Group Treatment of Trauma and Stressor-Related Disorders

    •    Posttraumatic stress disorder (PTSD) refers to the emergence of
    symptoms following exposure to stressors that overwhelm a person’s
    ability to cope.

    •    These stressors consist of both natural disasters such as floods and
    human violence as occurs in sexual assault, war and combat,
    childhood abuse, intimate partner violence, forced displacement from
    home, terrorist attacks, or serious accidents. 

    •    PTSD is manifested as symptoms in four cluster areas: avoidance
    (such as psychological numbing), hyperarousal, negative cognitions and
    mood, and re-experiencing (e.g. flashbacks and/or nightmares).

    •    Group interventions in treating PTSD began in the context of
    World War II when it was necessary to treat large numbers of soldiers
    suffering from what was then termed “shell shock” or “war neurosis.” 
    Since then, both a promising research database and extensive clinical
    observations offer support for the efficacy and effectiveness of group
    therapy for PTSD.

    •    In their recent meta-analysis of research studies, Sloan, Feinstein,
    Gallagher, Beck, and Keane (2013) conclude that group treatments are
    associated with significant pre- to posttreatment reduction in PTSD
    symptom severity.

    •    An accumulating wealth of practice-based evidence  (Buchele & Spitz,
    2000, Kingsley, 2007, Klein & Schermer, 2000) as defined in the
    Introduction to this section, similarly attests to the effectiveness of group
    interventions for the treatment of traumatized individuals.

A number of different group approaches for treating PTSD have been developed over the past two decades.  One primary conceptualization of these different approaches has been to categorize them as either “Trauma-focused” or “Present-focused” (cf. Classen et al., 2011).

    •    Trauma-focused group treatments aim at processing traumatic
    memories and experiences.

    •    Present-focused groups explore how symptoms impact current
    psychological and interpersonal functioning

    •    Trauma-focused and present-focused group approaches to treating
    PTSD have been found to be equally effective (Benish, Imel, & Wampold,
    2008; Burlingame, Strauss, & Joyce, 2012). 

In addition to this conceptual distinction, group treatments for PTSD also have been differentiated by the schools of psychotherapy that guide the work and the underlying principles that are thought to effect therapeutic change.  To date, the strongest formal research evidence has been garnered for cognitive behavioral modalities (cf. Bolton et al., 2004; Zang et al., 2014), particularly: 1) Cognitive processing therapy (cf. Alvarez et al., 2011; Chard et al., 2012; Monson et al., 2006); 2) Exposure therapy (Barrera, et al., 2013; Castillo, et al., 2012; Mott, et al., 2013; Ready et al., 2012; Resick et al., 2002; Smith et al., 2014), and 3) Trauma focused-therapy (Greene, et al., 2014; Karlin et al., 2010; Schnurr et al., 2003).

These treatments are thought to work primarily through processes of desensitization and the challenging of underlying pathogenic beliefs and assumptions, although much more research is needed in order to better understand the underlying mechanisms of change involved in these treatments.

In addition to cognitive-behavioral models, a range of other group treatments have been reported to be clinically effective, including psychodynamic (Foy et al. 2001; Kingsley, 2007), interpersonal (Campanini et al., 2010; Ray & Webster, 2010), supportive (Foy et al., 2001) and multifamily groups (Kiser et al., 2010; Sherman et al., 2011).

With what kinds of stressors and symptoms do group treatments appear to help?

Group treatment has been used to help people who have experienced a wide range of stressors. Some empirical evidence has been garnered for the successful group treatment for people who have experienced the following stressors:

    •    Childhood sexual abuse (Chard, 2005);

    •    War and combat (cf. Cox et al., 2014; Creamer et al 2006; Khoo et
    al., 2011);

    •    Forced displacement from home (Drozdek, 2014);

    •    Sexual violence (Bicanic et al., 2014; Karlsson et al., 2014). 

Research (Burlingame, Strauss, & Joyce, 2013) has also shown that group therapies can help with a variety of stress-induced symptoms, including):  hyperarousal, re-experiencing, avoidance/numbing, depression, self-esteem, anger, anxiety, guilt, lack of assertiveness, deficits in social functioning, substance use, HIV risk, and grief.

How do these group treatments help people?

A number of mechanisms of therapeutic change have been proposed, including specific techniques (e.g., desensitization; challenging of pathogenic beliefs and thoughts) and common therapeutic factors such as universality.  Virtually all of the group approaches emphasize the importance of creating a safe and protective “healing matrix” (Klein & Schermer, 2000) where the joining with others who share a traumatic experience can provide a sense of feeling deeply understood, helping to restore a sense of trust in the world and countering feelings of alienation and isolation. 

Are group treatments effective in dealing with mass trauma? Many efforts have been made to use group treatment in the aftermath of mass trauma (e.g., Klein & Phillips, 2008). For the most part these efforts are reported to benefit survivors; more rigorous and definitive studies are difficult to perform in the field post-event and often raise complex ethical issues.

While very promising, the literature is calling for additional work, via both formal research and astute clinical observations, in understanding more completely how groups benefit traumatized individuals (cf. Ford et al., 2014).  There is a need to address not only questions about outcomes (e.g., do group members improve, and in what ways?) but about the underlying processes that mediate change within diverse settings, different clinical populations, and varying clinical problems.

References

Alvarez, J., McLean, C., Harris, A. H. S. Rosen, C. S., Ruzek, J., & Kimerling, R. (2011). The comparative effectiveness of cognitive processing therapy for male veterans treated in a VHA posttraumatic stress disorder residential rehabilitation program.  Journal of Consulting and Clinical Psychology, 79, 590-599. http://dx.doi.org/10.1037/a0024466

Barrera, T.L., Motta, J.M., Hofsteina, R.F., & Tenga, E.J.(2013). A meta-analytic review of exposure in group cognitive behavioral therapy for posttraumatic stress disorder. Clinical Psychology Review, 33, 24-32.  http://dx.doi.org/10.1016/j.cpr.2012.09.005

Benish, S., Imel, Z. E., & Wampold, B. E. (2008). The relative efficacy of bona fide psychotherapies of post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review, 28, 746–758. DOI:10.1016/j.cpr.2007.10.005.

Bicanic, I., de Roos, C., van Wesel, F., Sinnema, G., van de Putte, E. (2014). Rape-related symptoms in adolescents: Short- and long-term outcome after cognitive behavior group therapy. European Journal of Psychotraumatology, 5, 1-8.

Bolton, E., Lambert, J., F., Wolf, E. J., Raja, S., Varra, A. A., & Fisher, L. (2004). Evaluating a cognitive-behavioral group treatment program for veterans with posttraumatic stress disorder.  Psychological Services, 1, 140-146.  http://dx.doi.org/10.1037/1541-1559.1.2.140

Buchele, B. & Spitz, H (Eds.) (2000). Group interventions for psychological treatment of trauma.  New York: American Group Psychotherapy Association

Burlingame, G., Strauss, B. & Joyce, A. (2013).  Change mechanisms and effectiveness of small group treatments.  In M.J. Lambert (Ed.), Bergin & Garfield’s Handbook of psychotherapy and behavior change (6th Ed.). New York:  Wiley.

Campanini, R.F.B., Schoedl, A.F., Pupo, M. C., Costa, A.C.H., Krupnick, J.L., & Mello, M.F. (2010).  Efficacy of interpersonal therapy-group format adapted to post-traumatic stress disorder: An open-label add-on trial. Depression and Anxiety, 27, 72-77. DOI:  http://dx.doi.org/10.1002/da.20610

Castillo, D.T., C’de Baca, J., Qualls, C., & Bornovalova, M.A. (2012). Group exposure therapy treatment for post-traumatic stress disorder in female veterans. Military Medicine, 177, 1486-1491.

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Drožđek, B., Kamperman, A. M., Tol, W. A., Knipscheer, J. W. &  Kleber, R. J. (2014). Seven‐year follow‐up study of symptoms in asylum seekers and refugees with PTSD treated with trauma‐focused groups.  Journal of Clinical Psychology, 70, 376-387.  http://dx.doi.org/10.1002/jclp.22035

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Greene, L.R., Harpaz-Rotem, I., Sanders, K.A., MacGregor, K., Wheat, A. Dorflinger, L., Klee, A. & Bullock, J.  (2014).  Group treatments within the Department of Veterans Affairs:  An update. In J. DeLucia-Waack, C. Kalodner, & M. Riva (Eds.), The handbook of group counseling and psychotherapy (2nd Edition).  Thousand Oaks, CA:  Sage.

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Kiser, L.J., Donohue, A., Hodgkinson, S., Medoff, D., & Black, M.M. (2010). Strengthening family coping resources: The feasibility of a multifamily group intervention for families exposed to trauma. Journal of Traumatic Stress, 23, 802-806. DOI:  http://dx.doi.org/10.1002/jts.20587

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.Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive Processing Therapy for Veterans With Military-Related Posttraumatic Stress Disorder. Journal of Consulting and Clinical Psychology, 74, 898-907.  http://dx.doi.org/10.1037/0022-006X.74.5.898

Mott, J.M., Sutherland, R.J., Williams, W., Lanier, S.H., Ready, D.J., & Teng, E.J. (2013).  Patient perspectives on the effectiveness and tolerability of group-based exposure therapy for posttraumatic stress disorder: Preliminary self-report findings from 20 veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 5(5), 453-461.  DOI:  http://dx.doi.org/10.1037/a0029386

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Schnurr, P., Friedman, M., Foy, D., Shea, M. T., Hsieh, F. Y., Lavori, P. W., …Bernardy, N. (2003). Randomized trial of trauma-focused group therapy for posttraumatic stress disorder: Results from a Department of Veterans Affairs cooperative study.  Archives of General Psychiatry, 60(5), 481-489.  http://dx.doi.org/10.1001/archpsyc.60.5.481

Sherman, M.D., Fischer, E.P., Sorocco, K., & McFarlane, W.R. (2011). Adapting the multifamily group model to the Veterans Affairs system: The REACH program. Couple and Family Psychology: Research and Practice, 1, 74-84.  DOI:  http://dx.doi.org/10.1037/2160-4096.1.S.74

Sloan, D. M., Feinstein, B. A., Gallagher, M. W., Beck, J. G., & Keane, T. M. (2013) Efficacy of group treatment for posttraumatic stress disorder symptoms: A meta-analysis. Psychological Trauma: Theory, Research, Practice, and Policy, 5(2), 176-183.  http://dx.doi.org/10.1037/a0026291

Smith, E.R., Porter K.E., Messina, M.G., Beyer, J.A., Defever, M.E., Foa, E.B., & Rauch, S.A., (2014).  Prolonged exposure for PTSD in a veteran group: A pilot effectiveness study.  Journal of Anxiety Disorders, 30(C), 23-27.  DOI:  doi: 10.1016/j.janxdis.2014.12.008

Zang, G., Song, Z., Zhao, Y. (2014). Review of group cognitive behavioral therapy for posttraumatic stress disorder. Chinese Journal of Clinical Psychology, 22(3), 560-563.       

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