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
• 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
• 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.
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/10.1037/1541-1522.214.171.124
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.
Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73, 965-971. http://dx.doi.org/10.1037/0022-006X.73.5.965
Chard, K.M., Schuster, J.L., & Resick, P.A. (2012) Empirically supported psychological treatments: Cognitive processing therapy. In J. Gayle & D. Sloan (Eds.), The Oxford handbook of traumatic stress disorders (pp.439-448). New York: Oxford University Press.
Classen, C. C., Palesh, O. G., Cavanaugh, C. E., Koopman, C., Kaupp, J. W., Kraemer, H. C., Aggarwal, R. & Spiegel, D. (2011). A comparison of trauma-focused and present-focused group therapy for survivors of childhood sexual abuse: A randomized controlled trial. Psychological Trauma: Theory, Research, Practice, and Policy, 3(1), 84-93. DOI:10.1037/a0020096
Cox, D. W., Westwood, M. J., Chan, E. K. H., Kivari, C., Dadson, M., Zumbo, B. D. (2014). Evaluation of a group intervention for veterans who experienced military-related trauma. International Journal of Group Psychotherapy, 64, 367-380. http://dx.doi.org/10.1521/ijgp.2014.64.3.367
Creamer M, Elliott P, Forbes D, Biddle D, & Hawthorne G. (2006). Treatment for combat-related posttraumatic stress disorder: Two-year follow-up. Journal of Traumatic Stress, 19, 675- 685. http://dx.doi.org/10.1002/jts.20155
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
Ford, J. D., Fallot, R. D., & Harris, M. (2014). Group therapy. In C. Courtois, & J. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp. 415-440). New York, NY: Guilford Press.
Foy, D.W., Eriksson, C. B., & Trice, G. A. (2001). Introduction to group interventions for trauma survivors. Group Dynamics: Theory, Research, and Practice, 5, 246-251. DOI: http://dx.doi.org/10.1037/1089-26126.96.36.199
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.
Karlin, B., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., Resick, P. A., & Foa, E.B. (2010). Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of Traumatic Stress, 23, 663-673. DOI: 10.1002/jts.20588.
Karlsson, M. E.; Bridges, A. J.; Bell, J., Petretic, P. (2014). Sexual violence therapy group in a women's correctional facility: A preliminary evaluation. Journal of Traumatic Stress, 27, 361-364. http://dx.doi.org/10.1002/jts.21911
Khoo, A., Dent, M. T., & Oei, T. P. S. (2011). Group cognitive behaviour therapy for military service-related post-traumatic stress disorder: Effectiveness, sustainability and repeatability. Australian and New Zealand Journal of Psychiatry, 45, 663-672. http://dx.doi.org/10.3109/00048674.2011.590464
Kingsley, G. (2007). Contemporary group treatment of combat-related posttraumatic stress disorder. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 35, 51-69.
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
Klein, R. H. & Schermer, V. L. (Eds). (2000). Group psychotherapy for psychological trauma. New York: Guilford Press
Klein, R.H. & Phillips, S. (Eds). (2008). Public mental health service delivery protocols: Group interventions for disaster preparedness and response, New York: American Group Psychotherapy Association
.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
Ray, R. & Webster, R. (2010). Group interpersonal psychotherapy for veterans with posttraumatic stress disorder: A pilot study. International Journal of Group Psychotherapy, 60, 131-140. DOI: http://dx.doi.org/10.1521/ijgp.2010.60.1.131
Ready, D. J., Sylvers, P., Worley, V., Butt, J., Mascaro, N., Bradley, B. (2012). The impact of group-based exposure therapy on the PTSD and depression of 30 combat veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 4, 84-93. http://dx.doi.org/10.1037/a0021997
Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70, 867-879. http://dx.doi.org/10.1037/0022-006X.70.4.867
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.