Psychological Reports, 1990, 66, 623-631. O Psychological Reports 1990
ADAPTED CHARACTER STYLES O F VIETNAM VETERANS W I T H POSTTRAUMATIC STRESS DISORDER ROGER J. SHERWOOD
Veterans Administration, ED.R. Horpital, Montrose, New York, Hunter College School of Social Work DAVID J. FUNARI AND ALEXANDER M. HEKARSKI
Veterans Administration, ED.R. Hospital, Montrose, New York Summary,-A total of 189 male Vietnam veterans who were admitted to a specialized inpatient treatment program were evaluated using the Millon Clinical Multiphasic Personality Inventory to assess character styles. The veterans were assessed for Posttraumatic Stress Disorder by using a subscale of the Minnesota Multiphasic Personality Inventory (MMPI) and 72% of the patients wele class~fied as having Posttraumatic Stress Disorder. The character styles of passive-aggressive, schizoid, avoidant, and borderline were significantly associated with these pdtlents. The most common 2-point profile was passive-aggressive and avoidant (8-2 or 2-8) and was significantly related to the diagnosis. While drug and alcohol abuse were common problem areas for the entire sample, the profile of patients with Posttraumatic Stress was different from those of substance abusers. These results indicate that treating Vietnam veterans with this disorder requires adopting strategies which indude a character style focus as well as a symptom focus.
The first comprehensive treatment program for Vietnam veterans as a unique and discrete population began in 1979 at the Palo Alto Veterans Administration Medical Center (Berman, Price, & Gusman, 1982). Currently there are 14 specialized inpatient Posttraumatic Stress Disorder (PTSD) programs and 194 Vietnam Veterans Outreach Centers specializing in services to t h s population. I n this section we briefly review the research and various treatment approaches being utllized with Vietnam veterans. Much of the research on treatment of Vietnam veterans has focused on the symptoms of Posttraumatic Stress Disorder. Flashbacks, nightmares, and intrusive memories were shown to respond to desensitization (Cellucci & Lawrence, 1978; Schindler, 1980) and to behavioral interventions such as flooding (Fairbank & Keane, 1982; Keane & Kaloupek, 1982). An inpatient unit based on behavioral principles reported some short-term success (Starkey, 1986). The autonomic arousal associated with this l s o r d e r has been treated with a variety of medications such as the beta blockers propran0101 and clonidine (Kolb, 1984), by phenylzine (Davidson, Walker, & Kilts, 'Please send reprint requests to Roger J. Sherwood, Hunter College School of Social Work, 129 Fast 79th Street, New York, NY 10021. We thank Richard Donn, M.D. (Chief of Staff, F.D.R. Hospital) for hls generous support of this research project. Thanks also to Hadass Ben-Elyahu for her assistance in the data analysis phases of the project.
62 4
R. J. SHERWOOD, ET AL.
1987; Milanes & Mack, 1984) and lithium carbonate (Kitchner & Greenstein, 1985; Van der Kolk, 1983). Group therapy has been the prime modality for dealing with the meaning of traumatic experiences (Brende, 1981; Jelinek, 1987; Parson, 1984; Walker, 1981). Numbing, isolation, and guilt have responded to abreaction (Horowitz, 1974) and cognitive restructuring (McWhirter & Liebman, 1988). There are few outcome studies which have examined the effectiveness of programs, and there is some evidence that progress in treatment has not been maintained (Perconte, Griger, & Bellucci, 1989; Perconte, 1987, 1989). These findings might indicate that focusing primarily on symptoms apart from the characterlogical context does not produce the desired long-term change. Since the symptoms being treated have been part of the veteran's functioning-in some cases for over 20 yr.-the resulting change in personality or character is of fundamental importance. I t can reasonably be asked whether or not inpatient treatment programs should be directed toward treating symptoms or changing character or some combination of both. Long-term outcome for Vietnam veterans may be more dependent on how effective treatment programs are at fostering and maintaining (through long-term outpatient treatment) character change and abstinence from drugs and alcohol than on short-term symptom relief. There has been limited investigation into character adaptation of the Vietnam veteran. Two studies (Hyer, Woods, Boudewyns, Bruno, & O'Leary, 1988; Robert, Ryan, McEntyre, McFarland, & Lips, 1985) have indicated that there may be a very homogeneous character adaptation among Vietnam veterans who have Posttraumatic Stress Disorder, however, control groups of Vietnam veterans without Posttraumatic Stress Disorder were not included in these studies. Most of these veterans were shown ro have Avoidant and Passive-Aggressive personality disorders. Other researchers have emphasized antisocial traits (Jordon, Howe, & Lockert, 1986; Lipkin, Scurfield, & Blank, 1983; Wilson & Zigelbaum, 1983) and borderline functioning (Berman, et al., 1982). Alcohol abuse (Jelinek & Williams, 1987; Koretzky & Rosenor, 1987) and drug abuse (Berman, et al., 1982) have also been documented as part of the adaptation to Posttraumatic Stress Disorder. This study compared the character styles of Vietnam veterans with and without Posttraumatic Stress Disorder, all of whom were admitted to a specialized inpatient treatment program. Implications for treatment interventions based on specific character styles are presented. METHOD This article presents one facet of an ongoing research project started in May 1985 at the Vietnam Veterans Evaluation and Treatment Program of the Veterans Administration F.D.R. Hospital Montrose, New York. Any veteran
POSTTRAUMATIC STRESS DISORDER
625
with service in Vietnam, with or without Posttraumatic Stress Disorder and/or exposure to combat, who needed intensive treatment was eligible for admission to the unit. The data for this paper were gathered between May 1985 and January 1989. During this period, 189 different individuals were admitted to the unit and are included in this study. One hundred sixty of these veterans were admitted once. Twenty-seven individuals were admitted twice and two individuals had three separate admissions. All 189 participants were men. Their ages at admission ranged from 32 to 5 1 yr. of age, with the average age being 38 yr. In terms of marital status, 33% were married, 29% were divorced, 23% were never married, 14% were separated, and 1% were widowed. Fifty percent of the sample was Caucasian, 40% AfroAmerican and 10% Hispanic. These individuals had entered the service between 1960 and 1974 with the average year of entrance being 1967. All of the patients had served in Vietnam. These men were discharged from the service between 1966 and 1984, the average year being 1970.
Data Collection Procedure
All patients admitted to the unit were eligible for inclusion in the study. During the first two weeks of the program the patients were given Millon's Clinical Multiaxial Inventory (Millon, 1983), the Minnesota Multiphasic Personality Inventory (MMPI), and an extensive social history questionnaire. The Millon inventory was utilized as the primary instrument to determine veterans' character styles. Posttraumatic stress levels were measured by the subscale of the MMPI developed by Keane, MaIIoy, and Fairbank (1984). A second measure of Posttraumatic Stress Disorder, the self-report Mississippi scale developed by Keane, Caddell, and Taylor (1988), was given to 30 patients. We received 148 valid Millon protocols and 132 MMPIs out of a possible 189. Forty-three individuals were in the program for less than three weeks, and this accounts for the majority of the missing test scores. We did an interitem correlational analysis to ascertain the degree of relatedness of responses on the MCMI inventory. The alpha level of internal reliability was estimated as .72. The MMPI subscale was used to divide the sample into two groups. Veterans who scored at or above 30 were evaluated as having Posttraumatic Stress Disorder. The average for that group was 38 and for the control group without Posttraumatic Stress Disorder was 24. Chi-squared analyses were used to compare the two groups on the personahty scales of the Millon inventory. RESULTS Table 1 presents the percent of veterans with Posttraumatic Stress Disorder. Based on the MMPI subscale, 72% of the sample were evaluated as having Posttraumatic Stress Disorder. Scores on this subscale showed a
626
R. J . SHERWOOD, ETAL. TABLE 1
PERCENT OF VETERANS WITHPOSITRA~?ATIC STRESS DISORDER BASED ONSUBSCALEOF MMPI (N = 132) Diagnosis
Veterans
NonPostrraumatic Stress Disorder (Scored
ADAPTED CHARACTER STYLES O F VIETNAM VETERANS W I T H POSTTRAUMATIC STRESS DISORDER ROGER J. SHERWOOD
Veterans Administration, ED.R. Horpital, Montrose, New York, Hunter College School of Social Work DAVID J. FUNARI AND ALEXANDER M. HEKARSKI
Veterans Administration, ED.R. Hospital, Montrose, New York Summary,-A total of 189 male Vietnam veterans who were admitted to a specialized inpatient treatment program were evaluated using the Millon Clinical Multiphasic Personality Inventory to assess character styles. The veterans were assessed for Posttraumatic Stress Disorder by using a subscale of the Minnesota Multiphasic Personality Inventory (MMPI) and 72% of the patients wele class~fied as having Posttraumatic Stress Disorder. The character styles of passive-aggressive, schizoid, avoidant, and borderline were significantly associated with these pdtlents. The most common 2-point profile was passive-aggressive and avoidant (8-2 or 2-8) and was significantly related to the diagnosis. While drug and alcohol abuse were common problem areas for the entire sample, the profile of patients with Posttraumatic Stress was different from those of substance abusers. These results indicate that treating Vietnam veterans with this disorder requires adopting strategies which indude a character style focus as well as a symptom focus.
The first comprehensive treatment program for Vietnam veterans as a unique and discrete population began in 1979 at the Palo Alto Veterans Administration Medical Center (Berman, Price, & Gusman, 1982). Currently there are 14 specialized inpatient Posttraumatic Stress Disorder (PTSD) programs and 194 Vietnam Veterans Outreach Centers specializing in services to t h s population. I n this section we briefly review the research and various treatment approaches being utllized with Vietnam veterans. Much of the research on treatment of Vietnam veterans has focused on the symptoms of Posttraumatic Stress Disorder. Flashbacks, nightmares, and intrusive memories were shown to respond to desensitization (Cellucci & Lawrence, 1978; Schindler, 1980) and to behavioral interventions such as flooding (Fairbank & Keane, 1982; Keane & Kaloupek, 1982). An inpatient unit based on behavioral principles reported some short-term success (Starkey, 1986). The autonomic arousal associated with this l s o r d e r has been treated with a variety of medications such as the beta blockers propran0101 and clonidine (Kolb, 1984), by phenylzine (Davidson, Walker, & Kilts, 'Please send reprint requests to Roger J. Sherwood, Hunter College School of Social Work, 129 Fast 79th Street, New York, NY 10021. We thank Richard Donn, M.D. (Chief of Staff, F.D.R. Hospital) for hls generous support of this research project. Thanks also to Hadass Ben-Elyahu for her assistance in the data analysis phases of the project.
62 4
R. J. SHERWOOD, ET AL.
1987; Milanes & Mack, 1984) and lithium carbonate (Kitchner & Greenstein, 1985; Van der Kolk, 1983). Group therapy has been the prime modality for dealing with the meaning of traumatic experiences (Brende, 1981; Jelinek, 1987; Parson, 1984; Walker, 1981). Numbing, isolation, and guilt have responded to abreaction (Horowitz, 1974) and cognitive restructuring (McWhirter & Liebman, 1988). There are few outcome studies which have examined the effectiveness of programs, and there is some evidence that progress in treatment has not been maintained (Perconte, Griger, & Bellucci, 1989; Perconte, 1987, 1989). These findings might indicate that focusing primarily on symptoms apart from the characterlogical context does not produce the desired long-term change. Since the symptoms being treated have been part of the veteran's functioning-in some cases for over 20 yr.-the resulting change in personality or character is of fundamental importance. I t can reasonably be asked whether or not inpatient treatment programs should be directed toward treating symptoms or changing character or some combination of both. Long-term outcome for Vietnam veterans may be more dependent on how effective treatment programs are at fostering and maintaining (through long-term outpatient treatment) character change and abstinence from drugs and alcohol than on short-term symptom relief. There has been limited investigation into character adaptation of the Vietnam veteran. Two studies (Hyer, Woods, Boudewyns, Bruno, & O'Leary, 1988; Robert, Ryan, McEntyre, McFarland, & Lips, 1985) have indicated that there may be a very homogeneous character adaptation among Vietnam veterans who have Posttraumatic Stress Disorder, however, control groups of Vietnam veterans without Posttraumatic Stress Disorder were not included in these studies. Most of these veterans were shown ro have Avoidant and Passive-Aggressive personality disorders. Other researchers have emphasized antisocial traits (Jordon, Howe, & Lockert, 1986; Lipkin, Scurfield, & Blank, 1983; Wilson & Zigelbaum, 1983) and borderline functioning (Berman, et al., 1982). Alcohol abuse (Jelinek & Williams, 1987; Koretzky & Rosenor, 1987) and drug abuse (Berman, et al., 1982) have also been documented as part of the adaptation to Posttraumatic Stress Disorder. This study compared the character styles of Vietnam veterans with and without Posttraumatic Stress Disorder, all of whom were admitted to a specialized inpatient treatment program. Implications for treatment interventions based on specific character styles are presented. METHOD This article presents one facet of an ongoing research project started in May 1985 at the Vietnam Veterans Evaluation and Treatment Program of the Veterans Administration F.D.R. Hospital Montrose, New York. Any veteran
POSTTRAUMATIC STRESS DISORDER
625
with service in Vietnam, with or without Posttraumatic Stress Disorder and/or exposure to combat, who needed intensive treatment was eligible for admission to the unit. The data for this paper were gathered between May 1985 and January 1989. During this period, 189 different individuals were admitted to the unit and are included in this study. One hundred sixty of these veterans were admitted once. Twenty-seven individuals were admitted twice and two individuals had three separate admissions. All 189 participants were men. Their ages at admission ranged from 32 to 5 1 yr. of age, with the average age being 38 yr. In terms of marital status, 33% were married, 29% were divorced, 23% were never married, 14% were separated, and 1% were widowed. Fifty percent of the sample was Caucasian, 40% AfroAmerican and 10% Hispanic. These individuals had entered the service between 1960 and 1974 with the average year of entrance being 1967. All of the patients had served in Vietnam. These men were discharged from the service between 1966 and 1984, the average year being 1970.
Data Collection Procedure
All patients admitted to the unit were eligible for inclusion in the study. During the first two weeks of the program the patients were given Millon's Clinical Multiaxial Inventory (Millon, 1983), the Minnesota Multiphasic Personality Inventory (MMPI), and an extensive social history questionnaire. The Millon inventory was utilized as the primary instrument to determine veterans' character styles. Posttraumatic stress levels were measured by the subscale of the MMPI developed by Keane, MaIIoy, and Fairbank (1984). A second measure of Posttraumatic Stress Disorder, the self-report Mississippi scale developed by Keane, Caddell, and Taylor (1988), was given to 30 patients. We received 148 valid Millon protocols and 132 MMPIs out of a possible 189. Forty-three individuals were in the program for less than three weeks, and this accounts for the majority of the missing test scores. We did an interitem correlational analysis to ascertain the degree of relatedness of responses on the MCMI inventory. The alpha level of internal reliability was estimated as .72. The MMPI subscale was used to divide the sample into two groups. Veterans who scored at or above 30 were evaluated as having Posttraumatic Stress Disorder. The average for that group was 38 and for the control group without Posttraumatic Stress Disorder was 24. Chi-squared analyses were used to compare the two groups on the personahty scales of the Millon inventory. RESULTS Table 1 presents the percent of veterans with Posttraumatic Stress Disorder. Based on the MMPI subscale, 72% of the sample were evaluated as having Posttraumatic Stress Disorder. Scores on this subscale showed a
626
R. J . SHERWOOD, ETAL. TABLE 1
PERCENT OF VETERANS WITHPOSITRA~?ATIC STRESS DISORDER BASED ONSUBSCALEOF MMPI (N = 132) Diagnosis
Veterans
NonPostrraumatic Stress Disorder (Scored
