“Brief Group Intervention as an Adjunct in the long term treatment of Trauma”
The paper discusses a brief group-analytic treatment group in the context of a long-term intervention for trauma. The common trauma was exposure to the risk of contracting Creutzfeldt-Jakob disease (CJD). An outline of sessions is presented along with the transposition and parallel processes taking place. Keywords: brief group psychotherapy, Creutzfeldt-Jakob disease (CJD), group-analysis, Infertility
In Australia from the 1960’s until 1985, over 2,000 individuals were treated by several specialist medical practitioners using extracts of human pituitary glands. The glands, removed from human cadavers, were processed to extract pituitary hormones, primarily human growth hormone (hGH) used for the treatment of growth hormone deficiency, and human pituitary gonadotrophin (hPG) for the treatment of infertility in women (Department of Human Services and Health, 1994).
During the mid 1970’s, research began to show that such human pituitary extracts could be implicated in the transmission of infectious diseases, particularly Creutzfeldt-Jakob Disease (CJD), a fatal dementia of insidious onset (sometimes more than 20 years between exposure and symptom development) caused by sub-viral particles called prions. No screening test to detect possible exposure to or active infection with CJD exists (Kaplan, Sadock & Grebb, 1994).
Because of these risks, the programme of treatment with pituitary extracts in Australia was ceased in 1985. At least four deaths of hPG recipients due to CJD have occurred in Australia since 1988.
For the women who underwent such treatment for infertility, the eventual discovery of the possible long-term risks of CJD was only part of the trauma. The long and arduous treatment programme for infertility using hPG injections involved frequent medical appointments, painful injections, frequent and impersonal gynaecological examinations and prescribed sexual intercourse. A possibly fatal and acute side effect of the treatment was ovarian hyperstimulation, accompanied by abdominal pain and distension and the risk of internal haemorrhage. Multiple births and their associated risks were also possible. Some of the women complained of acute and severe mood changes occurring during the hPG treatment.
In Australia in 1985, current hPG recipients were informed of the risks of CJD upon cessation of the programme. However, former patients were not formally traced and informed until 1990 at the earliest, via the individual treating doctors concerned. The lack of formal procedures for tracing patients and the often lengthy time delay between exposure to hPG and notification meant that tracing and informing hPG recipients was incomplete and irregular. Some women found out through letters, others through telephone calls; some contacted their doctor themselves after media reports in 1993.
A CJD Task Force was established by the Commonwealth Department of Health in May 1993, eventually leading to a CJD Newsletter and the formation of formal counselling and support groups. These groups and counselling services continue to operate as hPG recipients continue to live with the fear of contracting CJD in the absence of any available tests to confirm or deny possible infection.
The six women who formed the treatment group in this paper were individually referred to one author (CM), either for assessment for individual counselling or for the purposes of a medico-legal report (all of the women were involved in a class action against the treating doctors, the Health Department and other bodies following disclosure of the CJD hazard).
As each woman gave her individual history, it was clear that there were common themes. These included a feeling of deep anger towards those in the medical profession involved in their treatment – anger about the lack of informed consent, about the often glib and dismissive way that they were informed about the risk of CJD, about being “treated like guinea pigs “, about possibly being robbed of years of a healthy life. They all expressed fear of the future, of dying prematurely or “going mad” due to CJD, of passing on CJD to their families. There was a common feeling of shame and self-disgust, as all felt that the risk of CJD was a guilty secret that they had to keep from others for fear of rejection. In fact all were required to inform their doctors, dentists etc. of the CJD risk and their names were on a Health Department list of individuals who had been treated with these hormones.
All had had contact with the organised support group and received regular updates through this and the CJD Newsletter, yet were distrustful of these resources as they saw them as agents of the perpetrators (the Health Department, the doctors ) and only served to provide them with further statistics and data, but no hope. The shared affects were of anger, despair and anxiety, and a fear of living with uncertainty about what harm the treatment may have caused them.
Each of the women knew at least one other who was seeing C.M. and would sometimes mention one another in their individual sessions. As there was already a connection between them and given the commonality of their experiences and current problems, it was suggested by C.M. that a therapeutic group be formed to work through the collective trauma. The women were keen on this and saw it as a chance to form support for each other outside of the formal network offered to them by the Department of Health groups.
A brief group intervention, as an adjunct to long term treatment, was chosen in order to help the women get in touch with the trauma. Molnos (1995) outlines how group-analysis has much in common with brief psychotherapy. It was hoped that a closed, time-limited group could advance the therapeutic process along similar lines as brief psychotherapy. The authors offered an 8 session brief group-analytic psychotherapy program.
When the authors thought about what may lie ahead the following ideas came to mind. The group being run by a male psychiatrist with a female clinical psychologist (VA), as co-facilitator, set up the possibility for splitting. The authors felt that they needed to be aware of the ‘doctor abuse’ issue and that this may possibly be all put into the male doctor in the present group. The authors were aware that splitting of ‘the good doctor’ versus ‘the bad doctor’ may emerge. CM was seen very much as ‘the good doctor’ and the authors wondered what role VA may play. If the group was unable to split, then they would have to give up the idealisation of CM being their ‘good doctor’ and would hopefully be able to move on.
Issues were more complicated as CM was also their individual therapist/psychiatrist. The women had and would continue to be seeing him during and after the group program which added further complexities.
The authors were aware that they did not wish to replicate the trauma of the original medical treatment. Offering solutions was an impossibility and the authors did not wish to offer false hope, rather the group was intended to be a vehicle to help the women live with uncertainty.
Julie, a mother of seven (including triplets who died as neonates), married living in public housing, homeduties. Requested to pay for the sessions gradually. Previously worked as a clerical assistant in the fertility clinic.
Anne, a thin mother of three, married, working part-time, on antidepressants upon entry to group, her depression being a consequence of the trauma from the treatment.
Jean, a grandmother, the most active in suing the authorities involved. Working full-time, mother of nine children, two of whom were adopted (one of the adopted children was removed by authorities during the hPG treatment), married to her second husband.
Sarah, mother of two, divorced, living with her defacto and working part-time.
Rose, mother of two, married, working part-time in the family business, depressed in mood, experiencing mood swings especially anger outbursts.
Maria, adoptive mother of two and the only woman to have not conceived on the program. Working as a teacher but not coping. The infertility was still a secret in her family which was of Italian background.
The women felt strongly not to make this group confidential as “this” had been kept secret for too long. They wished to continue their out of session contact and were all planning to go for a coffee after the group.
Jean disclosed a lot very early in the group, losing her adopted daughter to the authorities as she had been unable to cope mentally while receiving the treatment. Maria disclosed she could not cope at work and sometimes just started crying in front of her class. They spoke of the government contractor who was meant to provide counselling being of no use, as they were there to “make it better and placate us …they are on the government’s side”.
The trauma of treatment as well as the daily horror of living in fear of getting CJD was discussed. Jean wanted people to know this happened. Rose said she eats to cope with the feelings inside. Anne looked very thin… All did go on to have children bar Maria who adopted hers.
A theme of symptoms of Post Traumatic Stress disorder emerged. The women spoke about the injections, the pain that went with it, the swelling of ovaries, stomach, the medical students looking at them with their legs in stirrups … the bad doctor whom they had trusted. It was all very vividly recalled. The women went on to think about male doctors and wondered what right did they have to experiment on them, “like rats” Sarah remarked. They felt that these male doctors did not care, had they been treated by women this would never have happened.
CM was the one male in the room, who sat very quietly. He too was a male doctor and in the women’s eyes “they were all the same”. The women seemed unaware of the paradox of CM in the room, whom they had described as’ the good doctor’ for getting this group together. VA felt quite connected to the women, being a woman and non-doctor herself. Was this the splitting that the authors had expected taking shape?
Giggling and joking was present and VA wondered if it was a way of coping when they were confronted with very difficult issues. How did they deal with the horror? Sarah said she thought of it every morning, “will I be able to walk to the bathroom?”. Others talked to their husbands or ate. Maria had her “special room” in which she would not be disturbed, where she wrote to her children.
The issue of guilt about having possibly passed the disease onto their children emerged. Not only had it affected their lives but now their children’s lives were also being affected. The women said that this group was bringing everything up that they had tried so hard not to think or talk about and that the week in-between had been extremely difficult.
VA had to run the group by herself as CM’s wife was sick and he had to baby-sit. All the women were impressed by his commitment to his wife and were very accommodating of his absence. (The image of him as the ‘good doctor’ was not challenged, despite him abandoning them to VA).
Talk followed about ‘the bad doctors’ and the outrage seemed to unite them. The group was experienced as very hostile towards VA. Maria, especially, was pressuring VA with questions – “why aren’t you teaching us coping skills? Every week I am getting worse and this is not what I wanted.” VA reflected that things were being opened up for all of them in the group that they did not wish to be reminded of. Jean asked VA what did she and CM think about what had happened to them. It felt as if they needed to hear the authors believed them and that what had been done to them was not okay.
Another theme centred around the issue of what this group was meant to achieve? “What happens when we finish?” VA was being pressured to provide answers. They wondered if in this group they were being experimented on, i.e. had such a group ever been run before? VA explored the paranoid thoughts of the possibility that CM and her were experimenting on them. VA wondered if this explained some of the hostile feelings towards her in the group.
The issue about not being able to disclose that you may have CJD was discussed. It brought with it the disclosure that you underwent a fertility treatment, that you were already damaged, “half a woman”. Maria stated that she felt like ‘quarter of a woman’ as she never went through the process of giving birth, “now its all finished, I am in menopause”. It brought a lot of grief to the surface for Maria, who was apologising for crying. Maria felt separate from the group, as all the others had given birth. At the end of the group VA offered that they could phone if they felt that they were not managing throughout the week (VA felt that she was releasing walking time-bombs).
By now it seemed clear that the group was looking for someone to tear apart. Everyone had been “trying to help them’ yet abused them. How did the present facilitators differ? VA had felt angry and ignored. The authors wondered if this was how the women must have felt during their treatment in the fertility clinic. The authors were providing a space where all the past turmoils were emerging. The rage within them was overwhelming. The authors felt that the last thing to do was to try to ‘repair’ them but rather they should try to understand what it must be like for them.
No one had worked with them on the original infertility issue. Their initial complaint was infertility, yet this never had to be addressed as they were offered a miracle cure. If this was parallelled to homosexuality, the treatment enabled them to stay ‘in the closet’. Yet the final outcome of the treatment, the possibility of having CJD was forcing them to come ‘out of the closet’. This meant they had to deal with having been infertile in the first place which none ever had to face nor were helped to work through in the first place.
It seemed that it was too painful to deal with the shame they felt. The authors wondered if whether they had been given a space to talk about their infertility, would they have agreed to such radical treatments? Maybe they would have gone on to adopt. Through having treatment these women had avoided addressing the shame they felt for being unable to conceive, at a time in society when it was expected for women to have children.
The authors felt that the group could be a place where the women could define what they needed to cope with. How were they coping with the sequelae of the treatment? How were they coping with the feelings of shame of having been infertile? How were they coping right now?
The authors wondered what may have been projected into CM? Was he the representative for medical people, the husband, the father? Was he like the doctors that abandoned them to this technical process? There had been a re-enactment where the idealised doctor abandoned them as patients. In this sense they did become laboratory animals. Yet at the same time they were trying to preserve the image of CM as the idealised doctor. In response to abandonment the doctors were idealised. The doctor that promises to give you a baby could not be attacked.
The re-enactment that had occurred unintentionally was that they had gone to a doctor for help as they could not cope (were unable to conceive), he told them about a program that may help, they were very desperate so they attended, they idealised the doctor who knows best but then abandons them to the treatment; they are left with prescribed group meetings which are traumatic and they feel they have been exposed. VA wondered if she was maybe the hormone that they were being injected with, in this sense she was like the prion. She had to go and fix them, make it all right, be the active ingredient as a group therapist, make them fertile, yet maybe she was also deadly.
The issue for the authors was how they could change the outcome. In the fertility program you went away and you had been damaged by it. The program had traumatised them, not only psychologically. On the surface those that fell pregnant were ‘cured’, yet the damage remained.
From being alive they went to not being alive. Infertility meant no CJD, a life. Paradoxically, being made fertile meant conceiving, being impregnated with the prion. The dilemma now was had they fallen with CJD, and CJD meant not having a life. Two decades ago they had waited to fall pregnant. This was like the black pregnancy, it was the antithesis of being pregnant, they did not want the signs of it (twitches, weakness, etc.). Having waited 25 years ago for any sign of being pregnant (eg no periods), they were now not wishing to see any sign of being pregnant with CJD. Even the absence of a sign was not reassuring as the fear remained.
The authors also wondered what was going on in the outside ‘coffee group’. They found out that the husbands met outside and realised that they had left them out, when maybe they should have been given a space (similar to the fertility clinic where the wife was dropped off).
The group, within 3 sessions, seemed to carry all the feelings of the fertility clinic and what had gone on there. It was like an emotional re-run of what had happened.
Maria had been quiet for most of the group until towards the end. Maria did not wish to talk as she was still very emotional about the issue of infertility, especially now as she was going through menopause.
The group discussed how difficult it was getting for all of them because the group was bringing up so many issues they had tried not to think about. The theme of the group being a parallel to the fertility treatment they received was discussed.
Maria arrives having changed her hair, presenting like a different person. She seemed much better – more alive within. Jean did a lot of talking about the injustice and how she “won’t let CJD ruin her life”. She was making plans for the future, to go overseas. Julie had not attended due to a gynaecologists appointment she had.
The main theme discussed centred around the trauma involved in the treatment at the infertility clinic, which was experienced by most as similar to rape. They discussed what they had gone through physically in a lot of detail, and all those feelings associated with it were now coming out. There was much less talk about the fear of having CJD. It centred more around the horror of the procedures. All wondered how they made it through.
During the break an interesting issue emerged between Julie and VA, as Julie did not feel that she should have to pay for the missed session, while VA insisted that she did. VA felt angry and not valued. Was this projection at work, was VA feeling how they had?
The women had gone along despairing, were given hope and were then left with CJD. Now that our program was nearing its end were the women wondering how it would be leaving them? This group had been like the fertility clinic, the last hope. It was as if they were in a compression chamber, and it felt inevitable that this ‘group package’ would be attacked. The women had not known what had been inside them, now it started to emerge.
Julie had phoned as she had not wanted to come but was persuaded to attend, CM was unexpectedly absent. The issue about the accounts and not wanting to pay for missed sessions was raised. VA wondered if it was being used as a vehicle to express their anger at health professionals/her by not paying? What was being carried by the non-payment issue? Was she the ‘bad psychologist’ and CM the ‘good doctor’?
Julie said that she wanted to make this her last group as she would “have to cope with it on my own anyhow”. Rose complained that when they see CM individually it was different, “you deal with your problems, here you hear about everyone else’s problems and it makes you feel worse”. A lot of violent feelings were aroused but when put to the group they denied feeling angry. They wondered what CM’s follow-up arrangements would be.
The issue of sex came up. “We knew nothing about sex… sex was to fall pregnant, not to have pleasure.” VA was carrying the ‘liberated women of the 90’s’ projections, she was “assertive and had it a lot easier”. The group discussed sex in greater detail than when CM had been there. Maria even said that she would never discuss this with CM. She had just started to sleep with her husband again. Maria had lost 10 kg and was feeling a lot better, it was as if years of burden had been lifted off her.<
VA was left alone with an enormous load which paralleled what they were left with. It seemed inevitable that their outrage erupt. The attack mounted on the structure of the group, via the fees, presented a chance to the fertility program.
The issue of the group being a repeat experience was emerging as the main one. The different experience the authors were hoping to provide, was one in which they would not be left with all the issues inside. It had been an opportunity to not deal with it alone. Despite this they were going to continue to live with the uncertainty of whether they had contracted the disease or not.
It had been hard to criticise CM as he had brought the group together and would be seeing them individually after the group finished. The split, that had not been fully addressed as yet, was between the placating of and rage against the health professionals. There was still the image of the ‘good doctor’ and the ‘bad one’. Was Julie rebelling, was it acceptable to buck the system? Was she carrying the rage by herself? Was it acceptable to attack health professionals? She was not like the others, passive and going along with things. Was she trying to demonstrate a sign of autonomy, and health?
Was Julie in touch with the rage within? Was she frightened of getting out of control and feared she may smash the group to pieces and that’s why she had to leave? Yet she could not be the only one that felt like this. She had had special treatment as a staff member of the fertility clinic. Was this the replication? She did not have to pay for the treatment then so why should she have to pay now? She was used to special treatment.
Did her not paying VA represent a way she could get to VA, to hurt her financially – symbolically representing the physical attacking that she could not do? Did Julie feel powerless, if at least she could win over VA then she could feel as if she could do something? However, they could not attack VA too much, as on the one hand she represented the vehicle for their rage, but on the other it would be destroying their only avenue of hope and support, in CM’s absence.
With two sessions to go the women did not really know what would happen to them in relation to the group and follow-up. Would CM see them all individually? How had the group impacted on their long-term relationship with CM?
Julie spoke about this being the anniversary of the death of her triplets and maybe that was why she was having a bad week. She had been told by her husband “to stop making such a drama and pull herself together”. She had to go to an agricultural exhibition and was proud to have managed her feelings about her son being at the cow stand all day.
Jean wondered where they would go from here? CM offered to see them all individually. The group started to process what they had gotten out of it. They did not feel alone any more, they now knew that others feel the same. All were surprised that they had talked about things that they had never talked about to anyone. Jean said that she now knew where the landmines were, “so you can’t accidentally tread on them and blow up, they are exposed”.
The last session was coming up and the authors wondered what would they be left with? Issues had been opened up and VA represented this opening up process. She would not be seeing them again. It was as if VA carried the ‘awareness’ and CM carried the ‘unawareness’. This played out their inner conflict between unawareness (not wanting to know) and awareness. How much could they afford to be aware? Yet what was repressed into the unconscious could still be influencing them, whatever had not been understood could act like a landmine. Julie’s triplets had not been buried yet, and therefore had not been psychologically put to rest inside her.
The authors were also only too aware that the women’s’ pain would continue when the lawyers would prod and poke them publicly all over again. The authors wondered if they were seeking protection in CM who would be writing reports for them.
Julie’s loss of the triplets was brought up, and she burst into tears, “I can’t talk about it”. They had been 52 hours old when they died and were taken from her. She had not been allowed to say goodbye, and continued to not know where they were buried. Julie had not processed her grief for the triplets. This had overshadowed everything until now. There was an urgency for this to be dealt with as the unprocessed loss would continue to dominate and interfere with her life.
The group felt that CM now knew them a lot better. He saw them as individuals rather than CJD victims! They felt assured by CM agreeing to see them and thanked VA for her help.
The day after the group finished Julie phoned VA and thanked her as she had found out where her triplets were buried and was going to their grave tomorrow with her husband. Over the next 9 months she paid all money owing.
It seemed that Julie had not had the internal security to go and see the triplets until after the group. The group had given the women a different sort of security, a space in which they felt cared about, an experience that they could carry with them wherever they went.
Following the conclusion of the group, all women bar Maria, attended CM’s rooms for individual sessions. The legal action is still ongoing 16 months later. The women in general perceived the group sessions as useful as it freed them up to discuss the trauma, as well as helping them form a support network that felt more real than the official support structures. Some were able to cease antidepressant medication, others made plans for the future that they had been unable to make prior to the group.
The above represents an account of running a homogeneous group with women who shared a common history. The group was extremely brief for a group-analytic group. However, parallel processes/transposition emerged very quickly and was able to be interpreted. This led to a corrective emotional experience rather than just intellectual insight. Transference reactions were able to be worked through as they occurred. The group also served asa space for appropriate grieving which had not been dealt with for over 25 years.
Inquiry into the use of Pituitary Derived Hormones in Australia and Creutzfeldt-Jacob disease, Executive summary of report. (1994). Department of Human Services and Health, GPO Box 9848, CANBERRA ACT AUSTRALIA 2601.
Kaplan, H, Sadock, B. and Grebb, J. (1994). Kaplan and Sadock’s Synopsis of Psychiatry.(7th Edition). Williams Wilkins: USA. p348.
Molnos, A. (1995). When the Individual Psychotherapist is a Group Analyst. Group Analysis, Vol. 28, 429-441.
Acknowledgments: The authors would like to thank Dr. Peter Bott for his supervision while conducting the group and the women of the group for consenting to the publication of this paper.
Vera Auerbach is Clinical Psychologist and Psychotherapist in Private Practice and also works part-time at Westmead Hospital, Sydney, Australia.
Dr. Chris McDowell a Psychiatrist in Private Practice and a consultant at Sutherland Hospital, Sydney, Australia.
Authors’ Address: P.O. Box 569, GYMEA NSW 2227, AUSTRALIA