From self-integration in personal schemas of morally experiences to self-awareness of mental states: A qualitative study among a sample of Portuguese war veterans

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Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695-706.

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Brief Summary

This study explored the understanding of the causes of their distress, the strategies used to cope with posttraumatic symptoms and the key resources and processes to which a group of veterans attributed their recovery from PTSD. Sample was composed of Portugues war veterans (N=60), all males, without brain injury, neuropsychological disorders, physical disability, and psychiatric illness previous to military duty. All participants received a diagnosis of PTSD related to war when they started treatment. Non-recovered group included 30 participants with current positive diagnosis of PTSD, randomly selected among a group of outpatient receiving both psychiatric and psychological treatment for at least the last ten years. Recovered group included 30 recovered patients since negative diagnoses for current PTSD. These participants were randomly selected among a group of former patients and did not receive any treatment during the past year. Participants had no deterioration of their clinical condition following treatment. Both groups showed no differences for demographic, military background, and treatment variables. Two individual semi-structured interviews were conducted. All interviews were audio-taped and transcribed verbatim. Analysis of the interviews’ transcripts was conducted using the Thematic and Categorical Analysis proposed by Bardin (2009). Codes were identified and labelled by tracking language and themes.

Six themes were identified to which participants attributed their recovery: war zone stressors, stressful life events, mental and coping strategies, self-integration in personal schemas of morally incongruent experiences, self-awareness of mental states, and perceived social support. Recovered participants showed higher occurrence of themes related to integration of the morally incongruent events within existing personal schemas or description of a process of transition in the integration of the morally incongruent events within existing self- and relational-schemas, capability to correlate their and others’ behaviors to emotional states or understanding their own mental states and behaviors through the others’ reactions, and description of a wider repertoire of coping strategies to cope with posttraumatic symptoms and current stress triggers. Non-recovered participantes showed higher occurrence of a severe discrepancy between self- and other schemas and the moral injury event, inability to understand their own behavior and other’s intentions and behaviors, childhood idealization, restriction of coping strategies strategies and inadequate or insufficient social support.

Recovery Model

Our findings suggest the benefits of psychoanalytic treatment with traumatized war veterans. Recovery from PTSD among those veterans was related to moral repair and higher mentalization abilities. Moral repair involved a gradual process of self-integration in personal schemas of morally incongruent experiences (Horowitz, 1992; Litz et al., 2009) resulting in the restoration of a sense of coherence achieved through assimilation of a new image of the body, images of others, and values and ideals in the structure of the self (Herman, 1992). Higher mentalizations abilities enabled recovered patients to find meaning to traumatic events and helped them to create a coherent narrative about the patient’s childhood history. This achievment seems to play a key role in recovery of self-concept and identity coherence (Horowitz, 1992).

These findings should be tested by using a longitudinal design to analyse the evolution of these processes in the psychoanalytic treatment of those patients. This framework should combine research on process and outcome.

Contact

Paulo Correia Ferrajão

Instituto Superior de Psicologia Aplica, Rua Jardim do Tabaco, 34, 1149-041 Lisbon, Portugal

Email: pauloferrajao@gmail.com