Upon successful completion of an evidence-based therapy (EBT) for military sexual trauma (MST), female veterans reported damaged self-concepts and uncertainty about their ability to effectively reintegrate into the family, work, and social community. A flexible, time-specific program called Gathering Insights Following Trauma (GIFT) was modeled on Kohut's self-psychology paradigm and was designed to help the veterans develop a cohesive self and achieve self-actualization through human interaction, education, self-reflection, and group processing. Program topics related to self-agency (control over own actions), self-coherence (sense of physical wholeness), self-affectivity (ability to experience feelings), and self-history (continuity with one's own past) encouraged veterans' personal growth and development by addressing mirroring , idealizing , and twinship needs.

In Kohut's self psychology, the self is considered the nascent core of the individual's personality. The self is influenced by sensations, thoughts, feelings, and attitudes that concern the individual and his or her environment (Banai, Mikulincer, & Shaver, 2005). Self psychology considers the constructs of attachment, self-cohesion, affect regulation, and adjustment as essential for the individual's optimal psychological development and well-being; therefore, it recognizes the intrinsic therapeutic value of understanding, empathy, and attunement (Banai et al., 2005). Self psychology also recognizes the importance of an individual's developmental needs and transferences. These include mirroring , or the need for self-object reflections of self-worth and value; idealizing , or the need to be close to a safe, calming, comfortable other; and twinship , or the need to feel like others. In the process of addressing the individual's developmental needs, the therapist regularly employs empathic attunement (the ability to think and feel the inner experiences of another person) and transmuting internalization (the process of internalizing self-regulation functions) as fundamental therapeutic techniques (Rowe & Mac Isaac, 1991).

The foundation for Kohut's self psychology is the “self”, a mental organizing system within the individual that manages his/her subjective experiences. The “self” is responsible for the growth and maturation of the individual's personality and plays an integral part in either its healthy development or in the creation of personality or “self” disorders (Banai et al., 2005). In self psychology, normal developmental experiences involve healthy growth established through interactive, interpersonal experiences that include three distinct types of self-object encounters. The first of these self-object encounters involves the interaction with persons who offer joy, approval, and support and who encourage emotional growth. The second involves a connection with powerful others who can be emulated and who provide a model of safety, calm, and comfort. The third self-object experience involves interactions with others who evoke a sense of connection and community. It is the combination of these three essential self-object experiences that provide the framework for a cohesive self-structure (Mitchell & Black, 1995).

Banai et al. (2005) described the cohesive self as a person who possesses a stable, positive, well-integrated set of personal qualities, ambitions, ideals, and values that enable the individual to accomplish desired goals. Thus, the cohesive self is able to exhibit a positive sense of identity, good values, meaning, and permanence. In essence, the cohesive self allows for the self-actualization of the individual's innate talents and acquired skills. Rowe and Mac Isaac (1991) have offered another insightful view that defines the cohesive self as a “well-functioning individual” who has the “capacity for empathic attunement, . . . the curiosity and wish to understand the needs of others, the ability to compromise and to delay satisfying one's own needs [in order] to meet the needs of others” (p. 72). Kohut maintained that a cohesive self has the ability to love with confidence and to be loved without fear of being rejected, to exhibit creativity that enthusiastically allows the individual to realize his/her innate potential, and to possess a genuine sense of humor that allows the individual to laugh at his/her sense of self-importance. To that end, self psychology focuses on the individual's ability to become a cohesive self, and it also asserts that a healthy sense of self-esteem can be restored through an effective therapeutic alliance between the therapist and the client (Corsini & Wedding, 1989).

Researchers who have investigated the recovery process from complex sexual trauma have suggested that healing proceeds in stages that consider and address the individual's present life stressors, personal problems, and ego functioning (Herman, 1992; Lebowitz, Harvey, & Herman, 1993). These stages emphasize realistic goal setting; strengthen perceptions of safety and stability; and develop coping skills, emotion regulation, and doable self-care regimens within the individual. The ultimate goal for this moving-forward model of recovery is implemented based on the individual's strengths and needs with a flexible client-centered focus. The ultimate goal of these recovery models is in essence the development of what in self psychology is referred to as a cohesive self , an individual who has the ability to reconnect with others, engage in meaningful activities, and enjoy life.

Method

In the pilot program, the group participants consisted of female veterans who resided in Appalachia and who had successfully completed an EBT for complex trauma related to posttraumatic stress disorder and MST. Specifically, four veterans, one Black and three White women, met once per week for six instructional/discussion sessions and two progress review meetings. Self-identified needs were requested from the veterans and became the focus of in-session psychoeducation. Individual assessments—the Beck Depression Inventory, Second Edition (BDI–II; Beck, Steer, & Brown, 1996 ) and the Beck Anxiety Inventory (BAI; Beck & Steer, 1993 )—were conducted pre- and postprogram as well as at a 5-month follow-up, and the results revealed an overall decline in the veterans' scores for depression and anxiety. In addition, a final written program evaluation was completed by each veteran who was encouraged to provide personal observations about the program and make recommendations to include or improve future group sessions.

A manualized, 8-week group therapy was developed and given the appellation GIFT. The topics presented during each session were identified as areas of need by the individual participants, and the identified topics reflected the common interests or needs of group members. Psychoeducational talks were obtained from a leader-compiled handbook of potential topics and were presented to the participants in the form of learning modules with printed handouts and practice activities. Interestingly, group-identified topics reflected the self-psychology tenet that the individual innately strives toward growth and development through human interaction. Learning modules focused on specific topics that included the following: understanding the etiology and identification of emotions ( self-affectivity ); assertiveness ( self-agency ); emotion regulation through cognitive and complementary and alternative methods ( self-affectivity and self-coherence ); and enhancing self-care skills using physical, intellectual, emotional, social, and spiritual charting ( self-coherence ). The pilot program consisted of a series of group meetings that included three interactional didactic groups, followed by one review/discussion meeting, and three more interactional didactic groups, followed by a final meeting for discussion.

Results

The GIFT program encouraged female veterans to identify areas of perceived needs through self-reflection. The individualized learning modules fostered positive self-concepts, effective interpersonal skills, self-empowerment, and resiliency. Results indicated an overall decline (7.6) in self-reported BDI–II scores (8.5) and BAI scores (6.75). Specifically, a reduction in the pre- and postscores of two self-report measures (the BDI–II and the BAI) demonstrated an overall decline in the veterans' scores. The initial mean BDI–II score was 24.5 (mild range), followed by a mean score of 19 (minimal depression) at the end of the 8 weeks. The mean initial BAI score was 44 (severe range), followed by a drop to a mean score of 34.75 at the end of treatment. Although this score remained in the severe range, it reflected a substantial reduction from the initial scores. Program evaluations provided by the veterans expressed satisfaction, improved self-perceptions, and positive impression about their ability to move forward.

Veterans provided specific feedback about the program that included the following comments: “The program helped me grow”; “The program . . . was totally helpful. Keep the group small, no more than six at a time”; “The lesson on being assertive was very well demonstrated . . . you do have to take care of yourself . . . the program gave you guidelines to follow”; and “[The program] will help with other relationships.” The veterans were also able to comfortably share observations about themselves and their peers. They commented on the “smiles and happiness” among the group members and noted that they seemed “more patient.” One veteran proudly observed that the group members appeared to “carry themselves differently” after having completed the program.

Discussion

The pilot group for the GIFT program had a positive impact on all participants. Using veteran-identified learning modules encouraged realistic identification of personal strengths and needs; it fostered self-empowerment and provided a foundation for the development of a cohesive self. The veterans reported that they were extremely satisfied with not only the customized content but also the method of delivery (psychoeducation with group processing). Veterans also reported that the knowledge and skills gained from the program were relevant to personal development and were likely to change their interpersonal communication skills. The GIFT program with its individualized curriculum produced an improvement in each veteran's sense of self-agency, self-coherence, self-affectivity, and self-history. There are several obvious limitations to this pilot program. The number of participants will certainly influence generalizability, and the small sample was not notably ethnically or racially diverse. The GIFT program was designed to address the stated needs of four female veterans who had experienced posttraumatic stress disorder and MST. In this program, veterans were provided with resiliency and empowerment information to assist them in addressing personal anxiety, depressive thinking, and trepidation about their ability to successfully reintegrate within family, work, or social community. The GIFT program provided each veteran with a “moving-forward” model for recovery and reintegration. In the course of the didactic discussions, it fostered personal growth and responsibility through self-reflection and processing. The program improved the veterans' self-efficacy and encouraged them to continue to develop cohesive selves. The core curriculum of the GIFT program can be completely modularized and manualized to ensure consistency of delivery and can be easily individualized, amended, or compressed to address specific needs and relevance for veterans. The program results suggest that identification and individualization of program content can enhance relevance and improve therapeutic outcomes for veterans. The program can be expanded, and additional topic-specific learning modules can be included in the core curriculum. The GIFT program has the potential to effectively enhance the outcomes of EBTs or other exposure therapies for male, female, and LGBTQ veterans who have experienced childhood, sexual, and/or combat trauma.

References

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Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory manual (2nd ed.). San Antonio, TX: Psychological Corporation.

Corsini, R. J., & Wedding, D. (1989). Current psychotherapies (4th ed.). Itaska, IL: Peacock Publishers.

Herman, J. L. (1992). Trauma and recovery. New York, NY: Basic Books.

Lebowitz, L., Harvey, M. R., & Herman, J. L. (1993). A stage-by-dimension model of recovery from sexual trauma. Journal of Interpersonal Violence, 8, 378–391.

Mitchell, S. A., & Black, M. J. (1995). Freud and beyond: A history of modern psychoanalytic thought. New York, NY: Basic Books.

Rowe, C. E., Jr., & Mac Isaac, D. S. (1991). Empathic attunement: The “technique” of psychoanalytic self psychology . Northvale, NJ: Jason Aronson.