I. Group Therapy

OBJECTIVE

Provide a supportive environment in which a patient with PTSD may participate in therapy with other PTSD patients.

BACKGROUND

The material in this annotation is taken primarily from David Foy and colleagues’ discussion of Group Therapy in the recent practice guideline, Effective Treatment for PTSD (Foy et al., 2000). This guideline represents the most recent and most comprehensive review of current treatments for PTSD available in the literature. Only one descriptive study of a group therapy program (Donovan et al., 2001) is more recent than the guideline.

The authors briefly review the use of group therapy for PTSD. They note that it first began to be used as a “front-line treatment” for PTSD in the 1970’s, and that it has continued to be used, and researched, up to the present. They note the intuitive appeal of providing this form of therapy to patients who, by the nature of their disorder, have to deal with “isolation, alienation, and diminished feelings” (Foy et al., 2000). They further acknowledge the possibility that group therapy may foster “survivor helping survivor” feelings in participants.

Foy et al. (2000) characterize group approaches as “supportive,” “psychodynamic,” or “cognitive-behavioral.” While all three approaches share certain features such as homogeneous groups, acknowledgement of the trauma, and normalization of traumatic response, they also differ in significant ways:

Supportive approach

• “Covering” approach in which the emphasis is placed on addressing current life issues
• Interventions explore middle-range affects such as frustration, with the goal of diffusing more extreme affects
• Less reliance on formal content or structured materials than psychodynamic or cognitive-behavioral groups
• Low demand on clients for homework or mastery of materials
• Designed to maintain a sense of interpersonal comfort and to keep transference at a low to moderate level
• Orients members toward current coping
• Can be conducted in a range of clinical and paraclinical settings

Psychodynamic (“Trauma focus”) approach

• “Uncovering” approach designed to address members’ specific traumatic experiences and memories
• Helps patients find meaning in the traumatic experience
• Encourages patients to confront the continuing issues presented by the experience
• Allows patients to trace painful affects back to their self-views and views of others, which may be irrational
• Seeks to provide appropriate affective involvement, monitored to control any overwhelming feelings and to offset the risk for precipitating dissociative reactions

Cognitive-behavioral (“Trauma focus”) approach

• “Uncovering” approach designed to address members’ specific traumatic experiences and memories
• Primary goals are to reduce symptoms, enhance members’ self-control, and improve quality of life
• Emphasizes application of systematic, prolonged exposure and cognitive restructuring to each individual’s traumatic experience
• Provides relapse prevention training through emphasis on mobilizing coping resources
• May feature an autobiographical emphasis
• Incorporates trauma processing

RECOMMENDATIONS

1. Consider group treatment for patients with PTSD
2. Current findings do not favor any particular type of group therapy over other types.

DISCUSSION

Foy et al. (2000) note that although group therapy is in common use for PTSD patients, very little research has been done to validate the effectiveness of group therapy, or to delineate those characteristics of therapy that lead to improved clinical outcomes. Their review is based on two RCTs, five nonrandomized trials, and seven pre-/post-treatment single-group studies. In light of the small number of studies, they recommend that group therapy be seen as potentially effective.

The guideline authors provide a useful guide to selecting candidates for group therapy:

Indications for Group Therapy (from Foy et al., 2000)

• Flexibility in personal schedule in order to meet group at appointed times
• Able to establish interpersonal trust with other group members and leaders
• Prior group experience, including 12-step groups
• Completion of a preparatory course of individual therapy
• Not actively suicidal or homicidal
• Shares similar traumatic experiences with other group members
• Compatible for gender, ethnicity, and sexual orientation with other members
• Willing to abide by rules of group confidentiality
• Not severely paranoid or sociopathic
• Has stable living arrangements

Contraindications for Group Therapy (from Foy et al., 2000)

• Active psychosis
• Severe organicity or limited cognitive capacity
• Pending litigation or compensation seeking

Indications for Trauma Focus versus Supportive Groups (from Foy et al., 2000)

• Individual can tolerate high anxiety arousal or other strong affects
• No active suicidality or homicidality
• Substance abuse or other comorbidities are under control
• Individual accepts rationale for trauma uncovering work
• Willingness to self-disclose personal traumatic experiences
• No current life crises

Two recent studies not included in the Effective Treatments for PTSD guideline provide a small amount of additional evidence for the effectiveness of group therapy. In the Rogers et al. (1999) study, 12 Vietnam War veterans were randomly assigned to either a single group session of exposure, or a single group session of eye movement desensitization and reprocessing (EMDR). In this study, at follow-up both groups “showed improvement on the Impact of Event Scale.” The EMDR group experienced “greater positive changes in within-session Subjective Units of Discomfort levels and on self-monitored severity of intrusive recollection.”

Donovan et al. (2001) present a descriptive study of a treatment approach that, “defined by a detailed manual, integrates elements of cognitive-behavioral skills training, constructivist theory approaches, SA relapse prevention strategies, and peer social support into a group-focused program.” They review outcome data for 46 male patients who received treatment between 1996 and 1998. The authors found that at six- and twelve-month follow-up, patients experienced significant improvement in Clinician-Administered PTSD Scale and Addiction Severity Index scores.