The National Center for PTSD published the following article on Group CBT Therapy in the PTSD Quarterly Vol 2 which is fascinating reading and very pertinent to anyone with Complex PTSD, PTSD or any trauma.
“Despite the rich history of group treatments for PTSD, there is a surprising lack of methodologically rigorous studies in this domain. We know that at one point, “rap groups” were seen to be the treatment of choice for Vietnam Veterans (Foy et al., 2000) and support groups still play a significant role in many agencies that serve trauma survivors, including Department of Veterans Affairs (VA) settings (Hundt, Robinson, Arney, Stanley, & Cully, 2015). Despite the popularity of support groups for trauma survivors, the group treatment research literature is characterized by open trial (e.g., Ready et al., 2008) or non-randomized designs (e.g., Resick & Schnicke, 1992), which are helpful in the beginning stages of treatment development. However, the number of randomized clinical trials (RCT) is limited. Consequently, there are currently no group treatments for PTSD recognized as evidence-based (e.g., VA & Department of Defense [DoD], 2010). In this article, we will summarize the current knowledge about group treatments for PTSD and highlight areas that deserve greater empirical focus. Sloan, Feinstein, Gallagher, Beck, and Keane (2013) conducted a meta-analysis of RCTs of group treatment studies for PTSD. Studies were excluded if individual and group components were mixed within a protocol, resulting in 16 studies, with a total of 1,686 participants. Most of these treatments were cognitive behavioral, however, the content of these protocols varied considerably. Group treatment was found to have superior treatment outcome effects relative to wait list (WL). However, no significant differences were observed for cognitive behavioral group interventions relative to other active treatments (e.g., present centered treatment). Moderator analyses revealed smaller effect sizes for males relative to females and military-related and childhood trauma relative to mixed trauma samples. These findings should be interpreted with caution, given the small number of studies. Another important observation is that each of the 16 studies examined a different group treatment.
Since this meta-analysis was published, only a handful of additional RCT group trials for PTSD have been published (e.g., Bass et al., 2013; Castillo et al., 2016; Morland et al., 2014; Resick et al., 2015). Clearly, this is an area ripe for needed study. Trauma-focused Group Treatment for PTSD Although the advancement of group treatment for PTSD has been limited by the lack of RCTs, there are a number of protocols that have promise and deserve further investigation. Examining group formats of currently available first-line individual PTSD treatment approaches (VA & DoD, 2010), such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE), is one obvious path to pursue. In fact, the first efficacy study of Cognitive Processing Therapy (CPT) used a group format of the treatment (Resick & Schnicke, 1992). Several additional studies have been conducted with CPT administered in group format, with variations including a cognitive only version of CPT, referred to as CPT-cognitive only (CPT-C; Morland et al., 2014; Resick et al., 2015), group CPT-C modified for cultural considerations (Bass et al., 2013), and a combined individual and group format of CPT (Chard, 2005). Most recently, Resick and colleagues investigated the CPT-C group format relative to group present-centered therapy (PCT) with a cohort of active duty service men and women diagnosed with military-related PTSD. Both group treatments consisted of 12, 90 minute sessions. Findings indicated significant reductions in PTSD severity for both conditions. A significant reduction was also observed for depression in the CPT-C only. Without inclusion of a no-treatment comparison, it is unknown whether significant reductions in PTSD are the result of treatment or other factors such as the passage of time or nonspecific group support.
It should be noted that the group format of PCT has been found to be a moderately efficacious treatment in several group trial studies (Classen et al., 2011; Schnurr et al., 2003) and superior to a no treatment comparison condition (Classen et al., 2011). Thus, the limited number of studies using group formats of the first line PTSD treatments, combined with a lack of a no treatment comparison, limits interpretation of the Resick et al. (2015) findings. Chard (2005) used a different approach to delivering CPT in a group format. In a study of women survivors of childhood sexual assault, Chard adapted the CPT protocol to include 27 sessions of group (17) and individual (9) sessions. Individual sessions were devoted to specifics of the individual event, including the trauma impact statement and trauma narratives. Group sessions were used to reinforce skills and concepts introduced in the individual sessions and to foster social bonds with other group members. Findings indicated significantly greater reductions of PTSD symptoms for the adapted CPT condition relative to a minimal attention (MA) comparison condition. Moreover, treatment gains for the adapted CPT condition were maintained at a one year follow-up. Given the various formats of group CPT that have been investigated, it is unclear at this time which format is the best to pursue for additional development. Although there is a large literature demonstrating the efficacy and effectiveness of Prolonged Exposure (PE) therapy, there are no current studies investigating a group format of PE. Exposure is thought to be a critical component to effective PTSD treatment (e.g., Institute of Medicine, 2008), so inclusion of exposure within group treatment for PTSD is important. There is debate, however, about whether conducting trauma exposure within the group setting (rather than individually) is problematic, owing to vicarious traumatization of other members. There have been a number of group protocols that have used various approaches to conducting imaginal and/or in vivo exposures in the context of treatment. For example, Schnurr et al. (2003) examined the efficacy of a trauma-focused group treatment (TFGT) compared to group PCT for military-related PTSD. Both treatment conditions involved 30 weekly sessions lasting 90 minutes, although sessions that included exposure lasted two hours. Imaginal exposure was conducted within the group by Veterans taking turns recounting their trauma event while other members listened. Each Veteran had two sessions devoted to recounting their trauma event, with imaginal exposure sessions starting in session 9 through session 22. In vivo exposure was not included in the protocol. The time needed to conduct imaginal exposure within the group for each group member was extensive and may reduce the potential cost-effectiveness of the group format. Schnurr et al. attempted to make up for the limited time for in-session exposure through daily homework utilizing audiotapes. Findings indicated both groups had significant reductions in PTSD symptoms, with no between treatment differences. Significant between treatment differences were only observed for participants who completed treatment, with significantly greater reductions in TFGT relative to group PCT. Notably, treatment dropout was substantially higher in the TFGT (23%) relative to group PCT (9%). Although information was not collected regarding reasons for dropout, participants may have found exposures conducted in-session difficult to tolerate. Ready and colleagues (2008) also conducted exposure in-session by adapting the approach used by Schnurr et al. (2003). In an open trial, these investigators examined the efficacy of group based exposure therapy (GBET) among 102 Veterans. The group protocol consisted of 3 hours of treatment twice a week for 16-18 weeks. A minimum of 60 hours of exposure was included (3 hours of within group exposure per Veteran, 30 hours of listening to recordings of imaginal exposure, and 27 hours of hearing other Veterans’ trauma accounts). Significant reductions in PTSD severity were observed. Notably, only three people dropped out of the group prematurely suggesting that the in-session exposures were well tolerated. It should be stated that the protocol included group members having lunch together, which likely facilitated group cohesion. Castillo et al. (2016) used a similar approach to conducting imaginal exposure. In this study, group treatment consisted of 90 minute, 16 weekly sessions with only three women Veterans per group. Participants first completed a trauma narrative as homework. Each Veteran received four sessions of imaginal exposure, in which they read their narrative out loud in the group session. The protocol also included cognitive and skills components. The group size was limited to three members to permit the increased dose of imaginal exposure conducted in session. Relative to a WL comparison, participants in the trauma-focused group had significant reductions in PTSD severity at post-treatment, with treatment gains maintained at 6 month follow-up. This protocol differs from Schnurr et al. (2003) and Ready et al. (2008) with a less time treatment protocol. Treatment dropout rate was 24%. Beck, Coffey, Foy, Keane, and Blanchard (2009) used a different approach to conducting exposure treatment in the group context. Rather than have group members recount their trauma accounts out loud in-session, group members are instructed to write their trauma narrative during session. The trauma narratives are conducted in two sessions. This approach has the advantage of efficient use of time as all group members are conducting imaginal exposure simultaneously. The approach also reduces the risk of triggering responses among fellow group members. In addition, the protocol, referred to as group cognitive behavioral treatment (GCBT), includes in vivo exposures conducted between sessions as homework. The protocol consists of 14, 2-hour sessions. Beck et al. found significant reductions in PTSD severity for GCBT relative to WL with a sample of adults who had motor vehicle-related PTSD. Treatment dropout rate was 27%. A study is currently underway to investigate the efficacy of GCBT relative to group PCT in a sample of Veterans diagnosed with PTSD (Sloan, Unger, & Beck, 2016). Taking a similar approach to Chard (2005), Beidel, Frueh, Uhde, Wong, and Mentrikoski (2011) used a combination of group and individual treatment. This protocol, referred to as Trauma Management Therapy (TMT), combines exposure therapy and social emotional rehabilitation. The exposure component is conducted in the individual sessions, whereas the social emotional rehabilitation is conducted using the group format. TMT is based on strong empirical evidence favoring exposure therapy delivered individually, which it combines with group treatment to address social functioning, thereby providing a more comprehensive approach. In a sample of 35 Veterans who were randomly assigned to TMT or exposure therapy without group treatment, both conditions displayed significant reductions in PTSD with no between-group differences. As anticipated, the TMT condition had greater improvements in social functioning relative to exposure only. Treatment dropout for TMT was 22% relative to 6% in exposure only The higher dropout rate in TMT may be due to the greater time commitment involved in this treatment relative to the exposure only condition. Although replication is needed, this approach may be particularly appealing to trauma survivors who have deficits in social functioning. To summarize, protocols for group treatment for PTSD have used different approaches to conduct exposure thought to be critical to successful treatment. Two studies have used a combined group and individual format (Beidel et al., 2011; Chard, 2005), whereas most studies have incorporated exposure-based techniques in the group context. However, the format used for imaginal exposure has varied, with most protocols asking group members to recount their trauma memory out loud while other group members listen. In contrast, Beck and colleagues (2009) had group members write their trauma account during session. Beck et al. and Castillo et al. (2016) also had a lower treatment dose than other treatments (Ready et al., 2008; Schnurr et al., 2003). Despite the dose differences, large withingroup effect sizes were observed for PTSD symptom reduction and similar treatment dropout rates were reported across the studies. Thus, no single protocol appears superior to another in terms of outcome effects. The protocols used by Schnurr et al. (2003) and Ready et al. (2008) are fairly time intensive. Similarly, the time required for protocols that use a combination of individual and group formats is greater than the protocols used by Castillo et al. and Beck et al. Given the data reported so far, it may be most cost effective to use a group treatment that involves less time. Group Protocols that Address Comorbid Conditions Comorbid psychiatric conditions are common in PTSD, thus a number of group treatments have been developed to target comorbid conditions. One such example is Dunn and colleagues (2007) who tested the efficacy of self-management group treatment among a sample of 101 male Veterans diagnosed with chronic PTSD and depression. Self-management group therapy is designed to target depression and includes self-monitoring of positive activities and daily mood, goal setting and self-reinforcement for gains. Relative to a psychoeducation group treatment, Veterans assigned to self-management therapy showed a small reduction in depression symptoms at post-treatment. However, this reduction was no longer observed at the follow-up assessment. Moreover, no between group treatment differences were observed for PTSD outcome. It should also be noted that 33% of participants assigned to self-management group dropped out prematurely compared with 12% in the psychoeducation group. Another approach to treating comorbid depression among individuals with PTSD is interpersonal therapy, which has been found to be efficacious in the treatment of depression. In an open trial study, Ray and Webster (2010) found significant reductions in PTSD and depression symptoms as well as improvements in interpersonal functioning following an interpersonal group treatment among a small sample of Vietnam Veterans. The interpersonal group treatment involved assessing dysfunctional relationship patterns, developing new social contacts, and re-establishing lost relationships. The group consisted of eight, 2-hour sessions. Cloitre and Koenen (2001) also found significant improvements in PTSD and depression symptoms for women who completed a 12-week interpersonal process group. However, no treatment gains were observed when groups included one or more members who had a diagnosis of borderline personality disorder.
Despite these promising findings for interpersonal therapy, there have been no additional studies of the efficacy of interpersonal group therapy for PTSD. Further investigation should be pursued in which a treatment comparison condition is included. Seeking Safety (SS) is a well-known group treatment that targets a common comorbid condition in PTSD, substance use disorder. This treatment is a present-focused, coping skills approach that includes skills in distress tolerance and affect management. SS is frequently used in VA healthcare settings, yet efficacy findings for this treatment have been mixed. Early studies consisted of either an open trial design or a no treatment comparison condition. Findings from these studies demonstrated that SS reduces PTSD symptoms as well as substance use (for a review see, Najavits & Hein, 2013). However, more recent RCTs that have included an active treatment comparison condition (e.g., psychoeducation or treatment as usual), find significant within group effects for all treatment groups but no significant between group effects (Hien et al., 2009; Zlotnick, Johnson, & Najavits, 2009). It should also be noted that across studies, the effect sizes for PTSD symptom reduction tend to be larger than what has been observed for substance use, which may indicate that substance use is more difficult to treat (Najavits & Hien, 2013). Taken together, the findings to date do not indicate that SS is superior to other active group treatments, including psychoeducation. The continued popularity of SS may reflect the need for a treatment protocol that addresses PTSD and comorbid substance use combined as well as the limited availability of such protocols. Human immunodeficiency virus (HIV) is another important comorbid condition among trauma survivors for which group treatment protocols have been developed. The rate of PTSD among individuals who are HIV positive is significantly higher than among the general population and those with PTSD tend to be less adherent to antiretroviral regimes, which can have fatal consequences (Beckerman & Auerbach, 2010). Thus, treatment of PTSD among HIV positive individuals is an important area to address. Sikkema et al. (2007) investigated the efficacy of a group treatment protocol designed to address trauma symptoms stemming from childhood sexual abuse among 202 HIV positive adults. The 15-session treatment uses a cognitive-behavioral model to address coping strategies for both sexual trauma and HIV infection. Significant reductions in PTSD symptoms were observed for the trauma and HIV coping treatment relative to a support group and a WL comparison conditions. No group differences were observed between the support group and the WL condition. In light of considerable comorbidity, efforts to address PTSD in a group treatment setting are wise to incorporate therapeutic components that also focus on co-occurring psychiatric and physical health problems. As noted, the literature on group treatments targeting two conditions simultaneously is in its infancy. It is possible that as this literature grows, we will have a clearer idea of whether treatments that address comorbid conditions are more efficacious, relative to interventions that target PTSD alone. While efficacy may be equal between these two types of group treatments, one can wonder whether other dimensions of difference may appear. For instance, patients may prefer group treatments that target both PTSD and a co-occurring issue such as depression, as this type of approach may better address their concerns. Similarly, patients may be less likely to drop out of treatment that they believe is addressing their needs.
Limitations of the Literature and Future Directions As noted, a number of limitations exist in the literature on group PTSD treatment. It is salient that many forms of group PTSD treatment have been developed, each with one, perhaps two, supportive studies. This diversity in treatment protocols and relative lack of supportive data from independent replications of these studies limits knowledge that can be gained and has led to the lack of an evidence-based group treatment approach for PTSD (Institute of Medicine, 2008; VA & DoD, 2010). Moreover, many extant studies are under-powered and fail to consider dependencies among participants. As discussed by Baldwin, Murray, and Shadish (2005), when treatments are conducted in a group, participants within each group share the specific group environment, leading to a lack of independence of observations. Analytic approaches need to account for the group clustering effect, a feature largely missing from the literature (Sloan et al., 2013). Exceptions are clearly present. For example, Schnurr et al. (2003) did their analyses by regarding the group as the unit rather than each patient as the unit. However, this methodological feature is unusual in this literature, at present. Clearly, the literature on group treatment of PTSD has room for growth, building on the most promising treatment approaches. As this literature evolves, greater attention is needed to methodological sophistication. Determination of cost-effectiveness and patient acceptability of group treatment would be a welcomed addition, particularly in comparison to individual approaches. With increased treatment demands and greater attention to patient-centered services, group treatments for PTSD need a more solid empirical foundation. References Department of Veterans Affairs & Department of Defense. (2010). VA/DoD clinical practice guideline for management of post-traumatic stress. Retrieved from http://www.healthquality.va.gov/guidelines/ MH/ptsd/cpgPTSDFULL201011612c.pdf Institute of Medicine. (2008). Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: National Academies Press.