Healthcare Training Institute - Quality Education since 1979
CE for Psychologist, Social Worker, Counselor, & MFT!!

Section 17
Discovering Commonality: Group Therapy for PTSD Survivors

Question 17 | Test | Table of Contents

Traumatic events destroy the sustaining bonds between individual and community. Those who have survived learn that their sense of self of worth, of humanity, depends upon a feeling of connection to others. The solidarity of a group provides the strongest protection against terror and despair, and the strongest antidote to traumatic experience. Trauma isolates; the group re-creates a sense of belonging. Trauma shames and stigmatizes; the group bears witness and affirms. Trauma degrades the victim; the group exalts her. Trauma dehumanizes the victim; the group restores her humanity.
Repeatedly in the testimony of survivors there comes a moment when a sense of connection is restored by another person’s unaffected display of generosity. Something in herself that the victim believes to be irretriev­ably destroyed- faith, decency, courage- is reawakened by an example of common altruism. Mirrored in the actions of others, the survivor recognizes and reclaims a lost part of herself. At that moment, the survivor begins to rejoin the human commonality. Primo Levi describes this moment in his liberation from a Nazi concentration camp:

"When the broken window was repaired and the stove began to spread its heat, something seemed to relax in everyone, and at that moment [one prisoner] proposed to the others that each of them offer a slice of bread to us three who had been working. And so it was agreed. Only a day before a similar event would have been inconceivable. The law of the [camp] said: "Eat your own bread, and if you can, that of your neighbor," and left no room for gratitude. It really meant the [camp] was dead. It was the first human gesture that occurred among us. I believe that moment can be dated as the beginning of the change by which we who had not died slowly changed from [prisoners] to men again."

The restoration of social bonds begins with the discovery that one is not alone. Nowhere is this experience more immediate, powerful, or convincing than in a group. Irvin Yalom, an authority on group psycho­therapy, calls this the experience of "universality." The therapeutic impact of universality is especially profound for people who have felt isolated by shameful secrets. Because traumatized people feel so alienated by their experience, survivor groups have a special place in the recovery process. Such groups afford a degree of support and understanding that is simply not available in the survivor’s ordinary social environment. The encounter with others who have undergone similar trials dissolves feelings of isolation, shame, and stigma.

Groups have proved invaluable for survivors of extreme situations, including combat, rape, political persecution, battering, and childhood abuse. Participants repeatedly describe their solace in simply being present with others who have endured similar ordeals. Ken Smith describes his first reaction to joining a group for combat veterans of the Vietnam War: "Since Vietnam I’d never had a friend. I had a lot of acquaintances, I knew a lot of women, but I never really had a friend, someone I could call at four o’clock in the morning and say I feel like putting a 45 in my mouth because it’s the anniversary of what happened to me at Xuan Loc or whatever the anniversary is. . . . Vietnam vets are misunderstood, and it takes another Vietnam vet to understand us. These guys perfectly understood when I started talking about. . . certain things. I felt this overwhelming relief. It was like this deep dark secret I’d never told anybody."

An incest survivor uses almost the same language to describe how she regained a feeling of connection to other people by participating in a group: "I’ve broken through the isolation which had plagued me all my life. I have a group of six women from whom I have no secrets. For the first time in my life I really belong to something. I feel accepted for what I really am, not my facade."

When groups develop cohesion and intimacy, a complex mirroring process comes into play. As each participant extends herself to others, she becomes more capable of receiving the gifts that others have to offer. The tolerance, compassion, and love she grants to others begin to rebound upon herself. Though this type of mutually enhancing interaction can take place in any relationship, it occurs most powerfully in the Context of a group. Yalom describes this process as an "adaptive spiral," in which group acceptance increases each member’s self-esteem, and each member in turn becomes more accepting toward others. Three women describe this adaptive spiral in an incest survivors’ group:

"I will look to this group experience as a turning point in my life, and remember the shock of recognition when I realized that the strength I so readily saw in the other women who have survived this.. . violation was also within me."

"I am more protective of myself. I seem ‘softer.’ I allow myself to be happy (sometimes). All of this is the result of seeing my reflection in the mirror called ‘group.’"

"I’m better able to take in the love of others, and this is cyclical in allowing me to be more loving to myself, and then to others."

A combat veteran describes the same experience of mutuality in his veterans’ group: "It was reciprocal because I was giving to them and they were giving to me. It was a real good feeling. For the first time in a long time it was like, Wow! I started feeling good about myself."

Groups provide the possibility not only of mutually rewarding relation­ships but also of collective empowerment. Group members approach one another as peers and equals. Though each is suffering and in need of help, each also has something to contribute. The group requisitions and nurtures the strengths of each of its members. As a result, the group as a whole has a capacity to bear and integrate traumatic experience that is greater than that of any individual member, and each member can draw upon the shared resources of the group to foster her own integration.

Evidence for the therapeutic potential of groups comes from across the spectrum of survivors. In one community survey, women escaping from battering relationships rated women’s groups as the most effective of all sources of help. The psychiatrists John Walker and James Nash, working with combat veterans, report that many of their patients who fared poorly in individual psychotherapy did well in a group. The veterans’ profound feelings of distrust and isolation were countered by the group "camaraderie" and "esprit de corps." Yael Danieli affirms that the prognosis for recovery of Holocaust survivors is much better when the primary modality of treatment is group rather than individual. Similarly,

Richard Moffica reports moving from therapeutic pessimism to optimism when his program for Southeast Asian refugees added a survivors’ support group.

While in principle groups for survivors are a good idea, in practice it soon becomes apparent that to organize a successful group is no simple matter. Groups that start out with hope and promise can dissolve acrimoniously, causing pain and disappointment to all involved. The destructive potential of groups is equal to their therapeutic promise. The role of the group leader carries with it a risk of the irresponsible exercise of authority. Conflicts that erupt among group members can all too easily recreate the dynamics of the traumatic event, with group members assuming the roles of perpetrator, accomplice, bystander, victim, and rescuer. Such conflicts can be hurtful to individual participants and can lead to the group’s demise. In order to be successful, a group must have a clear and focused understanding of its therapeutic task and a structure that protects all participants adequately against the dangers of traumatic reenactment. Though groups may vary widely in composition and structure, these basic conditions must be fulfilled without exception. Those who attempt to organize groups also quickly discover that there is no such thing as a "generic" group suitable for all survivors. Groups come in a variety of sizes and shapes, and no one group can be all things to all people. Different types of group are appropriate at different stages of recovery. The primary therapeutic tasks of the individual and group must be congruent. A group that might be well suited to a person at one stage of recovery might be ineffective or even harmful to the same person at another stage.

- Herman MD, Judith Lewis; Trauma and Recovery; BasicBooks: New York; 1992

Personal Reflection Exercise #3
The preceding section contained information about the benefits of group therapy for trauma survivors.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
A participant-randomized pilot hybrid II trial of group cognitive
processing therapy for incarcerated persons with posttraumatic stress
and substance use disorder symptoms: study protocol and rationale

- Zielinski, M. J., Smith, M. K. S., Kaysen, D., Selig, J. P., Zaller, N. D., Curran, G., & Kirchner, J. E. (2022). A participant-randomized pilot hybrid II trial of group cognitive processing therapy for incarcerated persons with posttraumatic stress and substance use disorder symptoms: study protocol and rationale. Health & justice, 10(1), 30. https://doi.org/10.1186/s40352-022-00192-8

Peer-Reviewed Journal Article References:
Contractor, A. A., Weiss, N. H., Dolan, M., & Mota, N. (2020). Examination of the structural relations between posttraumatic stress disorder symptoms and reckless/self-destructive behaviors. International Journal of Stress Management, 27(1), 35–44. 

DeCou, C. R., Mahoney, C. T., Kaplan, S. P., & Lynch, S. M. (2019). Coping self-efficacy and trauma-related shame mediate the association between negative social reactions to sexual assault and PTSD symptoms. Psychological Trauma: Theory, Research, Practice, and Policy, 11(1), 51–54.

Khayyat-Abuaita, U., Paivio, S., Pascual-Leone, A., & Harrington, S. (2019). Emotional processing of trauma narratives is a predictor of outcome in emotion-focused therapy for complex trauma. Psychotherapy, 56(4), 526–536. 

QUESTION 17
How does Yalom define an "adaptive spiral"? To select and enter your answer go to Test.