, J. Gayle Beck3 and Denise M. Sloan1, 2, 4
VA Boston Healthcare System, Boston, MA, USA
Boston University School of Medicine, Boston, MA, USA
Department of Psychology, University of Memphis, Memphis, TN, USA
Behavioral Science Division, National Center for PTSD, Boston, MA, USA
This work was supported in part by Grant I01 CX000467-01A1, Veteran’s Administration MERIT program awarded to D.M. Sloan and W. S. Unger, as well as funds provided by the Lillian and Morrie Moss Chair of Excellence at the University of Memphis (J. G. Beck).
The technique of organized group therapy began around 1905 with J. H. Pratt. Pratt led instructional groups with tuberculosis patients designed to provide information about their illness, when he realized the emotional support that patients were experiencing in the group format (Barlow et al. 2000). Other early pioneers included the social worker Jane Addams, who organized immigrant support groups in Chicago, as well as the psychoanalyst Trigant Burrow, who began experimenting with group psychoanalysis techniques in 1925 (Ward 2010). Group therapy for trauma-related difficulties appears to first be documented after World War II, when large numbers of veterans struggled with “battle fatigue” and the resources of support and treatment were deficient (Grotjahn 1947). Group treatment of trauma-related problems was further popularized with the introduction of “rap groups” for combat veterans in the 1960s (Foy et al. 2000). Since this era, substantial advances have been made in individual psychosocial treatment approaches for trauma-related disorders, including the development and testing of several empirically supported treatments (see Beck and Sloan 2012). Unfortunately, group treatments for trauma-related disorders have lagged behind these efforts, owing to considerable methodological issues that are intrinsic to the study of group therapy (see Beck and Sloan 2014; Sloan et al. 2012). This gap in our knowledge of effective group treatments is problematic as the group approach is frequently used in clinical settings (e.g., Rosen et al. 2004).
In this chapter, we will briefly review what is known about group treatment for trauma-related psychological disorders and describe the advantages of group treatment relative to individual-format therapies. Also, clinical aspects of group treatment for trauma survivors will be discussed, including various facets of clinical lore about treating trauma-related symptoms in a group setting. Finally, we will summarize key directions for clinical applications of group treatments for trauma-related disorders, as well as needed research directions.
23.1 History of Studying Group Treatment for Trauma Survivors
Early studies of group treatments for trauma survivors were conducted in the late 1970s and 1980s and examined the efficacy of group treatments for female survivors of child sexual abuse and sexual assault (e.g., Carver et al. 1989; Cryer and Beutler 1980). These initial studies often consisted of a single group of women in a supportive group environment without a comparison or wait-list condition. For example, Cryer and Buetler (1980) found that after 10 weeks of supportive group therapy, nine female sexual assault victims reported decreased distress, obsessiveness, and anxiety and increased expression of control. Although these findings were encouraging, the lack of a comparison condition in combination with the small sample size limited the conclusions that could be drawn from these studies.
Beginning in the mid- to late 1980s, there was a rapid shift to investigating more active group treatments, and researchers began to incorporate comparison conditions (e.g., Alexander et al. 1989; Resick et al. 1988; Roth et al. 1988). However, these studies continued to only include women survivors of child sexual abuse and sexual assault. In the late 1990s and early 2000s, researchers began to broaden examinations of the efficacy of active group treatments to survivors of other types of traumas, such as combat traumas (e.g., Schnurr et al. 2003) and motor vehicle accidents (Beck et al. 2009). The literature on group treatments for trauma-related symptoms has been growing considerably over the two decades.
23.2 Efficacy of Group Treatment for Trauma-Based Psychological Symptoms
With the increasing number of studies investigating the efficacy of group treatment for trauma-related symptoms, several recent reviews of group treatment for PTSD symptoms have been conducted. These reviews have focused on randomized controlled trials (RCTs) that included individuals who were at least 18 years old and either were identified as trauma survivors or diagnosed with PTSD (Beck and Sloan 2014; Sloan et al. 2013, 2012). Cognitive behavioral interventions that focus on exposure predominate in this literature, although a number of other therapeutic approaches are included (e.g., spiritually integrated therapy, interpersonal therapy). Overall, between-group effect sizes for group treatment in these RCTs are small to moderate; a meta-analysis by Sloan et al. (2013) noted that the average effect size was d = 0.24. Notably, these effects are smaller than those reported for evidence-based individual treatments for PTSD, which tend to obtain large effect sizes of at least d = 1.0 (e.g., Cahill et al. 2009). Another important aspect of the studies conducted to date is that the majority have included a no treatment, wait-list comparison condition. Thus, the significant between-group effect size indicates that group treatment for posttraumatic stress symptoms is better than no treatment. There are a number of group treatment studies for trauma survivors that are underway and include a treatment comparison condition. The findings of these studies will be important to advancing our knowledge of the efficacy of cognitive behavioral group treatments for trauma survivors.
Another important aspect of the studies conducted to date is that almost all of the cognitive behavioral group treatment approaches include exposure-based techniques as a central component of the intervention. This is not surprising given the evidence that exposure-based techniques are an essential feature of effective treatments for PTSD (Institute of Medicine 2008). However, the content of these exposure-based group treatments can vary considerably.
23.2.1 Exposure-Based Group Treatment
Several variations of exposure-based group treatment for trauma survivors have been developed, with considerable variability in the format in which imaginal exposure is conducted (e.g., written versus oral), the format of exposures (imaginal, in vivo), and the proportion of total treatment time that is dedicated to trauma exposure. In addition, the exposure-based group treatments involve a variety of treatment components, which can include cognitive restructuring, relapse prevention, and adaptive coping skills. For example, in their study of 360 male Vietnam veterans, Schnurr and colleagues (2003) conducted 30, 90–120-min sessions with 5 additional booster sessions. Of the 30 group treatment sessions, two sessions focused on autobiographical writing that included the trauma event, and 14 sessions focused on participants’ verbal recounts of trauma experiences within the group session. Beck and colleagues (2009) administered a total of 14, 120-min sessions to 44 motor vehicle accident survivors. Participants engaged in written trauma accounts conducted within the group treatment sessions. In vivo exposures were conducted outside of the treatment sessions and then reviewed during group sessions. Both group treatments examined by Schnurr et al. and Beck and colleagues also included components of cognitive restructuring and relapse prevention.
An important aspect of exposure-based treatment groups is that the majority of the studies included participants who had the same type of trauma exposure (e.g., motor vehicle accident, Beck et al. 2009; child sexual abuse, Classen et al. 2011; combat veterans, Schnurr et al. 2003), although a few studies have included participants with mixed-trauma events (e.g., Hollifield et al. 2007). It is also important to highlight that although some promising findings have been observed for these treatments, there does not yet appear to be any specific group treatment approach for trauma survivors that meets the criteria of a “well-established” or even “probably efficacious treatment” according to the standards described by Chambless and Hollon (1998). Furthermore, while exposure-based techniques all have the commonality of incorporating imaginal and/or in vivo exposures, the considerable methodological differences among these treatment approaches make direct comparisons difficult.
23.2.2 Non-exposure-Based Group Treatment Approaches
There is limited information on the efficacy of non-trauma-focused group treatment approaches for trauma survivors. As previously indicated, most RCTs of group treatment for trauma symptoms have focused on exposure-based approaches. However, there have been several RCTs of group treatment that feature non-trauma-focused approaches. For instance, Zlotnick and colleagues (1997) studied the efficacy of an affect management group treatment for women survivors of childhood sexual abuse relative to a wait-list control condition. Affect management group is a 2-h, 15-session treatment that emphasizes skills in effective methods to manage negative affect. Techniques include distraction, distress tolerance, relaxation, and self-soothing. Material from dialectical behavior therapy (Linehan 1993) is also incorporated. Difficulties in managing negative affect are a core problem among individuals with PTSD symptoms; thus, the approach to develop effective affect management skills has much appeal. Despite this appeal, findings from Zlotnick et al. indicated no significant group differences between participants randomized to the affect management treatment group relative to those randomized to the wait-list condition (between-group effect size d = .04). No additional studies of affect management group treatment for trauma survivors have been reported since the study by Zlotnick and colleagues.
Krupnick et al. (2008) investigated the efficacy of group interpersonal psychotherapy (IPT) for women diagnosed with chronic PTSD resulting from interpersonal trauma. Women were assigned to either the group IPT condition or a wait-list control condition. IPT consisted of 16, 2-h sessions. The treatment was adapted from Interpersonal Psychotherapy for Depression (Klerman et al. 1984) with the goal of improving interpersonal skills which, in turn, were hypothesized to improve interpersonal functioning. The adaptation of IPT for PTSD addresses how trauma histories negatively impact interpersonal relations. The goal of improving interpersonal skills is important given the substantial difficulties individuals diagnosed with PTSD have with interpersonal relationships (American Psychiatric Association 2013). Findings from Krupnick and colleagues indicated that individuals assigned to IPT showed significant reductions in PTSD symptoms relative to participants assigned to the wait-list condition (large between-group effect size d = .91).
More recently, Harris and colleagues (2011) examined whether a 2-h, eight-session spiritually integrated group treatment for military trauma survivors was efficacious in reducing PTSD symptoms relative to a wait-list comparison condition. This treatment uses preexisting faith resources to manage the impact of trauma. Reconciling spiritual beliefs that conflict with trauma experience is one aspect of the treatment, along with enhancing areas of spiritual functioning that contribute to positive functioning. This treatment approach has much appeal as trauma survivors can have difficulty reconciling the occurrence of traumatic events with their spiritual beliefs (Litz et al. 2009). Harris et al. found significant reductions in PTSD symptoms for the spiritually focused treatment relative to the control condition (between-group effect size d = .58).
Another type of non-trauma-focused group treatment is anger management. Difficulties in managing anger are a prominent problem for trauma survivors, especially veterans (e.g., Lloyd et al. 2014; Morland et al. 2012). Patients are generally motivated to receive treatment for anger problems, even when they are reluctant to receive trauma-focused treatment (Morland et al. 2012). Morland and colleagues (2010) compared anger management group treatment delivered in person to group anger management treatment delivered via videoconferencing. Participants were military veterans diagnosed with PTSD. As anticipated, findings indicated that veterans in both anger management group treatment formats had significant reductions in anger symptoms. Significant symptom reduction in PTSD was not observed, although this finding was not surprising given the treatment focus on anger management skills. This study is notable as it demonstrates that group treatment can be effectively delivered with the use of videoconference technology, which has implications for delivering treatment to trauma survivors in rural areas or areas in which there is a shortage of therapists with trauma treatment expertise.
One additional non-exposure-based group treatment approach that should be considered is present-centered therapy (PCT). PCT has been included in a number of PTSD treatment studies (e.g., Classen et al. 2011; Schnurr et al. 2003). Although PCT has been included as a comparison condition to control for nonspecific therapy effects (e.g., therapist contact, empathy), findings in a growing number of studies suggest that PCT is an efficacious group approach. For example, in a study of veterans with chronic PTSD, no significant between-group differences were found in PTSD symptom severity following treatment for veterans assigned to the group PCT relative to veterans assigned to an exposure-based group treatment (between-group effect size d = .14, Schnurr et al. 2003). Similar findings were obtained by Classen et al. (2011) who investigated the efficacy of trauma-focused cognitive behavioral group treatment relative to group PCT for women survivors of childhood sexual abuse (effect size d = .14). Importantly, Classen and colleagues also included a wait-list comparison condition and found that both group PCT and group CBT had significant reduction in PTSD symptom severity following treatment, relative to the wait-list control condition. These findings indicate that the significant reduction in PTSD symptoms observed for PCT and CBT was the result of the treatment and not some nontreatment-related factor (e.g., time).
These studies provide information on non-trauma-focused group treatment approaches that clinicians might consider. These group treatment approaches may be particularly useful for patients who are not willing to engage in trauma-focused treatment. The decision as to which group treatment approach to use will depend on the needs of the clients as well as the expertise of the clinicians. It should be noted that although efficacy has been found for group IPT, spiritually integrated group treatment, and group PCT, the comparison condition in each of the studies was a wait list (i.e., no treatment). It will be important to demonstrate that each of these treatment approaches is efficacious relative to a condition that controls for nonspecific group treatment effects (i.e., supportive counseling group).
23.3 Methodological Considerations of Group Therapy Studies
Although the evidence for group approaches to trauma-focused problems is growing, it remains considerably less developed than individual approaches for trauma survivors. A number of methodological considerations for conducting RCTs of group treatments have impacted the growth of this research area. First, a factor that must be accounted for in group treatment studies is the effect of the fellow group members on treatment outcome. Because members of a group affect each other, the group cohort effect needs to be accounted for in the analytic approach (Baldwin et al. 2005). This means that the degree of freedom for group treatment studies is the group cohort, not the individual participants, as would be the case for individual treatment studies. Accounting for the group cohort requires a much larger sample size to detect between-group effects than what is needed for individual treatment studies, which in turn increases the cost, time, and complexity of performing group treatment studies.
Another methodological consideration is that participants are randomized to groups, which means that a relatively large number of participants (e.g., 12–16) need to be gathered before randomization to two or more groups can occur. This requirement also means that participants need to be recruited in a relatively short period of time in order to prevent lengthy wait times prior to the start of treatment. Because participants will require some delay between enrolling in the study and starting treatment, there is a need to provide clinical management prior to the beginning of group treatment.
Relatedly, because a large number of participants are randomized and start treatment at the same time, this also means that the same group of participants needs to have follow-up assessments conducted at the same time. Conducting a large number of assessments in a very short period of time requires sufficient staffing. Thus, staffing needs for group treatment studies tend to be more demanding and complicated than what is required for individual treatment studies.
Another methodological consideration specific to research on group treatments of trauma-related disorders is whether to recruit groups of individuals who have experienced different types of trauma or to restrict the treatment to specific types of trauma (e.g., child sexual abuse, motor vehicle accidents, combat). While an advantage to mixed-trauma groups is a potential increase in the degree of generalizability and real-world application, such mixed-trauma groups also have the potential to increase intragroup difficulties and decrease the degree to which group members feel that they can relate to each other.
In considering this literature, it is notable that the most commonly studied individual treatments (PROLONGED EXPOSURE THERAPY AND COGNITIVE PROCESSING THERAPY; see Chaps. 8 and 10) have not been studied using the RCT design when administered in a group format, although RCTs are underway. Instead, most of the group cognitive behavioral approaches that have been studied are “package” interventions, treatments that include a mixture of some form of exposure, cognitive therapy, relapse prevention, treatment elements targeting depression, and the like.
One reason evidence-based treatments for PTSD have not been examined in a group format is because these treatments are difficult to conduct in a group setting. For example, a core component of PROLONGED EXPOSURE THERAPY is imaginal exposure of the trauma memory that is conducted in session. It may be difficult to conduct imaginal exposure within a group as one group member’s trauma account may trigger trauma memories from the other group members. It would be difficult to manage such trauma reactions of multiple group members while simultaneously conducting imaginal exposure with a specific group member. Moreover, group members may find the group experience to be aversive because of the triggering they experience. One alternative approach would be to have group members write their trauma accounts rather than providing a verbal account of the memory; the written trauma narrative approach has been successfully used by others in a PTSD treatment format (e.g., Beck et al. 2009). Alternatively, Chard (2005) modified COGNITIVE PROCESSING THERAPY so that the treatment sessions that focused on the patient reading the trauma accounts and trauma impact to the therapist occurred during individual treatment, whereas other sessions were conducted within a group setting. Combining individual and group sessions allowed for the benefits of the group setting to be obtained, such as the social component and normalizing of symptoms, while still delivering the components of the treatment that are best conducted in an individual format. Beidel and her colleagues (2011) used a similar treatment approach. Specifically, exposure-based treatment sessions were first delivered individually, and the remaining treatment sessions that focused on social skills were conducted in a group setting. Although conducting exposure-based components of PTSD treatment can be challenging in a group setting, Ready and his colleagues (2008) have reported success conducting imaginal exposure by verbally recounting trauma events within the group treatment setting. This treatment uses an intensive outpatient program to deliver PTSD treatment with a veteran population.
23.4 Considerations for Different Trauma Populations and Different Settings
The majority of group treatment studies for trauma-related symptoms that have been conducted have included only adult survivors of childhood sexual abuse and/or interpersonal violence. In addition, most of these studies included only women. Sloan and colleagues (2013) found that gender moderated within-group treatment effects for PTSD symptom severity; studies that included men were noted to have a significantly smaller effect size than studies that included women or mixed gender samples. However, a moderator effect was also observed for type of trauma, with studies that included combat veterans having a smaller within-group treatment effect than other trauma types. It is likely that the observed gender moderator effect was the result of trauma type as the studies that included men were also studies of combat veterans. The moderator finding suggests that combat-related PTSD may be more difficult to treat in a group format relative to other types of trauma. However, it may also be the case that participants with combat-related trauma represent a very chronic sample, and the chronicity of the disorder reduces the treatment outcome effect. Overall, the findings of group treatment for trauma survivors have limited application for clinical settings where mixed gender- and/or mixed-trauma-type groups are desired. Additional studies that mirror the clinical practice of groups with diverse patient members would be welcome in this literature.