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In this assessment of group therapy with WWII ex-POWs, the small cohort limits generalizations; however, we offer a longitudinal perspective on group process. Posttraumatic suppression and denial of emotions appears to be adaptive for time-limited periods but is not a long-term solution. More lasting changes in self-esteem and social interaction may be partially achieved through a supportive group environment that fosters cognitive synthesis and reorganization.

Psychotherapy with severely traumatized patients is a long, draining process that often produces strong countertransference reactions. It is difficult to therapeutically and ethically handle these personal responses. We feel that at different stages in therapy different ethical principles should guide the therapy. At the early stages, fidelity and nonmaleficence should be the guiding principles. As trust and confidence develop, therapists may have more personal freedom to act; beneficence, i.e., providing specific confident care then becomes the primary ethical principle. In later stages of therapy, promoting the principles of autonomy and justice come into play. As therapy further progresses, therapists' own needs, the principle of self-interest, may be utilized in the therapeutic relationship. Throughout therapeutic contacts with traumatized patients, therapists need to monitor their own needs, and find appropriate ways outside of therapy to cope with these often intense feelings. Continuing to feel therapeutically competent and ethically grounded, yet maintaining the personal strength and balance to treat traumatized patients, pose major challenges for therapists.

In depicting dysfunctional families Sam Shepard brought a greater intensity level to family portrayals than had previously been seen in modern American theater. In part, his plays appear to reflect the tumultuous tone of the late 1960s and early 1970s when American society was in flux and when the national uncertainty reached down to the basic unit of society, the family. Yet, despite addressing recently emerging social issues, Shepard's plays also depict universal family conflicts. There have been and always will be compelling forces that threaten domestic cohesiveness. While Shepard's families reflect extremely high levels of disorganization, they also demonstrate scenarios recognizable to all family therapists. They reassert the family's power and its influence on individual development. They also indirectly ask us to reflect on our current clinical practice and research. Family therapists need to continue to pay attention the content issues of family organization as well as therapeutic techniques. Shepard's plays remind therapists to look beyond internal dynamics in order to consider connections and affiliations that integrate families with outside communities. He underscores the importance of knowing the meaning and context of traditional rites of passage within families. Family therapists or other care providers may unwittingly undermine the significance of these family rituals by prescription of "expert" advice.

Cultural belief systems, along with traditional family and social role expectations, greatly affect psychosocial adjustment in individuals recovering from severe trauma. In the cross-cultural psychotherapy of posttraumatic stress disorder (PTSD) anthropological and sociological perspectives can contribute to a more comprehensive diagnostic formulation and suggest possible approaches to treatment.