many other people have made this project possible by offering their friendship and support during my six years in Ann Arbor.
I am particularly lucky to have John Bernitz and
Ted Steinberg as close friends.
My classmate Roger Lauer
has been a good companion who helped make more bearable the pitiful antics of the New York Mets. my family for their encouragement. Rona and Cyril Moscow as my inlaws.
I also want to thank I am fortunate to have They have shown a great
deal of interest in my work and have been always willing to help.
My parents, Selma and Sidney Cohen, who have
experienced many challenges themselves these past six years, have, as always, encouraged my work and offered their support.
Their optimism has been inspiring.
I have been wondering for some time now how I can ever adequately thank my wife, Ruth Moscow.
She had the (mis?)
fortune to meet me during my first week of graduate school classes at Michigan. signed on anyway.
She knew it would be a long haul but
She has been a wonderful companion for
both the spills and thrills.
Three years ago, she became my
wife, and five months, ago she brought into the world our precious baby daughter, Anna Sophia.
In ways I may never be
able to convey adequately, Ruth has made a difference in my life.
Her faith in me is reflected in every page of this
dissertation.
vi
TABLE OF CONTENTS ACKNOWLEDGEMENTS....................................... iii LIST OF
TABLES....................................... ix
LIST OF APPENDICES..............................
xi
CHAPTER I. INTRODUCTION..................................... 1 Trauma as "Personality Smasher" The Role of Integration Critical Comments Psychoanalytic Views of Trauma A Narrative Approach to Integration Trauma as the Road to Insight Conclusion II.
PREVIOUS EMPIRICAL FINDINGS AND PRESENTATION OF STUDY HYPOTHESES ............................. 39 Integration and Sealing Over in Major Mental Illness Recovery Style and Trauma Coping with Combat Overview of the Study Hypotheses
III. METHODS....................................... 58 Subjects Procedure Recovery Style Assessment and Measures of Validity Other Predictor Variables Measures of Current Functioning and Symptoms IV
RESULTS...................................... 104 Validity of Recovery Style Ratings
Association Between Recovery Style Measures, Other Measures of Coping, and Measures of Current Functioning A Model to Explain Continuity Models to Assess Contributions to Current Functioning Summary of Multiple Regression Analyses Predicting Current Functioning V
DISCUSSION
136
Summary of Results Validity of Recovery Style Ratings The Meaning of Continuity Lack of Continuity as a Reaction to Trauma Discussion of Findings Concerning Other Predictor Variables Conclusions and Directions for Further Research APPENDICES
166
REFERENCES
190
viii
LIST OF TABLES
Table I.
Combat Exposure: Descriptive Statistics and Frequencies.................................. 63
2.
Demographic Characteristics................... 65
3.
Defining Characteristics of Pre-War Integration and Sealing Over.......................... 68-69
4.
Defining Characteristics of Combat Integration and Sealing Over.............................. 71-72
5.
Rating Guide for Pre-War Integration and Sealing Over..................................... 74-75
6.
Rating Guide for Combat Integration and Sealing Over..................................... 76-77
7.
Combat Exposure Scale for Integration Interview 81-82
8.
Descriptive Data on Recovery Style Scores.......83
9.
Picture Coding Scale to Assess Psychological Mindedness............................... 87-89
10. Scales Created from Items Concerning Subjects' Pre-war Experiences....................... 93-94 II. Scale Created from Items Concerning Subjects' Vietnam Experiences.......................... 95 12. Scale Created from Items Concerning Subjects PostVietnam Experiences .......................... 96 13. Correlations Among Coders' Recovery Style Ratings and Ratings of Combat Exposure...............106 14. Correlations Between Prewar and Combat Recovery Style Ratings............................... 107
ix
15.
Correlations Between Recovery Style Scores and Psychological Mindedness, Monitoring and Blunting....................................109
16.
Correlations Between Psychological Mindedness, Recovery Style, and WAIS-R Vocabulary Subtest 112
17.
Descriptive Statistics for the Sample on Measures of CurrentFunctioning...................... .113
18.
Number of Subjects With Post-Traumatic Stress Disorder Diagnosis.......................... 114
19.
Partial Correlations Between Measures of Current Functioning and Recovery Style, Psychological Mindedness, Monitoring and Blunting.......... 115
20.
Partial Correlations Between Measures of Current Functioning and Recovery Style, with Extreme Scorers Excluded............................ 118
21.
Correlations Between Current Functioning and Variables Concerning Subjects' Pre-war, Vietnam, and Post-war Experiences.....................120
22.
Correlations Between Recovery Style Measures and Variables Concerning Subjects Pre-war, Vietnam, and Post-war Experiences..................... 122
23.
Multiple Regression Analysis to Identify Predictors of Continuity..................... 124
24.
Multiple Regression Analysis to Identify Predictors of PTSD Symptoms..................127
25.
Multiple Regression Analysis to Identify Predictors of Social Adjustment..............128
26.
Multiple Regression Analysis to Identify Predictors of Scores onthe MMPI-2 F Scale.... 130
27.
Multiple Regression Analysis to Identify Predictors of Scores onthe MMPI-2 A Scale.... 131
28.
Multiple Regression Analysis to Identify Predictors of Scores onthe MMPI-2 R Scale.... 133
29.
Multiple Regression Analysis to Identify Predictors of Scores on the MMPI-2 ES Scale... .134
x
LIST OF APPENDICES Appendix A.
Diagnostic Criteria for Post-traumatic Stress Disorder.................................... 167
B.
Integration-Sealing Over Scale for Psychosis.. .169
C.
Semi-structured Interview for Trauma Integration . . ............................................ 171
D.
Portraits of Three Veterans Who Used Different Recovery Styles.............................. 178
E.
Picture Story Task........................... 188
xi
CHAPTER I
INTRODUCTION
The last decade has seen a burgeoning interest in the effects of devastating life events and in how individuals manage to "recover" from them.
The appearance in 1980 of
Post-Traumatic Stress Disorder (PTSD) as a formal diagnostic category led to an outpouring of research studying the consequences of exposure to events "outside the range of normal human experience..."(American Psychiatric Association, 1987).
Studies have investigated consequences
of events such as rape (Resnick, Kilpatrick, & Lipovsky, 1991); criminal victimization (Kilpatrick et al., 1989; Terr, 1983); natural and manmade disasters (Baum, Gatchel, & Schaeffer, 1983; Green, 1982; McFarlane, 1988); physical and sexual abuse (Browne & Finkelhor, 1986; Steele, 1982) and combat (Kulka et al. 1990).
The literature has given rise
to a new paradigm of understanding, woven together from diverse sources, that not only specifies the mechanisms of how events become traumatic, but outlines the process of recovery as well. This view of trauma and recovery, articulated in strikingly similar ways by a number of independent investigators from diverse theoretical traditions, can be
2
summarized succinctly (Epstein, 1991; Horowitz, 1986; Janoff-Bulman, 1992; McCann & Pearlman, 1990; for reviews of this approach, see Roth & Dye, 1991, and Schwarz & Prout, 1991).
A traumatic event is an occurrence that severely
challenges the long-held, cherished beliefs and expectations of the individual exposed to it. In the face of a traumatic event, the world and self can no longer be viewed in the same way.
Where once the world was seen as safe, it is now
dangerous.
Where once the individual felt invulnerable, he
is now exposed as weak, frail, and at the mercy of forces larger than himself.
Where once others were seen as
trustworthy, they are now seen as cruel, abusive, or indifferent.
The clash between new experience and
trustworthy expectation is highly dissonant.
Recovery is a
process of dosing oneself with the painful new information about what has occurred in order to "integrate" it; this entails revising one's beliefs and assumptions about the self and world.
But this process may be complicated because
the negative affect stirred by such revisions can be overwhelming and destabilizing.
Trauma survivors may need
to avoid or deny the implications of a trauma to tame overwhelming affects.
As Horowitz (1986) wrote: "When these
serious life events occur they can shatter a person's reality, and the inner models of the world that have sustained the person must now be changed to accord with the new situation" (p. 110).
3
The focus on fundamental changes in core concepts in response to trauma raises the question of what, if anything, must be recovered in the process of recovery.
This
dissertation will study an aspect of recovery underemphasized in the prevalent paradigm.
Recovery, in my
view, is not just an acceptance of how the self is fundamentally different in the face of a new event.
Rather,
it requires an actual recovery of the enduring self that was traumatized.
It means owning not only the characteristic
tendencies that may have led the individual and the traumatic event to collide in the first place, but also recognizing one's enduring self in the way he appraised, reacted, and coped with an event found overwhelming or terrifying.
The proposition studied here was that in
addition to accepting the cognitive and emotional implications of the trauma, successful recovery from trauma involves an active search for continuity across the individual's personal history.
The process brings
inevitable changes in the self, but these are based on new insights that emerge as the individual confronts warded off aspects of self that the traumatic event may have touched upon.
Recovery means a recovery of the self. The study investigated recovery in Vietnam veterans
exposed to heavy combat.
The struggles of Vietnam veterans
during the 1970s first focused attention upon traumatic stress and led to its inclusion as a formal category in the Diagnostic and Statistical Manual of Mental Disorders
4
(American Psychiatric Association, 1980).
Vietnam combat
veterans were exposed to extremely trying circumstances, and have suffered severely as a result.
The chances of being
killed in combat in Vietnam, one study suggests, were seven times higher than in World War II (Hayman, Sommers-Flanagan, & Parsons, 1987).
Another recent study estimated that as
many as 15 percent (479,000) of the 3.14 million male Vietnam veterans suffer from PTSD (Kulka et al. 1990).
The
disorder is characterized by repetitive nightmares flashbacks, intrusive memories, emotional numbing and social withdrawal (for a full list of symptoms, see Appendix A). The experience of the Vietnam veteran, then, is a living laboratory to investigate the effects of stress.
This is
especially so now because veterans have had years since the war to work over their stressful experiences.
Though many
veterans have led difficult lives since the war and have been plagued by trauma-related symptoms, there are those who have managed to come to terms with their war experience and have found a way, in spite of its challenges, to make something useful of it (Egendorf, 1981; Hendin & Haas, 1984; Ursano, 1981) . A study of the factors related to recovery is also pertinent given the controversy in the field over the place of individual personality in reactions to major stressors. In recent years, two camps have clashed over the causes of symptoms that follow exposure to catastrophic events.
One
group has highlighted the role of predisposition, arguing
5
that those who suffer from severe symptoms following the experience of a traumatic event either already suffered from mental disturbances (Ettedgui & Bridges, 1985; Worthington, 1977), or were especially vulnerable to breakdown when confronted by major stress (McFarlane, 1986, 1987; Sudak et al., 1984).
Another group--probably the majority of
researchers in this field— has instead focused on qualities of traumatic events which in and of themselves are seen as capable of creating psychological disorders, regardless of the personality that may have experienced the stressor (for representative examples of this argument see Boulanger, 1986; Foy, Carroll, & Donahoe, 1987).
Disagreements about
the role of personality in the genesis of traumatic reactions have been heated, leading Reich (1990) to conclude:
"Seldom, in the psychiatric literature, has a
question resulted in such polarized and strongly held positions" (p. 65).
A look at the factors that contribute
to or detract from the recovery may help clarify issues raised in the literature concerning the role individual differences play in traumatic responses. The proposition tested here was that individual qualities lead some people to react to a major life event with curiosity and a strong need to accommodate it into their ongoing sense of themselves.
These qualities are
presumed to derive from early formative experiences and may be nurtured or inhibited by the post-trauma environment. The central hypothesis of the study was that those
6
individuals who isolate the event and fail to bring it within a coherent personal narrative that includes elements of who they were and how they reacted before the trauma will make less favorable adjustments.
Thus, though a
threatening, frightening experience such as combat would likely be destabilizing for almost anybody, what an individual makes of what happens to him and his attitude toward his responses will influence whether he masters the experience or is undone by it. My position takes a middle ground in the debate over predisposition: it acknowledges that the stressful event in itself has an important meaning and effect, but highlights the role of certain personality traits in promoting recovery.
It also takes into account the importance of the
post-war environment in modulating the influence of pre-war dispositions.
My interest in looking at personality factors
that make people resilient or vulnerable is congruent with recent literature highlighting a need for understanding individual factors that contribute to different outcomes following extreme events
(Flach, 1990; Lyons, 1991;
McFarlane, 1990) . To establish the rationale for my particular way of understanding the influence of what an individual brings to a trauma, it will be necessary to look more closely at the literature concerning traumatic reactions.
7 Trauma as "personality smasher" As noted above, a central idea now current among those studying the impact of traumatic events focuses on trauma as an external reality that violates fundamental assumptions regarding individuals1 senses of who they are as people and the kind of world in which they live.
Though articulated in
different ways, the core idea is that central beliefs, assumptions, or schemas related intimately to the individual's sense of self and world are threatened by a traumatic event.
Indeed, the definition of trauma from this
perspective is an event that threatens key, stabilizing beliefs. Because many of these beliefs are seen as universal, certain events can be defined by their very nature as being traumatic.
In this section, I
will
summarize a number of approaches that take this view, and then present a critique and reformulation with my own views. The position I have alluded to has been articulated in a number of different ways, using language derived from quite different conceptual systems.
Epstein (1990), in an
attempt to develop what he terms "a cognitive-experiential self theory," posited that individuals construct personal theories of reality that allow them to apprehend both the world and the self.
The postulates of these theories
develop over time through experience and operate preconsciously. A personal theory of reality hinges on four basic beliefs:
the world is benevolent and just; the world
is meaningful; the self is worthy; and people are
8
trustworthy. smashers."
Traumas, as Epstein put it, are "personality They confront the individual with realities that
force him or her to accomplish "a significant reformulation of basic views about self and world (p. 71)."
Unless
individuals can "accommodate" views of the self and world and modify their basic beliefs, they will be forced to resort to a variety of maladaptive solutions, including reorienting the entire personality around beliefs derived from the trauma.
Even when changes are not so extreme, the
trauma requires a reworking of earlier beliefs. The individual must accept that in the wake of the trauma, enduring beliefs are only true "within limits." Janoff-Bulman (1985, 1992) borrows Parkes' notion that individuals cling to an "assumptive world," which is defined as a "strongly held set of assumptions about the world and the self which is confidently maintained and used as a means of recognizing, planning and acting... (1975, p. 132, quoted in Janoff-Bulman, 1985, p. 17).
She focused on three
particularly salient, universal assumptions that are implicated in reactions to trauma:
the beliefs that the
self is invulnerable, that others are trustworthy, and that the self is worthwhile and competent.
This last belief is
challenged because the helplessness associated with an unpredictable event is often negatively evaluated, leading to negative evaluations of the self that experienced it. Citing evidence from cognitive psychology showing that schemas or beliefs are rigidly held and impervious to
9
change, Janoff-Bulman highlights the ways that trauma victims attempt to evade acknowledging the implied threat to their basic assumptions.
She particularly focuses on how
individuals deny the traumatic event to prevent themselves from having to revise their assumptions. They also use particular cognitive strategies in an attempt to cushion the blow of the trauma.
These include comparing one's
experience with others who had it worse and by so doing, making their own painful experience seem more acceptable; attempting, usually irrationally, to blame the self for the trauma, in order to feel that the event was not uncontrollable and unpredictable; and seeking to find meaning or reasons in the event by highlighting its positive, growth promoting qualities.
Victims utilize these
and other processes to manage the painful affects stirred by the trauma on the road to eventually ''integrating" the traumatic event into their conceptual schemes, thereby changing basic views of self and world. McCann and Pearlman (1990) presented a similar view in their "constructivist self development theory," highlighting again the ways the traumatic events impinge upon enduring "self-schemas." Their approach— a melange of ideas from cognitive psychology and psychoanalytic self-psychology— differs in that it highlights the importance of individual needs that influence the creation of "schemas" of the self and the way they are internally organized.
Thus, while
McCann and Pearlman acknowledge the ways that traumatic
10
events impinge upon universal beliefs, such as the assumption of invulnerability, these writers also lay special emphasis on the way that a person's "central needs" in such areas as power, trust, safety, esteem, and intimacy influence the way that a particular event may become traumatic.
A woman who has predominant self-schemata
organized around the need for independence, for example, might be especially traumatized by a rape in which her sense of self-control and autonomy were assaulted. For Pearlman and McCann, the process of recovery entails "resolving" schemata "disturbed" or "damaged" by traumatic events.
For the victim mentioned above, recovery
may mean acknowledging that the event called into question some of her beliefs and accepting the loss of the previous self that had managed to achieve a confident sense of independence.
In some cases, the treatment may entail
"mourning the loss" of the "previous self" (p. 317). A similar view is offered by Ulman and Brothers (1988), who draw upon psychoanalytic self-psychology. They saw a traumatic event as the "shattering and faulty restoration of central organizing fantasies of self" (p. 63).
Drawing on
ideas first elaborated by Kohut (1971), they highlighted the centrality in normal development of early fantasies of grandiosity and merger with nurturing figures (selfobjects). A cohesive sense of self develops out of an early relationship with nurturing figures who are able to mirror and approve of the child's sense of grandiosity, and who
11
allow the child to idealize them and feel a part of that sense of idealization through a psychological "merger.11 However, when parents cannot optimally meet the child's needs, he may compensate by continuing to fantasize unconsciously about himself as grandiose and in need of merger with powerful, idealized others.
These fantasies
protect the individual against a sense of being empty, fragmented, and bereft, and may provide important psychological sustenance.
However, traumatic events shatter
those fantasies, often communicating in no uncertain terms that the individual is not all-powerful; further, such events interfere with the individual's attempts to establish a sense of "idealized merger" with others who might protect him or her.
The result is a disintegration of the self,
which can no longer be sustained by protective, narcissistic fantasies.
Efforts to cope include desperate attempts to
restore central fantasies of grandiosity and concomitant symptoms of distress based on a sense that the self is now shattered. In this view, recovery requires psychotherapeutic treatment in which a relation with the therapist helps to modify the need for grandiose fantasies.
The therapist
empathizes with the victim's need to feel all powerful, invincible, and in contact with a powerful, idealized other. By "mirroring" and accepting the subject's needs, as well as attempting to understand the way the trauma impinged upon these central beliefs, narcissistic fantasies can be
12
"tempered and moderated," and the self becomes more solidified.
Treatment may involve reconstructing events
before the trauma which led to the development of compensatory grandiosity and idealization.
But it appears
that modification occurs mostly in relation to the therapist, who provides admiration and allows herself to be used as an idealized figure.
The trauma victim elaborates
central narcissistic fantasies in the therapy.
The client
internalizes the therapist's empathic appreciation and validation of the client's needs, leading to a stronger sense of self. While the terminology is different, the authors' noted the similarity of their approach with the work of JanoffBulman's who also highlighted the "shattering" of protective assumptions (pp. 20-21) . There does appear to be one potential difference.
Ulman and Brother's specified
particular vulnerabilities that may lead to a shattering of the self in the face of trauma, noting that breakdown is "determined by the degree to which sense of self...remains organized by archaic and illusory notions of personal grandeur or idealized merger" (p. 15).
In their case
studies, they attended to particular failures in empathy and response that victims experienced before the trauma and which accounted for their particular need to structure their selves around compensatory narcissistic fantasies.
The
authors describe these individuals as not receiving the necessary nurturing responses from caregivers that would
13
allow them to modify early narcissistic fantasies.
Thus,
this approach touches upon ongoing life-historical processes which influence the vulnerability to stressful events. However, the authors later contradict themselves, stating that "even normal childhood and adolescent fantasies typically fail to undergo sufficient developmental transformation, leaving most persons vulnerable to their traumatic shattering and faulty restoration" (p. 293).
It
is unclear, then, whether the fantasies shattered by trauma are universal in the same way as the beliefs and assumptions highlighted by Epstein and Janoff-Bulman.
The focus on
altering basic fantasies in the context of the therapeutic relationship appears congruent with the aims of the other theorists surveyed here. Perhaps the most widely known view of trauma and recovery is offered by Horowitz (1976, 1986).
A
psychoanalyst who attempted to translate psychodynamic concepts into the language of cognitive psychology, Horowitz posited a "completion tendency" similar to Freud's "repetition compulsion."
When a new reality occurs that is
significantly at odds with one's inner expectations, assumptions, and goals for the self, it forces a revision of these internal organizing structures to correspond with life events.
The mind has a tendency to complete unfinished
business and continually attempts to work over and "integrate" the new information; this need to confront the traumatic event accounts for victims1 frequent re
14
experiences of the trauma through dreams and flashbacks. But because the information associated with the traumatic event departs so radically from expectation and is associated directly with concerns related to the self, intense affects are aroused.
As a result defenses, or
"control processes," are instituted in an attempt to protect the individual from being overwhelmed. wrote,
As Horowitz (1986)
"Every recognition of the discrepancy between the
new state of affairs and the inner habitual model may bring emotional responses that are sufficiently painful so as to interrupt the information processing necessary to reach the completion point" (p. 94).
Processing of information may be
affected by personality styles that influence how affects and cognitions are organized and integrated; thus, Horowitz pays particular attention to documenting the ways that hysterical, obsessional, and narcissistic characters respond to stressful events.
Completion is reached when schemas are
revised to accept the stressful event as an enduring reality. The Role of Integration All of these theories emphasize the trauma victim's need to achieve fundamental changes in his or her sense of self.
Those who see trauma as "personality smasher" differ
in their emphasis on specific attributes of the self that influence the way the trauma is appraised and processed. Character style and central needs may influence ways in
15
which an event becomes traumatic and how it is resolved. There are even indications that exploration of the pre trauma self at times forms an important part of these theorists' clinical work with victims.
Horowitz at one
point stated that in some "chronic" cases, recovery involves exploration of enduring "role relationship models, unconscious fantasy scenarios, scripts, and life agendas" (p. 145).
And Ulman and Brothers at times explored early
experiences to account for their clients1 needs to structure their selves around fantasies of grandiosity and idealized merger with others.
But the need for actually focusing on
the pre-trauma aspects of self as a routine part of the process of recovery is not a central part of these theories (or at least it is not stated as such). Instead, they highlight the need to "integrate" the traumatic event by facing it, talking about it, abreacting it.
Recovery
involves an "emotional processing" of the traumatic thoughts and memories (Foa et al., 1989).
Confrontation with what
happened is supposed to make possible an accommodation of basic views of the self and world in order to bring about necessary changes of beliefs, schemas, and assumptions. In descriptions of recovery from trauma, the word integration arises again and again.
Though it is rarely
defined, the process appears to be closely tied to the self. In a review of therapeutic approaches with trauma victims, Schwarz and Prout (1991) noted that one common treatment goal is "facilitating integration of the self" (p. 371).
In
16
these conceptions, the memories of the trauma are presumed to be walled off or dissociated, and must be brought into awareness.
Roth and Dye (1991) spoke of the need to
"approach" traumatic material in order to "integrate" it. The traumatic event and presumably the responses it engendered are seen as alien and external to the individual, and it can only be brought within the self by making an effort'to directly confront it.
One common suggestion to
help individuals bear the pain of such acceptance is by noting that their responses are normal and predictable (Horowitz, 1986; Schwarz & Prout, 1991).
Some therapists
even read their clients the diagnostic criteria for PTSD (Ochberg, 1991). Critical Comments My critique of these approaches focuses on the ways that they restrict the possibility of developing individualized understandings of people's traumatic responses.
For instance, the definition of trauma as an
event that shatters particular expectations and assumptions raises a number of questions.
What about people who do not
believe in a just, benevolent world?
Are those who are more
cynical, suspicious and sociopathic less likely to be traumatized?
Alternatively, could someone with such a
cynical view be traumatized by experiencing a sudden encounter with extreme benevolence?
17
The self that must accommodate the trauma in the theories I have presented is a shadowy substance: a seat of universal beliefs, common needs, and similar grandiose fantasies. These approaches fail to elaborate upon the ways that a trauma is truly a personal experience, one that is appraised as traumatic due to highly individual idiosyncratic meanings (Lazarus & Folkman, 1984) and can be recovered from through a uniquely personal endeavor involving the creation of individual meanings (Hendin & Haas, 1984) . Except for some allowances for individual differences in character and distribution of central needs, traumatic experiences for these theorists smash a universal, rather than particular self.
This is a lofty, socially
desirable self that believes in invulnerability, the trustworthiness of others, and the basic worthiness of the individual as a person.
How these general themes
correspond to the unique imprint of an individual's life is not usually addressed as a central issue. The focus on internal schemas, beliefs, organizing fantasies and assumptions reflects an attempt to introduce the ways that individual constructions of meaning enter into the process of traumatization and recovery.
But by
insisting that the self as constituted before the trauma is relevant only to the extent that it is forced to change, these theories depart from an account of trauma recovery that fully takes into account the way that individual meaning is involved in traumatic reactions.
The
18
individual1s reaction to the event as traumatic would appear to reveal a tremendous amount about the specific meanings the event has assumed.
But these reactions are normalized
as typical of how people in general react to stressful events.
Normalizing the responses reflects a lack of
interest in the meaning of the event.
It robs the
individual of an opportunity to develop an individual sense of his own reactions and to own them as part of his particular life history. Further, these theories focus on traumatic events as alien, external influences.
The victim is just that:
a
passive respondent overcome by external circumstances who must change the way he sees himself in reaction to the trauma.
By positing a need for victims to alter themselves
in the face of traumatic events--to essentially cast aside their beliefs and assumptions--these theories may exacerbate the sense of helplessness often noted in trauma victims. Finally, though the importance of "integrating" the trauma is often specified, what "integration" means is left undefined.
The nature and process of the required changes
in self-concept and attitude remain unclear, except that it is evident that individuals need to face up to what has happened to them and accept it. This is not to say that these theorists totally ignore the personal meanings that their clients bring to events they find traumatic.
Again and again in clinical
descriptions, subjects are described as agents who actively
19
bring very particular histories and difficulties to the traumatic event.
Often, it appears that the treatment leads
to an increased understanding of who the individual was before the traumatic event, and brings about a greater continuity of the self.
But this process is disregarded in
favor of a conceptual focus on trauma as a universal event that is similar for almost everyone.
The lengths these
theorists go to highlight general "stress responses" results in theories that neglect the way trauma is created by the special character of the individual's personal history. Similar issues were raised by Haaken and Schlaps (1991) in a discussion of "incest resolution therapy."
They noted
some therapists' tendencies to focus exclusively on sexual abuse and to portray their clients as experiencing rather predictable, "normal" responses to trauma.
In many incest
treatments, therapists treat their clients as all-good, victimized children responding to bad parents.
Clients'
destructive wishes and impulses are usually reinterpreted as defensive responses to being abused.
As a result, Haaken
and Schlaps believe these clients' chances for gaining selfunderstanding are foreclosed by the model imposed by the therapist.
They argue for therapeutic approaches that allow
incest victims to elaborate their own particular responses to the experience of incest, including their unique feelings and fantasies.
They stated:
Part of the recovery process from sexual assault is to transform and transcend the experience and incorporate it into a broader sense of self.
20 Using therapy as a means of facilitating this requires attention to the person in the fullest possible sense {p. 44). In the next section, I will use psychoanalytic theory to present an alternative view of the way that the self changes in the process of recovery from trauma.
My view is based on
the notion that this can be accomplished by attending in the fullest possible sense to the way a traumatic event is woven into an individual's particular life history.
I believe the
approach I am presenting is useful in that it allows for a particularly idiographic and yet adaptive understanding of traumatic response.
It helps clarify the nature of external
events in a way consistent with the aims of the theories I summarized earlier which attempted to account for the constructive nature of human perception and cognition in response to trauma.
Further, acknowledging the central role
that rediscovering aspects of the enduring self plays in the recovery from trauma will allow me to present a clearly defined, theoretically sound understanding of what it means to "integrate" the trauma.
Psychoanalytic Views oJL Trauma Psychoanalysts have articulated two predominant understandings of trauma, which derive from strands of thought about trauma evident in Freud's work.
His best
known account sees trauma as overwhelming the ego and penetrating the "stimulus barrier," a hypothetical construct that protects the psyche against an influx of stimulation.
21
In this quantitative account of trauma, the intensity of external stimulation floods the ego, forcing it to deal with excess excitation that must be worked over and bound.
Freud
(1920/1955) noted this process particularly in the posttraumatic dreams of World War I veterans, who nightly revisited painful combat scenarios. Freud thought the ego1s efforts to master and bind the stimulation resulted in repetitive experiences of traumatic imagery. A second approach sees an event becoming traumatic because it resonates with conflicts that lie in the "deeper layers of the personality" (1926/1959, p. 129).
In contrast
to the first view which sees the trauma as an external event that is intense enough to overwhelm the individual who experiences it, in the second view, an event becomes traumatic because of the way that it is appraised by the individual, based on ongoing wishes and conflicts. These two basic positions have been maintained in current analytic discussions of trauma.
Some analysts see a
trauma as an event that overruns the symbolizing capacity of the ego (Cohen, 1980; Cooper, 1986; Krystal, 1988).
As in
the stimulus barrier approach, the individual is overwhelmed in a basic, functional way.
Here, ongoing meanings and
appraisals are seen as less important than the biological changes that follow from stress.
In this view, an event can
be so traumatic "that it surpasses a threshold beyond which the symbolic meanings of the event are less relevant to the form of the subsequent symptoms" (Phillips, 1991; p. 165).
22
This view corresponds in some ways with the notion of trauma as "personality smasher": the event is so big so as to demand an immediate adaptation of the individual. The alternative position sees trauma as defined internally, based upon the reaction of the individual to an event as a result of his own particular, wishes, fantasies and fears.
I have elsewhere termed this the "meaning-based"
approach to trauma (Cohen, 1990) . This position situates the creation of trauma within the individual in reaction to events that may have particular idiosyncratic meanings (Brenner, 1986; Schwartz, 1984).
As Brenner (1982) stated:
The unconscious meaning of an experience is always crucially important, whether the trauma be minor or overwhelming in its nature. A set of stimuli, i.e., an experience that is catastrophically traumatic for one person, may be of minor psychological significance to another. In adult life, at least, psychoanalytic evidence strongly favors the view that anxiety does not appear automatically as a consequence of an excessive influx of stimuli and, what follows from this, that it is never without ideational content (p. 65) . Thus, a trauma is an event that because of its idiosyncratic and highly personal meanings causes a state of overwhelming terror. This is not to say that traumatic experiences are completely idiosyncratic.
Similarities in traumatic
response are accounted for by the shared exigencies of human development, based both upon evolutionary and cultural factors.
Fundamental in this regard is Freud's
conceptualization of a trauma as a subjective experience of
23
helplessness" (1926/1959).
Models for appraising
helplessness are developed in infancy and early childhood when real events— such as the threatened loss of the mother, or ungratified instinctual needs— produce a state of what Freud termed "automatic anxiety."
The dysphoric nature of
such states of helplessness forces the child to become adept at determining and reacting to such threats.
As a result,
he develops the capacity for signal anxiety— a warning sign that a state of helplessness threatens to emerge.
Freud
concluded that early experiences of potential danger— particularly involving a threat of separation from the mother— lead to the development of a self-protective signaling system that will be employed in all future danger situations. Though the paradigmatic instance of the threat of helplessness is loss of the mother, with time, new threats emerge, such as loss of the mother's love, castration, and approbation by the superego.
Ideas or fantasies associated
with these threats can become dangerous in themselves. Signal anxiety provides the motive for defense: the need to avoid the development of a traumatic situation promotes attempts to ward off later experiences that remind the individual of early danger.
Later danger experiences--
including those that may come to be felt as traumas--are evaluated based upon the way that early, severe threats were experienced and represented in the mind.
This account
explains both the idiosyncrasy of one's reaction to threat
24
and the fact that some events are traumatic to almost everybody.
Because each signal anxiety system is likely to
be constituted differently based on one's constitutional nature and environmental experiences, there can be quite a variety of appraisals for the same situation. Alternatively, because the development of signal anxiety and defense is rooted in an adaptive, infantile attempt to ward off survival threats— such as abandonment by the mother— there is necessarily a convergence in the way that dangers are experienced.
Fundamental to this way of thinking about
trauma is the idea that the reaction to a stressful event is shaped by earlier experiences which determine what one finds dangerous and the way in which that danger is felt.
This
conception sees an event as traumatic because it touches upon something already latent within the self.
This is not
to say only that early traumas predispose individuals to subsequent traumas in the face of difficult events.
Each
individual has developed a set of particular responses to the ubiquitous threats of helplessness inherent in childhood.
Thus, there resides within all individuals the
potential to react to particular realities with a subjective appraisal of danger.
Such an appraisal may often be
associated with the actual, objective appraisal of danger, but this may not always be the case. A final element in the "meaning-based" approach concerns the assumed ubiquity of unconscious fantasy. Drives, wishes, and prohibitions from early life are
25
hypothesized to be constantly active in what Arlow (1969) has termed an "unconscious fantasy function."
The content
of the fantasies and the extent to which they become conscious is influenced by the signal anxiety system which has been developed in response to infantile threats of helplessness.
According to Arlow, this unconscious stream
determines the way in which incoming events are experienced, providing a "mental set" against which sensory stimuli are "perceived and integrated" (p. 8). way interaction:
This results in a two-
active fantasies determine how events are
experienced, while experiences call up particular fantasies. While this may strike some as diminishing the import of external reality, Arlow responded, "On the contrary, the perceptual data which facilitate the emergence of unconscious fantasies are effective precisely because they are not indifferent, because they contain features already present in preformed unconscious fantasies" (pp. 8-9) . On a surface level, this conception bears some relationship to the cognitive account of internal schemata that organize the incoming data of perception.
Unconscious fantasy can be
thought of as a particular type of schema, organized around primitive, wishful, and prohibitive central postulates about the self and world. In this view, the unbearable affects associated with trauma are stirred not because reality creates a discrepancy with what is expected, but because there is a similarity. As Renik (1981) writes, "The traumatized individual is
26
provided with actual perceptions that correspond all too closely to dreaded unconscious fantasy" (p. 177).
Thus, a
traumatic event is one where the individual appraises reality in such a way that it confirms a wished for and feared circumstance.
For a simple example, consider the
unconscious fantasy of a combat soldier who latently hopes that a comrade rather than himself will be killed in battle. This individual's wish may be connected to historically important fantasies related to his wish to outdo others competitively, or perhaps his wishes to see himself as worthy of surviving for his own sake.
When the comrade
actually dies, the soldier reacts as if his fantasies have come true.
The result is distress, because the fantasies go
against long-standing convictions--developed early in life— that to wish aggression upon others, or to feel invested in one's own survival is dangerous and could result in severe condemnation or punishment (and perhaps, an unbearable experience of helplessness).
The nature of the fantasies
and the related internal prohibitions associated with them depend on the particular life circumstances and history of the individual involved. When real events confirm the fantasy, anxiety related to the fear of the consequences associated with it emerges, and the ego attempts in a restitutive way to ward off the sense that an occurrence both wished for and feared has come true.
Such efforts may include the frequent sense of
unreality that descends in the aftermath of a trauma (Renik,
27
1981).
The sense of unreality, which may be experienced as
a disassociation or depersonalization, allows the individual to say: "What I feared coming true is not really happening, what I see is not real."
Perceptual reexperiences of
traumatic events, such as dreams and flashbacks, also may occur.
They may involve subtle but crucial distortions in
the traumatic event to undo its consequences.
An example is
a canoe accident victim who in reality needed to be pulled out of the water; he dreamed wishfully that he actively twisted through obstacles in the river (Lowenstein, 1949). Renik suggested these dreams occur in those individuals who were in some way materially damaged by a trauma and use the dream in a wish-fulfilling way to undo what occurred. Another motivator for repetition is to assure the victim that his fantasy did not actually come true.
As Renik
(1981) wrote: While a traumatic event stirs up dread unconscious fantasy, producing a sense of danger, it also gives evidence that the danger has been in reality escaped. Thus, the dreamer goes over and over the real circumstance of the traumatic event in painstaking detail in order to confirm that, "Yes, that was close; but it was not what I feared," or "That was bad, but not as bad as it might have been"...Exact repetition permits the dreamer to confirm that reality, even if it is eerily reminiscent of a threatening fantasy, ultimately proves to be different from the fantasy and safe (p. 178) . The theory outlined above explains trauma as an enactment of something unconsciously feared, an event that gives a stamp of reality to conflicted notions already present in the self
28
(Greenacre, 1967; Schwartz, 1984).
A trauma can only be
defined based on the individual's appraisal of the situation based on his own particular fantasy life and ways of reacting towards it.
An event that creates the trauma,
then, is not one that invalidates enduring beliefs because it is so different.
A traumatic event has an impact because
it is too familiar. This understanding helps explain the appeal of notions which see the trauma as an external event, situated outside the observer that runs completely counter to the individual's way of ordering his life.
If the individual
can see himself as a victim, who has no personal involvement in the trauma, he can protect himself from recognizing the impulses and fantasies within himself stirred by the event. When the individual highlights the trauma's unexpected nature and the way that it is repugnant to his values and beliefs, he distances himself from acknowledging that the event was frightening because it came too close to something within. From this perspective, then, an approach to recovery that focuses on highlighting the external and overwhelming nature of the trauma may provide some relief.
It helps
assure the individual that he cannot in any way feel responsible not only for the event that occurred, but his reaction to it.
In this understanding, the traumatic
response is seen as inevitable in almost anyone, and not the product of the individual.
Yet, such reassurances may be
29
ephemeral because they do not address the fact that reality has indeed come too close to an unconscious fantasy, threatening the individual with the premonition that it could do so again.
Symptoms such as traumatic dreams or
attempts to strangulate affects and impulses connected with important fantasies persist as a continuing effort protect against the possibility that reality again could come too close.
Trauma victims need to repeat their exposure to the
traumatic event in order to provide continuing reassurance that they are safe from the danger of their fantasies coming true (Renik, 1981). It is important to note here that what is being described is an intra-psychic process. Individuals are relieved when therapists assure them that they are victims and not responsible for either the traumatic event or their responses to it because they fear at some level that they are connected with what has occurred in reality.
Attending
to this sense of responsibility is not blaming the victim, for usually the trauma survivor is not actually culpable. Rather, the person is disturbed by his own wishes that now seem all too real. A Narrative Approach to Integration The theories I outlined at the beginning of this chapter imply that a traumatic event is of such magnitude that individuals must change themselves to adjust to it, and that therapeutic success lies in helping clients accept the
30
event as an overwhelming external force destined to change them.
These approaches create a distance between the
individual and his own reactions.
Telling victims that
their reactions are normal responses to trauma and that they must accept what has happened to them helps the sufferer "disclaim11 (Schafer, 1983) his pain and ward off aspects of the self to which it is related.
But, as already noted, the
real problem created by an event that comes to be traumatic is evaded. Implicit in the psychoanalytic theory of recovery from neurosis is the idea that warded off aspects of the self will no longer produce negative influences if they are brought under the control of the ego through consciousness. Freud (1933/1964) explained this process with his famous aphorism: "where id was, there ego shall be" (p. 80) . In practice, this means not just a cognitive acceptance of ideas inside the self, but a willingness to "own" those aspects of the personality as part of the self.
This
involves self-observation and the development of insight. Psychoanalytic insight can be defined as the willingness to look inward for intra-psychic components to current reactions.
Hatcher (1973) noted that self-
observations can be distinguished in the extent to which they involve specific, sophisticated statements about the self.
He wrote:
"The most complex forms show an increasing
appreciation of the contribution of the self to experience, so that the locus of explanation shifts from the outside to
31
the inside of the self" (p. 391).
The advantage of this
complex, internal focus is that it allows the individual to have a more sophisticated appreciation of external factors, which are no longer colored by elements related to the self. This focus develops in therapy through interpretations that encourage clients to widen the context with which they consider their actions and responses. Another way of explaining this mode of understanding is through a narrative perspective of the life-course.
The
literary critic Steven Marcus (1984) has highlighted how in an early case report, Freud described psychoanalysis as a narrative process whose goal was the help fill the gaps in the patient's understanding of his own life story. Commenting on Freud's (1905/1953) account of a patient he called Dora, Marcus concluded: Freud is implying that a coherent story is in some manner connected with mental health...and this in turn implies assumptions of the broadest and deepest kind about both the nature of coherence and the form and structure of human life. On this reading, human life is, ideally, a connected and coherent story, with all the details in explanatory place, and with everything (or as close as everything as is practically possible) accounted for, in its proper causal or other sequence. And inversely, illness amounts at least in part to suffering from an incoherent story or an inadequate narrative account of oneself (p. 61) . Only recently has the narrative quality of psychoanalytic therapy come into focus.
Schafer (1983), for
instance, has drawn attention to the particular form of narrative espoused through analytic treatment.
In his view,
32
analysts help their patients elaborate a richer and more coherent view of their life histories.
At any given moment,
an individual's sense of self is a "telling" of a current personal narrative (p. 219) . Psychoanalytic narratives are distinguished because they situate the subject as an "agent" who need not "disclaim" his own "actions."
Here, "actions"
can be taken to include also thoughts, feelings, fantasies, and wishes.
In addition, analytic narratives put a premium
on finding sameness across the life history, and working to understand the constituents of a person's life as a coherent, meaningful whole.
This does not neglect the
importance of events outside of the individual's actual control, but only acknowledges that people unwittingly end up writing these circumstances into an ongoing story of themselves. As Schafer (1983) wrote: ...through interpretation, the great extent to which the analysand is unconsciously the agent or author of his or her life gets to be established beyond doubt. The analysand emerges as deeply implicated in his or her suffering even if not as the only agent or source of the pain. On this basis, though not in any strict sequence, the analysand is better able to envision and pursue desirable alternatives to those aspects of existence that heretofore and consciously were passively suffered or at least perpetuated in an unquestioning manner. But the beneficial change brought about by analysis involves more than recognizing and accepting how much one has been implicated in developing the meanings, the forms, and the continuation of one's usually lifelong difficulties, and it involves more than recognizing the extent to which one has inappropriately assumed responsibility. For what has also changed is the analysand as life-historian, as maker of sense, as definer and designer of possible futures. I have described what amounts to a cognitive revolution on the part of the analysand (p. 191).
33
What emerges is a highly individualized account of the self marked by an ever-increasing sense of personal agency. Such a perspective seems particularly to the point in the case of trauma because those who experience devastating events are typically left with a sense of passivity and helplessness.
Owning aspects of the self aroused by the
trauma— or that even may be implicated in how it occurred— would likely restore a sense of personal mastery and control.
In addition to passivity, trauma victims are often
assaulted, seemingly paradoxically, by a sense of over responsibility for events that have occurred.
"Survival
guilt" leads individuals to unrealistically bemoan the fact that they did not do more for others, or even to curse their lucky fate in managing to live through a catastrophe. Reasoning with the victim does not usually reduce the guilt (Opp & Samson, 1989) . More helpful is an attempt to develop a fuller narrative account of this particular response. Such an account would not only connect the response with previous needs to take responsibility, but might necessitate acknowledging unconscious wishes to triumph and survive and the ways that warding off feelings about competition and success is part of the individual's ongoing history.
Doing
so would allow the individual to accept his own need to take blame, and allow him to recognize that in reality, he could not have done more.
As painful as it may be to arrive at
such a narrative, doing so promises to offer a sense of completeness, coherence, and identity with oneself.
34
The lack of a sense of identity can be palpable following trauma.
Erikson (1968) long ago noticed the
walling off of the self that occurs in traumatized combat soldiers.
Considering his contacts with World War II
veterans, he wrote: Above all, the men felt that they "did not know any more who they were": there was a distinct loss of ego identity. The sense of sameness and continuity and the belief in one's social role were gone...Rehabilitation work could become effective and economical only if the clinical investigation focused on the patient's shattered life plan and if advice tended to strengthen the resynthesis of the elements on which the patient's ego identity was based (pp. 68-69) . Others have also noted the disruption of identity found in combat veterans, which may be heightened by the fact that combat most frequently implicates young men who are struggling developmentally to solidify a sense of identity (Wilson, 1990).
Those who study the life course have
increasingly come to recognize that an enduring sense of continuity leads to favorable outcomes.
In an overview of
research life-long development, Cohler (1982) observed, "To the extent that persons can maintain a narrative which includes some past, present, and future in a consistent narrative, and continue to order this narrative to some subjectively perceived time, personal adjustment may be more effectively maintained" (p. 214).
35 Trauma as the Road to Insight To contrast with the alternative theories presented at the outset, then, recovery involves an attempt to weave a coherent account of the individual's life that helps to explain the reason a challenging event was appraised traumatically in the first place.
Rather than highlighting
the traumatic event as dissonant, it aims for synthesis. Changes in the conscious sense of self may occur, but these are the result of new perspectives gained into one's ongoing conflicts or tendencies.
The process may be painful because
it means facing painful aspects of the self that the individual may not have been aware of before.
But at the
same time, the trauma may press the individual to gain insight into his own particular wishes, fears, and ways of responding.
The major difference between the view being
put forth here and the theories reviewed earlier is that in the former account, the emphasis is on changing views of the self to admit the new experience, while' in the latter, the work is towards helping the individual connect the event and process it through existing schemata.
As a person begins
to make such connections, her view of herself is bound to change.
The result, as in all development, is both
assimilation and accommodation.
While I have developed this
account of recovery from trauma by emphasizing psychoanalytic narratives, the notion that individuals adjust to difficult events through this sort of assimilation and accommodation is seen by some as intrinsic to the
36
process of therapeutic change across paradigms {Stiles et al. 1990).
It also fits with a cognitive-emotional account
of coping that sees stress as developing based on appraisals made in unique ways by individuals, based on their own histories and personalities (Lazarus & Folkman, 1984). As I have noted, those who write about the process of recovery from trauma frequently stress the need for integration of the experience, but this is usually vague and undefined.
The ideas I have presented allow me to offer a
specific definition of “integration" as a process that involves looking inward in an attempt to create a continuity of understanding about the self— including how it was that the event became traumatic, the particular reactions that ensued, and why these specific ways were favored. I think it is important to clarify that when I speak of integration, I mean integration of the individual's response to the trauma.
As may be apparent from the discussion
already, there is frequently a semantic confusion about the word trauma.
The "trauma" has come to be seen as the
event--severe combat, for instance— and not the discrete response to some trying reality.
True, certain events
appear in themselves to be catastrophic and thus traumatic. Can one think of the Holocaust in any other way?
But using
the word in this way, as I have indicated, creates a distance between the individual and his own particular ways of responding, which likely represent aspects of his enduring life history.
Further, this definition of the word
37
makes it more difficult to account for the fact that though there are similarities, individuals do respond quite differently to similar catastrophic events (Hendin & Haas, 1984; Lyons, 1991; Van Putten & Yager, 1984) . The specific qualities of the event are central, but they are always appraised by an individual who has varying motives, beliefs, and experiences.
Thus, as I have
attempted to show, it is useful to think of the individualistic way in which an event becomes traumatic. The process of integration entails accepting responsibility for the whole set of responses that are brought into being by a stressful event and placing them into a personally meaningful context. Conclusion This chapter has presented a review of theoretical literature concerning the recovery from traumatic stress. An attempt has been made to offer an alternative approach to the prevailing understanding of recovery which sees a need for an alteration in self-concepts.
While the conscious
self may indeed change during recovery, the view I presented suggests that this process involves assimilating the traumatic event to enduring, conflicted aspects of the self. Through a process of insight, ongoing attitudes, wishes and beliefs are recognized and integrated into a coherent life narrative.
Ideally, the process of recovery will involve a
sense of curiosity about one's own responses and ultimately
38
result in a sense of continuity concerning one's reactions to the event.
I presume the process of recovery I have
described is stimulated or inhibited by the strength and nature of conflicts stemming from early experience including early relationships, stressors and family challenges.
The
process is further influenced, I believe, by a post-trauma environment that either encourages self-exploration and insight, or forces inhibition of these processes. This dissertation is an attempt to study these ideas by looking at whether the process I have described is likely to be present among those combat veterans who have "recovered" from their stressful experiences, and absent in those still struggling with reactions to trauma.
The next chapter will
review the empirical literature on integration and survey relevant research concerning coping with stress.
CHAPTER II
PREVIOUS EMPIRICAL FINDINGS AND PRESENTATION OF STUDY HYPOTHESES
This chapter will present previous empirical research on integration, comparing and contrasting it with empirical findings concerning the process of coping with traumatic stress.
I will then describe my study and elaborate
specific hypotheses. The concept of integration as described in the previous chapter owes much to the work of McGlashan, who has investigated this process in psychotics and severely disturbed psychiatric patients.
Noting long-standing
observations in the literature of the different ways individuals attempt to come to terms with an experience of psychosis, McGlashan (1987) identified two paradigmatic "recovery styles," "Integrators" are individuals who attempt to find "continuity in the mental activity and personality from before the psychotic experience, during psychosis, and through recovery (McGlashan, 1987, p. 681) . He added: The patients take responsibility for their psychotic productions...They have an awareness of both pleasure and pain involved in the psychotic experience and use their experiences as a source of information not ordinarily available to them regarding their conflicts, 39
40 relationships, and behavior. the experiences (p. 681).
They are curious about
In contrast, McGlashan identified another group who attempted to "seal over" their psychotic experience.
These
individuals regard their psychosis as "alien and interruptive to their lives and consequently seek to encapsulate it" (p. 681).
The cause of the psychosis is
seen as unrelated to personal problems or issues, and as a result, these individuals are adverse to investigating or exploring their symptoms. Integration and Sealing Over in Manor Mental Illness In a series of papers, McGlashan and colleagues described cases representing both kinds of recoveries (McGlashan, Docherty, & Siris, 1976); highlighted the way these styles could be detected in patient's artistic productions in the course of art therapy (McGlashan, Wadeson, & Carpenter & Levy, 1977); and noted the way that an inpatient treatment milieu could nurture or discourage each style (McGlashan & Levy, 1977) . As part of this line of research, they also specified how, from a psychoanalytic point of view, each style represents a particular means of conflict resolution in psychosis (Levy, McGlashan, & Carpenter, 1975). Most significantly, the concepts were applied in a follow-up study looking at outcome in a group of severely ill individuals who had been patients in a long-term
41
psychiatric hospital {McGlashan, 1987) . The 249 patients studied carried a range of diagnoses, including schizophrenia, borderline personality, bipolar affective disorder, and major depression.
Results showed that
11integrative" recoveries assessed by interview were associated with significantly better overall functioning after hospitalization.
Integration was associated with a
good outcome 77 percent of the time, whereas sealing over was found to be successful only 31 percent of the time.
The
overall correlation between integration and good outcome was .49 (p < .0001). Two significant methodological flaws were evident in this study.
The ratings of outcome were made by the same
individuals who judged whether the patient was integrating or sealing over.
McGlashan noted, however, that when
analyses were run that held constant the level of current adjustment, differences still emerged between the groups on data collected during the initial hospitalization. raters were blind to this information.
The
Integrators showed
higher intelligence, better premorbid work and social functioning, and increased treatment motivation.
The
ability of the raters to discriminate the two groups on these variables suggested that raters were picking up enduring styles, and were not merely influenced by bias. McGlashan concluded: "...[W]ith integration/sealing over, we are dealing with personality styles that are relatively enduring across long periods of an individual's adult life.
42
Rather than covariates of outcome, they may be seen as predictors of outcome, as reflections of premorbid health and coping resources" (pp. 683-684).
However, McGlashan was
careful to state that the correlational nature of the study precluded conclusions that particular outcomes were caused by particular styles of recovery.
This was especially true
because Recovery Style was assessed retrospectively, at the same time outcome was measured.
Only a prospective
longitudinal study would establish recovery style as a true predictor of outcome. Some of these deficiencies have been addressed in later studies.
Pressler (1990), for instance, used McGlashan's
definition of recovery styles in a follow-up study of previously hospitalized patients with Borderline Personality Disorder.
In this study, Recovery Style was measured
independently from symptoms and adjustment.
Here,
integrators reported significantly fewer psychiatric symptoms than sealers.
In a study of schizophrenics,
D'Angelo and Wolowitz (1986) also assessed Recovery Style separately from their dependent variable, defensive organization.
Integrators were less likely to use primitive
defenses such as denial, negation, and repression.
While
this may appear to follow logically from the definitions of the two styles (sealing-over involves an attempt to wall off emotional experience,
(Rifkin, 1987), D'Angelo (1987)
presented additional data indicating that sealing over is associated with more frequent hospitalization and more
43
difficult management problems on an inpatient psychiatric unit. These studies suggest that recovery style still is predictive even if it is assessed independently from outcome. Another study used hospital records in a prospective study of recovery style and outcome.
Marroquin (1983),
studying schizophrenic patients in a state hospital, developed a method to rate recovery style from chart records.
He was then able to follow patients for up to
three years, using attendance at first aftercare appointment and number of rehospitalizations as measures of adjustment. Here, again, Recovery Style was assessed independently from measures of outcome; raters were blind to the study hypotheses.
Results showed that sealers were rehospitalized
significantly more often than integrators.
Also,
integrators were more likely to attend their first aftercare appointments than were sealers.
Although low rates of
rehospitalization are not a direct indication of better outcome following hospitalization, they do suggest that over the two year period of the study, integrators did not decompensate to the point that they needed treatment in state facilities. sealers.
Such decompensation was more likely with
The finding is consistent with the studies
reviewed above which found integration to be highly associated with better outcomes.
But here integration was
measured at index hospitalization and could be studied as a predictor of outcome.
44 Recovery Stvle and Trauma McGlashan has suggested that the styles he developed for understanding recovery from psychosis are similar to those used by individuals responding to stress (McGlashan, Levy, & Carpenter, 1975; McGlashan, Docherty, & Siris, 1976).
But he did not provide definitions of the two styles
as they would become manifest in reaction to a stressful event. There have been no empirical studies of Integration and Sealing Over in a population of trauma victims. However, Smith (1985), in a speculative paper, applied the two terms to explain recovery from trauma.
He presented
some provocative ideas, suggesting that for combat veterans, social "sanction" for their acts of war allowed them to "seal over" the experience and avoid the painful task of integration of their own responsibility: Like hot wax, which can permeate each strand of a ball of loose ends of string, so too, in sealing over, sanction permeates the loose ends of experience, giving them meaning and binding them into a unit, immune from the demands of having to be integrated with the view of the self and the world prior to the event (p. 21). Because the Vietnam war was not ultimately "sanctioned" by society, Vietnam veterans were forced towards immediate integration, which was likely to be emotionally difficult. As Smith stated: This more arduous task involves not permeating an experience with an overall meaning, but rather, weaving each strand of the experience into the overall fabric of their lives. Rather than having an isolated set of meanings, specific only to that experience, these veterans face the task of integrating their experience
45 with notions of who they were before, during and after Vietnam (p. 25). Smith gave few specific examples of integration, did not cite McGlashan's work, and left unclear how his conceptions fit with established views of recovery style.
His ideas
suggest, however, the relevance of the post-trauma environment in the process of integrating or sealing over. Coping with Combat Although integration and sealing over have not been studied following traumatic events, similar constructs have been investigated in research looking at the process of coping with stress. The empirical literature concerning trauma has become increasingly focused upon the process of coping.
Coping models have become prevalent with the
realization that there are often a variety of responses to events that most people consider traumatic.
For instance,
though studies have found a strong association between severe combat in Vietnam and the development of PTSD, a number of individuals ranging from 30 to 73 percent do not develop the disorder (Boulanger, 1986; Card, 1987; Foy, Carroll, & Donahoe, 1987).
There is also an increasing
recognition that PTSD can become manifest in many ways (Atkinson, Reaves, & Maxwell, 1988; Rosenheck, 1985).
Given
the differences in response, researchers have focused on coping as a final common pathway between a major stressor and the development of a major stress disorder
(Benner,
Roskies, &. Lazarus, 1980; Kahana et al., 1988; Lyons, 1991).
46
Coping is generally defined as the individual's attempt to manage internal or external demands that are appraised as being taxing or aversive (Lazarus & Folkman, 1984).
The
most widely used framework for conceptualizing the coping process identifies two major classes of coping: focused coping and problem focused coping.
emotion-
Problem-focused
coping is concerned with strategies designed to manage or alter the problem giving rise to distress. Such strategies often include direct attempts to influence the environment and remove a stressor, but may involve internal changes such as "finding alternative ways of gaining gratification," "learning new skills," or "developing new standards of behavior" (Lazarus & Folkman, 1984) . Emotion-focused coping is characterized by attempts to manage emotional responses to the stressor.
Such efforts may include denial,
avoidance, or minimization of the implications of a stressful circumstance. A number of studies have investigated these two classes of coping in response to combat.
They have generally
concluded that emotion-focused coping is more often associated with poorer outcomes, including PTSD.
Problem-
focused coping has been associated with better adjustment. Green, Lindy, and Grace (1988) used a scale developed by Horowitz and Wilner (1980) and identified four coping responses they considered emotion-focused: event-processing, time out for reflection, reliance upon religion, and denial. These strategies were most predictive of a diagnosis of
47
PTSD.
Interestingly, event-processing, which the authors
defined as "active efforts to understand the war experience and give it meaning in the context of the present" was associated with poorer outcomes.
Event processing was the
least correlated with the measure of PTSD of the four emotion-focused factors studied.
Still, it seems most akin
to integration, which I believe will be associated with better adjustment.
It is hard to know what to make of this
finding, because only two of the items contributing to the scale were presented by the authors.
However, because event
processing was classed as a type of emotion-focused coping, it may be that the questions made it clear that gaining understanding was in the service of eliminating aversive emotions.
Event processing may have tapped a tendency to
avoid thoughts about the stressor and did not capture a process akin to integration. Nezu and Carnevale (1987) used an inventory developed by Billings and Moos (1981) and found that Vietnam veterans with PTSD used more emotional-focused strategies to cope with interpersonal difficulties than those without the disorder.
Solomon, Mikulincer, and Flum (1988) used the
Ways of Coping Checklist (Folkman and Lazarus, 1980) as adapted by Parkes (1984) to study Israeli combat veterans of the 1982 war in Lebanon.
Here, emotion-focused coping and
distancing were associated with greater levels of PTSD than problem-focused coping.
Fairbank, Hansen, and Fitterling
(1991) also used the Ways of Coping Checklist in a study of
48
repatriated World War II prisoners of war.
Subjects
included former prisoners with and without PTSD and a comparison group of second World War veterans who had not been held prisoner.
The study looked at the former
prisoners' strategies of coping with war memories, and the ways they coped with current stressors.
The findings showed
that those with PTSD relied mostly on an emotion-focused strategy termed "self-isolation."
Those without PTSD most
frequently used a strategy of "emphasizing the positive." The studies just reviewed pose a problem frequently encountered in research on coping.
It is often impossible
to know whether the coping processes described are discrete efforts at management of a stressor or are themselves symptoms of the disorder.
For instance, the studies
suggested that emotion-focused coping, distancing, and social isolation were more associated with PTSD.
But one of
the criteria for the diagnosis of PTSD includes "persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness" (American Psychiatric Association, 1987; p. 147).
One particular symptom of such
avoidance includes "feelings of detachment or estrangement from others." One remedy for this difficulty is to conceptualize coping processes in ways that are separate from symptoms or current functioning.
The more difficult
alternative is prospective studies in which coping styles can be sampled either before a traumatic event, or after an event but before symptoms develop.
49
It may be, however, that the problem is not methodological, but conceptual.
Styles of coping may be
inextricably linked to certain problems or disorders.
This
viewpoint is evident in the psychodynamic theory, where greater focus is often placed on maladaptive defenses than symptoms.
Lazarus and Folkman (1984) criticized studies in
which they believe certain coping styles are reflexively assumed to be associated with poorer outcomes.
"In order to
determine the effectiveness of coping and defense processes," they wrote, "one must be open-minded to the possibility that both can work well or badly in particular persons, contexts, or occasions" (p. 133).
They failed to
note, however, that certain outcomes— such as psychiatric diagnosis--are often defined in terms of the particular coping strategies involved, such as avoidance or denial. This problem is still present but in a more limited way in several other studies that do not use the Lazarus and Folkman coping framework.
Egendorf (1981) developed a
method for assessing complexity of reflective statements in transcribed interviews with Vietnam veterans. Reflectiveness was scored in particular interview segments if the subject's comments followed a particular sequence.
A
reflective sequence began with a characterization of a particular experience, was followed by comments specifying further the nature of that experience, and concluded with attempts to recharacterize the meaning of the experience in more complex terms.
The presence or absence of such
50
sequences were reliably coded by the researchers, and subjects were classified into groups considered high and low on reflectiveness. The results showed that those high on reflectiveness were more likely to indicate that things were going well with them following the war.
Further,
reflectiveness was shown to be an especially effective predictor of adjustment for those veterans at higher levels of combat.
Additional analyses showed that reflectiveness
was not explained by level of education:
it was present
only slightly more often in those who had more than a year of college.
The study illustrates the potential impact that
reflecting and making connections can have as a coping response.
The study is limited because its assessment of
current life satisfaction did not include a measure of PTSD. A potentially related finding comes from a study of Israeli combat veterans (Solomon, Mikulincer, & Arad, 1991). Here, two types of coping were assessed: monitoring and blunting (Miller, 1987).
Monitoring describes an attempt to
seek out information about a potential threat.
Blunting
consists of attempts to block out and avoid recognition of a threat. The study found that those soldiers who relied most on monitoring strategies were least likely to suffer from PTSD.
Blunting— whether used with or without monitoring—
was predictive of PTSD.
In additional analyses, Monitoring
was found to be associated with more problem focused and help-seeking strategies of coping (Lazarus & Folkman, 1984). Those who monitor, then, use active efforts to make changes
51
in the environment to cope with their distress.
Blunters
were more likely to use emotion-focused coping in which they attempted to manage their internal emotions. This finding might be due to a confound between avoidance symptoms and the coping response of blunting.
The finding that
Monitoring is effective was especially interesting.
It
contradicted the authors1 predictions that Monitoring and not Blunting would be associated with PTSD.
Monitoring was
expected to go along with PTSD symptoms such as hypervigilance and a repetitive focus on traumatic events. It is unclear whether monitoring is associated with attempts to reflect upon the meaning inherent in a traumatic event, but it appears to consist of an interest in attending to aspects of the stressor.
Perhaps monitoring should be seen
as a pre-condition for reflection upon and integration of traumatic events. A study by Casella and Motta (1990) looked at coping differences amongst Vietnam combat veterans who did and did not develop PTSD. already mentioned:
Their findings are related to those veterans who attempted to structure
their experience by attempting to provide "organization, conceptualization, or meaning to the [war] experience" were less likely to suffer from PTSD.
Those who could not
provide such structure were more likely to have PTSD, Structured items reflected a sense of clarity and certainty about the war experience and the self: "The politics of the war were clear to me;" "My religious beliefs were what
52
enabled me to get through each day."
Unstructured items
reflected confusion and a loss of a sense of identity: "While I was stationed in Vietnam, I no longer knew who I was or what was important in my life;"
"While in Vietnam I
didn't know what was going on around me."
In addition, the
study found that internal locus of control (Rotter, 1966) was characteristic of combat veterans without PTSD.
The
authors of the study suggested that ability to structure experience and internal locus of control may be related. This study appears to measure phenomena related to but not congruent with reflectiveness and monitoring. The studies just reviewed identified a series of coping maneuvers that appear conceptually related to Integration and Sealing Over.
Cutting across these dimensions is a
sense of control that allows the individual to actively relate to the experience of combat, whether that means paying attention to it through monitoring, transforming its meaning through reflecting, or creating a sense of clarity through structuring. The strategies investigated in these studies capture several aspects of integration.
A sense of curiosity about
the combat experience is evident in Reflectiveness.
The
need to focus on the details of traumatic experience is captured by Monitoring.
And the capacity to create a
synthesis among different contexts is hinted at in Structuring.
But these approaches leave out the life-
historical element implied in integration, where coping
53
involves identifying characteristic responses to trauma and creating a sense of continuity with earlier tendencies and dispositions.
Still, the positive association between
aspects of integration and better current functioning reported in these studies supports the principal hypothesis in this study:
Integration will be a predictor of fewer
PTSD symptoms and more favorable psychological and social adjustment. In addition, the review of the literature highlights a potential problem in the study of coping and trauma.
The
difficulty was especially noted in the studies of emotionfocused coping, where aspects of coping were similar to symptoms of the disorder.
The same problem may arise in the
study of Integration and Sealing Over.
Sealing Over might
be considered akin to denial or blunting.
If so, the
finding that this mode of response correlates with PTSD would follow definitionally and not say much about coping. However, Sealing Over, as defined here, is a broader concept that concerns not the avoidance of the trauma, but an unwillingness or inability to place it into historical context.
Indeed, someone who used avoidance in an attempt
to block out painful affects in Vietnam could be an integrator if he was able to identify this mode of response as a personally meaningful way of coping that had a longstanding history.
The inability to place one's
responses into a life-historical context is not captured in the PTSD diagnosis.
Still, the confound between coping and
54
functioning suggests that special attempts need to be made to ensure that the measures of Recovery Style are not really measuring symptoms. Overview of the Study This dissertation is the first attempt to apply the concepts of integration and sealing over to a population characterized by an exposure to severe stress.
The study
was intended to develop a rigorous definition of "integration" as a mode of recovery from trauma.
The
concepts borrowed from McGlashan and refined by Smith were utilized in an attempt to test whether actual recovery of aspects of the self in the process of responding to stress is associated with better functioning.
An interview and
coding scheme based on these ideas were developed and administered to a group of Vietnam combat veterans.
In
addition, an attempt was made to investigate individual factors that might contribute to an integrating or sealing style of response.
Research on childhood stressors suggests
that early experiences of chaos, deprivation, or confusion hinder the ability to develop a coherent sense of self (Marcus, 1989; Westen et al., 1990).
Such individuals often
have difficulty in dynamic therapies that require the capacity for insight and the ability to bring together various contexts to create a fuller understanding of their histories (Krystal, 1988; Shengold, 1989).
Further, the
coping literature has suggested that efforts at managing
55
stressors are often inhibited by unreceptive environments and a lack of social support (Flannery, 1990).
Social
support has been shown to enhance an individual1s resources for coping with difficult events (Lazarus and Folkman, 1984).
One effect of poor social support that is
hypothesized to impair recovery following trauma is the victim's inability to confide in others about the traumatic event or his or her reactions to it.
The opportunity to
confide in others following a trauma would promote Integration, since the individual would feel more comfortable thinking about the event and his or reactions to it.
The empathic support of other people following a trauma
is likely to help trauma victims reveal the most troubling aspects of their experiences; once these experiences are revealed and acknowledged, victims would then have the opportunity to think about them and integrate their responses.
Thus, a more favorable reception following the
war would nurture integrating responses to the experience of combat. With these ideas in mind, hypotheses were formulated concerning the relation among childhood environments, the veteran's reception following the war, and the capacity to integrate.
Interview data were collected on the subjects'
pre-war, Vietnam and post-Vietnam lives.
Questionnaire
measures of current functioning were the dependent variables.
The measures assessing subjects' pre-war
environments and post-war receptions were expected to
56
predict their recovery styles.
Recovery styles were
expected to predict PTSD symptoms and general current functioning. Hypotheses Hypothesis 1:
Integration and Sealing Over will be
reliable and valid indicators of Recovery Style.
This will
be demonstrated by highlighting the internal consistency of the constructs and testing their association with related measures, including psychological mindedness (Appelbaum, 1973) and Monitoring (Miller, 1987).
One way of testing the
consistency of the ratings will be to rate integration and sealing over from a portion of the interview concerning the subjects' prewar experiences. Hypothesis 2: Integration and its components, curiosity
and continuity, will predict current functioning as measured by presence of PTSD symptoms, general psychological adjustment, and social functioning.
These correlations are
expected to hold even when possible confounds, such as intelligence, are controlled.
Recovery Style rated from
subjects' reflections on pre-war experiences are also expected to correlate with current functioning. Hypothesis 3: Analyses will be conducted to identify
the best predictors of Recovery Style.
Data collected on
subjects pre-war history and post-war reception will be used to determine whether, as expected, unfavorable childhood experiences detract from the ability to integrate.
57
Unfavorable experiences to be studied include strict authoritarian family structures, occurrence of multiple stressors, emotional and behavioral difficulties in school, troubles with authority, and perceptions of parental figures as unhelpful.
Also, Integration is expected to be blocked
by experiences of being poorly received and misunderstood following the veteran's return from Vietnam. Hypothesis 4:
As stated above, Integration will be
associated with less stressful premilitary histories and better reception at home following the war, and thus is expected to be associated with current functioning as well. But Recovery Style will be a better indicator of current functioning than either of these two variables.
Further,
severity of combat— including participation in atrocities— will predict current level of functioning, as has been found in previous research (Breslau & Davis, 1987).
Integration--
presumed to reflect an enduring personality style— will be a more robust predictor of current functioning.
CHAPTER III
METHODS
Subjects. The central goal in recruiting subjects for this study was to find individuals exposed to similar types of extreme stress.
Controls were instituted to narrow the range of
combat experience with a recognition that excessively strict requirements for admission would limit the number of available subjects.
To ensure that subjects would be
relatively homogeneous with respect to combat experience, the study was limited to those veterans who served in Vietnam at some point between 1967 and 1969.
Though
soldiers may have had vastly different combat experiences during that time, the aims of the war and the morale of the troops were fairly uniform (G. Linderman, personal communication, 1991).
To ensure that participants had been
exposed to severe stress, subjects who expressed interest in the study were screened for level of combat exposure, and only those with significant combat experience were included. Finally, veterans currently hospitalized for psychiatric reasons were excluded, under the assumption that they were experiencing acute distress in an unusual
58
59
environment.
Including such subjects would make it
difficult to know whether differences between hospitalized and non-hospitalized subjects were artifacts of inpatient status or related to more enduring patterns based on their reactions to combat. The Gallops, Laufer, and Yager (1981) Revised Combat Scale, was administered by phone as a screening questionnaire.
The 10-item scale was developed for use in
the Legacies of Vietnam study, a nation-wide investigation of the lives of veterans (Laufer, Yager, Frey-Wouters, & Donnellan, 1981) . Watson, Juba, and Anderson (1989) compared the Gallops et al. scale with four other measures developed to assess the intensity of combat in Vietnam.
As
criterion measures of combat their study used the number of medals veterans earned that were "definitely indicative of combat;" the veterans' occupational specialties in Vietnam (MOS); and scores on the other combat measures being studied.
Of the five scales, the Gallops et al. scale
correlated most highly with the combat medals, MOS, and the other scales. Correlations between scores on this scale and a measure of PTSD showed that unlike other available measures, the Gallops et al. scale was "sensitive to combat but relatively unaffected by PTSD" (Watson, Juba, & Anderson, 1989; p. 101). Scores on the measure range from 0 to 14.
Laufer and
Frey-Wouters (1986), who helped develop the scale, stated that scores between 5 and 9 indicated moderate combat, while
60
10 and above were considered heavy combat.
Initially/ I
included those veterans with either moderate or heavy combat in the study. When it became clear that it would not be difficult to collect a sample of high combat veterans, the admission requirements were tightened to include only heavy combat veterans. In addition to screening for level of combat, an attempt was made to recruit veterans functioning at a variety of levels, including those currently doing quite well.
To that end, advertisements were placed in general
circulation newspapers and posted in factories and local stores so that veterans not associated with the veterans administration hospital or organized veterans' groups might respond.
Only towards the end of data collection, when it
appeared that subjects with PTSD might be underrepresented, was a posting placed at the VA hospital in areas where outpatients might see it. More than a hundred potential subjects called expressing interest in the study.
A small number decided
against being screened for the study when they realized they would need to come to the university for interviews, or that I was only interested in combat veterans who served between 1967 and 1969. interviews.
Ninety-nine completed phone screening
Sixteen of these potential subjects were not
admitted because of their low scores on the Gallops et al. scale.
Of the remaining subjects, 23 dropped out. Many of
these subjects did not show up for appointments.
They
61
either did not return follow-up phone calls or when reached said they had decided against participating. Several possible reasons may account for why subjects dropped out.
Notices describing the study stated that
participation would require about five hours of subjects' time, and they would be paid $30.
Several of those who
dropped out said changes in work schedules and demands at home made it impossible to complete the study.
Also, it
appeared that the prospect of talking about Vietnam with a psychologist put off some subjects.
In the postings and
during the screening interview, I stated that subjects were being recruited for a psychological study of the different ways individuals coped with their combat experiences. Several who dropped out said they decided against continuing when they received questionnaires in the mail and realized the study would involve aspects of their emotional lives. One veteran who said he did not want to reschedule a missed appointment said he had been in a PTSD program and feared that talking about Vietnam would bring back his symptoms. Another had just gotten out of a psychiatric hospital, and cancelled his appointment for the study because he decided to readmit himself for further treatment.
Another veteran
who dropped out referred to a questionnaire from the study he had received in the mail that included inquiries about his relationship with his parents.
"I don't mind talking
about Vietnam," he said. "But my relationship with my mother and father, I didn't want to get into."
Only a handful of
62
subjects who dropped out could be contacted, and it is impossible to know if reasons like those just noted were typical.
However, it may be that some of those who dropped
out were highly defended against discussing Vietnam or thinking psychologically, and those who participated might be somewhat more open to reflecting upon their experiences. The only variable for which systematic comparisons could be made was combat exposure.
There was no significant
difference between the mean combat score of subjects who completed the protocol (M = 11.25) and those admitted who later dropped out {M = 11.8), t(81) = -1.24, The final sample included 60 subjects.
p < .22). Ten subjects
with moderate combat exposure were admitted, and the mean score for this group was eight. The lowest score came from one subject with a six.
The individual items that
contributed to his score indicated that even this subject had been exposed to severely stressful events, including being stationed at a forward observation post, coming under fire from artillery or rockets, seeing Americans or Vietnamese killed or wounded, and being part of a unit that was ambushed.
The mean score for the entire sample and
frequencies for each item of the scale can be found in Table 1. Of the final sample of 60, 35 found their way to the study through general newspaper ads or postings at stores and factories; seven responded to the posting at the local Veteran's Administration hospital; five saw ads in veterans'
63
Table 1 Combat Exposure: Descriptive Statistics and Frequencies Gallops, Laufer, & Yager (1981) Combat Exposure Scale
It.em
No, Qf-sub'iectg
Percent
reporting ves
1. Part of land or navy artillery unit?
13
21.7
2. Flew in an aircraft over Vietnam?
57
95
3. Stationed at forward observation post?
56
93.3
4. Receive hostile incoming fire?
60
100
5. Encountered mines or booby traps?
46
76.7
6. Received sniper or sapper fire?
57
95
7. Unit ambushed?
44
73.3
8. Engaged VC or NVA in a firefight?
56
93.3
9. Saw Americans or Vietnamese killed or wounded?
59
98.3
10. Wounded in combat?
34
56.7
Mean total score: Std. Dev.
11.25
1.95
Note: Items 1-7 scored 1 point; 7-10 score 2 points
64
group publications; four were referred by another participant; and two heard about the study through a local veterans group.
The other seven learned about the study
from friends and colleagues who knew me. The mean age of the sample was 44.6 (SD = 3.13). Subjects' average age when they began their tours in Vietnam was 20.4 (SD = 3.06), which was somewhat higher than the average age of 19 for all Vietnam veterans.
The average
number of months (12.08; SD = 4.86) spent by the subjects in Vietnam reflects the fact that the usual tour in Vietnam was a year.
Forty one (68.3%) served in the army; 17 were
marines (28.3%), and two were in the Navy (3.3%).
Twenty
seven (45%) enlisted in the service voluntarily; 11 (18.3%) enlisted to avoid the draft; and one (1.7%) enlisted for legal reasons.
The rest of the sample (35%) was drafted.
Subjects came from all five levels of socioeconomic status described by Hollingshead (1975).
The average SES
score using Hollingshead's measure 40.7 (SD = 12.34). thirds of the group fell into classes III and IV: craftsmen, clerical [and] sales workers" and
Two
"skilled
"medium
business, minor professional technical" workers. Demographic data concerning race, marital status, education, and family income are reported in Table 2. Procedure Veterans who passed the screening were mailed a packet that included a consent form and five questionnaires they
65
TabLe-2. Demographic Characteristics
Eac.e
Number
White African-American Hispanic Native American
49 7 5 1
Percent 81.7 11.7 5.0 1.7
Education Junior High School Partial High School High School Graduate Partial College College or University Graduate Graduate or Professional Degree
2 3 8 27
1.7 5.0 13.3 45.0
10
16.7
11
18.3
38 19 3
63.3 31.7 5
9 5 7 8 11 4 8 8
15.0 8.0 11.7 13.3 18.3 6.7 13.3 13.3
Marital Status Currently married Divorced or separated Never married Income 0 - 9,999 10.000 - 19,999 20.000 - 29,999 30.000 - 39,999 40.000 - 49,999 50, 000 - 59,999 60.000 - 74,999 75.000 and over
66
were asked to fill out and bring with them to the first interview.
During the screening interview, they were
encouraged to call if they had questions or problems with the materials.
The first interview, conducted by two
trained project assistants, consisted of questions with forced-choice responses covering demographic information and aspects of the veteran's prewar, Vietnam, and post-Vietnam life (the specific areas of inquiry will be detailed below). In the second session, I conducted a less structured interview intended to assess Integration and Sealing Over. During this session, I also administered a task to measure psychological mindedness and obtained an estimate of verbal intelligence. RecoveryStvle Assessment and Measures of Validity Integration and Sealing Over:
In previous studies,
recovery style has been assessed in populations experiencing serious psychiatric disorders.
Researchers used a clinical
interview to probe for subjects' attitudes towards their "psychoses."
The responses were then coded on a six-point
scale based on how the answers corresponded with a list of 13 paired statements that reflected paradigmatic instances of sealing over and integration (see Appendix B). Combat exposure can hardly be considered an illness.
It was thus
necessary to alter McGlashan's definitions and paradigmatic statements.
For this study, integration was redefined as
the interest in and ability to identify typical aspects of
67
the self in one's own actions and responses.
Two of
McGlashan's paradigmatic statements concerning the subject's recognition of his own mental illness were eliminated. Another statement which suggested that integrators "enlist the help of others" in mastering their difficulties with psychosis was dropped.
This item appeared to focus on an
individual's capacity to relate to others and thus overlapped with current functioning, which was assessed separately.
McGlashan (personal communication, 9 July 1992)
reviewed the revised definitions and statements and stated that he believed they captured the "essence of the constructs" he had developed. A semi-structured interview to assess recovery style was developed and revised through informal piloting (see Appendix C). The first half of the interview concerned the veteran's life before the war and included inquiries into how he wound up in Vietnam, his family background, and his relationships with parents and siblings.
The subject was
asked to describe a memory from before the war of something he felt guilty about, and then encouraged to discuss his thoughts about why he acted as he did.
In order to aid
rating of the first part of the interview, a list of summary statements characteristic of integrators and sealers was drawn up (see Table 3). The second part of the interview concerned the veteran's combat experiences.
When subjects described
stressful events, they were asked to elaborate their
68
Table 3
Defining Characteristic* of Pre-War Integration - Sealing Over
Integration!
Staling ovtri
The Individual is curious about his childhood experiences and emotionally invested in understanding them. He regards them as importantly influencing his sense of himself as a person.
The individual is not curious about his childhood experiences, regarding discussion of them as unimportant, irrelevant, or not worth the effort. He does not bring the past to bear in understanding other aspects of his life. The past may be seen as bucolic and not worth much further discussion.
The individual is able to identify typical attitudes, struggles, conflicts, or dispositions that affected his behavior, and continued to influence him later in life.
The individual sees his behavior as a reflexive response to external circumstances, and cannot identify how his own desires or motivations might come into play.
The individual can see winding up in Vietnam as having to do in some way with ongoing struggles or conflicts that began in childhood and may have continued throughout his life. Even if he was drafted, "choosing* to go to Vietnam is seen as an enduring aspect of the Veteran's personality.
The individual sees winding up in Vietnam as having nothing to do with what was going on within him at the time; he sees himself as a victim of circumstances and is not interested in exploring or understanding the choices he made that led him to Vietnam.
The subject is interested in what led him to behave in a way that he felt guilty about, can identify typical elements of behavior and response, and uses the questions to understand himself further.
The subject is uninterested in understanding what he did; he may see his action as reflexive, and not having much to do with the kind of child he was. He doesn't think much about his own contribution and reaction to events.
Table 3 icontinued)
Defining Characteristics of Pre-War Integration - Sealing Over
Xntearationt
Sealing overt
Descriptions of family show the individual's interest in identifying and assessing what he made of his relationships with family members; thus, he is willing to go beyond simple characterizations and attempts to assess the formative role of the family member in his life.__________________ ___
The individual is not curious about the role a family member played in his later life, and is content with surface descriptions. He does not wish to elaborate on the significance of his family life in terms of whom he became later.
70
responses.
They were then encouraged to reflect upon the
ways they reacted, and were asked whether they found anything typical or characteristic in their responses. Subjects were also asked to report a memory of something they did they felt guilty about during combat, and to reflect upon what led them to respond in a way that generated a guilty reaction.
Interview questions also
included inquiries into whether the subject felt he was pretty much the same person during combat as he was growing up and after the war; if and how he felt changed by the war experience; and what he had learned about himself through combat.
Finally, the interviewer shared with the subject
his own linkages between the subject's combat reactions and personal history.
These connections, made at the very close
of the interview, were similar to tentative trial interpretations that might be made by a clinician in a psychotherapy evaluation.
Subjects were asked what they
thought of the interviewer's ideas, and whether they could think of better ways to explain some of their particular reactions to combat.
The second part of the interview was
coded using the summary statements listed in Table 4. Interviews were audiotaped and scores of integrating and sealing over were assigned by raters who listened to the tapes. For both the pre-war and combat section of the tape, three scores were assigned.
An overall rating was made of
the subjects' level of integration using a six-point scale
71
Table 4
Defining Characteristics of Combat Integration and Sealing Over Integration
sealing Over
The individual is aware of the continuity between his thoughts and feelings during combat and his emotional life prior and subsequent to combat.
The individual isolates the thoughts and feelings experienced during combat from his view of his emotional life prior to combat.
The individual's reactions to the stress of combat are experienced as personal, and are not seen as alien, or as completely determined by the stressful event itself.
The reactions to combat are seen as encapsulated, circumscribed responses which are alien and distinct from the individual's mental life before combat.
The individual feels responsible for the way he reacted to combat
The individual does not feel responsible for the way he reacted to combat.
The individual is curious about his own particular reactions to combat and is emotionally invested in understanding them.
The individual is not curious about his own particular reactions to combat and is not emotionally invested in understanding them.
The individual treats his Vietnam experience and how he reacted in combat as a source of new information about himself which he uses to modify his opinions and behavior.
The individual does not treat combat as a source of new information about himself and seeks to return to his pre-combat attitudes and behaviors.
The distress an individual has had in his life as a result of combat is seen as relating at least in a small way to ongoing difficulties or challenges he has experienced in coping with life problems _____or circumstances.__________
The distress the individual has had in his life because of combat is seen as totally due to the nature of what happened during the trying or stressful moments in Vietnam.
Tahla A
Continued)
Defining Characteristics of Combat integration and Sealing Over The individual is able to see positive aspects to having been in combat.
The individual cannot see any positive aspects to having been in combat.
The individual is able to see the way he reacted to combat and what he did during it as an important part of his life that is closely related to who he was before he went to Vietnam and who he has been since.
The individual may see combat as important to his life, but this importance derives soles from the nature of the war or the combat that occurred there and has no personal relevance to his life before the war.
The individual likes some of the reactions stirred up by combat, or brought about by fighting; he can acknowledge excitement about his experiences and take pleasure in activities that might in the civilian world be seen as reprehensible (such as aggression).
The individual hates all of the reactions he felt towards combat; he can11 acknowledge any pleasure or excitement in response to the activities of combat (such as aggression), and is intolerant of having experienced such feelings.
The individual can see that in spite of whatever losses there may have been, his combat experience has helped him come closer to obtaining satisfaction in his life.
The individual cannot see any way that his combat has helped him come closer to obtaining satisfaction in his life
73
where a one described a pure integrator and six described a pure sealer (see Tables 5 and 6 for description of scale points used to guide the raters). A review of McGlashan's published descriptions describing the recovery styles revealed two elements of recovery style:
curiosity about one's mental processes, and
the ability to integrate one's mental processes into a continuous sense of self (McGlashan, 1987; McGlashan & Carpenter, 1975) . Raters were thus asked to assign scores to each subject based on his curiosity about himself and his sense of self-continuity. using six-point scales.
These ratings were also made Conceptually, Continuity was seen
as concerning the subject's sense of himself as the same person over time who struggles with basically the same conflicts and acts based on the same tendencies and dispositions.
Curiosity was conceptualized as the
individual's interest in understanding his inner life and his willingness to engage in the process of figuring out how his behaviors and response make sense psychologically. Though it may seem difficult to separate each of these elements from Integration, it became clear in the course of coding that some individuals had a good sense of their similarity over time, but were not particularly interested in understanding more about themselves.
Others were curious
and seemed interested in explaining their particular reactions, but were unable to develop much of a sense of the history of their ways of responding or behaving.
In the
74 Table 5
Rating Quid* for Pre-War Integration and Sealing Over
IMTBORXTION
1.
Integrator!
This is a person who shows virtually no indications
of sealing-over, and impresses you as curious about how things fit together in his life.
He is able to make connections between
various aspects of his life.
This ability is evident especially
in response to the questions about the guilty memory, and the inquiry about how he ended up in Vietnam.
2.
Mostly uses integration: of sealing-over.
Again, this person shows few indications
But there may be one or two times in the first
part of the interview where the individual externalizes, becomes uninterested in making connections, or uses his own preconceived understandings to avoid developing further understandings. However, such occurrences are rare.
3.
Tends toward integration!
This individual is open to making links
his reactions to different experiences and the kind of person he was in general.
But these links are less sophisticated; the
individual can identify typical patterns, but can't go much beyond that.
However, he does seem to be interested in fitting things
together, and has some ability to do so.
SRALIHO-OVBR
4.
Tends toward sealing-over:
Here the individual may develop
psychological understandings in response to the guilt questions, but they are pro forma.
He can see how things go together when
pressed, and this way of thinking is not completely alien.
But
even though he may identify certain patterns or typical reactions, he prefers to minimize them and see all of his actions and
75 Table 5 (continued) Rating Guide for Pre-War Integration and Sealing Over
feelings as being determined by external circumstances (this may emerge especially strongly in the section asking about how the individual wound up in Vietnam).
5.
Mostly uses sealing-overt
No personal meanings of events or
enduring aspects of character are identified.
Little interest is
shown in understanding the personal meaning of winding up in Vietnam, or of the circumstances that led to the guilty memory. The early part of the individual's life is minimized and not seen as having had much impact, or large events that are acknowledged are externalized and seen as totally the result of circumstances or the influence of others. The individual does not dwell on or elaborate on his own personal motivations or reactions in the past and gives the indication that these are not important in understanding him today.
6.
Sealert
Exploration of pre-war life, and the identification of
characteristic patterns or motivations in this period of the individual's life are actively avoided.
This is a person who
doesn't think about himself in a way so that early experiences are highly regarded or interesting.
Either external forces totally
determined responses that are identified, or the individual provides a clipped, closed off account of the past.
This part of
the individual's life is seen as irrelevant or unconnected to what comes later.
Or the individual sees nothing that is talked about
as being at all typical or related to the enduring self, even the childhood self. negated.
Psychological understandings are avoided, or
He is invested in separating off aspects of his early
life, or not making connections.
76
Table 6
Rating Guide for Combat Integration and Sealing Over
INTEGRATION
1.
Integrator!
This is a person who shows almost no indications of
sealing over, and impresses you as being interested in fitting his combat responses with the rest of his life.
These individuals
show a good capacity to make connections between their responses to combat and how they responded at other times in their lives. They are eager to bring different aspects of their lives and experiences together and wish to integrate them into their overall sense of self.
They are curious about how they reacted to the
combat experience.
2.
Mostly uses integration!
Again, this person shows few indications
of sealing over, but there may be several comments about responses to combat responses where the individual externalizes, becomes uninterested in making connections, or uses his own preconceived understandings to avoid developing further understandings. However, such occurrences are rare.
3.
Tends toward integration:
This individual is open to making links
between his war experience and how he was before and after it. But these links are less sophisticated; the individual can identify typical patterns, but can't go much beyond that. However, he does seem to be for the most part interested in fitting things together, and has some ability to do so.
SEALING-OVER
4.
Tends toward sealing over:
Here the individual may agree with a
few comments made by the interviewer about links between his war experience and other aspects of his life, but does not seem really invested in them, and may not generate many ideas himself.
He is
77 Table 6 (continued) Rating Guide for Combat integration and Sealing Over
capable of seeing how things go together, and this way of linking things up is not completely alien, but he must be so.
pressed
He prefers to either minimize the war experience, or
todo
to
externalize and see all of his reactions as being determined by the circumstances of Vietnam.
5.
Mostly uses sealing overt
Responses to combat are seen as almost
completely determined by the nature of the war, and no personal or enduring aspects are identified.
Little openness is shown to
understanding the personal meaning of the combat experience.
Or,
alternatively, combat is minimized and not seen as having had any impact whatsoever.
Either way, there is a lack of interest and
inability to fit combat into the individual's enduring life story. Different experiences are kept separate, and there is no bringing together of aspects of the self across contexts. Little curiosity about internal reactions to the war is shown.
6.
Sealer:
Understandings of connections between the responses to
combat and enduring life themes are actively avoided.
This is not
the sort of person who resonates much with that way of thinking. The subject indicates that the nature of the war totally determined those responses.
The person comes across as having a
clearly differentiated sense of himself as a soldier in Vietnam; it is as if the person who fought there is completely different from the one who shipped over.
Psychological understandings about
the self are unimportant to this person, and are not a part of his life.
He doesn't care if he understands what about him led him to
respond as he does, or whether his sense of self coheres.
He goes
out of his way not to connect various experiences and reactions across different contexts of his life.
78
training sessions, the conceptual differences between Continuity and Curiosity were explained at some length, but there were no written instructions in the coding manual. Integration was rated both if the subject had already integrated aspects of his experience or was receptive to doing so in the course of the interview.
Those who had
already achieved some degree of integration were rated as being more integrated.
Appendix D presents synopses of
interviews with three subjects: one who was high on Integration, another high on Sealing Over, and third in which neither style predominates. A central concern in developing the assessment of Integration was the possibility that Recovery Style would be conflated with current adjustment.
Clinicians often assume
that "insight" and reflectiveness are signs of psychological health.
It was feared that this bias might distract the
raters from relying solely on evidence of Recovery Style in the tapes.
Because the dependent variables concerned
current functioning and symptoms, it was necessary to reduce this threat to the validity of the measure of Recovery Style.
A number of strategies were employed to ensure that
raters focused on indications of Recovery Style and not functioning. Questions in the interview did not address current functioning, and if indications of symptoms or problems arose, the interviewer attempted to steer subjects into material related to recovery style.
A detailed coding
79
manual was developed with hypothetical examples in an attempt to help coders identify specific examples of each style.
The term "Sealing Over" was considered pejorative
and perhaps suggestive of poor functioning.
In order to
prevent the possibility coders would use the rating to describe subjects who revealed difficulties in the interviews, this style was referred to as "Differentiation" in the coding manual and in meetings to discuss ratings. addition, a small deception was introduced.
In
Coders were
told that the subjects were a homogeneous group with respect to current level of functioning, and that attempts to link the Recovery Styles and current functioning or symptoms would confuse them and possible jeopardize the reliability of the ratings. The prewar section of the interview was expected to reveal little of the veteran's current functioning. Integration was assumed to be a general style of responding that would apply to the way subjects thought about other aspects of their lives in addition to combat. It was expected that an integrating attitude towards prewar events would be strongly associated with the ability to integrate reactions to combat.
Prewar and post-war ratings could not
be made independently from each other, since the second part of the interview would be confusing without the context from the veteran's past established in the first section.
Thus,
it was likely that the two ratings would be highly correlated.
It was assumed, though, that the first rating
80
could be considered a less biased rating of Integration because that portion of the interview contained little information on subjects' functioning. To determine whether ratings of Recovery Style were influenced by level of combat revealed in the interview, a four point scale was created to assess the severity of combat discussed by each subject.
Though the subjects were
screened at the outset for level of combat exposure, they might differ in their willingness to reveal aspects of combat.
The ratings were used to determine whether the
Recovery Style ratings were independent of the amount of combat revealed in the interview.
The scale is presented in
Table 7. Two graduate students in clinical psychology and one B.A.-level research assistant, who were blind to study hypotheses and underwent extensive training, coded each of the tapes.
Coders met regularly to discuss independently
scored responses in order to prevent coder drift. Reliability training did not focus on obtaining complete agreement between coders on each scale point.
Differences
between a score of a one and two or a five and six were not considered theoretically relevant.
The scale points served
as guidelines to help coders consistently rate whether subjects showed more or less Integration or Sealing Over. Reliability for each rating was measured using an Cronbach's alpha coefficient.
Alpha levels were high.
Coefficients
and descriptive statistics are shown in Table 8.
Table 7
Combat Exposure Scale
Heavy and protracted combat t You have the impression that the individual was exposed to horrifying, severe, demanding ordeals that were fairly constant.
Listening to him describe his
experiences, you get the sense that terrible things have happened repeatedly to him.
That is, severe combat was not an occasional
occurrence, but happened with some regularity over time.
Severe
combat could consist of witnessing death, destruction, or torture; being in a situation where one's own life was threatened; or being called upon to fire upon, fight with, or kill others.
Incidents
involving the death or torture of civilians should also be considered a part of combat. considered severe combat.
Also, being wounded should be
Examples of individual incidents would
be burning a village, being pinned for hours in the middle of an ambush, being on a plane or helicopter that crashed.
Heavy combat, but limited in duration, or constant exposure to stressful combat situation!
The individual experienced severe
combat as defined above, but it was not protracted.
Rather, it
was something that happened on some occasions, but was not ongoing.
Or, the individual was exposed to ongoing severe danger
but not horrifying combat experiences (being shot at in a helicopter, nearly being missed by a bullet).
Moderate, protracted combat!
The individual is exposed to
fighting, shooting, rocket attack repeatedly.
However, there
isn't a sense that the individual was exposed to the worst the war had to offer.
The individual was surely in the midst of war, but
may have managed to avoid the most horrifying experiences.
Table_7_( continued)
combat Exposure Seal*
Moderate combat, limitedt
The same sort of experiences as rated
in three, but only for sporadic periods.
The individual was
mostly behind the lines, and had only a few experiences which do not seem extraordinary.
He was at the base a few times when
rockets landed, or came under attack and fired.
But these things
did not happen in an ongoing way, for days at a time.
83 Table 8 Descriptive Data on Recovery Style Scores
Ratincr
Mean
2R
Median
Prewar Curiosity
3 .77
1.01
4.00
.86
Prewar Continuity
3 .50
.97
3.33
.79
Prewar Integration
3.63
1.04
3.67
.87
Combat Curiosity
3 .84
1.28
4.00
.90
Combat Continuity
3 .47
1.26
3.67
.85
Combat Integration
3 .66
1.18
1.26
.89
Note: Rated using a six point scale; 1 = most integrating; 6 = most sealing over.
84
For each rating, coders were also asked to write a paragraph stating their rationale for their scores.
The
rationales focused exclusively on criteria for coding and mentioned little about subjects' current functioning. Discussions of the coding were marked by attention to the coding criteria.
When the ratings were completed, coders
were each asked to guess what they thought the hypotheses might be.
All three suspected that the goal of the study
was to show that Integration was associated with better functioning and sealing over with the presence of psychiatric symptoms. influence their scores.
But they stated this belief did not Over time, the raters said they
were able to notice some association between whether subjects mentioned current difficulties and Sealing Over Recovery Styles.
The attempt to distract coders from
differences in current functioning by introducing a deception appeared to have little influence.
In spite of
the statement that subjects were homogeneous in terms of current adjustment, the coders reported that they were able to notice what appeared to be gross differences in amount of psychopathology based on what the subjects said about themselves in the interviews.
However, they said that the
lack of specific inquiries about current functioning left them unsure in many cases how well subjects were doing and whether they were suffering psychological difficulties. appeared that raters were only able to detect differences
It
85
between those who were having extreme difficulties and those who were doing very well. TAT Measure of Psychological Mindedness:
To provide an
independent check on the validity of the recovery style ratings, a task to assess subjects' psychological mindedness was included.
Psychological mindedness is defined as "[a]
person's ability to see relationships among thoughts, feelings, and actions, with the goal of learning the meanings and causes of his experiences and behavior" (Appelbaum, 1973, p. 36).
This dimension appears closely
related to integration, and was expected to be highly correlated. Psychological mindedness was assessed using the Picture Coding Scale for the Thematic Apperception Test (Hatcher et al. (1990).
Subjects were asked to make up stories in
response to Cards 4 and 14 from the Thematic Apperception Test (Morgan & Murray, 1934).
The usual administration
procedure was employed in which subjects were requested to make up a story with a beginning, middle, and end, and to provide a sense of what the characters were thinking and feeling.
In line with Huebner's (1987) suggestion, subjects
were then given the following instructions: Some people think that a story like this can tell something about the person who wrote it, so that someone who heard your story would learn something about you as a person. What might your story tell about you? Heubner (1987) found that ratings of psychological mindedness based on the responses to this part of the task
86
could accurately distinguish graduate students in clinical psychology from those in the sciences.
Her study suggested
that the task validly assessed psychological mindedness.
In
my study, subjects were given additional prompts to clarify the nature of the connections between story and self.
This
was done to assure that those subjects who were not adept at verbal description would have ample opportunity to make clear their ideas (the instructions for the TAT task are included in Appendix E). Tapes of TAT task were transcribed. Low scores on psychological mindedness were assigned to subjects who could see little or no connection between their stories and themselves.
Higher scores were given as subjects were able
to provide more complex and well-elaborated connections between the stories and their own typical ways of reacting and responding.
The highest scores were reserved for those
subjects who were able to identify personal conflicts or defenses that were evident in the story, or affected the way they created their stories.
Guidelines for rating stories
on a seven-point scale are shown in Table 9. Coders were three undergraduate psychology students and a B.A.-level research assistant.
In reliability training, the goal was
not complete agreement on each scale point, because no predictions were made based on individual points.
The idea
was to reliably assess whether subjects were more or less psychologically minded.
Coders met regularly to discuss
independently coded responses in order to guard against
Table 9 Picture Coding Scale to Assess Psychological Mindedness
The subject cannot find any links at all between his story and himself. The subject negates or denies a personal meaning of his or her response. The subject's response is characterized by sarcasm or a mocking tone. Here, some connection to the self is identified, but then lampooned or ridiculed, and the whole idea of making connections in this way is disparaged. The subject explains the story as reflecting something that happened to him, but the reasoning is simplistic. Essentially, subjects at this level are saying that the card reminded them of something that happened to them, and they told the story so it reflected their own experience. They are essentially associating to the story, and there is little or no reflection. Why this particular memory would surface, or the meaning of what they did is left unexplored. Essentially, there is nothing of psychological interest in the story. Subjects at this level will revert to explanations seizing upon the qualities of the card alone to explain how their stories arose. "His expression was such that I could only tell this story..." "This looks like something from a Clark Gable movie, so I thought of one I had saw, and this is what would happen in a movie like this." "I don't think you can learn much from this one..." The subject can go beyond relating a specific incident to the card and talks of how the story reflects his own particular dispositions. However, the dispositions described are superficial, socially desirable, and do not reflect subjects' awareness of their own conflicts or struggles. There is minimal reflection. "I'm a caring person." "I try to find the bright things in life." These is no ability to speculate why the story arose as it did today, or that it may have been sparked by a particular concern or interest that was uppermost in the individual's mind when he made up the story. Further, aspects of the story are left out or avoided by the individual's explanation. A story about in which the subject concludes that he is a caring person
88 Table 9 fcontinued) Picture Coding Scale to Assess Psychological Mindedness
includes a section in which the character shoves his wife before deciding not to leave her. Subjects can score in this category if they strongly identify with the character, saying, "that's just like what I would do," and then identify a particular disposition or behavior. 5.
Dispositions identified in response to the card are more complex, and may reflect negative areas or particular troubles with which the individual struggles. So the individual may identify with the character, but provide a more psychologically adept sense of the likeness. The self-observation thus contains a complex set of reflections or motives. "I don't like to get close." The reasons why this is so are not elaborated. Also, the subject does not have a good sense of why he was motivated to tell a story that reveals this aspect of his personality.
6.
The subject can begin to identify conflicts and talk about mixed feelings or emotions. "I'm a person who doesn't like to think about sad things, but my story ends up being sad." "I don't like to get close because I'm afraid of getting hurt." He can provide some account of why he may have come up with the story he did. "I must have Vietnam on my mind because of coming here for this study. That must be why I told a story that has to do with the feelings I had back then." Still, there may be aspects of the story that are evaded in explanations for how the story arose and what it tells about the individual.
7.
Subject can clearly articulate ambivalent or conflictual aspects of himself in the story. He may see how more than one character reflects differing feelings or motives inside of him. He can identify with some sophistication why the story emerged as it did, and he integrates almost all of the content that emerged in the story in his attempt to relate it to himself. It becomes clear that the subject recognizes and understands his own defensive maneuvers. "I made it end that way because I can't stand to think of people
89 Table 9 (continued) Picture Coding Scale to Assess Psychological Mindedness ending up unhappy. But I had them fighting, so I must think an awful lot about how people fight and struggle. So my story must tell about my own mixed feelings." "I realize I get very angry at women, so you can see why I made up. a story about a man being especially polite; this is my way of handling that anger that has to do with my mother." Or: "Talking about my childhood with you made me think about my own trouble with anger at my father. I think that explains why the woman ends up winning over that man."
You can see the scale as a progression. 1-3 reflects a lack of awareness the significant aspects of the self have been inserted into the story. 4-7 indicate increasing awareness on the part of the subject that he has inserted himself in the story and that it reflects their own concerns, conflicts, and psychological issues. At the higher levels, subjects tend to abstract from the story rather than talking about direct parallels. They move from identifying simple dispositions and characteristics ("I'm a searcher") to describing in complex ways how they function psychologically ("I struggle with intimacy"). Note: This is a modification of the scale created by Hatcher et al. (1990) .
90
coder drift.
Cronbach's alpha coefficient was calculated to
assess the reliability of ratings for each of the cards. For Card 14, alpha = .88.
For Card 4, alpha = .92.
Scores
on the two cards were summed to produce a total Psychological Mindedness score for each subject.
This score
was based on responses to a discrete task where subjects did not have the opportunity to reveal much about their current functioning.
The TAT score was expected to be correlated
with the measures of integration.
This finding would
further establish the integration ratings as separate from current functioning and symptoms. WAXS-R Vocabulary Subtest:
Integration involves a
complicated ability to reflect and think abstractly about oneself.
In order to establish whether integration is a
discrete style of coping independent from intelligence, subjects were administered the Vocabulary subtest from the Wechsler Adult Intelligence Scale-Revised (WAIS-R) (Wechsler, 1981).
This subtest is understood as the best
estimate of overall intelligence and most resilient to situational distress or anxiety (Allison, Blatt, & Zimet, 1968) . Other Predictor Variables Individual History Interview (XHX) and Background Questionnaire (BQ): Data concerning veteran's pre-war,
Vietnam and post-war experiences that were to be used as predictors of recovery style and current functioning were
91
obtained through a structured interview and a brief paper and pencil questionnaire.
Questions were taken from the
Boston Clinical Interview for PTSD, developed by Terrence Keane at the Boston Veterans Administration Medical Center, and interview items used in the National Vietnam Veterans Readjustment Study (Kulka et al. 1990).
Though both of
these interviews contain items designed to measure PTSD, they also include a variety of questions concerning pre-war upbringing, stressful aspects of combat, and how veterans were received when they returned from their service in Vietnam.
Many of these items were combined and included in
the Individual History Interview (IHI). Those items which would be awkward or lengthy to administer aloud were presented in written form as part of the Background Questionnaire (BQ). For the purposes of analysis, items were grouped together based on content to form a series of scales.
Because the number of response choices differed
amongst the various items (for example, some questions were coded on a two-point scale, while others used a five-point scale), item values were converted to z-scores.
The
internal consistency of each scale was estimated using Cronbach's alpha. discarded.
Scales with alpha scores below .60 were
The result was five scales concerning the
veteran's background before the war (Strict Upbringing; Educational Problems;
Trouble with Authority; Perceptions
of Parents and Family Cohesion); one concerning combat experiences in Vietnam; and one concerning the veteran1s
92
perception of how he was received when he returned to the United States following the war (Reception). Another scale that contained additional items about subjects' combat experiences, especially participation in atrocities, was also created (Combat). The alpha levels for each scale and a list of items contained in it are presented in Tables 1012 . Miller Behavioral Style Scale:
To assess how well
integration functioned as a predictor of current symptoms and functioning in comparison with another widely used measure of coping, this scale devised by Miller (1987) was included.
The scale is designed to assess two styles of
coping with threat— Monitoring and Blunting— that appear conceptually related (but not identical to) integration and sealing over.
Those who monitor seek out information during
threat, while blunting is used to block out awareness of a threatening circumstance and its implications.
The
questionnaire asks subjects to vividly imagine they are experiencing four hypothetical situations involving threat. Each scene is following by eight statements describing different ways of coping.
Subjects are asked to mark which
of the responses they would choose.
For example, one
scenario states: "Vividly imagine that you are being held hostage by a group of armed terrorists in a public building. Which of the following would you do?"
An example of a
blunting strategy is: "I would think about how nice it’s
93
Table,IQ. Scales Created from Items Concerning Subjects' Prewar Experiences
Strigfc- Upbringing
Aloha = .65
Family was very religiously observant. Religion had a large influence on growing up. Strict family discipline. Educational Problems
Alpha = .63
Amount of school completed before entering the military. How did you do in school— academically? How did you do in school— conduct? Were you suspended? Were you expelled? Were you in fights frequently? Access to Feelings
Alpha = .69
How often were you afraid before the war? How often were you sad before the war? How often were you angry before the war? Getting in Trouble
Alpha = .70
Had legal problems (before the war). Times arrested. How often did you use alcohol? Did you have problems with alcohol? Did others think you had problems with alcohol? Did you get in trouble because of your alcohol use? How often did you use drugs?
94 Table 10 (continued) Scales Created from Items Concerning Subjects' Prewar Experiences
Family Cohesion
Alpha = .79
Did you experience the following events (each event a separate item) ? Death of biological mother, father Death of non-biological mother, father Death of full sibling, half sibling, close friend Death of relative (1st instance, 2nd instance, 3rd instance) Serious illness to self (1st, 2nd instance) Serious illness to mother, father, sibling Drug or alcohol abuse mother, father Mental illness, mother, father Extra-marital affair, mother, father Parental divorce; separation Frequent moves Parental jail sentence Physical neglect Frequent absences of mother, father Low family economic status Parents had trouble making ends meet Did you experience the following events and if so how frequently? Responsible for primary care for other family members Sexual contact with a family member Inappropriate sexual contact with a non-family member Physical abuse by father, mother, other Bitter fighting between parents Did the following events occur and if so how severe were they? Traumatic event (accident disaster), self Traumatic event (accident disaster), family member Note: Items taken from the Individual History Interview and the Background Questionnaire. Item phrasing altered and condensed because of space constraints.
95
Table 11 Scale Created from Items Concerning Subjects' Vietnam Experiences
Combat
Alpha = .84
Number of months spent in Vietnam Type of duty (combat or combat support) In a situation where a prisoner was injured. Witnessed or was directly involved in prisoner injury? In a situation where a civilian was injured. Witnessed or was directly involved in civilian injury? Personally responsible for the death of a civilian. Involved in terrorizing, wounding civilians. Involved in torturing, wounding or killing hostages or prisoners Involved in death or maiming by booby traps or mines. Involved in the use of napalm, white phosphorous or cluster bombs on villages Involved in mutilation of bodies of the enemy or civilians How many buddies lost in Vietnam? With buddies when they were killed. How many buddies injured? With buddies when they were injured. Branch of service (marines indicate most combat; army second; navy third) Received decorations for combat
Note:
Items taken from the Individual History Interview and the Background Questionnaire . Item phrasing altered and condensed because of space constraints.
96 Table 12 Scale Created from Items Concerning Subjects Post-Vietnam Experiences
Reception
Alpha = .76
To what extent do you agree with these statements? Americans made veterans feel at home after the war. People respected you for serving your country. People made you feel proud to have served your country. In general how did you feel people received you? How did you feel you were received by your family? Did you experience negative reactions (being spit upon, called a baby killer, etc)? How often did such events occur? After your first two years back, were there friends you could confide in just about anything? After your first two years back could you confide in a spouse or partner just about anything?
Note: Items taken from the Individual History Interview and the Background Questionnaire. Item phrasing altered and condensed because of space constraints.
97
going to be when I get home." monitoring response:
The following is a typical
"I would make sure I know where
everypossible exit was."
In studies of moderate stress,
such as that experienced by patients undergoing routine medical procedures, those who used Blunting showed less stress and arousal (Miller, 1990) . Monitoring strategies led patients to feel more anxious and aroused.
However, in
a study of Israeli combat veterans who experienced a combat stress reaction during the 1982 Lebanon war, Blunting was associated with more PTSD symptoms than Monitoring (Solomon, Mikulincer, & Arad, 1991).
Monitoring can be considered a
pre-condition for integration, in which the individual attempts to attend to a threatening stimulus and thus is in a position to understand its personal meaning.
The
questionnaire is scored by counting the number of total monitoring and blunting items. Measures of Current Functioning and Symptoms Clinician assessments of functioning and symptoms would have been desirable, but time constraints made it necessary to rely upon valid and reliable questionnaire measures.
The
goal was to assess PTSD symptoms as well as general psychological functioning in other areas.
Though PTSD spans
a discrete set of symptoms, it may not capture difficulties or symptoms beyond those included in the diagnostic criteria.
Three measures of current functioning and
symptoms were included.
98
Mississippi Scale for Combat Related PTSD (M-PTSD):
The M-PTSD is a 35-item questionnaire that uses five-point Likert scales to assess presence and severity of DSM-III PTSD symptoms in Vietnam veterans. to 175.
Scores can range from 35
A previous study showed the measure had high
internal consistency (alpha = 0.94) and good test-retest reliability (r = .97) (Keane et al., 1988). It can be used as a continuous measure to assess the severity of PTSD symptoms.
When appropriate cutoff scores are used, the
scale can be used to assess accurately the presence or absence of PTSD.
In a comparison with four other widely
used PTSD scales, the M-PTSD was shown to have the highest degree of association with diagnoses of PTSD made using the Structured Clinical Interview for DSM-IIIR (McFall et al., 1990).
In studies that included thoroughly evaluated
Vietnam combat veterans with PTSD, non-PTSD patients and well-adjusted veterans, the M-PTSD had a sensitivity that ranged between .93 and .94 (Keane et al., 1988; Schlenger & Kulka, 1987).
Thus, the scale was able to correctly
identify 93 and 94 percent of veterans in those studies determined to have PTSD.
The scale had a specificity of .89
and .80., indicating the percentages of non-PTSD veterans it correctly identified.
There is some debate over the best
cutoff score for diagnosing PTSD in a non-psychiatric population.
Watson (1990), in a comprehensive review of
psychometric measures of PTSD, suggested 107 is the best
99
cutoff score to use in non-psychiatric settings.
The scale
will be used here as a continuous measure of PTSD symptoms. Minnesota Multi-phasic Personality Inventory, 2nd edition (MMPI-2) :
The MMPI-2 was used as a measure of
general psychological functioning in an attempt to get a broader picture of overall functioning, including symptoms not necessarily indicative of PTSD.
The first edition was
one of the most widely used personality inventories. The second edition removed archaic or poorly worded items and it was normed using new samples.
The 567-item inventory has
three highly regarded validity scales, nine clinical scales, and a series of thoroughly tested supplementary scales. The number of scales used to assess current functioning was reduced in order to simplify data analysis.
Five scales
were selected that have been identified as the best indicators of overall functioning (Graham, 1990). Comparisons of the 186 items in all five of the scales showed that only five were repeated on more than one scale. The F (Infrequency) Scale was designed as a validity scale, but its sixty items are also considered an overall indicator of the degree of psychopathology.
High scores on
F are correlated with clinical scales 6 (Paranoia) and 8 (Schizophrenia). High scorers also may present with severe neurotic or psychotic disorders.
The A (Anxiety) Scale
emerged as the first factor in a factor analysis of the items in validity and clinical scales (Welsh, 1956).
Welsh
proposed A as a an indicator of general "maladjustment."
100
High scores on the 39-item scale indicate distress, anxiety, discomfort and general emotional upset (Hathaway & McKinley, 1989).
Low scores reflect an absence of emotional distress.
The R (Repression) scale consists of 37 items that emerged as the second factor in Welsh's analysis.
Subsequent
studies indicate that the scale is misnamed since it does not correlate with other measures of repression (Watson, et al. 1987).
Kassenbaum, Couch, and Slater (1959) suggested
it is a measure of general adjustment in which high scores reflect introversion and inhibition.
The MMPI-2 manual
describes low scorers as "outgoing, energetic, expressive, uninhibited, and informal people with enthusiasm for living" (Hathaway & McKinley, 1989; p. 37).
The final MMPI-2 scale
used in this study was ES (Ego Strength). It was initially created in an attempt to predict which patients would respond well to psychotherapy, but the scale's utility in accomplishing this task is questionable (Graham, 1990). Instead, the total score on the 52 items in the scale is seen as "an indication of overall psychological adjustment" (Graham, 1990, p. 149) . High scorers are "fairly well put together emotionally" (Graham, 1990, p. 150), while low scorers have poor self-concepts, physical ailments, and difficulties adapting to problems (Hathaway & McKinley, 1989). To ensure that MMPI-2 protocols included in the data analyses were valid, decision rules were cheated in order to eliminate subjects who responded randomly, exaggerated or
101
underreported.
However, the cutoffs were chosen
conservatively because there appeared to be little incentive for dissimulating in this study.
Graham, Watts, and
Timbrook (1991), using MMPI-2 data, proposed that the F scale was the best indicator of attempts to exaggerate or dramatize psychopathology {fake bad). He suggested that in a population of normals, raw scores above 18— the 93rd percentile— would raise suspicions that the profile is not valid.
However, he also noted that this cutoff score would
be too low in a population of psychiatric patients, since
it
would exclude those suffering genuine distress. Research using the MMPI with Vietnam veterans has raised a further complication.
One study found that 50
percent of veterans with PTSD had F scores above the 88th percentile (Hyer et al. 1987). Another study which used a sophisticated psycho-physiological test battery to detect the presence of PTSD also found extremely high F scores amongst Vietnam veterans who had PTSD (Orr et al., 1990). These researchers inspected the content of the F scale items and found that many of them were consistent with the symptoms of PTSD (e.g., "I have nightmares every few nights;" "I believe my sins are unpardonable"). In my study, the risk of eliminating true cases of PTSD was deemed less acceptable than the possibility of including invalid profiles.
As a result, profiles with high F scores werenot
excluded.
An inspection of the data found that four
subjects had F scores higher than 18.
All but one would be
102
classified as having PTSD on the M-PTSD scale.
The other
subject's score of 96 was nine points below the M-PTSD cutoff of 107 that was being used in this study.
To ensure
that this subject was not responding randomly to the MMPI-2, his profile was scored using the Variable Response Inconsistency (VRIN) Scale.
This is a new, experimental
scale that detects inconsistencies in the way similar items are answered.
This subject's VRIN score of six was not
indicative of random responding. To detect profiles where individuals may have been exaggerating how well they were doing (faking good), scores on the L (Lie) scale were inspected.
Graham, Watts, &
Timbrook (1991) found that the L scale used alone worked best in identifying faking good by males.
He noted,
however, that cut-off scores were somewhat arbitrary since either low or high scores lead to a considerable number of incorrect classifications.
Accepting the risk of including
some invalid profiles, I chose a raw cut off score of eight. In Graham's study, a raw score of eight led to correct identification of 96 percent of the honest profiles and 67 percent of the fake-good profiles.
Using this score, three
subjects were eliminated from the analyses of MMPI-2 data. Social Adjustment Scale (SAS): Weissman and Bothwell's
(1976) Social Adjustment Scale was employed to measure subjects' satisfaction with relationships, family life, and work.
The SAS is a 54-item self-report questionnaire that
focuses on subjects' ratings of their occupational role,
103
social and leisure activities, family unit, parental responsibilities, relationships with significant others, and economic independence.
Items are rated on a five point
scale where lower scores represent more favorable responses. The scale instructs subjects to review their lives over the past two weeks to respond to the questionnaire items.
The
scale has high internal consistency (alpha = .74) and good test-retest reliability (r = .80).
It has been shown to
discriminate well between psychiatric and non-psychiatric populations (Weissman, Sholomskas, & John, 1981). has been used widely in psychiatric research.
The scale
The scale
yields scores on six subscales and total score comprising all of the items.
The total score was used here as the
measure of social adjustment.
CHAPTER IV
RESULTS
This chapter reports the findings of the study.
First,
I present results of analyses pertaining to the validity of the Recovery Style ratings.
Next, tests of hypotheses
concerning Recovery Style as a predictor of current functioning are presented. of correlations.
These are reported in the form
The intercorrelations among current
functioning and other variables, including family background, combat exposure, and reception following the war are also explored.
Finally, I report the results of a
series of multiple regression analyses in an attempt to test the best predictors of Recovery Style and current functioning. Validity of Recovery Style Ratings Several analyses tested the validity of the ratings of Recovery Style.
The first questions addressed concerns the
independence of the Recovery Style ratings from other information contained in the interviews.
To determine
whether the raters were influenced by the amount of combat experience reported by the subjects, correlations were 104
105
computed between each judge's ratings of Recovery Style and his or her estimates of the level of subjects' combat exposure.
Combat was measured using the combat exposure
scale developed for this project (Table 7). reports the results of this analysis.
Table 13
The direction of most
of the coefficients suggests a tendency for more intense combat to be associated with Sealing Over Recovery Styles. But only one of the correlations is significant.
Thus,
there is little evidence that Recovery Style ratings were unduly biased by level of combat noted by the raters. To test the consistency of Recovery Style scores, correlations were calculated between scores on the pre-war section of the interview and scores on the combat section. Though each rater coded both sections of the tape, they were instructed to make their ratings independently.
Thus, it
should be expected that the correlations would be high, and it would be cause for concern about the consistency of the measure if they were not.
Table 14 shows the correlations
are high and significant.
However, since the ratings were
not made independently, it is difficult to conclude for certain that these results give a true estimate of the consistency of the constructs across different contexts. In an attempt to establish the external validity of the Recovery Style ratings, the relationships between Recovery Style and measures of two related constructs— Psychological Mindedness and Monitoring-Blunting— were explored. Psychological Mindedness was coded from the responses to two
106 Table 13 Correlations Between Recovery Style Ratings and Ratings of Combat Exposure
Rater 1 Prewar Prewar Prewar Combat Combat Combat
Integration Curiosity Continuity Integration Curiosity Continuity
Combat Exposure -.17 -.16 -.23 -.20 -.32* -.19
Rater 2 Prewar Prewar Prewar Combat Combat Combat
Integration Curiosity Continuity Integration Curiosity Continuity
-.11 -.16 -.11 -.14 -.09 -.15
Rater 3 Prewar Prewar Prewar Combat Combat Combat
Integration Curiosity Continuity Integration Curiosity Continuity
-.02 .12 -.04 -.06 -.06 -.08
Note: Recovery style coded on a six-point scale where 1 is most integrating, 6 is most sealing. Combat coded on a four-point scale where 1 is most severe combat and 4 is the least. * p < .05
107 Table 14 Correlations Between Prewar and Combat Recovery Style Ratings
Prewar Ratings Integration
Curiosity
Continuity
Combat Ratings Integration
77*
.69*
.74*
Curiosity
81*
.76*
.77*
Continuity
66 *
.58*
.68*
* p < .0001
108
TAT stories.
Correlations between the scores for each of
the two stories were calculated to see if they were consistently measuring the same construct.
The results
showed the ratings for the two TAT cards were correlated with each other (r = .28; p < .03), but not as highly as might be expected on a test where the same format and rating scale was used.
Cronbach's alpha, a measure of internal
consistency, was computed for the two scores and also was low (.32).
It is unclear why the scores were not correlated
more highly; it may be that each TAT card pulled for very different reactions by subjects.
To get a consistent
measure, it may be necessary to use more TAT cards. Typically, five to ten TAT cards are given in a test battery, but time constraints made that impossible here. Because the two scores were not highly correlated, scores from each of the TAT cards as well as the combined scores were used in the correlations with the measures of Recovery Style.
Alpha coefficients were also calculated for both the
Monitoring and Blunting scales of the Miller Behavioral Style Scale.
The alpha coefficients for Monitoring and
Blunting were .78 and .66 respectively.
The reliabilities
were acceptable, showing the consistency of the subjects' responses to the items on each scale. Correlations among Recovery Style, Psychological Mindedness and Monitoring and Blunting are reported in Table 15.
The results indicate that Psychological Mindedness is
109 Table 15 Correlations Between Recovery Style Scores and Psychological Mindedness, Monitoring and Blunting PMl^
PM2^
Prewar Integration
-.26*
-.39**
-.41**
-.004
-.07
P-Curiosity
-.27*
-.43**
-.44***
.06
-.08
P-Continuity
-.21
-.37**
-.37**
-.05
-.11
Combat Integration
-.32*
-.46*** -.48***
.17
-.06
C-Curiosity
-.42** -.52*** -.59***
.13
-.13
C-Continuity
-.19
.24
-.02
PM1
.04
-.10
PM2
-.15
.30*
Total PM
-.07
.13
-.36**
Total PM^
-.34*
Monitor
Blunt
Note: Psychological Mindedness coded on a 7-point scale where 1 is the least and 7 is the most psychologically minded. Higher scores on Monitoring and Blunting indicate that subjects selected more of the items on those scales.
* p < .05 ** p < .005 *** p < .0001
Psychological Mindedness score on TAT Card 14. Psychological Mindedness score on TAT Card 4. ^Combined scores from both TAT cards.
110
related to the six Recovery Style scores.
However, there
does not appear to be much association between Monitoring and Blunting and either Recovery Style or Psychological Mindedness.
The one exception was the significant
correlation between Blunting and high scores on the Psychological Mindedness scale for TAT Card 4.
This result
is counter to my expectation that blunting would be associated with low Psychological Mindedness and more Sealing Over.
Thus, the hypothesis that the Recovery Style
ratings would be associated with related constructs was only partially supported.
Still, the association between
Psychological Mindedness and Recovery Style is important in establishing the ratings of Recovery Style as independent of current level of adjustment.
The Psychological Mindedness
ratings were made from a brief spoken response to a TAT card where there was little opportunity for subjects to reveal aspects of their current functioning.
It appears from these
results that a good part of the variance in the Recovery Style scores can be attributed to aspects of reflectiveness and insight and cannot be attributed solely to indications of adjustment evident in the interviews.
Interestingly,
correlations between Psychological Mindedness and ratings of Curiosity appear stronger than those with Continuity.
This
suggests that the Psychological Mindedness ratings are based more on the individual's curiosity about himself than his ability to place his experiences into a continuous sense of self.
Ill
Finally, to determine the extent to which Recovery Style and psychological mindedness were associated with level of intelligence, correlations were calculated between these measures and scores on the WAIS-R Vocabulary Subtest. The results are presented in Table 16.
The Recovery Style
scores were correlated with the measure of general intelligence.
As a result, additional analyses of the
Recovery Style measures controlled statistically for level of intelligence.
Psychological Mindedness was not
associated with level of intelligence. Association Between Recovery Style, Other Measures of Coping, and Measures of Current Functioning Table 17 summarizes scores on the measures of current functioning.
The table also includes alpha coefficients
indicating the internal consistency of the subjects' M-PTSD and SAS responses. MMPI-2.
Reliability was not calculated for the
Previous studies have established the test as
reliable for a range of populations (Graham, 1990).
Table
18 reports the number of subjects carrying a PTSD diagnosis based on scores from the M-PTSD. Partial correlations were calculated between the six measures of current functioning and Recovery Style, Psychological Mindedness, Monitoring and Blunting. WAIS-R vocabulary subtest score was partialled out. appear in Table 19.
The Results
Interestingly, of the six ratings of
Recovery Style, the strongest predictor of current
112
Table 16 Correlations between Psychological Mindedness, Recovery Style Ratings and WAIS-R Vocabulary Subtest
WAIS-R Vocab
-.30*
P-Curiosity
-.30*
P-Continuity
-.35*
Combat Integration C-Curiosity
-.35*
C-Continuity
-.22
*
Prewar Integration
l to 00 *
Recovery Style
PM11
.17
PM22
.06
Total PM3
.15
WAIS-R Vocabulary Subtest results based on scaled scores based on norms derived by Wechsler (1981), where 10 is the mean score. Higher scores indicate higher general intelligence. Mean subtest score for the sample was 11.08 (s.d. = 2.82).
*
p < .05 ■'■Psychological Mindedness score on TAT Card 14. ^Psychological Mindedness score on TAT Card 4. ■^Combined scores from both TAT cards.
113 Table 17
Descriptive Statistics for the Sample on Measures of Current Functioning
Median
Measure
M
SD
M-PTSD (n= 60)
85.3
21.67
85
F Scale1 (n=56)
59.59
16.43
58
A Scale (n=56)
55.68
13.96
53
R Scale (n=56)
50.54
9.41
50
Es Scale (n=56)
42.98
10.14
43
SAS Total (n=60)
1.96
.04
1.93
Alpha .93
.62-
For all measures of adjustment except ES, higher scores indicate more symptoms and difficulties. For ES, lower scores indicate more difficulties.
1MMPI data were missing for one subject; data from three others were removed because their protocols were judged to indicate "faking good." ^The SAS is made up of sections with items pertaining only to some subjects (such as those who are parents). The total score is derived by figuring the mean of the items answered. A single alpha could thus not be computed for the entire sample. What is reported is the mean alpha for the nine separate sections scored.
114 Table 18 Number of Subjects with Post-traumatic Stress Disorder Diagnosis
Diagnosis
Number
Percent
PTSD
10
16.67
No PTSD
50
83.33
Diagnosis assigned using M-PTSD; score of 107 used as a cutoff.
115 Table 19 Partial Correlations Between Measures of Current Functioning and Recovery Style, Psychological Mindedness, Monitoring, and Blunting
PTSD
SAS
A
F
(n=60) (n=60)
R
ES
(n-56) .08
.15
-.00
-.10
P- Curiosity
.24*
.09
.13
.24* -.02
-.11
P-Continuity
.30*
.30*
.15
Combat Integration
.20
.20
.23*
.15
.30* -.10
C-Curiosity
.11 .
.12 ** .20.
.07
.14
.01
C-Continuity
.39**
.35**
.28*
.29*
-.33*
Psych. Mind, (total)
.15
Monitoring
.36**
o o
.07
1
in
.08
-
h-»
-.12
1
.43*** .41** .45***-.01 O
-.13
o
Blunting
-.06
.30*
*5* o
.09
)
.21*
o CM
Prewar Integration
-.20
-.17 -.32* -.04
Note: Scaled total scores on WAIS-R Vocabulary Subtest were partialled out. For all measures of adjustment except ES, higher scores indicate more symptoms and difficulties. For ES, lower scores indicate more troubles. * p < .05 ** p < .005 *** p < .0001
116
functioning across all six adjustment measures was Continuity assessed from the combat portion of the interview.
The results show that those subjects who fit
their reactions to combat into a continuous sense of themselves over time were less likely to report symptoms of PTSD, difficulties in general psychological functioning, or impairments in social adjustment.
The other Recovery Style
ratings were in the predicted direction and at times significantly correlated with measures of adjustment.
The
findings thus appear generally to support the hypothesis that integrating Recovery Styles are associated with better functioning.
But the results also show that one component
of Recovery Style— Continuity as assessed from the combat portion of the interview— is a more powerful predictor of adjustment. The total Psychological Mindedness rating did not predict current functioning, and several of the correlations were in the opposite direction from what was predicted. Higher scores appeared to be associated with poorer adjustment. Monitoring— the tendency to seek out information about a stressor— was a powerful predictor of current psychological difficulties.
Blunting— the attempt to block
out thoughts about a threatening stimulus— was not significantly associated with the measures of current functioning.
For the most part, the coefficients for
blunting were negative, indicating that counter to the
117
hypothesis, higher blunting scores tended to be associated with better adjustment. In this analysis, it appears that the ratings made during the combat section of the interview were better predictors of current functioning than those made in the pre-war section.
One possibility is that this portion of
the interview contained more incidental indications of the subjects' current functioning.
Thus, findings could be
accounted for by the confounding of Recovery Style with adjustment.
To test this possibility, additional
correlations were computed between Recovery Style and the measures of functioning.
But this time, the most extreme
scorers on each of the dependent measures were excluded from the tests on the assumption that those who scored the highest or lowest on the measures would be most readily identified by the raters as either doing poorly or well. Removing the extremes would show whether the findings held even with subjects who were more homogeneous with respect to current functioning.
Those scoring in roughly the top and
bottom ten percent on each of the six measures of current functioning were removed.
Partial correlations were again
calculated, controlling for intelligence.
The results,
presented in Table 20, showed that with the extremes removed, there were fewer significant correlations. However, Continuity was still a predictor of current adjustment.
It correlated with PTSD, A Scale and ES Scale
and showed a trend towards significance with the R Scale.
118
Table 20 Partial Correlations Between Measures of Current Functioning and Recovery Style, with Extreme Scorers Excluded
PTSD Subjects Prewar Integration
SAS
46
46
.12
-.02
F
A
R
ES
45
43
45
42
-.01
.05
-.02 -.12
-.08
.07
-.05
-.15
-.02
-.18
P- Curiosity
.15
.002
P-Continuity
.16
.07
Combat Integration
.26** -.05
.03
.16
.21* -.11
C-Curiosity
.09 . -.11
.07
.08
.01
C-Continuity
.39**
.09
.29** .24*
.06
.007 .13
-.13 -.34**
Note: Scaled total scores on the WAIS-R Vocabulary Subtest were partialled out. * p < .10 ** p < .05
119
It is unclear whether the raters1 scores were biased by indications of adjustment only at the extremes.
There may
have been obvious differences even between those subjects who scored in the moderate ranges on the measures of functioning.
But removing the extreme scorers showed that
Continuity still is a relatively good predictor of functioning and offers some reassurance that the findings are not to be accounted for just by rater bias. Table 21 presents correlations between current functioning and the scales derived from items in the Individual History Interview and the Background Questionnaire (see tables 10-12).
The results showed that
for the most part, more difficult experiences before the war were not associated with poorer current functioning.
The
one significant association was between more negative perceptions of parents growing up and poorer current social adjustment.
The measure of combat— which highlights
involvement in atrocities and the loss of friends in battle-appeared somewhat predictive of current psychological difficulties.
Though only one of the relationships was
significant (with the F Scale), the directions of the correlations indicated that those who had more severe combat experiences as defined by this scale tended to have more problems with their current functioning.
The subjects'
perceptions of how they were received following the war was the most powerful predictor of current difficulties amongst the variables studied in these analyses.
The correlation
120
Table 21 Correlations Between Current Functioning and Variables Concerning Subjects' Pre-war, Vietnam, and Post-war Experiences
PTSD
SAS
F
A
R
ES
(n=56)
(n=60) (n=60) .11
.20
.14
- .04
.09
-.06
Edprobs
.08
.01
.08
- .00
.15
-.05
Trouble
-.11
-.09
.14
O 1 O o
Parents
.09
.40**
.12
.15
Cohesion
.15
.16
.02
.09
.23
-.22
Combat
.20
.12
.36*
.16
.18
-.20
Reception
.64*** .49*** .52*** .48***-.05 -.50
•
Strict
.13
.09 -.10
Note: For predictor variables, higher scores indicate more pre-difficulties, poorer parental relationships, more severe combat experiences, and poorer post-war reception. * p < .05 ** p < .005 *** p < .0001
121
between Reception and PTSD symptoms was .64.
This indicated
that those veterans who described the way they were received following the war as most negative had the most PTSD symptoms, social adjustment problems, and general psychological difficulties. A Model to Explain Continuity The preceding analyses have shown that, amongst the Recovery Style measures, Continuity rated in the combat section of the interview was the best predictor amongst the Recovery Style measures of current functioning.
The next
analyses were undertaken to understand better what contributes to Continuity.
Table 22 presents partial
correlations between Recovery Style measures, including Combat Continuity, and the scales derived from items in the Individual History Interview and the Background Questionnaire (see tables 10-12). Scores were partialled out.
WAIS-R Vocabulary Subtest
The hypothesis tested here was
that Recovery Style would be influenced by unfavorable experiences before the war and how one was received afterwards.
Specifically, more chaotic and difficult
circumstances before the war and a poor reception afterwards was expected to influence negatively the possibility of gaining continuity. The results show that only three variables were correlated with Continuity: Trouble, Reception, and Combat.
122
Table 22 Partial Correlations Between Recovery Style Measures and Variables Concerning Subjects' Pre-war, Vietnam, and Post-war Experiences
Integ. Strict
Prewar Cur.
Cont.
Integ. -.07
Combat Cur.
Cont.
-.10
-.19
-.02
Edprobs
.16
.09
.19
Trouble
-.25*
-.14
-.27*
-.31*
-.21
Parents
-.08
-.07
-.08
-.05
-.03
-.06
Cohesion
-.19
-.17
-.20
-.19
-.17
-.13
.30*
-.08 .33*
.01 .22* .40**
Combat
.29*
.28*
.26*
.37**
.29*
.36**
Reception
.12
.07
.18
.19
.06
.34**
Note: Scaled total scores on WAIS-R Vocabulary Subtest were partialled out. For predictor variables, higher scores indicate more pre-difficulties, poorer parental relationships, more severe combat experiences, and poorer post-war reception. * p < .05 ** p < .005
123
The correlation between getting in trouble and Continuity was negative, indicating that those who got into more trouble growing up were likely to demonstrate more of a sense of continuity concerning their war experiences. To determine the unique contribution of each variable when compared with all of the others, a stepwise multiple regression analysis was computed.
All of the pre-war
variables and Reception were entered.
Combat severity as
measured on the scale developed from the IHI and BQ questionnaires was also included to determine whether Continuity is affected by the level of the stressor; this possibility was indicated by the significant correlation between Combat and Combat Continuity.
The WAIS-R vocabulary
subtest score was entered as a control variable.
The model
was developed using a stepwise procedure in which each variable was individually tested for inclusion and exclusion.
Table 23 summarizes the resulting model.
variables were included;
Three
Trouble, Reception, and Combat.
The best predictor of Combat Continuity was Trouble, though in the opposite direction of the prediction.
Increases in
the amount of conduct difficulties growing up were associated with increases in the sense of continuity.
The
model shows that the sense of continuity was negatively affected by a more unfavorable reception following the war. This finding supports the hypothesis that Integration would be blocked by negative reception following the war.
Combat
was not predicted to be an important contributor, but was
124
Table 23
Multiple Regression Analysis to Identify Predictors of Continuity Multiple R = .570 Proportion of Variance Explained:
.325
F(3,55) = 8.84, p < .0001
Variables Trouble
beta -.352**
Reception
.270*
Combat
.263*
Variables eliminated: WAIS-R Vocab; Edprobs; Cohesion; Parents; Strict; Monitoring; Blunting and Psychological Mindedness. * p < .05 ** p < .005 *** p < .0001
125
included to assess whether the level of stress influenced Continuity.
The results indicated that it did.
Increases
in the amount of combat on this scale were associated with a diminished sense of continuity. Models to Assess Contributions to Current Functioning In order to test the hypothesis that Recovery Style is a better predictor of current adjustment than either pre-war problems, level of combat or post-war reception, additional multiple regression analyses were conducted.
For each
measure of current functioning, a model was developed to identify the most important predictors and their magnitudes. The models were created using a similar multiple regression procedure for each of the six measures of current functioning.
WAIS-R Vocabulary was entered first as a
control variable so that the effects of Recovery Style apart from intelligence could be studied.
The second step
included variables concerning pre-war experiences (see Table 10):
Strict; Edprobs; Trouble; Parents; and Cohesion.
Combat (Table 11) was entered in the third step. (Table 12) was included on the fourth step.
Reception
The last step
included measures of coping: Combat Continuity, Psychological Mindedness, Monitoring and Blunting.
Combat
Continuity was chosen from amongst the six Recovery Style ratings because the partial correlations showed it to be the best predictor of current functioning on all the scales. total of 12 variables was entered in each equation.
The
A
126
results of this analysis were inspected and the model was refined by eliminating those variables for which the regression coefficient was not significant at the p < .20 level.
This level was chosen in order to maximize the
chances of including as many potential variables in the final model as possible.
The final models for each of the
six scales are presented in Tables 24 through 29. PTSD Symptoms:
equation (Table 24).
Five variables were included in the By far the strongest predictor of
increases in PTSD symptoms as measured by the M-PTSD was more unfavorable reports of reception following the war. The next best predictor was intelligence as measured by the WAIS-R Vocabulary subtest.
The coefficient was negative,
indicating that increases in intelligence were associated with decreases in PTSD symptoms.
Combat Continuity was
next, followed by Psychological Mindedness.
Monitoring, in
this model, was not a significant predictor of PTSD symptoms.
Overall, the model supported the usefulness of
Combat Continuity as a predictor of PTSD symptoms, but the hypothesis that Recovery Style would be the strongest predictor was not supported. Social Adjustment:
equation (Table 25).
Five variables were included in the
The strongest predictor of social
adjustment as measured by the SAS was perception of parents. More negative perceptions of parents predicted poorer levels of social adjustment.
Monitoring was the next best
predictor, followed by Reception and Combat Continuity.
127
Table 24 Multiple Regression Analysis to Identify Predictors of PTSD Symptoms
Multiple R = .754 Proportion of Variance Explained:
.568
F(5,53) = 13.93, p < .00001
Variables Reception
beta .462***
WAIS-R Vocab
-.260*
C-Continuity
.236*
Psych Mind.
.193*
Monitoring
.174
PTSD symptoms measured using the M-PTSD, Variables eliminated: Trouble; Edprobs; Parents; Strict; Cohesion; Combat; Blunting. * p < .05 ** p < .005 *** p < .0001
128
Table 25 Multiple Regression Analysis to Identify Predictors of Social Adjustment
Multiple R = .713 Proportion of Variance Explained: F{5, 53) = 10.96, p < .00001
Variables
beta
Parents
.364***
Monitoring
.309**
Reception
.244*
C-Continuity
.226*
Strict
.152
Social adjustment measured using the SAS. Variables eliminated: Trouble; Edprobs; Cohesion; Combat; Blunting; WAIS-R Vocab; Psychological Mindedness. * p < .05 ** p < .005 *** p < .0001
129
Strict Upbringing was included in the equation but was not significant.. The results show the importance of a pre-war factor in level of social adjustment.
Though a measure of
Recovery Style is predictive of the level of social adjustment, the hypothesis that it would be the strongest predictor was rejected. The F scale is a set of items from the MMPI-2
F Scale:
that has been found to be a good measure of overall maladjustment; it is particularly associated with paranoid and psychotic thinking.
The model for this scale included
five variables (Table 26).
Increases in the reception score
predicted the largest increases in the F Scale scores. Monitoring was next, followed by Combat.
WAIS-R Vocab and
Strict Upbringing were included but not significant predictors.
This model did not include Combat Continuity,
and the hypothesis that a measure of Recovery Style would be the best predictor of functioning as measured by the F Scale was not supported. A Scale:
The A scale, a subset of MMPI-2 items,
measures distress, anxiety, discomfort and general emotional difficulty.
The model to predict scores on this scale
included three variables (Table 27).
The most powerful
predictor of A Scale scores was Reception, followed by Monitoring.
Increases in these variables predicted
increases in A scale scores.
Combat Continuity was included
but was not significant; thus, it is impossible to conclude
Table 26
Multiple Regression Analysis to Identify Predictors of Scores on the MMPI-2 F Scale
Multiple R = .675 Proportion of Variance Explained:
.455
F (6,48)= 6.68, p < .00001
Variables
beta
Reception
.378**
Monitoring
.249*
Combat
.243*
WAIS-R Vocab Strict
-.200
.163
Variables eliminated: Trouble; Edprobs; Cohesion; Parents; Blunting; C-Continuity; and Psychological Mindedness. * p < .05 ** p < .005 *** p < .0001
131 Table 27 Multiple Regression Analysis to Identify Predictors of Scores on the MMPI-2 A Scale
Multiple R - .589 Proportion of Variance Explained:
.346
F (3,51)= 9.01,, p < .0001
Variables Reception
beta .359**
Monitoring
.326*
C-Continuity
.09
Variables eliminated: WAIS-R Vocab; Edprobs; Cohesion; Parents; Strict; Trouble; Combat; Blunting and Psychological Mindedness. * p < .05 ** p < .005 *** p < .0001
132
that the relationship between Continuity and A Scale scores is not the result of chance factors. R Scale:
The R Scale is an MMPI-2 subscale found to
measure general adjustment, and is particularly associated with introversion and inhibition.
The model to predict
scores on this scale included three variables (Table 28). Combat Continuity was the strongest predictor of R Scale scores, followed next by Cohesion. the coefficient was negative.
Reception was next, but
This indicated that reports
of more unfavorable reception following the war were associated with lower scores on the R scale.
Lower scores
are said to describe individuals who are expressive, uninhibited and zealous about life, but also may indicate individuals who are pushy or aggressive (Graham, 1990).
The
model confirms the hypothesis that a measure of Recovery Style would be the most potent predictor of current functioning as measured by the R Scale. ES Scale: The ES Scale is an MMPI-2 scale that measures
overall psychological adjustment.
Unlike the other MMPI-2
scales, lower scores are associated with poorer functioning. Results of the analysis are presented in Table 29.
The
model to predict scores on this scale included four variables. predictors:
Two of the variables were significant Reception was the best predictor of ES Scores,
followed by WAIS-R Vocab.
Monitoring and Psychological
Mindedness were included, but were not significant.
Thus,
it is impossible to conclude that these relationships are
133
Table 28 Multiple Regression Analysis to Identify Predictors of Scores on the MMPI-2 R Scale
Multiple R = .480 Proportion of Variance Explained:
.231
F (3,51) = 5.10, p < .004
Variables
beta
C-Continuity
.445**
Cohesion
.438**
Reception
-.368*
Variables eliminated: WAIS-R Vocab; Edprobs; Parents; Trouble; Strict; Combat; Monitoring, Blunting, and Psychological Mindedness. * p < .05 ** p < .005 *** p < .0001
134 Table 29 Multiple Regression Analysis to Identify Predictors of Scores on the MMPI-2 ES Scale
Multiple R = .600 Proportion of Variance Explained:
.360
F (4,50)= 7.04, p < .0001
Variables
beta
Reception
-.409**
WAIS-R Vocab
.235*
Monitoring
-.216
Psych. Mind
-.165
Variables eliminated: Edprobs; Parents; Trouble; Strict; Cohesion; Combat; Combat Continuity and Blunting. * p < .05 ** p < .005 *** p < .0001
135
not the result of chance factors.
Combat Continuity was not
included in this model. Summary of Multiple Regression Analyses Predicting Current Functioning In an effort to see how Recovery Style compared as a predictor of current functioning with other variables, multiple regression models were created to predict each of the six measures of current functioning.
Combat Continuity,
the measure of Recovery Style included in each model, was not always the best predictor of scores on the adjustment measure.
It was included as a significant predictor in four
of the six models.
It was found to be the best predictor of
functioning in the model predicting R Scale score. One's reception following the war was a significant predictor in all six of the models.
Monitoring was a significant
predictor in three of the models. Other predictors were significant, but not across all of the analyses.
CHAPTER V
DISCUSSION
Summary of Results This study was intended to assess the role of Recovery Style in response to the stress of combat.
The constructs
examined were chosen based on a theoretical analysis of weaknesses in the most widely recognized paradigm used to explain how individuals recover from traumatic events.
One
specific style of recovery— Integration— was proposed as an important contributor to an individual's recovery from a traumatic experience.
Integration was operationally defined
based on earlier work with the concept completed by McGlashan (1987) . To further understand the process of integration, two of its components— curiosity about the self and continuity of the sense of self over time— were also studied. The results of this study showed that the measures of Recovery Style could be rated reliably and appeared to have some validity as indicators of a discrete style of processing stressful experiences.
One component of Recovery
Style, Combat Continuity, was shown to be a strong predictor of current functioning, including PTSD symptoms. 136
This
137
finding remained, even when extreme scores on the measures of current functioning were removed in an attempt to eliminate a possible bias in the Recovery Style ratings. Other important predictors of current functioning identified were Monitoring, the tendency to seek out information about stressful events, and Reception, the way individuals perceived how they were received by others on their return from the war.
An analysis attempting to identify what
predicts Continuity identified three associated variables: more conduct difficulties growing up, less combat exposure in Vietnam, and better reception following the war. Additional analyses attempting to identify the relationship among predictors of current functioning did not support the hypothesis that Recovery Style would be the strongest predictor.
While Combat Continuity was the best predictor
for one scale, it was not included in two models, and it was the third or fourth best predictor in the other three. Still, Combat Continuity was for the most part a stronger predictor of current functioning than variables concerning subjects' upbringing and their exposure to combat. Reception was more consistently predictive of the various measures of current functioning than any other scale. Validity, of Recovery Stvle Ratings One goal of the study was to demonstrate that Recovery Style could be reliably and validly rated.
Trained raters
were able to reliably score tapes for the Recovery Styles.
138
Measures of the Recovery Style from the prewar and combat sections of the interviews were highly correlated, supporting the consistency of the ratings.
I attempted to
establish the validity of the ratings in a number of ways. The most serious threat to validity was the possibility that judgments made about Recovery Style really reflected indications of the subjects' levels of functioning which might have made their way into the interviews inadvertently. Raters indicated that they were able to notice some gross differences in adjustment amongst the subjects, but they did not believe this influenced their scoring. Several efforts to test the construct validity of the ratings were incorporated into the study design.
One was to
check the relationship between the Recovery Style scores and measures of similar constructs that were not scored from the Recovery Style interview.
This was partially successful:
the Recovery Style ratings were correlated with a measure of Psychological Mindedness coded from TAT cards.
The Recovery
Style ratings, however, appeared to be unrelated to two other constructs that I initially supposed were related: Monitoring and Blunting.
I had considered Monitoring to be
a pre-condition for Integration, because it consisted of an individual's need to seek out information about a threatening situation.
I thought that individuals who used
this coping style would be more inclined to use the information they sought to better understand the personal meanings of a stressor.
However, a closer look at what each
139
construct measures indicates why the findings were opposite of the prediction.
Monitoring and Blunting concern the
individual’s inclination to search for or avoid information related to a threatening situation.
Recovery Style has more
to do with the individual's ability to conceptualize the meaning of a threatening situation.
It may not involve
seeking information about the threat itself, but consists of efforts to gain an understanding of one's reactions to it. It may be that some individuals can establish a sense of continuity about their use of either Monitoring and Blunting strategies and others cannot.
For instance, one individual
may use monitoring strategies, but cannot identify this proclivity as a particular pattern that has an important personal history.
Another individual may have developed an
elaborate understanding of his need to monitor.
Both may be
high on Monitoring, but they would differ with respect to Recovery Style.
This may explain why Recovery Style and
Monitoring are not associated. Another attempt to ensure that ratings of Recovery Style were not biased by data related to current functioning involved the use of ratings on the prewar section of the interview.
It was expected that there would be fewer
indications of current adjustment in this section. If the prewar ratings were correlated in the predicted direction with the measures of current functioning, it would support the validity of the ratings as unbiased by level of adjustment. Though the results showed that there were
140
significant associations between the prewar ratings and adjustment, the most potent predictor was Continuity as rated in the combat portion of the interview.
One reason
for this may be that the ratings from the second portion of the interview were more effectively measuring Recovery Style.
In the coding meetings, the raters spoke of their
difficulty being certain about their ratings of the prewar section.
They said they were particularly helped in the
combat section by the interviewer's trial interpretations. Here, the interviewer shared his ideas about possible connections between prewar tendencies and the subjects' particular responses to combat.
It was thus possible to see
to what extent individuals were drawn to this type of thinking and whether they could work with such connections. Trial interpretations of this sort were not provided at the close of the prewar interview, and as a result, raters often felt they did not have enough data to be confident of their ratings. The finding that the combat section ratings were more predictive of current functioning may indicate that these are more accurate measures of Recovery Style. Another possibility is that the combat portion of the interview provided more indications of current functioning which biased the ratings.
In an attempt to test this
possibility, those individuals with extreme scores were eliminated and partial correlations were repeated. number of correlations no longer proved significant, Continuity still appeared to be a good predictor of
While a
141
adjustment, especially PTSD.
This analysis cannot
definitively establish the independence of the ratings from incidental estimates of current functioning.
But it does
provide some support for the ratings not being unduly influenced by indications of either extremely good or poor functioning.
Further, the fact that the measures of
Integration and Curiosity were not strongly correlated with adjustment may also speak to this issue.
Clinicians value
curiosity as much as a sense of continuity.
If raters were
reacting on the basis of their bias, one would expect the Integration and Curiosity ratings to be more strongly associated with the measures of adjustment than they were. Further support for the fact that raters do not necessarily associate Recovery Style with measures of current adjustment comes from an earlier study where psychodynamically trained coders assigned Sealing Over scores to a large number of normal control subjects (Lohr, 1992, personal communication). While this does not speak to the ratings made in my study, it suggests that links between Recovery Style and current adjustment are not totally dependent on coder bias.
I think it is possible, then, to
conclude that the ratings of Recovery Style were reasonably independent from indications of current functioning, and that the results of this study can be interpreted as meaningful on their own terms.
However, in future studies,
additional efforts should be made to ensure that ratings of Recovery Style are not biased.
One possibility would be to
142
reword descriptions of Sealing Over in a more positive way. The defining statements in Tables 3 and 4 for the most part highlight what Sealers fail to do and have negative, judgmental connotations.
It also would be useful to study
Recovery Styles in a population completely homogeneous with respect to adjustment.
If Recovery Styles are seen as
discrete personality attributes, then one would expect to find different styles in a normal group.
Such findings
would indicate that differences in Recovery Style reflect aspects of personality that are not exclusively explained by psychopathology.
Such a study might also lead to a better
understanding of what contributes to the sense of continuity. The Meaning of Continuity If we accept the construct validity of the Recovery Style ratings, the results of the study are intriguing.
Of
all the measures of Recovery Style, Continuity measured in the combat section was found to have the most predictive power.
The measure of whether subjects had identified
continuities between their responses to combat and prewar aspects of their lives was more strongly associated with better functioning than measures that tapped subjects' curiosity about themselves.
Combat Continuity was more
effective than Integration as a predictor of current adjustment.
While the measures of Continuity and Curiosity
were highly correlated, the Continuity ratings may capture
143
something important not tapped by the Curiosity ratings, or by the ratings of Integration, which were based on both a sense of continuity and curiosity.
Whatever that is, it is
not reflected in the ratings of Psychological Mindedness, which though correlated with Continuity scores, did not predict adjustment.
One explanation for the effectiveness
of Continuity as a predictor is that it reflects the fact that useful insights about the self have already been achieved.
Individuals high on curiosity may not have gone
as far to develop coherent, useful narratives to explain their lives.
Alternatively, more curious individuals may
not have had a stable sense of themselves before their combat experience.
The Integration ratings may have been
less effective because they were determined in part by curiosity, reflecting a degree of uncertainty and a need to search which was not present in those rated higher on Continuity. Because the study was correlational, it is impossible to determine from the data what causal role Continuity plays in the recovery from trauma. two possibilities.
However, the results suggest
Continuity could result from an
individual1s attempt to make sense of his combat experience and is part of a process, that when completed, leads to the resolution of problems in functioning.
In this view,
Continuity would truly be a discrete style of recovery.
It
is also possible that those who have a strong sense of continuity now had a stronger sense of self before the war,
144
and this was a protective factor against later problems. Anecdotal material from the interviews supports both conclusions. A number of those who managed to gain a sense of continuity described rather turbulent efforts to come to terms with their combat experiences in which they reflected upon their lives and came away with important insights.
For
instance, Mr. C., a veteran described in Appendix D, spoke of a need to understand how things fit together.
This led
him to work through his Vietnam experience, even though he sometimes was faced with painful thoughts about himself. His sense of continuity appeared to be established in reaction to his experience in Vietnam, which prompted him to explore his conflicts concerning his relationship with his father.
But before he achieved this understanding, he
described a rather painful period after the war in which he had many difficulties. The establishment of continuity seemed to be a his way of coping with the pain with which he was struggling. Other subjects described an assured sense of self that they took with them into combat.
For some, it seemed that
this strong sense of self prevented them from being overwhelmed by events or tempted to become involved in activities such as atrocities that would lead them to feel guilty later.
Thus, it may be that Continuity works
protectively in two ways:
some individuals are traumatized,
but manage to work towards Continuity as a means of
145
resolution.
Others have an especially strong sense of self
that keeps them from being traumatized. Both understandings of the role of Continuity are supported by previous literature.
Lindy (1988) saw
Continuity as developing over time in the course of therapeutic work.
In a study of psychodynamic psychotherapy
with Vietnam combat veterans, he found that "continuity of self" was a "key ingredient in the patient's perception of his own personal recovery" (p. 317).
Lindy noted the
emergence of a sense of continuity in eleven of 22 veterans who took part in follow-up research interviews assessing the effectiveness of their psychotherapies.
Continuity appeared
to emerge through "recently recognized interests, activities, or traits which connected the veteran with a positive sense of himself before Vietnam" (p. 318).
Lindy's
conceptualization of Continuity is different from mine.
In
my investigation, Continuity was not limited to reconnection with positive aspects of self from before the war.
It
amounted to a recognition of ongoing conflicts--including negative experiences— that accounted for particular responses in Vietnam.
Still, Lindy's observation suggests
that some individuals may wall off connection with their prewar selves following trauma, and that recovery is a process of reconnection. Hendin and Haas (1984) made a similar observation in their therapeutic work with Vietnam combat veterans.
They
noted that typically, traumatized Vietnam combat veterans
146
make few efforts to link traumatic experiences in combat with prewar life experiences.
They concluded:
If anything, they tend to see their lives as beginning— and often ending— with combat. The ability to see combat in the context of other life experiences is usually a sign of the lessening of the stress disorder {p. 60). This observation suggests that a sense of continuity is not present at the beginning of treatment, but develops in the course of recovery.
It is unclear from both Lindy and
Hendin and Haas's observations whether Continuity is the vehicle which promotes recovery, or a byproduct of it. But regardless of its etiology, Continuity has been observed to emerge anew in the process of recovery from trauma. The protective function of a continuous sense of self— what might be termed a sense of ego identity— has also been highlighted by a number of writers.
Most notable has been
Erikson (1956), who has identified the development of a stable sense of identity through adolescence as an important influence upon one's reactions to subsequent challenges throughout the life course.
Identity was defined as "a
persistent sameness within oneself" and "a persistent sharing of some kind of essential character with others" (p. 57).
At one point, Erikson (1963) conceptualized a
soldier's breakdown during combat as a disruption of a pre existing ego-identity. Kohut's (1971) notion that optimal functioning is dependent upon the establishment of a cohesive sense of self also appears to be relevant.
He
suggested that early experiences of empathic parenting allow
147
an individual to develop a cohesive sense of self that wards off later psychological disturbances.
Horowitz and Zilberg
(1983) described a "superordinate self organization" which brings together diverse self representations and accounts for an individual's sense that he or she is the same person over time.
They noted that some people have a superordinate
self organization which works more effectively at establishing continuities between contrasting self-schemas. This ability to bring together diverse self-images allows individuals to develop insight and work effectively in psychodynamic psychotherapy.
Patients without the ability
to integrate contrasting images of the self are seen as more difficult to work with and often suffer from more severe disturbances.
Kernberg (1975) has emphasized the phenomenon
of splitting in patients with character disorders. Typically, splitting involves the separation of perceptions of others into those that are all bad and those that are all good.
But the similar splits can occur in self-
representations. The result is an unintegrated, oscillating sense of self. The roots of a strong sense of identity and a cohesive sense of self are seen as developing early, as the child begins to function independently.
Part of the process of
maturation involves the coalescing of various images of self and others into a consistent patterns, so the young child begins to recognize himself as a separate being, with a sense of his or her own agency (Lictenberg, 1975).
148
Increasingly, theorists have focused on identifying defects in the development of "self-constancy" (Lax, Bach, & Burland, 1986). The finding that Continuity in the veterans studied here predicted better functioning following the war may reflect differences in the sense of self present before the war that could be traced to very early experiences of self development. Speaking against this possibility is the fact that prewar experiences likely to impair the development of a strong, coherent sense of self were not associated with Continuity.
For instance, the Cohesion scale captured a
number of stressful life events that would likely hinder an individual's ability to establish a continuous sense of self.
Items included deaths of caretakers or siblings,
traumatic events, such as physical or sexual abuse, substance abuse by parents, and parental divorce.
Neither
Cohesion nor the Strict Upbringing Scale nor the Educational Problems scale was related to the presence of Continuity. The only prewar variable associated with Continuity was Getting in Trouble, and this finding was the opposite of what was expected.
Individuals who got into more trouble,
reflected in their reports of legal problems and difficulties with drugs and alcohol before the war, had a greater sense of continuity.
The meaning of this finding
will be discussed at greater length below. However, the lack of association between self-reports of troubles in the family growing up and Continuity must be
149
interpreted cautiously.
The data about prewar experiences
were based on subject self-report and could not be verified independently.
It may be that some individuals either
suppressed negative experiences from before the war or have repressed them and are unable to consciously recall them. Recent research has noted the way that a "repressive personality" can distort self-reports so that they paint an unrealistically benign picture of the individual (Weinberger, 1990).
Those who established Continuity in my
sample may have been more open to negative aspects of their past and thus were more willing to report them. In summary, it is difficult to conclude with certainty whether the predictive power of Continuity reflects primarily the presence of a resilient self before the war, or the ability to establish such continuity as part of a style of recovery in reaction to a traumatic event. It is possible that each explanation applies to some subjects. In some individuals, both processes may be operating. Lack of Continuity as a Reaction to Trauma Alternatively, lack of Continuity may not be either an indicator of prewar vulnerability or the failure to make use of an effective Recovery Style.
Rather, lack of Continuity
could be considered a direct effect of traumatic experience. In this view, the differences in Continuity reflect varying levels of traumatization.
This conclusion is supported by
studies that suggest that one of the key consequences of
150
trauma is dissociation— the splitting off of traumatic memories from the self through extreme efforts to deny them. In its most dramatic form, dissociation entails a complete alienation from the enduring self, so the individual no longer knows who he or she is.
This may become evident
through a sense of depersonalization or derealization,
in
extreme cases, the result may be fugue states and the development of multiple personalities.
A recent review of
the traumatic stress literature has suggested that PTSD— now considered an anxiety disorder--might be classified as a dissociative disorder in future diagnostic manuals (Davidson & Foa, 1991) . Lack of Continuity in my sample does not appear to reflect true dissociation.
Subjectshad awareness of who
they were, and had not lost touch completely with their prewar identities; at least they were able to describe the kind of children they were.
But there was often a dramatic
split between what occurred in Vietnam and the prewar personality.
Subjects who manifested a lack of Continuity
stated readily that they felt they were no longer the same people they had been before the war. Support for the notion
that thelackof Continuity is a
symptom of a traumatic response comes from the finding that both level of combat and reception following the war predicted Continuity.
Thus, while individuals were screened
to be homogeneous with respect to combat experience, some differences in the intensity of stress they experienced may
151
have remained.
The combat scale that predicted Continuity
was different from the screening questionnaire in that it focused particularly on combat stressors that involved the witnessing of or participation in atrocities, including the killing or wounding of civilians or prisoners.
Breslau and
Davis (1987) found that participation in atrocities was highly predictive of a later PTSD diagnosis. It may be that this particular stressor leads to the development of PTSD and the development of a lack of Continuity.
Lack of
Continuity may reflect the individual's defensive efforts to ward off acceptance of the self that participated in violent activities.
Seeing one's actions in combat as part of an
enduring pattern means accepting personal responsibility for heinous acts and the painful guilt that would be stirred by it.
Lack of Continuity, then, could be seen as a defensive
response to the traumatic experience of becoming involved in atrocities. The association between a poor reception at home following the war and a lack of Continuity can be explained in a similar way.
Individuals who reported poor receptions
may have been singled out for particular derision and thus are reacting not only to traumatic experiences in combat, but to hostile treatment following the war.
Lack of social
support following trauma has been identified in a number of studies as predictive of more trauma-related difficulties (Flannery, 1990).
The lack of social support may have
detracted from the sense of continuity as well as
152
potentiating post-traumatic symptoms.
The association
between reports of poor reception and current difficulties was supported decisively in this study.
The Reception
measure correlated strongly with all six measures of current functioning. The finding that the lack of Continuity is predicted by poor reception can be explained by considering the importance of external validation in the maintenance of identity.
Erikson (1963) states, "The sense of ego identity
...is the accrued confidence that the inner sameness and continuity prepared in the past are matched by the sameness and continuity of one's meaning for others..." (p. 261). For soldiers returning from Vietnam, being called "a baby killer" contrasts sharply with the prewar sensation of going to combat in a noble effort to serve the country; thus, not only has one's own view of the self changed, but others now view the individual quite differently.
Further, the social
perception of the self as some kind of monster was likely to become entangled with the individual's own sense of guilt about participation in aggressive action.
Intense guilt
would discourage a personal exploration of the meaning of one's traumatic responses. The finding of the importance of reception in this study is consistent with Smith's (1985) suggestion that the lack of "sanction" for participation in combat was especially difficult for Vietnam veterans.
As a result,
veterans were forced to ward off acknowledgement of their
153
sense of responsibility for their actions in combat in response to intense hostile pressure coming from their environment.
They may have been responding like the therapy
client who can explore his own hostile impulses only in the presence of a therapist whose non-judgmental stance prevents him from being overwhelmed with guilt. Similarly, combat veterans may have delayed or avoided seeking personal meanings of the war for fear of the reactions of others, which would augment their own feelings of guilt. These explanations do not definitively establish that a lack of continuity is necessarily the result of the dual trauma of combat and hostile reception following the war. One's willingness and ability to participate in atrocities cannot be considered apart from one's personality.
Hendin
and Haas (1984) concluded that "precombat adaptation" prevented certain veterans they studied from participating in atrocities.
These veterans, who did not develop PTSD,
were seen as calm under pressure, able to create and impose a sense of structure in the face of chaos, and willing to accept their own and other's limitations and emotions. Laufer, Frey-Wouters, and Gallops (1985) found that draftees were significantly more likely than those who enlisted to become involved in violence towards non-combatants, suggesting that prewar factors account in some way for participation in atrocities.
Those who enlisted and wanted
to become involved in the war may have had less sensitivity to the helplessness of being in combat and were thus able to
154
manage their reactions without resorting to atrocities. Another possibility is that allowing oneself to be drafted, without securing a deferment or enlisting, reflects certain personality characteristics that make the individual vulnerable to participating in atrocities.
In Vietnam, many
soldiers enlisted to avoid the draft because they were told that they could choose their military assignment.
Those who
did not take this opportunity may have had passive or selfdefeating personality traits that may have made it more difficult for them to resist pressure from others to become involved in atrocities. Further, reception in my study was measured by selfreport, and it is difficult to know whether the ratings reflect actual experiences of hostile reception.
Perhaps
those veterans who were the most guilty about their combat experiences were most sensitive to post-war slights.
These
individuals may also have needed to project self-critical tendencies onto others to assuage their sense of guilt.
As
a result, such individuals would likely report feeling more criticized by society at large.
Given the limitations of
the study, it is impossible to know for sure whether lack of Continuity reflects a personality disposition from before the war, or is in fact the result of a poor post-trauma reception. In attempting to understand the meaning of Continuity, it is necessary to discuss the intriguing finding that those who reported more conduct disturbances before the war were
155
more likely to have a strong sense of continuity.
The
analyses also showed that getting in trouble was not significantly associated with level of current adjustment. The low correlation between this variable and PTSD was negative, indicating that conduct troubles tended to be associated with fewer PTSD symptoms.
This finding
contradicts previous suggestions that anti-social behavior before the war leads to PTSD symptoms afterwards (Hendin and Haas, 1984; Worthington, 1977). One explanation is that those individuals who engaged in anti-social behavior before the war and then wound up in combat were not confronted with a major discrepancy between their prewar selves and what they were called upon to do in the Vietnam.
They may have been more comfortable with the
aggressive and anti-social activities that define combat. Those who did not get in trouble much before the war may have been overcontrolled or excessively defended.
Combat
may have unleashed impulses and emotions that had been kept in check before the war but were now deeply disturbing and could not be easily integrated.
A clinical example that
supports this position comes from my work with a Vietnam combat veteran who was raised in a strictly religious family and was always, as he described it, a very good boy.
He
rarely, if ever, gave vent to angry or annoyed feelings. combat, he was filled with intense rage, and on his own initiative became involved in a number of atrocities, including the killings of innocent civilians.
He was
In
156
continually bewildered by his participation in these activities, and could not identify precursors of them in his prewar life.
His angry impulses emerged during combat, when
he was under a great deal of pressure.
He could not find
any way to make sense of his reaction, precisely because his prewar life was marked by no conscious recognition of these feelings. An alternative explanation is similar to that offered for the lack of association between the other prewar scales and either Continuity or current functioning.
Veterans who
admitted their troubles with authority may have been more willing to consider their pasts and reveal significant events, including those that reflected negatively upon them. Other veterans who were having more current difficulties might have been less likely to detail their troubles before the war.
In this view, the actual experiences before the
war may have been quite similar, but the more distressed group was unwilling to reveal these negative events.
Some
individuals might have attempted to minimize ongoing life difficulties in order to highlight the negative impact of their combat experiences.
These individuals may blind
themselves to the importance of prewar experiences as part of a 11compensation neurosis:"
they are compelled for
financial or psychological reasons to attribute their difficulties solely to the trauma of combat. My discussion of Continuity has raised a number of possible explanations for its association with better
157
psychological functioning, but has produced no definitive answers.
However, one common factor seems congruent with
all of the explanations explored so far.
No matter whether
Continuity is seen as a Recovery Style, a sign of prewar resilience, or the absence of a traumatic symptom, it still appears to signal the presence of a sense of control and agency.
Those who can elaborate a sense of continuity are
implicitly taking responsibility for how they reacted to combat. Traumatic situations are by definition characterized by a subjective experience of helplessness (Freud 1926/1959) . Those who acknowledge their particular reactions to the trauma as part of their continuous selves are no longer conceiving of the traumatic event passively as an experience that is completely external.
One hypothesis
is that no matter how the individual arrives at it, a sense of continuity is empowering.
That is, a firm sense that the
responses to trauma are uniquely one's own and part of an enduring pattern of self contributes to a sense of personal agency.
This sense of agency counteracts the effects of
being put in a helpless state.
A sense of personal control
has been frequently reported as a buffer against suffering negative consequences following stress (Lazarus & Folkman, 1984). The idea that Continuity is associated with a sense of personal agency brings us back to my introductory discussion of current theories about the recovery from traumatic events. The literature I reviewed suggested that recovery
158
from trauma required an acceptance of the way one's self was altered by the trauma.
I argued that by conceptualizing the
trauma as a noxious external event that must be faced and accommodated, these theories neglected the personal meanings that lead the event to become traumatic.
They also tended
to diminish the life-historical importance of the individual's ways of responding to a traumatic event. The result was that these theories failed to acknowledge the importance of fostering a sense of agency in trauma victims. Instead, they conceptualized trauma victims as passive respondents overcome by external circumstances who must change themselves to recover. The findings of the study, however, suggest that recognizing the personal meaning of one's traumatic responses was a key ingredient to overcoming the stressful experience.
Those combat veterans who were doing the best
did not view themselves as inevitably changed by their traumatic experiences. While acknowledging the importance of their time in Vietnam, they were able to see their reactions to combat as continuous with earlier aspects of their lives.
They developed a consistent life narrative in
which Vietnam was not seen as an aberration but was woven into their unfolding life story.
The results suggest that
the process of recovery from trauma does not mean casting aside or revising the pre-trauma self to accept the catastrophic events.
Normalizing an individual's traumatic
responses may discourage an understanding of their personal
159
meanings.
For therapists working with traumatized combat
veterans, and perhaps other trauma victims, the results suggest the need for a renewed focus on understanding the personal meanings of the traumatic event and the reactions it produces.
Forcing the individual to expose himself to
memories of the traumatic event in order to accommodate it does not appear to be sufficient.
The protective effects of
Continuity reported in this study indicate the need for therapeutic approaches that help individuals develop more coherent narratives that include their reactions to the traumatic experience.
Many therapeutic approaches often
focus on the responses to trauma as generic, normal responses that vary slightly between trauma victims.
In
contrast, this study suggests that it may be more helpful to orient therapy towards developing understandings of the idiosyncratic meanings of the traumatic event. It appears that an important aspect of therapeutic work with trauma victims should be understanding the meanings of individuals1 traumatic responses and attempting to discover how these reactions are consistent with clients' life histories. Discussion of Findings Concerning Other Predictor Variables The results of the multiple regression analyses revealed a number of robust predictors of current functioning aside from Continuity.
There were also a number
of variables expected to be associated with Continuity which were not related.
160
The variables concerning veterans' experiences before the war were noteworthy for not being associated with post war adjustment. In only one of the models did a prewar variable appear to play an important role.
Perception of
one's parents while growing up was the strongest predictor of current social adjustment, but did not predict PTSD symptoms or current functioning as measured by the MMPI-2 scales.
The lack of prewar predictors of PTSD is congruent
with earlier studies that have found that pre-military factors have little importance in the prediction of PTSD (Foy, Carroll, & Donahoe, 1987; Green, et al., 1990).
The
finding that a prewar variable is the strongest predictor of social adjustment suggests that there may be multiple negative sequelae from trauma that are accounted for by different, interacting causal factors.
On the other hand,
the notion that perception of early caretakers would be associated with how one gets along socially later may not be specific to the trauma of combat. It appears to support the hypotheses of psychoanalytic object relations theory {Kernberg, 1975).
This theory highlights the role of
internalized representations of early important relationships in determining the quality of later relationships. The lack of prewar predictors of post-combat distress is consistent with earlier research.
But the fact that
level of combat was only predictive of one of the measures of current functioning appears to be unprecedented.
Many
161
recent studies have identified severity of combat as the leading predictor of PTSD symptoms following combat (Foy, Carroll, & Donahoe, 1987; Foy & Card, 1987; Green, et al., 1990; Penk et al., 1981).
However, none of these studies
have attempted to control the level of combat experienced by subjects using screening questionnaires.
The comparative
homogeneity of the sample— all had experienced severe combat— may account for the results here.
Still, what this
finding suggests is that the intensity of the traumatic event may be necessary but is not sufficient to explain the development of post-traumatic difficulties.
Among
individuals who undergo similar stressful experiences, other predictors must be taken into account. The one significant association between combat and a measure of current functioning involved the MMPI-2 F Scale. This result may suggest that those veterans involved in atrocities suffer from bizarre or psychotic thinking, which is reflected in high F Scale scores. The main predictor of current functioning across all the measures of current functioning was Reception.
The
meaning of the reception scores has been discussed briefly above.
However, one intriguing finding was not addressed:
the negative association between Reception scores and the R Scale from the MMPI-2. scores on this scale.
Here, poor reception predicted lower This may indicate that reception
following combat can at times be associated with an indicator of better adjustment.
However, while low R Scale
162
scores are often indicative of outgoing, spontaneous individuals, they also may depict those with negative qualities, including impulsiveness, aggressiveness, sarcasm, and self-indulgence (Graham, 1990).
Given the other
findings, it is most likely that reception is associated here with the negative characteristics indicative of poorer functioning. Another robust predictor of current functioning in the study was Monitoring.
In populations of mildly stressed
individuals, such as those undergoing medical procedures, monitoring has been associated with higher levels of anxiety (Miller, 1990) . But in the one previous study of combat veterans, Monitoring was predictive of better functioning (Solomon, Mikulincer, & Arad, 1991). expected here.
Similar results were
I considered Monitoring a pre-condition for
Integration, because the individual would be prone to seeking information about the traumatic event and thus might be more willing to conceptualize its personal meaning.
I
thus expected that Monitoring, like Integration, would be associated with better current adjustment.
Instead,
Monitoring was a consistent predictor of poorer current functioning.
One possibility is that those who used this
style as an enduring means of coping with threat became overwhelmed by their traumatic experiences and suffered more symptoms.
This would be consistent with Miller's hypothesis
that Monitoring leads to an -intensive focus on the
163
threatening stimulus, resulting in a higher state of arousal (Miller, 1990) . It is more likely, however, that Monitoring predicted poor functioning because it is closely related to a symptom of PTSD.
The diagnostic criteria note that PTSD victims are
often hypervigilant for the recurrence of threat (American Psychiatric Association, 1987).
Disturbed Vietnam veterans
are typically extremely suspicious and distrustful.
Some
have been known to patrol their homes with weapons, expecting intruders or compulsively investigating noises they find suspicious.
Hendin and Haas (1984) speak of "the
paranoid adaptation" of some combat veterans.
In this
light, Monitoring statements on the Miller Behavioral Style Scale can be understood as reflections of certain veterans' needs to maintain vigilance.
For instance, monitoring
strategies described in the questionnaire include: "I would make sure I knew where every possible exit was;" and "I would listen carefully to the engines for unusual noises and would watch the crew to see if their behavior was out of the ordinary."
Thus, it makes sense that more disturbed
veterans would endorse these particular styles of response. It is this maladaptive means of coping that accounts for their difficulties.
The possibility that Monitoring
reflects a personality style evident before a trauma that predicts a poor adaptation can only be studied through a prospective study with pre-trauma measures of coping.
164 Conclusions and Directions For Future Research The study has established Continuity as a relevant variable associated with level of functioning following a traumatic event. While this construct was conceptualized as personal style of recovery, my discussion has suggested a number of ways of understanding the current presence of Continuity.
The fact that so many possibilities remain
reflects the retrospective nature of the study, which is a significant limitation.
Because data were collected
following the trauma, it is impossible to know for sure how different variables were causally related to one another. The most effective— and most difficult— remedy for this problem is a prospective study in which individuals are studied before they undergo a traumatic event.
Traumatic
events cannot be introduced as experimental manipulations, however, and the costs of collecting data from a large enough group of subjects to ensure that a significant number will experience traumatic events are prohibitive.
A more
likely remedy would be a controlled study of treatment interventions, in which the emergence of adaptive styles of coping could be studied.
It would be interesting to see
whether the beneficial effects of treatment are associated with the development of increased continuity of self.
Even
a longitudinal study, in which traumatized subjects could be studied over time to investigate the fluctuations in their sense of continuity, would be useful.
165
The strengths of this study were that it involved a group of veterans carefully screened for level of combat. The assessment of their ways of responding to combat was extensive, and a wealth of data concerning prewar, combat, and post-combat variables were collected.
Most
significantly, the study drew attention to Continuity as an important predictor of current adjustment in a population of subjects exposed to severe stress.
Many clinicians
intuitively recognize the desirability of helping their clients create more complete and coherent narratives of their lives, including their early experiences.
This study
appears to establish the soundness of this clinical wisdom. It also suggests that current theories concerning the recovery from trauma need to provide better accounts of the ways in which individuals connect their present lives with their pre-trauma pasts as they attempt to overcome stressful experiences.
APPENDICES
166
PLEASE NOTE
Copyrighted materials in this document have not been filmed at the request of the author They are available for consultation, however in the author’s university library.
appendix A pages 167-168
University Microfilms International
169
APPENDIX B
Integration/Sealing-Over Seal* in Psychosis
Integration The individual is aware of the continuity between his thoughts and feelings during the psychosis and his emotional conflicts prior and subsequent to his psychotic episode.
Sealing-Over The individual isolates the thoughts and feelings experienced during the psychosis from his view of his emotional life prior and subsequent to his psychotic episode.
The psychosis is experienced by the individual as personal, rather than as alien or visited upon him by some outside force.
The psychosis is seen as an encapsulated, circumscribed event which is alien to, and distinct from, that part of his mental life which the individual calls his own.
The individual feels responsible for his psychotic thoughts and acts.
The individual does not feel responsible for his psychotic thoughts and acts.
The individual is curious about his psychotic experiences and is emotionally invested in understanding them.
The individual is not curious about his psychotic experiences and is not emotionally invested in understanding them.
The individual treats the psychosis as a source of new information about himself which he uses to modify his opinions and behavior.
The individual does not treat the psychosis as a source of new information about himself and seeks to return to his premorbid opinions and behavior.
The individual enlists the help of others in mastering the conflicts related to his psychosis and/or life difficulties.
The individual tends not to enlist the help of others in mastering the conflicts related to his psychosis and/or life difficulties.
The individual blames his illness on his own difficulties in coping with his life problems.
The individual blames his illness on other persons or environmental events.
The individual views himself as having had an emotional or nervous breakdown.
The individual views himself as having fallen prey to a medical or medical-like illness.
The individual is able to see positive aspects to having had a psychotic episode.
The individual is unable to see any positive aspect to having had a psychotic episode.
170
APPENDIX B teontlnumd)
Integration/Sealing-Over Seal* in Payohoaia
Integration
Sealing-Over
The individual feels his psychotic experience has had a strong impact on his life.
The individual minimizes the importance or impact of his psychotic experience on his life.
The individual's attitude toward mental illness is less fearful and negative than prior to his psychosis.
The individual's attitude toward mental illness remains fearful and intolerant.
The individual likes some of the unusual feelings and ideas that he experienced during his psychosis.
The individual is repelled by the unusual feelings and ideas that he experienced during his psychosis.
The individual feels that his psychosis helped him come closer to obtaining satisfaction in real life.
The individual feels that his psychosis has made it harder for him to obtain satisfaction in real life.
171 APPENDIX C
SEMI-STRUCTURED INTERVIEW FOR TRAUMA INTEGRATION Robert Cohen MA December 1991
GOAL:
This is an interview designed to determine whether subjects have integrated their reactions to traumatic events, or whether they are capable of doing so when given the opportunity. The questions are intended to generate responses that can be coded for integration or sealing-over.
INTRODUCTION: I may have told you some of this when we spoke before, but this is what I am interested in studying. People who have done studies with other veterans have found that they are pretty different in how much their experiences stay with them over the years, and exactly how their experiences stay with them. They also are different in how they reacted to and experienced combat. I'm trying to understand these differences better in this study. I hope that as we talk, we will understand something of how you reacted to and experienced combat. Since I am interested in the differences in the way people responded to combat, it would be helpful to know some about your background. So I hope it is ok to ask you— at least at the beginning— some about your growing up.
The interview will be exploratory, much like a clinical interview. Subjects will be encouraged to explicate their own experiences rather than speaking about Vietnam veterans in general.
172
PART ONE:
BACKGROUND AND PRE-WAR EXPERIENCE
1. Spend some time getting to know the person and finding out a little about their general background, including how they wound up in Vietnam. Where do you live now? Have you been there all your life? Where did you live before? How did wind up going to Vietnam— were you drafted, did you enlist? If drafted, find out some about that. If they enlisted, get the reasons for that. What were you up to just before you went to Vietnam? Tell me a little about your background before the war?
2.
Begin to focus on family life before the war.
What was your growing up like? Who did you live with? What was your family like? What was your father like,whatkind ofpersonwas he? What sort of relationship did you have with him? What was your mother like,whatkind ofpersonwas she? What was your relationship like with her? How did you get along?
If subject provides constricted descriptions, or is confused, the interviewer can ask: What was his/her personality like?
Also, get description of other important figures such as step-parents, grandparents, etc., who seem to have had formative roles in the subjects upbringing. How about your siblings, what were they like? you get along?
How'd
Is there anything that I didn't ask about, anything important about your growing up that hasn't come up so far?
3. The next section is designed to elicit a significant memory from before the war that has the stamp of the subjects own actions on it. The goal is to see if the subject can "integrate" these memories by asking what his understanding is of why he behaved in this way. We will then have a sense if the individual can integrate something that does not have to do with the war.
173
I'd like you to again think of the time before the war and tell me something you regretted, or felt guilty about. Something you had second thoughts about. Something you had questions about. I'm not interested so much whether you got in trouble, but something you felt guilty about. This is the kind of thing that everybody feels growing up— even if they are well-behaved for the most part.
If the subject produces a memory where the guilt concerns and event he had no control over, or no role in, ask for another memory. Tell me about something that had to do with you in some way. Not something that just happened to you, or where you had no choice.
If the subject cannot come up with a memory of this sort from childhood, it is acceptable to ask about something recent, as long as it doesn't have to do with the war. 4. Probe for the individual's understanding of why he did what he did. What do you make of the fact that you did that then? How do you understand that? Was that characteristic of you?
It may be necessary to reframe the question, especially when asking whether the response is typical. Is it typical? I don't mean that you did exactly that behavior often, but is it typical that you reacted in that way/ felt that way?
5. If it is not sufficiently clear whether the response indicates the individual's ability to integrate, get another example. Again, if the subject cannot come up with something before the war, ask for something after the war that didn't have to do with Vietnam.
174
PART TWO:
VIETNAM EXPERIENCE
1. The next portion of the interview will explore the individual's ability to integrate both events from the war and the war experience in general. This part of the interview will have more to do with your experiences in Vietnam. When you think back on it/ what stands out in your mind about the Vietnam experience?
It will be helpful to get a sense of the subject's ability to integrate his overall sense of the war. It will be important in doing this to ask about this tactfully, so the subject does not interpret the question as diminishing or negating the impact of the war experience. I sea that what stands out for you is the feeling of.... I know you never were exactly in that situation before, but what you felt— is that something you ever felt before? Have there been other times in your life you felt like that? 2. Next, try to get the veteran to tell you about some traumatic memories. Focus in on specific memories, and try to get a narrative of what happened in each event.
The goal here is to elicit the subject's typical responses to stressful circumstances. First, ask about the general response to the event. Do not focus on reflexive responses ("my heart was racing," "I flinched"), but ask about more ongoing feelings, thoughts, and even defenses. What ware the stressful or difficult moments in Vietnam. What do you remember in particular? What happened? Explain that. How did you react? What did you do? Feel? Think? How about over time— how did you react, what did you think? What was your way of dealing with that? What did you think about it?
3. Now, ask some questions to see if the subject can reflect upon his reaction. It might be helpful before posing the question to briefly summarize the interviewer's
175 understanding of how the subject reacted ("I get the sense that you tried to block it out..."). What do you make of having reacted that way? Is it typical of you? Where do you think that came from? Did you ever do anything like that before? How do you understand it? Were you always the kind of person who would react that way? I've heard before that others did that, but people reacted a lot of ways. Why do you think that was your way? 4. Now, focus on something the subject did that he felt guilty or regretful about. The goal here is again to be sure we are seeing whether individuals can integrate events that have their own personal stamps on them. Keep this veteran focused on combat.
Some subjects may find this question as accusatory, and it may be helpful to let them know that you understand that people did many things in combat, and you are not necessarily interested in huge mistakes, just anything that they might regret. Steer away from experiences that seem reflexive or, in the context of wartime, could not reasonably be avoided (for instance, shooting a child who was about to detonate an explosive and kill American forces). Is there something you did in Vietnam that you felt guilty about or regretted? Something you did or did not do? Something you had second thoughts about? Something that went against your grain? Anything you wish you did differently in the face of combat or threat?
5. See if the subject understands what it was that got to him about these experiences— what lead him to do what he did or feel what he felt. Again, it may be important when determining whether the veteran sees his actions as typical to explain that we do not mean whether he ever behaved in that way before (eg., killed people). Rather, was there anything familiar in the fact that he got upset or was undone in that particular way and behaved in that particular way. What do you make of having done that? Why do you think you did that?
176 Where did that reaction came from? Did you ever do anything like this before? Is this typical of you in any way? I know you were never in exactly in that situation before, but still, was there anything familiar or typical in the fact that under this kind of pressure you would feel that or do that?
Though patterns may be apparent to the interviewer, these should not be verbalized until it is possible to get a clear sense of whether the veteran himself can identify them. 6. If someone knew who knew you well before the war had been able to see how you were or what you did in combat, would they be surprised? Would you be recognizable to them? What would be surprising?
7. In this next question, try to keep the veteran focused on what he learned about himselfas aperson, not on what he learned in general. Did you learn anything new about thekind of person you are from your combat experience? What did you learn? How has this infozmation proven useful/ harmful? How? 8. Has your combat experience in any way altered how you see yourself? What has changed about you?
9. In the next section, the interviewer is attempting to see if the subject can find continuities between dealing with the traumatic events of combat and a later trying or traumatic event. The goal is also to see if this discussion leads the veteran to consider the pre-war roots of the reaction. Some subjects may answer the initial prompt by relating a dream or flashback from Vietnam. The interviewer should ask for something that actually happened after the war. Since the war, has anything extremely frightening or traumatic happened to you? How did you react (what did you feel, etc)? What did you make of that reaction? Was it similar to how you reacted to other things? Were you always a person who responded in these ways?
177 Where did the reaction come from?
10. Before completing the interview, the interviewer should comment on connections and themes that are apparent in the material. This can only be done when the interviewer has gotten a thorough sense of whether the individual is able to do this on his own. Here it is possible to draw together material from throughout the interview. The best comments here will be like good interpretations in therapy: the material will be just out of the subject's awareness, and not overly abstract or experience-distant. Sometimes it will be difficult for the interviewer to formulate such interpretations. If nothing comes together, the interviewer should use this section to ask more general questions: eg., how did the experience of having your father die contribute to how you were in Vietnam? After sharing an insight and getting the veteran's reaction, ask he following questions: What do you think about that? Had you ever thought about that before? What do you think about it now? Does it really seem to go together, or do you think there is a better way of looking at it than mine?.
178 APPENDIX D
PORTRAITS OF THREE VETERANS WHO USED DIFFERENT RECOVERY STYLES Portrait of a Veteran who Seals Over Pre-war portion of the interview: Mr. A. went to Vietnam because he was drafted. He said he was scared when he got his draft notice and he thought about not going. He believed he had some options to avoid the draft. But he felt he had to serve because everybody else was going and he had a patriotic duty to his country. Mr. A. painted a rosy picture of his life before the war. ''Everything was going great/" he said. "I was working in a factory and things were going smooth." Growing up, Mr. A. said that he was "an average kid" who lived in "an average American middle-class family." He said that his father was an average factory worker: "He was just an average guy." He mentioned that his father drank, but was not abusive. He briefly described his mother as a woman without much of a personality who worked outside the home and cleaned the house. Mr. A. described her as a "cold person." Mr. A. said that he did not think much about his relationship to his mother or father growing up. When asked about his siblings, Mr. A. said he did not have much in common with them and they got along "alright." Mr. A.'s account of his childhood was dominated by a tendency not to look too closely at what went on, though it is possible to speculate that his mother's coldness and his father's drinking might have had important meanings to him. Mr. A. was asked to describe a memory of something he had felt guilty about growing up. He mentioned not applying himself in school and skipping classes to go fishing. He quickly added that he did not regret these things at the time. Mr. A. was asked what he made of his not applying himself. He said he did not know. He said there was nothing typical or characteristic in his attitude to school. He recalled being bothered that others applied themselves as little as he did and did better in school. But he had few thoughts about why that bothered him. "I don't know how I felt," he said. "I have no idea." Mean scores:
Integrating-Sealing Over: 6.00 Curiosity: 6.00 Continuity: 5.67
Summary: Mr. A. was scored as a sealer because he showed little interest in exploring personal motivations and he was not curious about himself. He preferred thinking about himself as an average person. He chose to see himself as a person not much affected by his upbringing. Though
179 there were aspects of Mr. A.'s experience that might have led to an elaboration of personal responses, Mr. A. appeared to be the sort of person who gravitated to external explanations that did not have much to do with his inner life. Vietnam portion of the interview: Mr. A. was asked at the outset of the second section what stood out the most for him about Vietnam. His immediate response was that Vietnam changed him. Mr. A. said that when he first arrived in Vietnam he was astonished by the pleasure other GIs took in killing people. A month later, he became the same way. He also noted how angry the soldiers were when he first arrived, especially those who had lost their buddies. He didn't understand that at first. "I had been passive and easy-going," he said. "I went from being a passive person into being an animal. I never came back to the person I was. I became a completely different person." While he was in Vietnam, Mr. A. said he didn't show many feelings, though he was very scared. This was quite different from how he was before Vietnam. He used to be a person who expressed his feelings and was quite outgoing. He described being ambushed one time when everybody on the tank in front of his was killed immediately. His way of responding was to be matter of fact. "It didn't affect me," he said. He responded stoically, the way he was trained. When asked if this response was at all typical, Mr. A. said he could see no similarities to ways he responded before the war. He also described his attempts to manage stressful situations by getting high and blocking things from his memory. He identified these responses as being the opposite of the way he handled things when he was growing up. When he was growing up, he said he thought about things and tried to figure them out. He said that Vietnam taught him not to think about things. In response to a question requesting him to describe something he did in Vietnam that he felt guilty about, Mr. A. mentioned times that he shot into villages. When asked to explain how he understood why he did what he did, he explained that he did this because he was angry about his buddies getting killed and wanted to seek revenge. It was a way of discharging his anger. The interviewer asked Mr. A. if it had been typical of him to find ways to discharge his anger, and again Mr. A. drew a sharp line between what he did and Vietnam and how he responded before the war. "No, no, no!" he said. A portion of the interview centered on whether Mr. A. felt that he was pretty much the same person in Vietnam as he was growing up. He said with a great deal of certainty that people who knew him before the war would not have recognized him. "War turned me into an animal," he said. The interviewer attempted to press Mr. A. to find some links between how he was growing up and how he handled Vietnam. For instance, the interviewer noted some similarity between
180 the way Mr. A. had described himself as reacting without feeling in Vietnam and his description of his mother as cold. This provoked a spark of interest in Mr. A.. He said this was an idea that he had not thought of before. But he conclude^ that the similarity must have been hereditary. It did not appear that he saw any psychological connection between his experience of his mother growing up and his later attitudes. Mean scores:
Integrating-Sealing Over: 5.67 Curiosity: 5.67 Continuity: 5.67
Summary: Mr. A.'s scores place him among the subjects who were rated as the most sealed over. He was scored as a Sealer because of his sense of himself changing completely while in Vietnam. Indeed, Mr. A.'s conviction that Vietnam made him a different person was his most prominent feeling about his war experience. The interview indicated that Mr. A. compartmentalized Vietnam from the rest of his life and that he avoids making connections between how he was during combat and his life before the war. He preferred to see all of his actions in Vietnam as related to his training and to the nature of combat. He focused on the external characteristics of things, and for the most part was not curious about what goes on inside of him.
Portrait of a Veteran Showing a Mixture of Integration and Sealing Over Prewar portion of interview: Mr. B. described a very difficult relationship with a father he described as abusive. He chose to enlist in the marines following an incident in which he punched his father and was brought before a judge. The judge said Mr. B. could join the military or he would go to jail. He was first stationed in the Philippines, but later volunteered for duty in Vietnam in order to escape what he described as "an overly serious relationship with a woman." Growing up, Mr. B. stated that he was in constant fear of his father who beat him severely. Mr. B.. described his mother as a tramp who slept with many men and eventually divorced his father. Mr. B. said he despised his mother, but was reluctant to really discuss his feelings about her in the interview because "no one should even think that way." He described how his father treated him differently from his brothers and sister. Mr. B. got the idea that his father didn't really believe that Mr. B. was his own child. Mr. B. said the family environment was harmful to himself and his siblings. "All of us have low self-esteem," he said. "Our father broke our will." After a while, he said,
181 he stopped standing up for himself and put up with his father's treatment. For instance, if his family went on a picnic with other families and played some games as a group, Mr. B. was forced to compete last. If he won, the prizes still went to other children. Incidents like these led Mr. B. to stop trying, and he identified this passivity as a rather characteristic attitude. Mr. B. said that punching his father was his way of finally standing up to him and attempting to gain back a sense of control, though he said even this did not "erase the pain." In response to an inquiry about a memory of something that he felt guilty about, Mr. B. described a time that he killed a snake. Asked what he made of this act, he at first provided externalized explanations. In the south, where Mr. B. grew up, he said, people are taught to hate snakes. When the interviewer asked him to explain more of his motivation for killing the snake, Mr. B. said, "I have no idea." He did not see his reaction as being at all typical, saying that he raised animals and would never wish to kill them. With some additional thought, though, he said, "Something must have been bothering me. Maybe I wanted to beat somebody else." He then suggested that perhaps this was his way of responding to the fact that he had been beaten nearly every day by his father. Mr. B. also mentioned a time when he was younger that he had killed a baby duck and he wondered if this too could have been his way of grappling with his abuse by his father. The interviewer then wondered to what extent Mr. B. felt that this response to his father's beatings was in some way typical of him. Mr. B. responded: "I give what I get." Mean Scores:
Integration-Sealing Over: 2.67 Curiosity: 2.33 Continuity: 3.00
Summary: Mr. B.'s scores placed him in the middle of the sample. The coders saw him as able to provide some sophisticated explanations for his own responses and reactions but found him unable to do this consistently. For instance, he took little personal responsibility for the relationship troubles that led him to volunteer for transfer to Vietnam. His ideas about what motivated him to kill the snake and the baby duck were psychologically astute. He managed to connect what he did with a continuous sense of himself as a person who "gives what he gets." But the raters wondered how committed he was to these explanations, including the insight he developed about the snake and duck incidents. He seemed to be responding to the interviewer's efforts to encourage him to reveal his psychological understandings of himself, but the affective quality of his responses suggested to the coders that he was not really invested in this way of thinking.
182 Vietnam Portion of the Interview: Mr. B. talked of how at first in Vietnam he wasn't scared. Mr. B. attributed this to being young, having little experience, and being trained not to be affected. He described himself as very daring, and spontaneously asked the interviewer if he thought that he had purposely put himself in danger. When the interviewer asked what made Mr. B. think that, he retracted the idea and said that the way he reacted was pretty "normal" for people new to combat. Mr. B. ended up experiencing many painful and fearful moments, including the deaths of two buddies. He noted a feeling of not being able to stand watching someone be hurt or killed and being helpless to do anything about it. He connected this feeling to a time after the war that he saw a car accident and was hoping that the people inside were dead because he did not "want to watch anyone die." He said he had a particular fear of seeing someone die and not being able to help, but provided little further explanation for why this might trouble him. One of Mr. B.'s most stressful moments in Vietnam was the time he was wounded. Although he was scared and thought that he was going to die, Mr. B. made jokes because he wanted his buddies to remember him as brave. When asked if this was a typical way for him to respond to stressful situations, Mr. B. generalized. "Denying our fear helps us to survive," he said. "If I was going to die, I might as well face it and not be a baby." He also said that his response was "normal" and determined mostly by his training. He could see little that was typical or characteristic of him in it. Mr. B. was a squad leader and talked of his efforts to be very fair, including his willingness to go into dangerous situations with his squad to "show them I didn't think myself any better than them." When asked where his desire for fairness may have come from, at first he was puzzled. But he then said that he thought his situation as a child was not fair. "A person on the receiving end of a bad situation may have more awareness and empathy," he said. "Possibly that was true for me." Mr. B. also spoke of an overpowering feeling of despair and pessimism he felt in Vietnam. When asked what he made of that feeling, he first connected it to boot camp where the marines had no control over their fates. He then noted that the feeling might have been similar to his childhood, where he felt trapped. "There were no good days and I didn't see any around the corner," he said. One of the guilty memories Mr. B. related was of a time when he led his squad into a village where it was ambushed. Mr. B. had asked the men who were on night patrol with him if they wanted to go into the village to "get some pussy." Outside of the village they were ambushed. One of his men was killed and two were wounded. When asked about his understanding of what had led him to do what he did, he said
183 that all the men were "horny...all guys get horny. It was just a bad judgement call." In the section of the interview focusing on Mr. B.'s sense of identity in Vietnam, he said he thought people who had known him before the war would have been very surprised by his actions there. "I was kind of gutsy," he said. "I wasn't allowed to be gutsy before." Toward the end of the interview, the interviewer picked up on Mr. B.'s concern raised earlier that he had put himself in harm's way. Mr. B. seemed to get uncomfortable. "My mother always said I'm accident prone and my sisters think I have an unconscious wish to harm himself," he said. "That's not true." However, he did mention at this point that he could have avoided the mission in which he was shot, which happened six days before he was supposed to leave Vietnam. He said he did it anyway because it was important to him to be involved in the war. The interviewer asked Mr. B. some additional questions to clarify the ways in which he saw his life before Vietnam affecting how he reacted there. In spite of some of his earlier connections, Mr. B. seemed to become committed to viewing his experience in Vietnam as what he called a "separate story" from what he had experienced at home. Vietnam was a "whole new start away from my father. In Vietnam I was able to dismiss childhood from my mind." Reminded of his earlier connection between his despair as a child and his pessimism in Vietnam, he now was uninterested in the parallel. "That [pessimism] is normal when you are in a bad situation," he said. At the very end, Mr. B. continued to be unsure what influence his growing up had on him in Vietnam. "Childhood might have had an impact on who I was in the Marine Corps, but maybe not," he said. "In the Marine Corps they train you so much that you were physically weak and they take away from you everything that is civilian. They tear you down and bring you back up as a Marine. They took a 17 year old boy and brainwashed him." He did not appear to see his experience of his training in the Marine Corps as at all similar to some of the feelings of being out of control that he had elaborated about his upbringing. Mean scores:
Integration-Sealing Over: Curiosity: 4.6 7 Continuity: 4.33
4.00
Summary: While Mr. B. came remarkably close at times to seeing continuity between his pre-war self and how he was in Vietnam, he always moved away from integration toward emphasizing the distinctiveness of his military experience. In the end, Mr. B. stressed that the experience of Vietnam was largely colored by military training and the Vietnam environment. Mr. B. often was not inclined to identify his own personal motivation and reactions, tending to halt further inquiry by saying what he experienced was "normal."
184 He hinted that he had some awareness of a tendency to wind up in dangerous situations, even volunteering the idea himself at one point. But he needed ultimately to dismiss the thought, and wound up stressing strongly the ways his war experience was unconnected to aspects of his earlier life.
Portrait of an Integrating Veteran Mr. C. acknowledged readily that his conflicts with a difficult, strict father led him to enlist in the service. He described his relationship with his father as being the most important influence on his later life, including his experience in the military. He poignantly spoke of how much he had wished for a close connection with his father: "I really wanted the approval and affection of my father." But his father called him names and belittled him. Mr. C. spoke of how he rebelled as a teenager against his father, and mentioned a particular time that he struck his father. Mr. C. felt that the military would be a way of escaping the painful situation at home: "I was looking to get away. The military was like a vacation." He spontaneously spoke of how Vietnam helped him to understand his childhood. "Vietnam desensitized me and made me more aware of what was going on," Mr. C. stated. "Many of my Vietnam buddies expressed a lot of depression and anger and wanted to be isolated. I experienced that before I went to the military. As a result of Vietnam, I seem to have been able to understand what was going on with me behaviorally as I was growing up. It for me was the most important thing, trying to understand what was going on between my father and me." When asked how Vietnam helped him understand his upbringing, Mr. C. stated: "In the military I was recognized as a person with a good head on my shoulders and I began to wonder if [growing up] I was rebellious or if my father was a maniac." He said that being recognized as a talented soldier helped him perceive more clearly how withholding his father had been of praise and validation. Mr. C. showed some tendency to externalize in his portrayal of his abusive father, but he was able to own his strong wishes to rebel against his father, which he recognized as being very much a part of him. Mr. C. also elaborated on ways that his relationship with his father helped prepare him for the authority structure in the military, but stated that in the military he could accept authority more readily. When asked to provide a memory of something he felt guilty about growing up, Mr. C. described in detail the incident in which he had struck his father. It happened during the summer when he was working for his father's Pre-War Portion of the Interview:
185 business. Mr. C. had stayed out all night and came in late for work. His father was seething with anger. His father belittled him in front of the other employees and then hit him. Mr. C. described not being able to stand the humiliation, especially because he had tried so hard in the past to be the good boy. Not willing to tolerate his father's abuse anymore and feeling he no longer had any way to vent his anger, Mr. C. struck him. In describing his reaction, Mr. C. provided an externalized explanation, saying that his anger had been pent up for a long time, but was released at this moment because he was tired. However, in additional discussion, he was able to connect his reaction to his ongoing sense of himself as a rebellious person. In additional elaborations of his pre-war life, Mr. C. was willing to take a fair amount of responsibility for his own responses. For instance, he spoke of the time he found a pornographic picture on the ground while walking to school. He said that finding it stimulated an excessive drive to be excited by pornography that lasted for quite a while. Mr. C. remarked: "I wish I hadn't found it." Mr. C.'s initial account was externalized in this way, for he acted as if his feelings were the result of having found the picture. When the interviewer wondered if the picture had appealed to Mr. C. because it seemed so forbidden in his strict household, Mr. C. became immediately intrigued. "Oh, that's good!," he said. "I sensed that, there's a definite connection." This led him to continue to talk about his sense of himself as a "reactionary" person. He appeared to mean that he always felt himself to be a person who rebelled and reacted. He then spontaneously connected this attitude to his need to strike back at his father. Mean scores:
Integration-Sealing Over: Curiosity: 1.33 Continuity: 1.00
1.67
Summary: Mr. C.'s scores characterize him as one of the most integrating subjects in the sample. He appeared interested in his past and spoke of it as a valuable part of his life that shaped his reaction to Vietnam. He also developed sophisticated insights about his childhood and its effect on him, such as his notion about the appeal of the pornographic picture. He reacted with great interest to the interviewer's comment about the picture and seemed very invested in fitting things together about his early life. There were times when he began to disavow some of the personal meanings of his responses, but he usually went beyond these explanations to ideas that had to do with his inner life and characteristic reactions. He thought psychologically, spontaneously elaborating on his experiences with further insights. The coders felt Mr. C. showed a strong desire to understand his past and its influence on his later life.
186 Vietnam portion of interview: Mr. C. piloted a helicopter as part of Special Forces unit that often undertook missions in Cambodia. His job was to insert teams of soldiers onto the ground. Six out of ten times, he recalled, the troops immediately came under fire and it was his job to go back and retrieve them in the midst of heavy combat. Mr. C. described many stressful moments, including times that his helicopter was under fire, or he thought it was malfunctioning. He saw a fair amount of blood and gore; at times he had to pick up body parts and put them into plastic bags. In exploring his ways of reacting to these stresses, Mr. C. said that he endeavored the stay "cool as a cucumber." He stated: "I was not going to allow myself to be shook up. I was going to die with dignity." When asked what he made of this attitude, he readily connected it to times he had needed to steel himself during his childhood. He described in some detail how his father forbade him to play on the football team until his senior year. By then, it was too late to make the starting team, and he had to sit on the bench. Then, his father made fun of him because he wasn't playing. He recalled being furious with his father. But his response was to try to be "ok," and "stuff it." He usually tried outwardly not to show signs of the turmoil he was experiencing, though, as he said, he sometimes couldn't help being "reactionary." During the war, Mr. B said, "I continued to stuff it." He also described as continuous his need to remain loyal, which developed from growing up in a small, close knit community. This attitude continued during the war: "I was in charge of 30 guys and wasn't going to let them down." When asked to describe a guilty memory from the war, Mr. C. talked of times that he became "gung ho" and went out on night patrols in his chopper, using a spotlight to find people on the ground that he could kill. In describing his motivations for these actions, he talked initially of wanting to get revenge for the deaths of his buddies. But with some additional thought, he connected this reaction with lifelong concerns, including his sense of himself as "reactionary." He talked of how in order to mollify his father, he needed to be the "good boy." He had to be home early from dates, and could not join the football team. Kids in school ridiculed him for not being "macho." As a result, he believes he felt a special need to show his toughness. He felt an inner urge to show that he was powerful and masculine. "I wanted to be tough and show people," he remarked. Mr. C. connected this wish to the frustration he felt in his relationship with his father, where he never received approval, and was often made to feel less than a man. When questioned about his identity in Vietnam, Mr. C. quickly stated that he felt that he was very much the same person in Vietnam as he was growing up. Typical characteristics that he found similar included being loyal, hard working and a leader. Mr. C. said his experience in
187 Vietnam also made him more aware of the rage that was living inside of him. He learned he had a capacity to engage in violence. But he also felt that he was always a caring person, and this came through in his devotion to the men who served under him. He said that he always wanted to help people and this attitude continued after Vietnam. He now works with juvenile delinquents. Interestingly, Mr. C. spoke spontaneously of a time of great difficulty he suffered following the war when he was upset with some of the things he had done in combat. He spoke of how trying to make sense of his reactions in combat helped him enormously, and led to some of the understandings he shared in the interview. Mean Scores:
Integration-Sealing Over: 1.33 Curiosity: 1.33 Continuity: 1.33
Summary: Mr. C.'s integration scores reveal that he was one of the most integrating subjects in the sample. The coders assigned him the scores they did because of his strong tendency to analyze his reactions to Vietnam and relate them back to his childhood. Mr. C. was also open to interviewer's interpretations and often elaborated upon ideas or questions to provide his own insights. Mr. C. was interested and curious about himself and it was clear that he had thought on his own a great deal about his life and how his Vietnam experience fit into its overall pattern. Mr. C. seemed to use the Vietnam experience as a source of insight about himself.
188 APPENDIX E
PICTURE STORY TEST Instructions: I'm interested in creativity and how creative you can ba. I'd like to show you a coupla of pictures. For each one, I'd lika you to make up a story with a beginning, middle, and end. Tall me what lead up to it, what's happening now in the picture, and how it turns out. It need not ba a long, involved story, just the outline of a plot. (Do NOT ask for the characters thoughts and feelings at this point.) Because I will be talking with you later about the story, I will be writing it down. I may ask you to stop so I can get it down on paper.
Say the subject number on the tape. the TAT, using cards 4 and 14.
Then administer
1. If the stories are unelaborated, give prompts (not about thoughts and feelings) to fill them out. Use elements of the original instructions. What led up to it? How's it end? Why is the person doing that? Just make something up.
2. When both stories are finished, go back to first story. Read it to subject to refresh his memory (turn off tape first). Turn the tape on again and ask whether the story was transcribed correctly. Then ask for what the characters are thinking and feeling. Tell me a bit more about what the characters are thinking and feeling. 3. Some people think that a story like this can tell something about the person who made it up, so that someone who heard your story would learn something about you as a person. Do you think your story could tell something about you? How? What might your story tell about you?
Subjects may have difficulty understanding this aspect of the task. It may be necessary to ask several other
189 questions to see if the subject can make connections when pushed a bit. Some subjects will say, "I’m like that, I do that, I feel that." The interviewer should then ask for examples. You said you are.... just like the character in the story. Give me an example.
Try to keep the subject focused on the story. There may be a tendency to move from an idea elicited by the story to associations that move farther and farther from the story. How does that fit with your story? So the story tells this about you?
Finally, if the subject does not spontaneously comment on why the story was created as it was and what that says about him, it is acceptable to ask about this. The goal is to see if the subject can develop an understanding not just of similarities between themselves and the events and characters that populate the stories, but whether the fact that the story is told as it does says something about them. way,
How do you understand that you made the story up this today? Doe8 it say anything about you that you made it up this
way? You probably realize that you could have made up any number of stories for this card. Why do you think it came out this way?
6. Go to second story, turn off tape. Read to subject to refresh memory. Turn on tape and repeat numbers two and three above.
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