How to Run a Group of PTSD Veterans
Using Simple Methods of Self-Therapy

Vietnam vets are misunderstood, and it takes another Vietnam vet to understand. Combat related PTSD is the same the whole world over. So too is the road to recovery. This is the main reason why veterans get together in groups: only other vets can really understand. This, and the fact that a supportive group can usually do more to help than a single friend, however prepared that friend may be.

When the group meets for the first time, all are equal. Throughout all the following meetings the members of the group will continue to be equal, all decisions affecting the group being made by the whole group. Nevertheless, at a certain stage it helps to have a group leader to hold things together, a suitable member of the group who has been selected unanimously for the job by the others.

Responsibilities of the Group Leader

The responsibilities of the group leader basically consist in calling the other members of the group to meetings, generally seeing that all members are OK, for example following up any member who doesn't turn up to a meeting (he may have gone to ground in desperation and is in a bad way). The group leader also acts a kind of chairman during the discussions, making sure that no one gets left out, that everyone has a chance to say his bit. As group leader, the individual obviously has less freedom to speak out himself. To solve this problem, the group may elect to circulate the job of leader around the group, each holding this position for a month or two at a time. This enables all members to experience the leadership role, while not denying any one of them the role of ordinary member with the freedom this gives to tell one’s story on an equal basis with the others.

When the group has passed the initial phase of getting to know each other, and decided to attempt a deeper dive into the specific problems of each member, the group leader can take on the additional responsibility of guiding the group through this more demanding phase of self-therapy. To do this he needs knowledge and skills that few ordinary veterans possess.

The following short description of group work is basic information that potential group leaders need to be aware of before they decide to take on the responsibility of running a group. This is more or less what you will be letting yourself in for, should you find yourself as leader of a group that sticks together, with members who are determined not to leave any stone unturned on their journey to recovery.

GROUP WORK

Self-therapy in a group context passes through several, fairly well defined phases. Each phase must be passed if group members are to gain any lasting benefit from the work.

There are three different types of group, one developing from the other during the course of the self-therapy process. The three groups also represent three different phases in that process.

Group 1 / Phase 1: Safety, Recognition and Intention

The first kind of group is based on a model developed by AA (Alcoholics Anonymous). This is an open group, usually without a professional leader. Leadership passes in turn from one to the other of the group members. The group is open in the sense that anyone can turn up, even if only to watch and listen during a single meeting. No one needs to speak if they wish to remain silent. No attempt should be made to penetrate the deeper levels of the trauma at this stage. Detailed descriptions of traumatic experiences by members should be avoided. The purpose of such a group is instead to establish a degree of safety for its members, building the basic sense of security needed for facing the second phase when the trauma is confronted.

Veterans not only speak; they listen. Some may wish do nothing else at the beginning. During meetings, information is shared about the nature of PTSD. The listening veteran is forced to consider whether or not he has this problem. If he recognises that he has, (no easy matter for some), he will eventually reach the point where he determines to do something about it. Out of Recognition comes Intention. The veteran forms an intention to work with his problems, together with the others. The second kind of group is about to be born.

The job of the group leader throughout this early stage is to ensure that each member of the group has the opportunity to make the mental journey from what may be an initial attitude of suspicion and scepticism, to a final state of acceptance and determined intention. This, without the pace being forced in any way. Each veteran must feel that he is free to make his own decisions in his own time. The form of meetings is that of open discussion, where everyone who wishes to speak has the right to do so, without interruption, until he has had his say. The group leader’s role is that of "facilitator", easing the way during the discussion for each individual group member and for the group as a whole.

How to start a group (group 1 level):

1. Gathering the group

Make contact with other vets that you suspect may benefit from joining a group, meet them, show them the list of symptoms of PTSD, talk to them, and suggest that together you meet regularly once a week or once a month, for example in each other’s homes, or some neutral location.

2. Getting started

Firstly, you need to get to know each other. Each vet in turn tells the story of his life to the others, with special emphasis on the war years. No interruptions until he has finished. There is no need to go deeply into any traumatic events at this stage. It can take quite some time (a few sessions) before everyone has had their say.

3. Have I got PTSD?

Together, study all information you can get your hands on about PTSD, the symptoms etc. Then get each group member to describe how he feels today, and what has happened to him during the years since he left the army. Ask each other, and yourself, whether or not this means that you are suffering from PTSD. When each member has admitted openly to the others that they actually do have PTSD, ask yourselves the question: OK, so what do we do about it?

4. Decision to form a closed group

At that point, a decision must be made as to whether or not the group should go over into phase 2, forming a closed group (group 2) in order to get into close combat with the trauma. Some guys may not yet be ready for this step. Suggest that they find some more vets who they think may benefit from group 1 work, and start a new group. Keep contact between the groups. The experiences of the one can be of help to the other. It’s teamwork that counts.

Group 2 / Phase 2: Remembrance and Mourning

The second kind of group is often a constellation of members from the first group who decide the time is right to delve deeper into their problems. This is a closed group, meeting on a regular basis, preferably with a professional "guide" (therapist) as leader. The guide, or group leader, should remain the same person throughout; chopping and changing is not a good thing. The group leader may be a psychotherapist or other professional worker with the right training and right experience for the job. It can also be a veteran. The veteran who feels himself capable of taking on this role has probably gone some way on the road to resolving his trauma. Ideally, he should already have passed through each of the phases in the self-therapy process and been a member of each kind of group. This does not only mean that he will know what to expect; he will also have reached a point where he has a strong desire to make amends by dedicating his new-found strength to helping other veterans who are worse off than he. He will also have learned something of the skills of "containment" - the art of listening to the horrifying accounts of others without either becoming hardened to or emotionally entangled in their pain. To the extent that he can do this, he will be effective in creating the space needed for others to solve their own problems. The leader of a group in this phase is still a facilitator.

As Remembrance and Mourning implies, the purpose during this phase is to dig up and confront repressed memories of the traumatic experiences that are the source of the present problems of each group member. The process begins with Recall, the effort to remember, and describe in detail, traumatic events from the past. It passes over into Reliving, the act of description plunging the veteran into the event itself. This is the toughest part of the whole process. The veteran sees the sights, hears the sounds, tastes the tastes, and smells the smells of that event. He experiences the tumultuous emotions he felt at the time. During this phase the total attention and support of the other members of the group is vital. The group leader encourages and guides this support so that it can do most good.

The intense reliving of the event and the emotions this arouses in the veteran, often shift him rapidly over into a state of Mourning. He is plunged into the grief-work that was never engaged in at the time of the original traumatic experience. The concentrated support of the others in the group is also vital here. The mourning may be for a comrade who is dead, for crimes committed, mistakes made, opportunities lost, or simply for loss of innocence.

Psychologists and others who have helped people through the mourning process (either for someone they loved, or for themselves, for example if they have just heard that they have an incurable disease) have noticed five clearly defined stages; Denial, Rage, Bargaining, Sadness, and Acceptance.

Denial: is screaming "No! No!' at the time of the trauma. It is also "Never Happened!" and "Didn't affect me!" People can get stuck in denial for years.

Rage: People get stuck in the rage stage, too, screaming and lashing out at everyone around them, or coldly angry and unable to change.

Bargaining: Stuck bargaining includes veterans who will only get well if the VA (Veterans Administration) gets perfect or if Jane Fonda goes to jail.

Sadness: The sadness stage is very difficult for most survivors because of our feel-good culture. Being sad is practically illegal. Sadness refused leads me to deep depression, but today if I start to feel depressed, I ask myself what do I need to feel sad about. If I can identify and feel it, I don't get depressed. Sadness needs to be felt. What happened to you was sad, painful, grievous. The only way out is through. Those feelings won't kill you. It is okay to grieve. Grief is part of life.

Acceptance: The final stage. Yes this did happen. It was bad and it has affected me. I have a scar, but I survived. In time, I may be able to use my experiences to help other survivors."

From this list it is clear that the different stages of mourning run throughout the entire therapy process. The man with PTSD who has not yet begun to face his problem is stuck in one or other of the first two stages, Denial or Rage. The man who has accepted that he has a problem, but has not yet dared to take the plunge in dealing with it, is stuck in stage three, Bargaining. Sadness comes after confrontation with the trauma. Acceptance is the main characteristic of the final phase in self-therapy.

Group 3 / Phase 3: Recovery and Return

Reconstruction and Reconnection

This is the final phase of Recovery, a recovering of that which had been lost (peace of mind), and a Return of the veteran to the everyday world as a transformed, probably wiser, human-in-being.

After mourning, the veteran has to confront the fact that a great deal has happened to him during the past months or even years (the self-therapy process can take a very long time; nothing should be rushed). He is confused. Unrecognised bits of himself that were hidden and repressed have come to the surface and float around together with those parts of his personality that he is familiar with. The life-force has begun to stir in him again and seeks new expression. During the phase of Reconstruction he has to bring the bits together into a coherent whole and find ways of channelling the life-force in constructive ways. He seeks to consolidate his new identity. The group leader (and the group as a whole) acts as a mirror during this phase, reflecting the growing self-awareness of the veteran back at himself, and, where appropriate, pointing out connections and links, and those areas where more work needs to be done.

This leads into a phase of Reconnection, the veteran’s new self, forged in the closed world of his group, has to re-establish connections with the outside world. During Reconnection, a return to a more open form of group is necessary. This is the stage where the veteran commences the process of rebuilding his life — a long and arduous business. Mutual support is also important here, since a number of psychological and practical problems must be faced that can be more easily solved with the help of others in the same position. The veteran’s friends are used to him being the way he was before; they are not going to find it easy to accommodate this new person in their midst. The veteran does not need to lose his old friends, but he might want to seek out new. He should also seek practical ways of giving expression to his new-found confidence. He may wish to change his present work, or if unemployed, he may now find the strength to find work. He may decide to study some new subject, either at school/university or in his free time. Finally, he may wish to find ways of making amends for the mistakes of the past. In all this, having supportive contact with other men in a similar position can be of enormous help.

METHODS OF WORK

Twelve steps to recovery:

Group work implies the need for some form of system or method to give structure to the different phases in the self-therapy process. Talking vaguely around the problem gets one nowhere. Probably the best known and most widely used method in dealing with PTSD of all kinds, including combat related PTSD, is "The Twelve Step" program. This was originally developed by Bill Wilson, one of the founders of AA (Alcoholics Anonymous). It has been successfully adapted for work with Vietnam vets all over the USA.

The essence of the Twelve Step program is a combination of two apparent opposites: support and confrontation. The veteran feels the solid support of the group, while at the same time the group does not allow the veteran to avoid doing that which must be done.

The Twelve Step program:

(an adaptation of the AA model for use with combat veterans with PTSD)

Stage by stage, each member of the group "bites off" each of the following statements or states of mind. For the group as a whole to be agreed that each state has been collectively reached obviously requires a lot of hard work and takes time.

1. We admit that we suffer from PTSD and that we are powerless to control the symptoms. In other words, our lives have become unmanageable.

2. We have come to believe that a Divine Power greater than ourselves can restore us to a healthy and normal life.

3. We have made a decision to hand our will and our lives over to the care of that Divine Power, whether we call it God or whether we believe that it is a latent strength that lies within our own souls.

4. We have made a searching and fearless moral inventory of ourselves.

5. We have admitted to the Divine Power, to ourselves and to another human being the exact nature of our wrongs. We have also seen why: the mechanisms that drove us to commit those wrongs. We have seen the wrongs that have been done to us, and we have also seen why: the mechanisms which drove our persecutors to commit those wrongs.

6. We are entirely ready to have the Divine Power remove all these, our defects of character. We are entirely ready to have the Divine Power take off our shoulders all hate and lust for revenge on those who have wronged us.

7. We humbly ask the Power to remove our shortcomings, our hates and our lusts for revenge.

8. We have made a list of all persons we have harmed, and are willing to make amends to them all.

9. We have made, or will soon make direct amends to such people wherever possible, except when to do so would injure them or others.

10. We have continued to take personal inventory and when we were wrong promptly admitted it.

11. We have sought through prayer and/or meditation to improve our conscious contact with the Divine Power as we understand It, praying only for knowledge of It’s will for us and for the power to carry that out.

12. Having had a spiritual awakening as the result of these steps, we have tried to carry this message to other veterans and to practice these principles in all our affairs.

To the uninitiated, the program may sound a bit weird, but the fact remains that many thousands of veterans all over the world, including those with a strong aversion to organised religion of any kind, have g ained an enormous amount from treating the Twelve Steps seriously and following the path they define. Until any better method has been developed, this system seems to be the best available. It works. To the question "why?", it can be said that following the way of the Twelve Steps tends to wipe out guilt and shame. Since guilt and shame are fundamental elements in all forms of PTSD, more than anything else such a cleansing has the power to change the life of the veteran.

Other Methods

There are other, complementary methods that can be used in group work. Keeping a journal is one. Writing down one’s story in a book, and then describing experiences, thoughts, emotions, memories, and dreams on a daily basis, is very useful for gaining distance to one’s problems. Rereading the journal also enables the veteran to keep track of his own progress.

Many methods tackle the problem that words are usually not enough when it comes to telling one’s full story. Bodily sensations, emotions, feelings, even things visual, are very difficult to put into words, unless one happens to be a poet. Some systems enable the veteran to give concrete, wordless expression to these aspects of his story. A few examples are given below:

Psychodrama, a method where the group acts out certain events in the veteran’s past, group members taking the different roles in his story, including his own, while the veteran himself directs "the play". The veteran sees his own role in the event from the outside and his own and others’ actions and motivations become much clearer. Memories of forgotten details will often be thrown up in the process.

Making Drawings and Paintings of traumatic events is also a useful method. The scene is made concrete and the memory can be jogged ("I think the armoured vehicle stood here, and I was behind this rock"). Painting is also an excellent way of giving expression to less concrete, but very pertinent aspects of memory, such as the feelings and emotions that were aroused at the time of the event ("It felt like this: all red and black"). As with psychodrama, the most important benefit comes from placing the memory of the event, both of its course and the veteran’s emotional reactions, outside the veteran’s mind and body, somewhere where it can be dispassionately observed and learned from.

Psychophysical exercise. Unconscious psychic stress affects the well-being of the veteran’s body; unexplained aches and pains of various kinds are a common feature of PTSD. These pains may ebb away of themselves during the course of self-therapy as the veteran approaches recovery. On the other hand, the problem can be approached from the other end. Regular body massage often loosens the chains of the mind. It becomes easier to talk, easier to remember, especially when it comes to lost emotions. At the end of self-therapy, working out, massage, running, squash and in other ways getting the body back into trim, are an excellent way of confirming and extending the new self-confidence of the veteran.

The group leader, even a professional, is unlikely to be familiar with all these techniques. An expert in one or other of these fields can be brought into the group over a limited period of time, if the group as a whole is agreed. The group leader’s role in such a situation is to ease matters for the expert and assist him or her in the work.

Conclusion

The potential group leader may easily feel that the task is beyond him. The role seems to demand knowledge and skills, and a course of training, which he neither has the time, money, nor ability to acquire. Don’t be put off. You may not yet be ready to take on a group. On the other hand, you may be far more capable of the task than you suppose. Much can be picked up on the way. Practical experience is the greatest teacher. But the system and methods described above are available, and can be learned without too much trouble, bit by bit, perhaps through a series of courses spread out over time. They have been successfully practised before by others in a similar situation to yourself, but are not necessarily essential. Each group (and each group leader) should always find its own way, the way that feels most comfortable. You have to find your way.

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