From: jewell@mace.cc.purdue.edu (Larry Jewell)
Subject: 'NamVet Newsletter, Vol.5, no.7 (5/6)
Organization: Purdue University
Date: Sat, 29 Aug 1992 23:50:21 GMT


     
     In the exPOW therapy group,  members often protect each other from 
     sad feelings.   When a group member cries,  it is not uncommon for 
     another member to attempt to change the subject,  rather than stay 
     with the feeling.   It is important for the therapist to stay with 
     the  feeling and to empathize with it,  modeling this behavior for 
     the  group  members.   It  is  also  important  to  interpret  the 
     protectiveness  of  the group members as adaptive while they  were 
     POWs but as no longer adaptive.  Depression no longer means death.
     
     The most common service-connected diagnoses of exPOWs are "anxiety 
     related disorders."  (Veterans Administration [VA],  1980,  p.123; 
     see also Oboler,  this volume).   It may well be that anxiety is a 
     defense  against  the depression,  and the depression is  so  well 
     disguised  that all that is seen on disability evaluations is  the 
     defense.  Wolf  and Ripley describe "the shallow optimism"  or  "a 
     sort of dull euphoria" (1947, p. 191) after repatriation.  This is 
     probably  a  reaction  formation,  defending  against  depression.  
     Nevertheless, there is a pervasive,  chronic,  generally low-grade 
     depression found in most exPOWs that is apparent to anyone who has 
     worked  with  them  on  a long-term  basis.   This  depression  is 
     generally manifested in feelings of despair, defeat,  and failure.  
     This  low-grade  depression was itself adaptive in protecting  the 
     
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     self  against  disappointment,   which  was  so  frequently  felt.  
     Indeed,  even  today these men are almost surprised when something 
     good happens to them, and cannot believe it to be true.
     
     FEAR OF LOSS OF CONTROL
     Early  in the group,  one member mentioned a fear of heights,  and 
     one  after  another group member acknowledged that they too had  a 
     fear  of  heights;  all  but one group member  shared  this  fear.  
     Acrophobia  is symbolic of a more general fear of loss of control.  
     Several members commented that they feared that they would slip or 
     fall or even jump from a height.   This is fear of loss of impulse 
     control.   Fear  of loss of control is a key issue in the problems 
     with interpersonal relationships faced by these veterans.  Control 
     issues were the problems most frequently cited by the wives in the 
     wives group, as well.  It is not surprising that these exPOWs fear 
     loss  of  control since they had little or no control  over  their 
     lives while prisoners.  Furthermore, they had to "keep the lid on" 
     their feelings and behavior.  Humiliation was common, and displays 
     of  anger  were severely punished,  sometimes by  death.   Mr.  C. 
     recently  had a dream,  about which he felt "wonderful."   In  his 
     dream,  another  therapy  group member managed to leave a line  of 
     prisoners  and  steal  some potatoes from under the noses  of  the 
     Japanese.  He  was no longer under their control.  POWs found many 
     ways  to maintain some feeling of control.   They made up  comical 
     names  for the Japanese guards,  or managed to find a way for some 
     infected stool to end up in the food of the Japanese officers.
     
     In  working with the control issue,  it is best not to insistently 
     confront or attack the defense - such assaults only strengthen the 
     defensive response.  If the therapist respects their needs for the 
     defense, these veterans, in their own time,  will slowly let go of 
     their overtly strong need for control
     
     GUILT AND SHAME
     There is no exPOW who has not asked himself the question, "Why did 
     I make it and others did not?"  Mr.  A.  describes being placed on 
     one  "hell  ship"  and  his  six closest friends  were  placed  on 
     another. The ship carrying his friends was attacked and sunk,  and 
     they all died.   There is,  of course,  no logical explanation for 
     his  survival and his friends'  deaths,  yet he has been trying to 
     understand  it for over forty years.   When his own son suffocated 
     to  death about five years ago,  nearly replicating his own almost 
     fatal  experience  when his tank overturned in a river during  the 
     defense  of  Bataan,  it  brought back the old guilt and  the  old 
     question,  "Why not me?"   Survival guilt (see T.  Williams,  this 
     volume)  is especially prominent with WW II Pacific Theater exPOWs 
     and Korean exPOWs.  This is due to two factors:  first,  there was 
     an  extremely high mortality rate among these two groups;  second, 
     because  of  the unbelievable harsh conditions to which they  were 
     subjected, these men sometimes did things of which they were later 
     ashamed.  Often this shame is unrealistic,  and out of proportion.  
     For example, a Korean exPOW, Mr.  D.,  feels guilty because he was 
     not  able to bring out every American captured in  Korea.   Others 
     feel  guilty over such things as eating while their comrades  died 
     of starvation.
     
     Sometimes  this guilt is so great that the individual cannot  face 
     other  exPOWs.   The  clinician  should be sensitive to  this  and 
     gently explore it.   When the guilt does not abate even after such 
     
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     exploration,  the  exPOW's wishes to be seen individually,  rather 
     than  in group,  should be respected.   I have made the mistake of 
     pushing such an individual into group therapy,  and the result was 
     counter-therapeutic.
     
     In  their  article,  Wolf and Ripley make an observation  that  is 
     relevant here:  "Among the survivors two personality types seem to 
     dominate: (1) those with features of psychopathic personality, and 
     (2)  personalities  of  the highest order  of  adjustment"  (1947, 
     p.186).   It  is  clear that these two personality types were  the 
     most  adaptive  in  dealing with the  POW  experience,  albeit  in 
     different  ways.   Notably,  the  findings of the  "Morgan  Board" 
     regarding  the  factors that enabled some to survive while  others 
     died  (Oboler,  this  volume)   contain  characteristics  of  both 
     personality types.
     
     Mr.  E.,  for  example,  grew  up  on  a ranch  in  Wyoming  under 
     conditions of severe deprivation.   He had learned to take care of 
     himself at a very young age,  and had also learned to make do with 
     very  little  in  the way of food,  shelter,  and  especially  the 
     emotional  closeness  of  other  human  beings.   He  developed  a 
     somewhat  sociopathic personality style,  which served him in good 
     stead  throughout his more than 39 months of Japanese captivity as 
     well as in his career as a senior "non-com" after the war.
     
     In contrast,  Mr.  A.,  who was described above,  was the son of a 
     minister  and had a successful professional career after the  war.  
     He  survived  his  39 months of Japanese captivity  through  close 
     association with other prisoners and holding fast to the religious 
     and  moral values he grew up with.   Mr.  A.'s feelings might more 
     properly  be  called "guilt"  and  Mr.  E.'s  "shame."   Mr.  E.'s 
     feelings are more primitive, and he has poorer ability to tolerate 
     them.   Mr.  A.  is seen in group therapy;  Mr.  E.  in individual 
     therapy.
     
     At  times,  the  guilt is manifested in  various  self-destructive 
     behaviors,  ranging  from mild to  severe.   Mr.  D.  compulsively 
     involves  himself  in  helping  other  exPOWs,  even  at  his  own 
     emotional  expense.   His need to help other exPOWs has interfered 
     with  his marriage and with his own therapy.   Another individual, 
     Mr.  F.,  convinced  that  he did not deserve to survive  his  POW 
     experience, refused psychiatric treatment and hindered attempts to 
     increase  his  service-connected compensation.   He  was  recently 
     diagnosed with pancreatic carcinoma,  and may have delayed getting 
     this  condition  diagnosed out of his unconscious need  to  punish 
     himself.   Still  another individual,  Mr.  G,  has found a way to 
     almost literally repeat his POW experience by becoming involved in 
     a relationship with a German woman from the town where he was held 
     prisoner.   She  is pathologically jealous,  perhaps to  psychotic 
     proportions,  and prevents him from significant contact with other 
     people - in effect, keeping him a prisoner.
     
     This symptom - pathological guilt -  is perhaps the most difficult 
     to deal with because there is at times some reality to it.   There 
     is no satisfactory answer to the question: "Why not me?", and POWs 
     did  behave in ways that whey would not normally behave.   What is 
     most  helpful is to assist the exPOW in recognizing the  abnormal, 
     psychotic  nature  of what he has been through,  and to  help  him 
     recognize that it is not shameful to do what one can to survive in 
     
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     such  a situation,  as well as recognize that HIS BEHAVIOR did not 
     kill  his  comrades.   For  those who are able to  tolerate  group 
     therapy, the acceptance by their comrades in the group seems to be 
     most effective in dealing with the guilt.
     
     OVERSTIMULATION
     We   have   encountered   several  exPOWs  who  are   subject   to 
     overstimulation,  which  in  this  context may be  defined  as  an 
     inability   to  tolerate  a  normal  degree  of   affect.    These 
     individuals look very agitated and extremely anxious,  and at such 
     times they often cannot speak intelligibly, need to leave the room 
     and  pace  about,  or  engage  in some  other  motor  activity  to 
     dissipate  the affect.   A similar phenomenon has been noted among 
     (nonPOW) combat veterans:  "In my experience,  motor activity as a 
     defense  against painful affects...  is the ;rule with traumatized 
     patients" (Schwartz, 1984, p.54).
     
     It seems that this symptom is often confused with anxiety,  but it 
     is  qualitatively  different from anxiety.   It is more  like  the 
     symptoms  frequently observed in adult psychotherapy patients  who 
     were  victims of physical or sexual abuse as children,  who,  like 
     the  POWs,  had to tolerate sensations they were not physically or 
     emotionally able to discharge at the time.
     
     This  concept of overstimulation needs elucidation to help explain 
     the prevalence of so-called anxiety disorders among exPOWs,  their 
     fear   of   loss  of  control,   the  often-observed   anger   and 
     irritability,  and  possibly  the vivid nightmares  and  flashback 
     phenomena.   It  may  be a later manifestation of  the  hysterical 
     conversion reactions frequently observed by Wolf &  Ripley (1947). 
     In responding to symptoms of overstimulation, it is not helpful to 
     try  to impede the physical discharge unless such discharge  would 
     be dangerous.   However,  AT A LATER TIME,  helping the individual 
     put his affect into words is an important treatment intervention.
     
     NIGHTMARES
     At  the  time  of their repatriation,  exPOWs  almost  universally 
     experienced nightmares.  Themes were generally rather close to the 
     individual's experience,  either during captivity or when captured 
     (Segal, 1974, p.10; Wolf & Ripley, 1947, p.86).   With the passing 
     of  time,  the  prevalence of nightmares seems to have  diminished 
     among most exPOWs.  However, during periods of stress, in response 
     to  current  events  like hostage situations,  or  at  significant 
     anniversaries (e.g., Pearl Harbor, V.E. or V.J.  Day,  the fall of 
     Bataan,  etc.),  nightmares  often reappear.   The various  losses 
     being experienced by WW II exPOWs, now in their 60s,  also seem to 
     have contributed to an increased frequency of nightmares.   Common 
     nightmare   themes  center  around  being  threatened  and   being 
     helpless.  For example,  Mr.  C.,  a survivor of the ;surrender of 
     Corregidor,  frequently  dreams of being attacked by the Japanese, 
     having  one  of  his grandchildren with him,  and running  out  of 
     ammunition.   Other dreams are less clearly understood.   Mr.  H., 
     who was captured at the Battle of the Bulge, sometimes experiences 
     strange, confusing, "science-fiction-type" dreams, which he cannot 
     understand.   He  says he gets the ;same feeling of being lost and 
     confused that he had as an infantryman lost in the fog at the time 
     he was captured.
     
     These  dreams seem to be a way of discharging psychic energy,  and 
     
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     can be very helpful,  not only in their energy discharge function, 
     but  also  as a means for understanding the internal conflicts  of 
     these veterans.  In individual and group therapy, it is helpful to 
     encourage these patients to talk about their dreams and nightmares 
     so  that they can come to understand them.   As with the dreams of 
     any  psychotherapy patient,  the level of interpretation should be 
     appropriate ot the needs and capabilities of the patient.
     
     ACUTE PSYCHOSES
     In their 1947 article,  Wolf and Ripley state:  "Eight (of thirty-
     five)  patients had psychoses.   Three of these were classified as 
     schizophrenia, one as manic depressive psychosis, manic type,  and 
     one as paranoid condition.   One patient had a delirium associated 
     with  cerebral  malaria  and two were considered to  be  psychotic 
     because of nutritional deficiency." (p.185)
     
     ALthough there is no way to be certain,  I would speculate that at 
     least some of these patients would not be more correctly diagnosed 
     as having PTSD with psychotic features.
     
     Some  of  the exPOWs I have met have described experiences in  the 
     early  years  after repatriation as very similar  to  "flashbacks" 
     described by Vietnam veterans with PTSD>  These sometimes occurred 
     during  hypnagogic  or  hypnopompic  states,  and  at  times  were 
     difficult to distinguish from nightmares.
     
     Other  exPOWs  experienced psychotic symptoms of longer  duration, 
     but still not the more global deterioration that is characteristic 
     of schizophrenia.  Mr. I., a B-17 gunner taken prisoner in Germany 
     in 1943,  was hospitalized in 1948 for 2 years in a state hospital 
     where he was treated with electroconvulsive therapy (ECT) after an 
     incident of bizarre and uncharacteristic behavior.   On admission, 
     the  examining psychiatrist noted that,  "During the time [of  the 
     incident, Mr., I.]... felt as if he were watching a movie and that 
     he  was not doing it at all.   Afterwards,  he felt very  guilty." 
     (Clinical Record, 1948)
     
     The psychiatrist wrote further that:
     At  other times he noted that people were talking about him as  he 
     passed  them  on  the street.   He is sure that they  were  making 
     derogatory  remarks  about him although he did not hear what  they 
     said.   Although he has no idea what they were saying he thinks it 
     may be about the way he was dressed.   This is very similar to the 
     experiences in prison camps when the guards would see him pass and 
     make remarks about his appearance, etc.  Also, when he became very 
     tense, usually at night,  he would smell rubber burning and blood.  
     This  compared  ot  his experience in the burning  plane  and  the 
     sights  he saw in prison camps.   Vivid nightmares bothered him  a 
     good  deal at first and he also heard his name being  called;  the 
     voice was similar to that of a friend who called to him just after 
     his  landing in the bay and before his friend's parachute  carried 
     him  under.   The  nightmares  were a repeat  performance  of  the 
     experience in the Army (of seeing 1200 Jews killed).   In addition 
     to  his irritability and nervousness,  he has had several  periods 
     when  he  felt as if he were floating in  air,  light-headed,  and 
     describes a "funny feeling" all over.  Also,  several times he has 
     just  felt  suddenly  like getting away from things  and  wandered 
     impulsively with no special goal in mind.  He knows he should not, 
     but seemingly cannot stop himself. (Clinical Record, 1948)
     
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     Mr. I. received a diagnosis of DEMENTIA PRAECOX, or schizophrenia, 
     at   that   time.    He  required  only  one   other   psychiatric 
     hospitalization since: for one month, in 1969,  when he suffered a 
     "psychotic break" after seeing a war movie.
     
     His disability examination in 1983 noted that: "It appears that he 
     has  suffered  in the past from a post-traumatic stress  disorder, 
     however,  although  symptoms of this disorder remain,  I would not 
     currently  diagnose him as suffering from such a disorder.   It is 
     my firm opinion, however, that his generalized anxiety disorder is 
     a direct result of his POW experience." (Clinical Record, 1983)
     
     Mr.  I.  was  most  likely  MISDIAGNOSED  as  schizophrenic,   and 
     consequently  treated with ECT.   More likely,  he had a PTSD with 
     psychotic  features of an hysterical,  dissociative nature.   This 
     sort of misdiagnosis is, unfortunately, not uncommon:
     
          It  seems that the florid symptoms of repetitive anxiety 
          attacks,   panic  states,   dissociative  paranoid  rage 
          states,   and   other  dissociative  phenomena  such  as 
          "flashbacks"    often   lead   to   the   diagnosis   of 
          schizophrenia,  rather than PTSD.   Despite dissociative 
          phenomena  observed in these veterans,  reality testing, 
          and other ego functions known to be severely impaired in 
          schizophrenic  disturbances,  remain  intact.   (Parron, 
          1984, p. 17)
     
     Other exPOWs begin to show psychotic symptoms related to their POW 
     experiences  when  an organic brain syndrome weakens  their  usual 
     defensive structure.  Mr. C., for example, who was described above 
     as suffering from frequent nightmares, has become psychotic on two 
     occasions,  both immediately following major surgery.   On both of 
     these  occasions,  he believed he was -  and behaved as if he were 
     still  -  a captive of the Japanese.   He attempted to  physically 
     assault  hospital personnel and to escape from his hospital  room, 
     almost  jumping from his second-story window.   On both occasions, 
     he needed ot be restrained for several days.
     
     Mr.  J.,  a European Theater exPOW who developed a chronic organic 
     brain  syndrome  in  his mid-60s after a  successful  professional 
     career,  concurrently  began ruminating about his POW experiences.  
     He  eventually became paranoid and began hallucinating that people 
     were  breaking into his home and believed that he had to guard it.  
     In the hospital, during an initial mental status exam, he reported 
     that the current president was Roosevelt.
     
     Whether  such  cases fully meet the criteria for PTSD is  probably 
     not  very important.   What is important,  however,  is that  such 
     symptoms are undoubtedly related to the patient's POW experiences.  
     It is not unusual to see exPOWs with psychotic symptoms.   Much of 
     the  time,  the  POW  experience  provides  a  better  etiological 
     explanation  than  does a diagnosis of  schizophrenia.   As  noted 
     above, however, this is not to deny the importance of predisposing 
     personality factors.
     
     ANXIETY
     Anxiety  disorders  are the most common type of  service-connected 
     disability.    Anxiety  is  a  normal  response  to  the  constant 
     
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     uncertainty  with which POWs had to contend.   As discussed above, 
     it    appears   that   anxiety   is   sometimes   confused    with 
     overstimulation.   Several  of  the  patients we  have  seen  have 
     experienced   panic   attacks,   which   is   also   a   kind   of 
     overstimulation.
     
     As  these  veterans become involved in  treatment,  their  general 
     level of anxiety tends to decrease, and they become overstimulated 
     less easily.   However,  at the Denver VAMC,  anti-anxiety agents, 
     such as benzodiazepines, and tricyclic antidepressants,  have been 
     used  with  good  results with this  population  (see  Yost,  this 
     volume).
     
     INTERPERSONAL DISTANCING
     The need to keep a certain amount of distance from other people is 
     a  common symptom among exPOWs.   It is often seen in marital  and 
     family   relationships  as  well  as  in  work  relationships  and 
     friendships.   We have sometimes noticed a peculiar combination of 
     distancing  and dependence.   There is often a considerable amount 
     of  dependence  on  a spouse or interdependence  between  spouses, 
     accompanied  by  an  avoidance of any real intimacy.   It  is  not 
     unusual  to  find  a chronic state of conflict,  which  keeps  the 
     spouses connected, yet maintains a certain amount of distance.
     
     At  times,  there is a repetition of "prisoner-guard"  patterns in 
     POW marriages.  In some of these marriages, one spouse will always 
     take  the prisoner role and the other the guard role;  in  others, 
     there  is  an interchangeability of roles,  but the basic  pattern 
     does not change.  The combination of distancing and dependency may 
     be  understood in light of the POW experience.   POWs needed  each 
     other desperately, yet they also needed to keep a certain distance 
     because of the possibility(sometimes probability)  of the death of 
     their comrades.
     
     The  subject of POW marriages deserves much more treatment than is 
     possible here (see C.  Williams,  "Women Partners,"  this volume). 
     However,  we have found it very helpful,  especially in the wives' 
     group,  to  explain  the "prison-guard"  dynamic and to use it  to 
     explain  interactional patterns otherwise difficult to understand.  
     It  is  helpful to note that this pattern was adaptive in the  POW 
     situation but is no longer necessary.
     
     DISTRUST OF NONPOWs
     There  is  a chronic feeling of being misunderstood among  exPOWs.  
     The  assumption  that  nonPOWs  will not  understand  is  in  part 
     realistic  (cf.,  Hickman,  this volume).   The VA system has  not 
     always  responded with understanding toward these veterans.   Many 
     were  told  after repatriation to "just forget"  about  their  POW 
     experiences.   This  we now know is an impossibility.   Many  were 
     told by clinical staff, who themselves must have felt helpless and 
     hopeless,  that  they  had "K-Z syndrome"  or "concentration  camp 
     syndrome" or "POW syndrome,"  and that nothing much could be done.  
     The  feeling  of  being misunderstood is also the  result  of  the 
     psychotic  nature  of  the  POW  experience.    What  exPOWs  have 
     experienced  is often so far beyond the range of normal experience 
     that  they cannot imagine that anyone would believe what they have 
     to say.  Indeed, they sometimes mistrust their own memories.   And 
     it  is  not  uncommon for the clinician to disbelieve  what  these 
     people  tell  them  as a defense against fully  comprehending  the 
     
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     horror.   I  have found myself disbelieving something an exPOW has 
     told  me,  only  to  realize at a later time that it  was  my  own 
     inability  to  tolerate the awful nature of what I was being  told 
     that created my disbelief.
     
     The  exPOW's  belief that he will not be understood also serves  a 
     defensive purpose. First,  if he will not be understood then there 
     is  no  need  to have to open up old wounds and  talk  with  other 
     people  about his experiences.   Second,  if he does describe  his 
     experiences to others, and is not then understood,  he will not be 
     as  disappointed.   The corollary to the feeling that nonPOWs will 
     not  be  able to understand them is the belief that  other  exPOWs 
     already  understand,  and  thus do not have to be told  the  awful 
     details.  When exPOWs talk among themselves, they frequently avoid 
     dealing  with their more troubling memories.   They often focus on 
     the humorous aspects or "high points" of their experience.  Guilt, 
     fear  of  overstimulation,  and  above all,  protection  of  their 
     comrades,  leads  them to avoid talking about the most  unsettling 
     experiences.   If  they  already understand,  there is no need  to 
     talk.
     
     LOW SELF-ESTEEM
     Disorders  of self-esteem and chronic lack of self=confidence  are 
     common among this population.   Often there is an overcompensation 
     through a brittle, narcissistic personality structure that is very 
     vulnerable  to  narcissistic  injury.   These men  were  prisoners 
     during  a period of their lives when self-esteem is developed  and 
     reinforced  through  success.   They had few  successes.   Indeed, 
     while  POWs,  they were subjected to almost continuous humiliation 
     and  defeat.   There is a tradition of victory in the  U.S.  Armed 
     Forces,  and  these men were not victors.   Among Pacific  Theater 
     exPOWs, there is often a feeling that "we lost our war."
     
     Successes after repatriation have remedied these traumas with some 
     exPOWs.   However,  with  many  of these individuals  the  various 
     physical  and  emotional disabilities they received as  POWs  have 
     prevented further successes.  In some cases, the intense shame and 
     guilt have led to a sort of "vicious cycle."  Mr.  K.,  a European 
     Theater  exPOW,  who was eventually forced by his intense guilt to 
     drop out of the group and fail in treatment,  attempted and failed 
     in more than two dozen jobs.
     
          ...a  crisis  is  to be expected once  the  rapture  (of 
          repatriation)  recedes and the realities of life appear.  
          Some  physical disabilities take years to overcome,  if, 
          in  fact,  they  are  ever overcome.   Being  below  par 
          psychologically  as  well  as  physically,   the  former 
          prisoner has little chance of holding his own, yet finds 
          himself  in  daily competition with  completely  healthy 
          people.   He  is  almost programmed to lose  and  social 
          decline  often follows.   There is a high divorce  rate.  
          The   inability   to   feel   belonging   anywhere,   or 
          understanding by anyone,  leads to increased alcohol and 
          drug use (Russell, 1984, p.253)
     
     Some  exPOWs  defend against their feelings of low self-esteem  by 
     refusing to acknowledge their POW status.  For example, they avoid 
     POW  organizations,  free or low-cost license plates often offered 
     to  exPOWs,  and  treatment for their physical  and  psychological 
     
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     wounds  offered  at VA medical centers.   Some exPOWs  present  at 
     first   as  self-centered,   overbearing  individuals.    This  is 
     generally  an  attempt  to compensate for feelings  of  low  self-
     esteem,  and  -  as  with  most defenses -  is best  not  directly 
     confronted.  It will disappear when it is no longer needed.
     
     For  other exPOWs,  the status of being an exPOW or as a  disabled 
     veteran  is their PRIMARY SOURCE of self-esteem.   When they begin 
     to feel better about themselves as whole people,  they are able to 
     see themselves as more than just exPOWs.
     
                          TREATMENT CONSIDERATIONS
     In writing this chapter, I asked the exPOW group,  after two years 
     of  treatment,  what  had  been  most helpful  to  them  from  the 
     therapists  and  from other group members.   From the  therapists, 
     what  was  cited  most often was a willingness to listen  and  the 
     ability  to  understand what was being related with  interest  and 
     respect.  In addition, a willingness to allow the group members to 
     maintain  their  defenses as long as they needed them,  or as  one 
     member  put it,  "To allow us to wander around in left field for a 
     while," was noted as helpful.  What was cited as most helpful from 
     other group members was their interest and caring.
     
     COUNTER-TRANSFERENCE
     The   most  difficult  issue  for  therapists  working  with  this 
     population  is counter-transference.   It is essential not to push 
     these people away, like others have,  because the therapist cannot 
     tolerate  what  he  is hearing or feels helpless  and  frustrated.  
     Rejection  is a major fear,  and exPOWS are sensitive to even very 
     subtle  signs.   It  is difficult to really listen to  stories  of 
     death, illness, torture, and general inhumanity, to empathize with 
     feelings of hopelessness,  intense sadness,  humiliation,  lack of 
     control,  and  mortal  fear  without such defensive  reactions  as 
     disbelief,  intellectualization  or other pulling away,  or subtly 
     discouraging talk about these experiences.
     
     When  the  group  was starting,  I usually  warned  group  members 
     against  "telling war stories."   I thought I had good reasons for 
     this, having experienced combat veterans' using often-told stories 
     of  their  combat experiences to avoid affect.   However,  what  I 
     didn't  realize  until later was that what I had said  discouraged 
     group  members  from  talking  about some of  their  most  painful 
     experiences.   This  was  unconscious on my part,  and I  did  not 
     realize it until over a year later when several group members told 
     me about the inhibitory effect of my initial statement.
     
     During  the  first  two months of the POW group,  I  found  myself 
     frequently  experiencing  nightmares of being a POW myself  or  of 
     being  a victim of similar experiences to those being described by 
     the  group  members.   Just  hearing about these  experiences  had 
     precipitated  a  kind  of  derivative traumatic  neurosis  in  me, 
     shorter  in duration and less intense,  but nevertheless very real 
     to  me;  it  went  away  as  I was able to talk  about  it  to  my 
     co=therapist  and  other colleagues.   Any therapist working  with 
     this  population  must  convey his willingness to  listen  to  the 
     exPOW's  he  is working with.   Not every therapist can work  with 
     every  population.   If a therapist cannot listen emphatically  to 
     material of this sort without undue injury to himself,  it is best 
     to avoid working with exPOWs.  With this population,  perhaps even 
     
     NAM VET Newsletter                                         Page 70
     Volume  5, Number  7                                 July 27, 1991

     more  than with other psychotherapy patients,  failures in empathy 
     are  far more significant than failures in techniques.   A  superb 
     discussion of the counter-transference issues involved in treating 
     concentration  camp survivors,  which is applicable as well to the 
     treatment of exPOWs, may be found in De Wind (1984).
     
     INITIAL CONTACT:  EVALUATION OF TREATMENT NEEDS
     In the setting in which I work,  many of the exPOWs referred ot me 
     are  not  coming  as  a result of their  request  for  psychiatric 
     treatment.   Many  of  them  have  been seen  for  exPOW  protocol 
     examinations,  where it was suggested that they talk to me.   They 
     are  generally not presenting with an acute condition,  or even an 
     acute  exacerbation  of a chronic  condition.   Nevertheless,  the 
     intensity  with which they present often makes it APPEAR that they 
     have an acute condition.   We believe this is due to the fact that 
     POW  issues  are  always just below the surface,  and  when  these 
     patients  finally find someone whom they feel will listen to them, 
     their   presentations  have  great  intensity.    Almost   without 
     exception,  exPOWs feel they have not been heard in the past,  and 
     when they finally feel they've found a listener,  there is a sense 
     of great relief.
     
     A  psychiatric evaluation or a psychiatric referral may be seen as 
     a narcissistic injury, and the ;referring clinician as well as the 
     evaluating  mental health professional needs to be aware of  this.  
     Although   the  exPOW  may  have  marital   problems,   difficulty 
     controlling  anger,  problems  with  interpersonal  relationships, 
     depression, or other psychosocial difficulties, these problems are 
     generally  chronic,  and he may have become used to them.   He may 
     have  long  ago given up hope of changing  anything.  I  generally 
     begin  by  explaining  what I do,  note some of  the  more  common 
     problems  I  have  observed in exPOWs,  and try to  determine  the 
     individual's  interest  in  my services.   Knowing what  sorts  of 
     psychosocial  problems  other exPOWs experience helps the  veteran 
     normalize  his  problem  and soften the blow to  his  self-esteem.  
     KNowing  what  services are available makes it easier to  ask  for 
     help.   I  attempt  to  explain  the  connection  between  current 
     symptoms  and past experiences,  and ask the exPOW if any of  this 
     fits him.  I generally focus primarily on group therapy, because I 
     strongly  feel  that  in  the great majority of cases  it  is  the 
     treatment  of  choice  for  this  population  (see  Jelinek,  this 
     volume).   However,  I also explain and sometimes offer individual 
     or couples treatment.
     
     I  usually  expect  some  resistance  to  getting  into  a  group.  
     However,  I have come to respect the STRONGLY STATED desire to not 
     get  into  a  group.   Some exPOWs cannot tolerate  group  therapy 
     because  of overwhelming guilt or shame.   They cannot face  other 
     exPOWs.   Others  do  not  have the ego strength to  tolerate  the 
     affect  generated by the content of these groups.   Still  others, 
     because of character pathology, may be too disruptive of the group 
     process.
     
     Some  exPOWs referred ot me are not interested in treatment;  they 
     simply  want help in dealing with the VA system.   Providing  such 
     services  may be all the individual wants or needs,  or may be the 
     first step to getting into treatment.
     
     It  is significant to note that for some exPOWs,  especially those 
     
     NAM VET Newsletter                                         Page 71
     Volume  5, Number  7                                 July 27, 1991

     from  the  European  Theater,  the  experience  surrounding  their 
     capture  was more traumatic than the POW experience  itself.   Mr. 
     L., for example,  a B-17 pilot,  became significantly more anxious 
     when  describing bailing out of his plane,  being followed down in 
     his parachute by a German fighter, and then nearly being killed by 
     the civilians who surround him when he reached the ground.
          After  landing,  I  peeked  over the  small  knoll  that 
          surrounded  me to see if anyone was coming.   There  was 
          about  25 or 30 of them,  and armed with  knives,  guns, 
          clubs,  pitchforks,  axes,  and other forms of concealed 
          weapons.   I  knew then that everything was finished and 
          that I may as well quit.  Consequently,  I simply raised 
          my hands and stood up.   Immediately I was surrounded by 
          about 20 persons, all of whom tried to talk to me at the 
          same time.  I'd heard German in school before,  but this 
          jabbering  could have been Chinese,  for all I know  and 
          cared.  At first,  they didn't dare come near me because 
          they thought I had a gun.   You see,  the type of heated 
          flying  suit  that  I was wearing had  a  little  brown, 
          rectangular  junction  box on its right-hand side  about 
          the  hip level.   I had to tear it off to convince  them 
          that it wasn't a gun, or I probably would have been shot 
          right there on the spot.   When they closed in around me 
          somebody  gave  me a rabbit punch from behind.   I  fell 
          down.   When  I got up,  somebody hit me on the shoulder 
          with a club, knocking me down again.   I had just got up 
          again when a wheezing little old man stepped up in front 
          of  me  and  took  a swing at me  with  a  double-bitted 
          woodman's axe, causing me to fall down again.   That was 
          a  good  thing because the axe swung about a  foot  away 
          from  me.   While I laid there on the ground,  he lifted 
          his  axe  to take another swing when a little  Frenchman 
          hopped  out  of the crowd,  stood over me and  began  to 
          reason  with  the German.   He must have put  his  point 
          across  because  the little German backed away  and  the 
          Frenchman  helped me to my feet.   By now I was having a 
          great  deal of trouble in standing erect due to my  leg, 
          but nevertheless, they forced me to start walking toward 
          the  village.   In  order that I wouldn't run away  they 
          made  me drop all my flying clothes down around my legs, 
          except  for  my  shirt,  which is the  only  thing  they 
          allowed  me for coverage,  and grabbing the loose  arms, 
          made me move on ahead of them.  Just before entering the 
          town  a  woman stuck a camera in my face and  got,  what 
          later  probably  turned  out to be a  very  embarrassing 
          picture. (Unpublished diary)
     
     Mr.  M.  still  feels guilty about his decision to try and make it 
     back  to England in his crippled B-17,  during which time two crew 
     members  were killed.   Neither Mr.  M.  nor Mr.  L.  report being 
     affected as much from their stays in POW camps,  despite suffering 
     significant hardships and deprivation there.
     
     The  fact  that  for some European exPOWs their capture  was  more 
     traumatic  than  was  their internment may help  account  for  the 
     observation  that "there does not appear to be a specific  minimum 
     length  of  internment before anxiety neurosis really  appears  in 
     former  European  Theater  POWs;   this  disability  occurs  in  a 
     significant  number  of  the  POWs interned a  few  days  just  as 
     
     NAM VET Newsletter                                         Page 72
     Volume  5, Number  7                                 July 27, 1991

     certainly as it does in those interned several years." (VA,  1980, 
     p.84)
     
     GROUP PSYCHOTHERAPY
     We  believe strongly that group therapy is the treatment of choice 
     for  most  exPOWs.   The group experience is therapeutic for  many 
     reasons,  but  primarily  because it is only in group  that  these 
     veterans  feel understood and accepted BOTH by other exPOWs and by 
     nonPOWs.
     
     Group  members and therapists differ in their SYMBOLIC function in 
     the group.   This is in addition to the different roles they play.  
     Group  members  are  symbolic of fellow POWs  (see  Rheault,  this 
     volume).   Their understanding and acceptance is the understanding 
     and acceptance of the other prisoners in the camp.   The therapist 
     (or therapists),  on the other hand,  is symbolic of all nonPOWs,m 
     of  family,  of  friends,  and  of  the  society  at  large.   The 
     therapist's  understanding and acceptance are on a different level 
     and  have  a  different  significance than  that  of  other  group 
     members.  Both are essential, but each is different.
     
     Some  observations  about the development of the now  two-year-old 
     exPOW  group  at Denver VAMC may be helpful.   This is a group  of 
     only  WW  II  exPOWs.   Approximately half the group is  from  the 
     European  Theater.   (Although difficulties combining members from 
     both  Theaters  of  War have been noted by  other  therapists,  we 
     encountered  no problems in this area.)   The group initially  had 
     six  members and two therapists.   It now has ten members and  one 
     therapist.   One member has permanently terminated from the group, 
     and  one  of  the therapists left the group due to a  job  change.  
     Nearly  all  group  members attend the  weekly  one-hour  sessions 
     whenever they are in town.   Three members spend winters in warmer 
     climates than Denver,  and several other members travel frequently 
     and  consequently  miss sessions during their  travels.   However, 
     average weekly attendance is about seven or eight members.
     
     After  the first few sessions,  it was observed that the group was 
     exhibiting  unusually  strong and fast bonding among the  members.  
     The group BECAME a group,  and developed into a SOLID GROUP,  more 
     quickly  than  any other group with which I have been  associated.  
     Related  to  this  phenomena  was the  initial  exclusion  of  the 
     therapists  because  of the feeling that "they won't  understand."  
     The  therapists were commonly ignored in group interaction  during 
     the  early  weeks  and months of the group.   There  was  also  an 
     unconscious  attempt  on the part of nearly all group  members  to 
     protect each other from painful affect.  Whenever one member would 
     begin  to  talk about a painful experience or would begin to  show 
     any  emotion,  another  member or members would either change  the 
     subject  or  direct questions of a factual nature toward  him,  to 
     move  him  away from the feelings.  This was interpreted time  and 
     time again, and even after two years, it still occurs.
     
     We  also  noticed  the development of a "pre-group  group"  and  a 
     "post-group group."  Some of the members would meet in the canteen 
     for coffee for an hour or so before the group, and would go to the 
     canteen for coffee after the group.   We wondered whether this was 
     another way of excluding the therapists.   We also speculated that 
     it might be a defense, necessary for the modulation of affect, and 
     necessary  for  the  members to keep  attending  group.   At  some 
     
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     Volume  5, Number  7                                 July 27, 1991

     points,  a  kind  of  "prisoner-guard"   role-play  seemed  to  be 
     occurring, with the therapists being seen as guards.
     
     Because  of  exPOWs'  exquisite sensitivity to affect and fear  of 
     loss of control, defenses against affect play an important part in 
     the process of the group.  It is the therapist's role to track the 
     defenses and interpret them when appropriate.  It is a difficult - 
     yet  essential  -  task to recognize when defenses are  necessary, 
     either  for the group or for an individual,  and when they can  be 
     interpreted  and  the affect tolerated.   Some therapists  working 
     with  this population in group therapy have noted that shifts from 
     present material to past material is a defense maneuver.  It is my 
     impression  that  EITHER  a  shift from past to  present  OR  from 
     present to past can be defensive,  but that neither is necessarily 
     so.   It  is  important to track where the affect is at any  given 
     time.  Descriptions of events from the past,  especially when they 
     are  recently  re-repressed  or have not been  shared  with  other 
     people, can contain tremendous affect,  just as some recent events 
     may  not  be affect-laden.   The therapist's empathy  in  allowing 
     himself  TO  FEEL WITH the group or one or more of its members  is 
     the key here.  The goal, of course, is to enable the group members 
     to experience and tolerate previously intolerable affect.
     
     In  our therapy group,  the initial defensive angry stage began to 
     break down after about three to six months, at which point sadness 
     became the most prominent feeling.  Simultaneously,  members began 
     to   talk  about  the  therapists'   (and  other   nonPOWs')   not 
     understanding  them.   There  was a shared group fantasy that  the 
     therapists must either be bored or overwhelmed.   It was extremely 
     helpful  when the group could recognize and talk about this as its 
     fear with ALL nonPOWs.  At a later point, the expectation of being 
     misunderstood was more clearly analyzed.   NEARLY ALL of the group 
     members  felt "disfigured on the inside,"  whereas only SOME  bore 
     physical  disfigurement.   There  was  an expectation  that  since 
     others  could  not SEE their psychological scars,  they could  not 
     understand their pain.
     
     Another  noteworthy  observation  is the group's response  to  the 
     absence of its members.   Whenever a group member or therapist was 
     absent, there was a serious concern about where he was and whether 
     he  was  "O.K."   This was especially significant when  the  group 
     member  did  not  call in to explain his absence.   When  the  one 
     individual  who  terminated from the group did so under less  than 
     ideal  circumstances,  viz.,  during a period of  depression,  the 
     group was extremely concerned about his well-being, and whether or 
     not they had "chased him away."   Some members had teased him in a 
     rather mild way a few weeks before his termination,  and they felt 
     intensely  guilty about doing this,  blaming this incident for his 
     leaving.   It  became  clear that unexplained  absences  rekindled 
     feelings  from the POW experience when absence usually meant  that 
     the missing person was dead.  The guilt generated by the premature 
     termination  of the group member had revived feelings of  survivor 
     guilt.   The  group was so concerned about this member that  about 
     six weeks after he had left they wrote him a card expressing their 
     concern; unfortunately, the card was not answered.
     
     INDIVIDUAL PSYCHOTHERAPY
     Some  exPOWs are seen in individual psychotherapy,  but only  when 
     group  treatment  is clearly contraindicated.   Two exceptions  to 
     
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     Volume  5, Number  7                                 July 27, 1991

     this  are (1)  using the individual treatment to help prepare  the 
     veteran  for group treatment,  and (2)  the occasional  individual 
     session  that  may  be  necessary while the veteran  is  in  group 
     treatment  to help him deal with some particularly difficult issue 
     that he cannot YET talk about in group.   Ideally,  the goal is to 
     reach  a level of comfort where any issue can be dealt with in the 
     group.
     
     Individual  treatment  cannot  accomplish  one  of  the  essential 
     psychotherapeutic   goals   obtainable   in   the   group,   viz., 
     understanding  and acceptance by other exPOWs.   Individuals  with 
     lesser  ego strength or with overwhelming guilt or shame are  most 
     appropriately   seen   for   individual,    rather   than   group, 
     psychotherapy,  and for them,  individual psychotherapy does serve 
     this purpose.
     
     A  word about marital treatment may be appropriate here.   I  have 
     seen  several  exPOW  couples for marital treatment,  and  I  have 
     recommended  it  in several other  cases.   However,  the  marital 
     dynamics  are usually so influenced by the POW experiences that  I 
     recommend  marital treatment only in addition to,  not instead of, 
     group therapy.
     
     WIVES' GROUPS
     We  are now completing a weekly,  time-limited (six months)  group 
     for  wives of exPOWs,  which was done with a female  co-therapist.  
     The  initial  goals for this group were (1)  to educate the  wives 
     about  the  basic  dynamics  of  exPOWs  in  order  to  help  them 
     understand  their husbands and their marital relationships better, 
     and (2)  to assist the wives in forming their own informal support 
     network.
     
     Five  wives  began the group;  four are  completing  it.   Initial 
     results  seem  promising,  with  all members  noting  an  improved 
     understanding  of their husbands,  themselves,  and their  marital 
     relationships,  and  two  members noting distinct improvements  in 
     their marriages.   One of these had been in individual and couples 
     therapy  for over two years before this group,  but showed  little 
     improvement.   Some of the women have also begun seeing each other 
     and  calling  each  other  outside of the group  for  both  social 
     activities and support.
     
     The  decision  to  make the group time-limited was  based  on  our 
     intention  not to foster unrealistic dependence on the VA  system.  
     A previous open-ended group for wives of veterans being treated at 
     the  mental hygiene clinic had encouraged but could not meet  such 
     dependency  needs,  and when the group was disbanded,  some of the 
     participants  felt severe disappointment and anger.   Setting this 
     group  as time-limited avoided this problem,  and does not seem to 
     have had any adverse effects.
     
                                CONCLUSION
     ExPOWs  are  a  very special subgroup of the  veteran  population.  
     They  have been subjected to some of the harshest treatment of any 
     of   our  veterans  and  as  a  group  have  probably  been   more 
     misunderstood.  This misunderstanding has exacerbated pre-existing 
     feelings of guilt, shame, unworthiness, and anger.
     
     Consequently,  perhaps  the  greatest service we can  provide  for 
     
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     Volume  5, Number  7                                 July 27, 1991

     these  veterans is to demonstrate enough  empathy,  patience,  and 
     willingness  to listen so that they will feel more understood  and 
     accepted.   This  requires creating an environment where they  can 
     tell  their  stories to their comrades and to us  -  the  American 
     society that has never really listened, let alone full understood, 
     the experiences and sacrifices of these extraordinary individuals.
     
                                REFERENCES
     DE  WIND,   E.   (1984).   Some  implications  of  former  massive 
       traumatization    upon    the   actual    analytical    process.  
       INTERNATIONAL JOURNAL OF PSYCHOANALYSIS, 65, 273-281
     
     PARRON,  E.R.  (1984).   The reparation of the self:  Clinical and 
       theoretical  dimensions  in  the  treatment  of  Vietnam  combat 
       veterans. JOURNAL OF CONTEMPORARY PSYCHOTHERAPY, 14, 4-56
     
     RUSSELL,   C.F.   (1984).    The   captivity  experience  and  its 
       psychological consequences.  PSYCHIATRIC ANNALS, 14, 250-254
     
     SCHWARTZ,   H.    (1984).    Unconscious   guilt:    Its   origin, 
       manifestations,  and  treatment  in the combat veteran.   In  H. 
       Schwartz (Ed.), PSYCHOTHERAPY OF THE COMBAT VETERAN (pp. 47-84). 
       New York: Spectrum Publications
     
     SEGAL, J. (1974).  Long term psychological and physical effects of 
       the POW experience: A review of the literature. SPRINGFIELD, VA: 
       NATIONAL TECHNICAL INFORMATION SERVICE
     
     VETERANS ADMINISTRATION (1980). POW:  Study of former prisoners of 
       war. WASHINGTON, DC:  Veterans Administration Office of Planning 
       and Program Education
     
     WOLF, S. & RIPLEY, H.S.  (1947).  Reactions among allied prisoners 
       of  war subjected to three years of imprisonment and torture  by 
       the Japanese. AMERICAN JOURNAL OF PSYCHIATRY, 104, 180-193
     























     NAM VET Newsletter                                         Page 76
     Volume  5, Number  7                                 July 27, 1991

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       and grief, guilt and shame,   II         IIXXXXXXXXX         XX
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                                          II          IIX
      Adam and Eve tried to hide from God; II          II
      Moses, born Hebrew and raised Egyptian IIII        IIII
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      Job, losing his children and all he owned,   II          II
       became sorely diseased;                       IIII        III
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                                                                I
      "And surely I am with you always, to the very end of the age"
                           Matthew 28:20
     
     NAM VET Newsletter                                         Page 77
     Volume  5, Number  7                                 July 27, 1991



     ==================================================================
                            Letters To The Editor
     ==================================================================

                           Letters to the Editor
     In  this section of NamVet are printed letters that are sent to me 
     either  via  NETMAIL  at  1:321/203  or  USSnailed  to:  Berkshire 
     Veterans'  Center,  Inc.,  Attn:  NamVet  Editor  -  P O Box  2056 
     Pittsfield,  MA 01202.   Generally,  the letters should be in good 
     taste  (whatever  THAT is -  never tasted a letter  yet)  and  may 
     provoke or generate conversation(s).  In ALL cases, Letters to the 
     Editor must contain your name,  address and telephone number where 
     I can reach you.   If you do NOT want your name published/printed, 
     please  let me know.   The right to edit and/or otherwise  "polish 
     up"  Letters  to the Editor is herein reserved.   What you see may 
     not be EXACTLY what I received.    -=< Joe -
     
                  Is Colonel Millard Peck Talking Funny?
                               *-Anonymous-*
     
        Tell ya what bothers me about the "Millard Peck resignation.  
     The use of the language and the implication he had little or no 
     knowledge of the efforts of those in the other "Intelligence 
     Agencies" to cover their tracks and confuse the issues.
     
        First of all, the language.  
     
     From a full bird with lots of staff time.  Look closely at 
-- 
#Larry W. Jewell (ex-USN)     WWII-L Listowner    jewell@mace.cc.purdue.edu # 
#"Sunday's horoscope is noteworthy because of its strange, sudden and wholly#
#unpredictable and inexplicable occurrences, affecting all phases of life." #
#--"Your Horoscope," L.A. Evening Herald Express, Saturday, Dec. 6, 1941.   #