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A triage model of psychotherapeutic group intervention
A Triage Model of Psychotherapeutic Group Intervention Mark Evans and Grace Marad
The cofaciiitator of a veteran’s therapy group conducted by a Veterans Administration (VA) clinical nurse specialist uses his participant-observer role to analyze the theoretical constructs used in the group. A unique group psychotherapy model blending nursing triage techniques with “hot seat” client focus and interpersonal theory is presented and compared with similar models. Clinical
issues arising from its use among combat veterans with post-traumatic stress disorder at a New Hampshire VA Medical Center are also discussed. Copyright 0 1993 bg W.B. Saunders Company
G
ROUP THERAPY continues to be considered by a number of clinicians to be the treatment of choice for combat veterans suffering from post-traumatic stress disorder (PTSD) (Scurfield, 1985). A number of group modalities have been used to address PTSD since the informal “rap groups” of the early 1970s were formed by veterans, ranging from support groups to behavior modification (Smith, 1985; Williams, 1980). Early groups used a “hot seat”, a process in which members took turns as the focus of group attention. This particular model, intended to break down resistance and denial, used confrontation and group normative pressure as interactional dynamics (Smith, 1985). This model found less favor as psychotherapeutic groups replaced veteran peer support groups (Galloucis & Kaufman, 1988). Client focus in the “hot seat” manner has been replaced in combat PTSD group work by more traditional models of thematic interaction among group work by more traditional models of thematic interaction among group members with varying levels of direction from the facilitator (Galloucis & Kaufman, 1988; Scurfield, 1985). From the Veteran’s Administration Medical Center, Manchester, NH. Address reprint requests to Grace A Marad, RN, MSN, Clinical Nurse Specialist, and Mark C. Eoans, MA, VA Medical Center, Nursing Services, 718 Smye Manchester, NH 03104. Copyright 0 1993 by W.B. Saunders Company. 0883~9417/93/0704-ooo8$3.00ool0
244
Archives
A TRIAGE MODEL
A clinical nurse specialist working with outpatient combat veterans, Grace Marad, MSN, has developed a group therapy model in which nursing triage and the client “hot seat” of rap group models of the 1970s are combined to create a different dynamic. Marad, having facilitated a veteran’s group for several years, has permitted a psychology graduate student to participate as a cofacilitator of this group for 1 year, collecting data using a case study approach. During this time, the theoretical constructs used in Marad’s group practice have been identified and compared with those of existing models. This comparison has indicated that a nursing-based theoretical perspective for outpatient groups is unique and effective. Group Population and Needs
Marad serves the Veterans Administration (VA) Medical Center in Manchester, NH. The client population for her anger management group consists of Vietnam combat veterans with Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised (DSM III-R) diagnoses of PTSD (APA, 1980). All participants are referred by individual VA therapists and are considered to have high intensity symptomatology and low levels of social coping skills. The group meets twice each week for 90minute outpatient sessions. There are 8 to 10 par-
of Psychiatric Nursing, Vol. VII, No. 4 (August), 1993: pp. 244-248
A TRIAGE MODEL
ticipants, who have attended an average of approximately 80 meetings. It is proposed in the work by Horowitz & Solomon (1975) that post-traumatic stress is cyclic in its symptom clusters, meaning that a client would display the somatic and emotional effects of intrusive memories and survivor guilt followed by a period of anxiety control, denial , and avoidance behaviors. Even veterans with similar social, educational, and combat backgrounds could display a wide range of needs during any given group session. In addition, common continuing responses to PTSD include social isolation, alienation, hypervigilence, and rage (Berkowitz, 1980; Scurfield, 1985). As Friedman (1988) notes: Drug-mediated attenuation of intrusive or hyperarousal symptoms facilitate therapeutic work on guilt, grief, intimacy, rage, and other issues. It also appears that catastrophic exposure to trauma is followed by stable biological alterations in the sympathetic nervous system, neuro-endocrine system, and sleep/dream cycle. Such alterations appear to be unique to PTSD and distinguish it from major depression and panic disorder despite similarities in symptomatology tp. 284).
Many group intervention models based upon the work of Yalom (1985), emphasizing a group developmental approach based on such factors as group cohesion, self-disclosure, trust, therapist genuineness and presence, have reported success with inpatient veteran populations (Makler, 1990; Miller, 1983). Grace Marad, working with an outpatient population, has adapted the concepts of nursing theorist Hildegard Peplau (1978) to the work of combat-trauma psychotherapy. Peplau’s conceptual model of intervention calls for a blending of interpersonal group process work with skills associated with traditional nursing roles when treating medical patients. Such a blend is created in the use of triage by the facilitator and members of her veterans anger-management group. The Triage Model In Use
Marad has developed through years of practice, a triage model for this group that is intended to ameriolate disparities between participants and promote social integration. Each session begins with one client in the “hot seat”, but the goal is shared empathy, not confrontation, and the focus is based on need, not rotation. Triage in the psychotherapeutic group process
245
begins for Grace Marad before the group even assembles. During the half hour before session, she gathers information about the participants from a number of sources. Clients are greeted as they arrive. In these brief encounters, Marad observes the client’s affect, mood, level of functioning, and often learns about between-session changes in symptomatology as well as any social or family events with special significance for the client. Patient charts are reviewed for the results of any between-session appointments with individual therapists, psychiatrists, or physicians. Marad examines the notes from the previous group session, as well as notes from intersession conversations with participants. By the time she enters the group room, she had already monitored the “vital signs” of her clients. The triage process, prioritization of treatment, begins immediately. Marad scans the room as she checks in with each veteran. In some faces she looks for incongruence in affect or mood from previous conversations, in others for indications that previous difficulties had not improved. Because PTSD is a highly physiological disorder, Marad is especially attentive to body cues of intense PTSD symptomatology: anger, hypervigilence, fatigue, dissociation, and depression are often evident in the faces and bodies of the participants. The severity of symptomatology and of psychosocial stressors are gauged during these opening exchanges. All these men are in pain, but some are clearly in trouble. A significant decline in functioning linked with an increase in PTSD symptom severity is given first priority. Marad comments upon the need to pursue a dialogue with the priority-need participant: Often I have to draw them out. It’s common with these vets (with FTSD) that when they are in the most pain they won’t say anything until you bring them ‘into the room’ with questions.
Other clients are included as the dialogue is quickly widened into a group discussion. Their perceptions of the priority situation, parallels in their own experience, and implications for other veterans and families are sought. The content and themes of these offerings are focused by the facilitator through questions and interpretation, and the focus remains upon the prioritized client.
246
EVANSAND MARAD
A typical exchange: CLIENT A: I want to talk about the drive up here. It’s a real pain to drive as far as I have to go. It can really be hard if you haven’t MARAD: gotten any sleep the night before. (turns to client B) You look as if you haven’t slept in a couple of days. CLIENT B: (I’m) not tired. (to client B) Can you tell us what MARAD: your sleep has been like? CLIENT A: (Responding to the question from client B) I took a nap on Tuesday. (I’ve) been awake since then. Does anybody else have a problem MARAD: with sleeping? CLIENT C: Sure. Sometimes I go for days like that. (turns to client B) But, man, I got to tell you that you aren’t looking so good. CLIENT B: I don’t feel so good either. Flashbacks . . . (to client A) How do you think he MARAD: looks? What could we do to help? CLIENT A: I wasn’t really looking, but now that you mention it, (client B), you might want to think about seeing a doctor for some new medication. This staying up just won’t do for long. CLIENT B: Worried about me, are you? Yes, we’re all a little concerned MARAD: when it happens. Maybe you could tell us what may have brought on the flashbacks and kept you awake . . . Interactions are kept highly focused on the prioritized situation, but Marad emphasizes the practice of empathy and interpersonal communications over intrapsychic themes or problem-solving: Those will follow in time, but I am a strong believer in H.S. Sullivan for these groups. These clients have terrible isolation and tremendous disturbances in their ability to relate to other people. Many of them do not care if they live or die, they are that affected, and getting them to care for another vet is a powerful way to get them caring for themselves.
The use of triage focus does not result in diminished group cohesion, but becomes an experiential exercise in interpersonal relations. This focus also achieves another important goal, the leveling of the client-need base.
The severity of symptomatology and functioning can vary significantly among clients in any group setting; these differences can prove especially challenging in open groups (Makler, 1990) and outpatient groups (Smith, 1985), and the group that Marad facilitates is both. An intended by-product of triaged treatment for psychosocial issues is, as Marad points out, to: bring the group to a place where no one individual’s problems are so powerful and so unacknowledged that he finds he cannot afford to participate and has to leave or ‘act out’ just to get some relief.
The focus-group that follows triage lasts from 10 to 20 minutes. During this time, Marad continues to reevaluate her priorities for group support. If other veterans are in need of focused attention, the center of group attention will shift from one client to another until the group has addressed issues that would otherwise force those clients who are in particularly severe emotional pain towards an inward locus of attention, instead of a more interpersonal locus, so that group work can be effective. However, if this is not the case and the group’s affect and need for individual support are somewhat normative, she will gently bring this portion of the group process to a close. The technical goal as a facilitator, at this point, is to encourage the participants to complete the major business of individual difficulties and crises, offering closure and review, and cueing the veterans to begin the interactional group process in as natural a fashion as possible. Marad comments: It’sparticularly therapeutic for these painfully isolated clients to learn how to talk with others in interactions which are not rigid or ritualized.
A peer support group model gradually comes into play, and the remaining hour in the session is shaped by those themes that emerge among client interactions. The closing of the group includes not only a summary of the themes that arose in the discussion, but a recap of the initial issues of the prioritized member and the responses of the rest of the group. Marad encourages this kind of relationshipbuilding in session, during breaks, and even between sessions. She acknowledges great influence from nursing theorist Hildegard Peplau, who wrote that nursing needed to emphasize interpersonal as
247
A TRIAGE MODEL
well as physical healing, with a de-emphasis on roles and their attending distortions, if long-term healing and growth are to be maintained. (Peplau, 1991) Veteran Perceptions of The Model
Participants in this outpatient group, discussing their perceptions of group interactions with the first author, identify reenactment qualities, consistency with inpatient VA programs and interpersonal skills building within the model used by Grace Marad. The rescue of one member by the others appears to reenact a frame of mind reminescent of bonds both in combat and inpatient recovery. One veteran has likened the beginning of group to “suddenly realizing that your point man on the patrol is down. You don’t leave your buddy-you go in there and help” (Client A, personal communication, 28 November 1991). The role of debriefing, a military-style recounting of significant events, has been of recognized value in inpatient individual and group treatment. The triage portion of the Manchester VA group has been seen by another participant as reenactment of that process as well: It’s like being out on an L.P. (listening post) all week (living in the community) and coming in for a debriefing. The one you listen to first ought to be the one who made contact, not the first one who has anything to say (Client B; personal communication, 28 November 1991).
Reduction of social alienation through modeled altruism, reported in the literature (Galloucis & Kaufman, 1988; Fischman & Ross, 1988), is described as a notable therapeutic feature of this group model by participants (Clients A-E, personal communication, November 28, 199 1). The veterans discuss their perception of being in the “hot seat” when unconditional positive regard and parataxic clarifications are used instead of confrontation: CLIENT B: You’ve got to understand. We don’t let people on the outside put us in any “hot seat”. . . . My wife tries to do that. She means well, but I just tune her out. The difference is that here, it’s our decision to be in the “hot seat’ ’ . CLIENT A: Only another vet can tell you what is what. And if we see a vet in trouble, we’re there.
CLIENT B: It’s not just that either. When other people put you in the “hot seat”, they do it to put you down. Here it’s because they’re trying to help. Other people try to humiliate us . . . to hurt us. CLIENT D: We sense what each other feels. The veterans also express a perceived therapeutic value in the time-limited focus segment of the group: CLIENT C: We go with whoever is hurting until we know they’ll make it out in one piece. CLIENT B: My wife would stay around like you guys would, and she knows when I’m in trouble just like you guys would, too, but she just doesn’t know when to shut up. CLIENT A: Another vet doesn’t pity. And family, they don’t know how to look you dead in the eye and say they care without pity. Help me out of this, and then just back off enough for me to stand up like a man. Veterans confirm that the focused intervention also has a leveling effect, which allows a more balanced group discussion once priority issues have been addressed. However, several have indicated that they have often attempted to extend such sessions in order to avoid discussion of more anxiety-provoking themes. “If Grace’d let us get away with it, we’d talk about somebody else all day,” comments Client A (Personal communication, November 28, 1991). DISCUSSION The triage model as practiced by Grace Marad appears particularly suited to the long-term management of, and recovery from, PTSD symptomatology. The plethora of physiological, social, cognitive, and emotional triggers that could result in crisis make prioritized intervention during group sessions an attractive model for this population. This intervention, because it is enacted through the group, also provides a rich source of thematic work for later discussion. Because different clients need focused support each week, the model acts naturally to break down the assumption by participants of rigid group roles, such as the ‘harmonizer’ or ‘deviant’ (Cory & Whiteside, 1990). A wide range of interpersonal communications
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schemes are experienced as both roles and situations change. The unchanging focus on modeled empathy and clarification promotes general social values and skills, which in turn support successful group exploration. However, there are drawbacks to triage in group process. Veterans have acknowledged that the light that exposes one client produces shadows on another. Avoidance tactics, driven by strong selfprotective mechanisms, could reduce the inattentive facilitator to focus on fewer and fewer members, whose repeated attention from the group would promote dysfunctional social skills, whereas others do no therapeutic work at all. There is also a real danger that the group could become “stuck” in a crisis intervention posture unless the facilitator carefully weaves in thematic and process similarities between group members when attending to an individual’s pressing needs. This group, with its focus on distorted or avoided interpersonal relations, may be sensitive to socialized gender differences in communication styles; cultural and ethnic differences could also be a significant factor in the limitations to usage of a triage model in group psychotherapy. Transference and countertransference would also be of concern in the use of this model, and facilitators would have to be particularly careful to monitor their triage choices and intensity of intervention when providing focused treatment. Finally, a benefit and drawback to the widespread use of this model also concerns its designer’s grounding in the field of nursing. Although rapid assessment is a recognized part of psychotherapeutic practice, rapid response is not. This style of client work in the group setting, so natural to the clinical nurse specialist, could prove alien and uncomfortable to other disciplines with other perspectives and historical paths of treatment. Further study of this model through periodic symptom and interpersonal skills assessments is indicated, as are careful comparisons of this model with other group models through controlled longitudinal outcome studies. CONCLUSION
The perceptual and somatic assaults on many combat veterans continue long after the war has ended. The nights still bring fresh attacks and no
real sleep. Anger at so many, fear of so much, and guilt for having survived when others did not, color each hour of the veteran suffering from PTSD. A model that acknowledges the immediacy of symptomatology without being tied to a more group developmental or recovery-tasks model is clearly desirable for the long-term survivors of trauma. REFERENCES Berkowitz, M. (1980). Themes in treatment of Vietnam veterans. In T. Williams (Ed.), Post-traumatic Stress Disorders ofrhe Vietnam Veteran. (pp. 133-135). Cincinnati, OH: DAV Press. Gory, B., & Whiteside, R. (1990). Structured role assignment and other techniques for facilitating process in adolescent psychotherapy groups. Adolescence, 25, 343-351. Fischman, Y., & Ross, R. (1988). Group treatment of the exiled survivors of torture. American Journal of Orrhopsychiatry, 60, 135-142.
Friedman, M. (1988). Toward rational pharmacotherapy for Posttraumatic Stress Disorder: An interim report. American Journal of Psychiatry, 145, 28 l-285. Galloucis, M., & Kaufman, M. (1988). Group therapy with Vietnam veterans: A Brief review. Group, 12, 85-102. Horowitz, M., Solomon, G. (1975). A prediction of delayed stress response syndromes in Vietnam veterans. Journal of Social Issues, 31, 67-80.
Makler, S. et al. (1990). Combat-related, chronic posttraumatic stress disorder: Implications for group therapy intervention. American Journal of Psychotherapy, 44, 381-395.
Miller, M. (1983). Empathy and the Vietnam veteran: Touching the forgotten warrior. Personnel and Guidance Journut, 62, 149-154.
Peplau, H.E. (1978). Psychiatric nursing: Roles of nurses and psychiatric nurses. Inrernational Nursing Review, 2.5, 41-47.
Scurtield, R. (1985). Post-trauma stress assessment and treatment: Overview and formulations. In C. Figley (Ed.), Trauma and Its Wake: The Study and Treatment of PostTraumatic Stress Disorder. New York, NY: Brunner/
Maze1 Smith, J. (1985). Rap groups and group therapy for Vietnam veterans. In S. Sonnenberg, R. Blank, & J. Talbott (Eds.), The Trauma of War: Stress and Recovery in Vietnam Veeterans. Washington, DC: APA Press. Sullivan, H.S. (1953). The inrerpersonal theory of psychiatry. New York: WW Norton. Williams, T. (1980). A preferred model for development of interventions for psychological readjustment of Vietnam veterans: Group treatment. In T. Williams (Ed.), PostTraumatic Stress Disorders of the Vietnam Veteran.
Cincinnati, OH: DAV Press. Yalom, I. (1985). The Theory and Prucrice of Group Psychotherapy (3rd. ed.). New York, NY: Basic Books.
The cofaciiitator of a veteran’s therapy group conducted by a Veterans Administration (VA) clinical nurse specialist uses his participant-observer role to analyze the theoretical constructs used in the group. A unique group psychotherapy model blending nursing triage techniques with “hot seat” client focus and interpersonal theory is presented and compared with similar models. Clinical
issues arising from its use among combat veterans with post-traumatic stress disorder at a New Hampshire VA Medical Center are also discussed. Copyright 0 1993 bg W.B. Saunders Company
G
ROUP THERAPY continues to be considered by a number of clinicians to be the treatment of choice for combat veterans suffering from post-traumatic stress disorder (PTSD) (Scurfield, 1985). A number of group modalities have been used to address PTSD since the informal “rap groups” of the early 1970s were formed by veterans, ranging from support groups to behavior modification (Smith, 1985; Williams, 1980). Early groups used a “hot seat”, a process in which members took turns as the focus of group attention. This particular model, intended to break down resistance and denial, used confrontation and group normative pressure as interactional dynamics (Smith, 1985). This model found less favor as psychotherapeutic groups replaced veteran peer support groups (Galloucis & Kaufman, 1988). Client focus in the “hot seat” manner has been replaced in combat PTSD group work by more traditional models of thematic interaction among group work by more traditional models of thematic interaction among group members with varying levels of direction from the facilitator (Galloucis & Kaufman, 1988; Scurfield, 1985). From the Veteran’s Administration Medical Center, Manchester, NH. Address reprint requests to Grace A Marad, RN, MSN, Clinical Nurse Specialist, and Mark C. Eoans, MA, VA Medical Center, Nursing Services, 718 Smye Manchester, NH 03104. Copyright 0 1993 by W.B. Saunders Company. 0883~9417/93/0704-ooo8$3.00ool0
244
Archives
A TRIAGE MODEL
A clinical nurse specialist working with outpatient combat veterans, Grace Marad, MSN, has developed a group therapy model in which nursing triage and the client “hot seat” of rap group models of the 1970s are combined to create a different dynamic. Marad, having facilitated a veteran’s group for several years, has permitted a psychology graduate student to participate as a cofacilitator of this group for 1 year, collecting data using a case study approach. During this time, the theoretical constructs used in Marad’s group practice have been identified and compared with those of existing models. This comparison has indicated that a nursing-based theoretical perspective for outpatient groups is unique and effective. Group Population and Needs
Marad serves the Veterans Administration (VA) Medical Center in Manchester, NH. The client population for her anger management group consists of Vietnam combat veterans with Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised (DSM III-R) diagnoses of PTSD (APA, 1980). All participants are referred by individual VA therapists and are considered to have high intensity symptomatology and low levels of social coping skills. The group meets twice each week for 90minute outpatient sessions. There are 8 to 10 par-
of Psychiatric Nursing, Vol. VII, No. 4 (August), 1993: pp. 244-248
A TRIAGE MODEL
ticipants, who have attended an average of approximately 80 meetings. It is proposed in the work by Horowitz & Solomon (1975) that post-traumatic stress is cyclic in its symptom clusters, meaning that a client would display the somatic and emotional effects of intrusive memories and survivor guilt followed by a period of anxiety control, denial , and avoidance behaviors. Even veterans with similar social, educational, and combat backgrounds could display a wide range of needs during any given group session. In addition, common continuing responses to PTSD include social isolation, alienation, hypervigilence, and rage (Berkowitz, 1980; Scurfield, 1985). As Friedman (1988) notes: Drug-mediated attenuation of intrusive or hyperarousal symptoms facilitate therapeutic work on guilt, grief, intimacy, rage, and other issues. It also appears that catastrophic exposure to trauma is followed by stable biological alterations in the sympathetic nervous system, neuro-endocrine system, and sleep/dream cycle. Such alterations appear to be unique to PTSD and distinguish it from major depression and panic disorder despite similarities in symptomatology tp. 284).
Many group intervention models based upon the work of Yalom (1985), emphasizing a group developmental approach based on such factors as group cohesion, self-disclosure, trust, therapist genuineness and presence, have reported success with inpatient veteran populations (Makler, 1990; Miller, 1983). Grace Marad, working with an outpatient population, has adapted the concepts of nursing theorist Hildegard Peplau (1978) to the work of combat-trauma psychotherapy. Peplau’s conceptual model of intervention calls for a blending of interpersonal group process work with skills associated with traditional nursing roles when treating medical patients. Such a blend is created in the use of triage by the facilitator and members of her veterans anger-management group. The Triage Model In Use
Marad has developed through years of practice, a triage model for this group that is intended to ameriolate disparities between participants and promote social integration. Each session begins with one client in the “hot seat”, but the goal is shared empathy, not confrontation, and the focus is based on need, not rotation. Triage in the psychotherapeutic group process
245
begins for Grace Marad before the group even assembles. During the half hour before session, she gathers information about the participants from a number of sources. Clients are greeted as they arrive. In these brief encounters, Marad observes the client’s affect, mood, level of functioning, and often learns about between-session changes in symptomatology as well as any social or family events with special significance for the client. Patient charts are reviewed for the results of any between-session appointments with individual therapists, psychiatrists, or physicians. Marad examines the notes from the previous group session, as well as notes from intersession conversations with participants. By the time she enters the group room, she had already monitored the “vital signs” of her clients. The triage process, prioritization of treatment, begins immediately. Marad scans the room as she checks in with each veteran. In some faces she looks for incongruence in affect or mood from previous conversations, in others for indications that previous difficulties had not improved. Because PTSD is a highly physiological disorder, Marad is especially attentive to body cues of intense PTSD symptomatology: anger, hypervigilence, fatigue, dissociation, and depression are often evident in the faces and bodies of the participants. The severity of symptomatology and of psychosocial stressors are gauged during these opening exchanges. All these men are in pain, but some are clearly in trouble. A significant decline in functioning linked with an increase in PTSD symptom severity is given first priority. Marad comments upon the need to pursue a dialogue with the priority-need participant: Often I have to draw them out. It’s common with these vets (with FTSD) that when they are in the most pain they won’t say anything until you bring them ‘into the room’ with questions.
Other clients are included as the dialogue is quickly widened into a group discussion. Their perceptions of the priority situation, parallels in their own experience, and implications for other veterans and families are sought. The content and themes of these offerings are focused by the facilitator through questions and interpretation, and the focus remains upon the prioritized client.
246
EVANSAND MARAD
A typical exchange: CLIENT A: I want to talk about the drive up here. It’s a real pain to drive as far as I have to go. It can really be hard if you haven’t MARAD: gotten any sleep the night before. (turns to client B) You look as if you haven’t slept in a couple of days. CLIENT B: (I’m) not tired. (to client B) Can you tell us what MARAD: your sleep has been like? CLIENT A: (Responding to the question from client B) I took a nap on Tuesday. (I’ve) been awake since then. Does anybody else have a problem MARAD: with sleeping? CLIENT C: Sure. Sometimes I go for days like that. (turns to client B) But, man, I got to tell you that you aren’t looking so good. CLIENT B: I don’t feel so good either. Flashbacks . . . (to client A) How do you think he MARAD: looks? What could we do to help? CLIENT A: I wasn’t really looking, but now that you mention it, (client B), you might want to think about seeing a doctor for some new medication. This staying up just won’t do for long. CLIENT B: Worried about me, are you? Yes, we’re all a little concerned MARAD: when it happens. Maybe you could tell us what may have brought on the flashbacks and kept you awake . . . Interactions are kept highly focused on the prioritized situation, but Marad emphasizes the practice of empathy and interpersonal communications over intrapsychic themes or problem-solving: Those will follow in time, but I am a strong believer in H.S. Sullivan for these groups. These clients have terrible isolation and tremendous disturbances in their ability to relate to other people. Many of them do not care if they live or die, they are that affected, and getting them to care for another vet is a powerful way to get them caring for themselves.
The use of triage focus does not result in diminished group cohesion, but becomes an experiential exercise in interpersonal relations. This focus also achieves another important goal, the leveling of the client-need base.
The severity of symptomatology and functioning can vary significantly among clients in any group setting; these differences can prove especially challenging in open groups (Makler, 1990) and outpatient groups (Smith, 1985), and the group that Marad facilitates is both. An intended by-product of triaged treatment for psychosocial issues is, as Marad points out, to: bring the group to a place where no one individual’s problems are so powerful and so unacknowledged that he finds he cannot afford to participate and has to leave or ‘act out’ just to get some relief.
The focus-group that follows triage lasts from 10 to 20 minutes. During this time, Marad continues to reevaluate her priorities for group support. If other veterans are in need of focused attention, the center of group attention will shift from one client to another until the group has addressed issues that would otherwise force those clients who are in particularly severe emotional pain towards an inward locus of attention, instead of a more interpersonal locus, so that group work can be effective. However, if this is not the case and the group’s affect and need for individual support are somewhat normative, she will gently bring this portion of the group process to a close. The technical goal as a facilitator, at this point, is to encourage the participants to complete the major business of individual difficulties and crises, offering closure and review, and cueing the veterans to begin the interactional group process in as natural a fashion as possible. Marad comments: It’sparticularly therapeutic for these painfully isolated clients to learn how to talk with others in interactions which are not rigid or ritualized.
A peer support group model gradually comes into play, and the remaining hour in the session is shaped by those themes that emerge among client interactions. The closing of the group includes not only a summary of the themes that arose in the discussion, but a recap of the initial issues of the prioritized member and the responses of the rest of the group. Marad encourages this kind of relationshipbuilding in session, during breaks, and even between sessions. She acknowledges great influence from nursing theorist Hildegard Peplau, who wrote that nursing needed to emphasize interpersonal as
247
A TRIAGE MODEL
well as physical healing, with a de-emphasis on roles and their attending distortions, if long-term healing and growth are to be maintained. (Peplau, 1991) Veteran Perceptions of The Model
Participants in this outpatient group, discussing their perceptions of group interactions with the first author, identify reenactment qualities, consistency with inpatient VA programs and interpersonal skills building within the model used by Grace Marad. The rescue of one member by the others appears to reenact a frame of mind reminescent of bonds both in combat and inpatient recovery. One veteran has likened the beginning of group to “suddenly realizing that your point man on the patrol is down. You don’t leave your buddy-you go in there and help” (Client A, personal communication, 28 November 1991). The role of debriefing, a military-style recounting of significant events, has been of recognized value in inpatient individual and group treatment. The triage portion of the Manchester VA group has been seen by another participant as reenactment of that process as well: It’s like being out on an L.P. (listening post) all week (living in the community) and coming in for a debriefing. The one you listen to first ought to be the one who made contact, not the first one who has anything to say (Client B; personal communication, 28 November 1991).
Reduction of social alienation through modeled altruism, reported in the literature (Galloucis & Kaufman, 1988; Fischman & Ross, 1988), is described as a notable therapeutic feature of this group model by participants (Clients A-E, personal communication, November 28, 199 1). The veterans discuss their perception of being in the “hot seat” when unconditional positive regard and parataxic clarifications are used instead of confrontation: CLIENT B: You’ve got to understand. We don’t let people on the outside put us in any “hot seat”. . . . My wife tries to do that. She means well, but I just tune her out. The difference is that here, it’s our decision to be in the “hot seat’ ’ . CLIENT A: Only another vet can tell you what is what. And if we see a vet in trouble, we’re there.
CLIENT B: It’s not just that either. When other people put you in the “hot seat”, they do it to put you down. Here it’s because they’re trying to help. Other people try to humiliate us . . . to hurt us. CLIENT D: We sense what each other feels. The veterans also express a perceived therapeutic value in the time-limited focus segment of the group: CLIENT C: We go with whoever is hurting until we know they’ll make it out in one piece. CLIENT B: My wife would stay around like you guys would, and she knows when I’m in trouble just like you guys would, too, but she just doesn’t know when to shut up. CLIENT A: Another vet doesn’t pity. And family, they don’t know how to look you dead in the eye and say they care without pity. Help me out of this, and then just back off enough for me to stand up like a man. Veterans confirm that the focused intervention also has a leveling effect, which allows a more balanced group discussion once priority issues have been addressed. However, several have indicated that they have often attempted to extend such sessions in order to avoid discussion of more anxiety-provoking themes. “If Grace’d let us get away with it, we’d talk about somebody else all day,” comments Client A (Personal communication, November 28, 1991). DISCUSSION The triage model as practiced by Grace Marad appears particularly suited to the long-term management of, and recovery from, PTSD symptomatology. The plethora of physiological, social, cognitive, and emotional triggers that could result in crisis make prioritized intervention during group sessions an attractive model for this population. This intervention, because it is enacted through the group, also provides a rich source of thematic work for later discussion. Because different clients need focused support each week, the model acts naturally to break down the assumption by participants of rigid group roles, such as the ‘harmonizer’ or ‘deviant’ (Cory & Whiteside, 1990). A wide range of interpersonal communications
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schemes are experienced as both roles and situations change. The unchanging focus on modeled empathy and clarification promotes general social values and skills, which in turn support successful group exploration. However, there are drawbacks to triage in group process. Veterans have acknowledged that the light that exposes one client produces shadows on another. Avoidance tactics, driven by strong selfprotective mechanisms, could reduce the inattentive facilitator to focus on fewer and fewer members, whose repeated attention from the group would promote dysfunctional social skills, whereas others do no therapeutic work at all. There is also a real danger that the group could become “stuck” in a crisis intervention posture unless the facilitator carefully weaves in thematic and process similarities between group members when attending to an individual’s pressing needs. This group, with its focus on distorted or avoided interpersonal relations, may be sensitive to socialized gender differences in communication styles; cultural and ethnic differences could also be a significant factor in the limitations to usage of a triage model in group psychotherapy. Transference and countertransference would also be of concern in the use of this model, and facilitators would have to be particularly careful to monitor their triage choices and intensity of intervention when providing focused treatment. Finally, a benefit and drawback to the widespread use of this model also concerns its designer’s grounding in the field of nursing. Although rapid assessment is a recognized part of psychotherapeutic practice, rapid response is not. This style of client work in the group setting, so natural to the clinical nurse specialist, could prove alien and uncomfortable to other disciplines with other perspectives and historical paths of treatment. Further study of this model through periodic symptom and interpersonal skills assessments is indicated, as are careful comparisons of this model with other group models through controlled longitudinal outcome studies. CONCLUSION
The perceptual and somatic assaults on many combat veterans continue long after the war has ended. The nights still bring fresh attacks and no
real sleep. Anger at so many, fear of so much, and guilt for having survived when others did not, color each hour of the veteran suffering from PTSD. A model that acknowledges the immediacy of symptomatology without being tied to a more group developmental or recovery-tasks model is clearly desirable for the long-term survivors of trauma. REFERENCES Berkowitz, M. (1980). Themes in treatment of Vietnam veterans. In T. Williams (Ed.), Post-traumatic Stress Disorders ofrhe Vietnam Veteran. (pp. 133-135). Cincinnati, OH: DAV Press. Gory, B., & Whiteside, R. (1990). Structured role assignment and other techniques for facilitating process in adolescent psychotherapy groups. Adolescence, 25, 343-351. Fischman, Y., & Ross, R. (1988). Group treatment of the exiled survivors of torture. American Journal of Orrhopsychiatry, 60, 135-142.
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