Dr. Ruzek is associate director of education, Mr. Young is disaster services coordinator, and Dr. Walser is psychologist at the National Center for Posttraumatic Stress Disorder and Veteran’s Affairs Palo Alto Health Care System in Menlo Park, California.
Disclosure: The authors report no financial, academic, or other support of this work.
Please direct all correspondence to: Josef I. Ruzek, PhD, National Center for Posttraumatic Stress Disorder, Education and Clinical Laboratory Division, VA Palo Alto Health Care System, 795 Willow Rd, CA 94025; Tel: 650-493-5000; Fax: 650-617-2769; E-mail: firstname.lastname@example.org.
• Group treatment of posttraumatic stress disorder (PTSD) can enable helpful comparison with other trauma sufferers and may promote the recognition of the “normality” of posttraumatic reactions.
• Education groups focus on helping PTSD survivors understand their experience and familiarize themselves with available treatment options; coping skills training focuses on teaching them how to incorporate the support recovery techniques they learn about.
• Repeated exposure to distressing aspects of traumatic memories can help reduce the fear and arousal associated with the trauma, correct faulty perceptions of danger, improve perceived self-control of memories and accompanying negative emotions, and strengthen adaptive coping responses under conditions of distress.
• Group cognitive therapy focuses on educating patients about the relationships between thoughts and emotions, exploring negative thoughts commonly held by trauma survivors, identifying personal negative beliefs, developing alternative interpretations or judgments, and practicing new thinking.
What are the advantages of using group treatment for individuals diagnosed with posttraumatic stress disorder (PTSD) and other trauma-related problems and what are the goals of the different types of group intervention? As one of the most common modes of posttrauma care, groups can be used to provide support, educate participants about PTSD, teach trauma-related coping skills, or facilitate therapeutic exposure and cognitive restructuring. Although research to date is limited, existing evidence suggests that group therapy may be a potentially effective intervention for PTSD. This article outlines several varieties of group intervention, explores issues related to patient selection, and discusses considerations in establishing and managing group services.
There are several potential advantages to the use of group treatment as a modality in care for trauma survivors with posttraumatic stress disorder (PTSD). First, many trauma survivors feel alone in their experiences. Meeting and sharing with other survivors of a similar trauma can promote a sense of acceptance and belonging. This may be especially useful for those (eg, Vietnam veterans, sexual assault survivors) who encounter negative reactions from others regarding their experience and for whom social alienation may be especially strong. Group treatment enables comparison with other PTSD sufferers and may promote the recognition of the universality of posttraumatic reactions. In addition, they may encourage adaptive functioning through modeling of coping behaviors (eg, self-disclosure) of other survivors. From a provider perspective, group treatment can be cost-efficient in comparison with individual counseling.
Whether these potential benefits of groups render them effective treatments for PTSD is not clear. Very little research has addressed the effectiveness of group treatments for PTSD. In a recent review,1 <20 group psychotherapy outcome studies were located, and only two were randomized-controlled trials. Most existing studies focus on individuals with chronic PTSD, and most have obtained positive treatment outcomes. Evidence, to date, therefore suggests that group treatment is beneficial for those with chronic PTSD, but research in this area is in its infancy and more study is required before the impact of group treatment can be confidently asserted. In particular, there is little research comparing different kinds of group treatments, and no studies comparing group with individual treatment. In addition, little is known about the processes through which group treatments benefit trauma survivors. Despite these limitations of the data, group treatment for PTSD is recommended as “potentially effective” in the International Society for Traumatic Stress Studies (ISTSS) practice guidelines.2
Group interventions for trauma survivors may take many forms. Groups may be used to provide social support, trauma-related education, training in skills for coping with PTSD symptoms and other posttrauma challenges, or opportunity for detailed exploration of traumatic experiences and associated emotions. In the following sections, we review a variety of group alternatives, patient matching considerations, and process issues.
Varieties of Group Treatment for Posttraumatic Stress Disorder
Social support is likely one of the most powerful components of group interventions for PTSD. In fact, some group treatments for PTSD focus primarily on providing social support as the primary active ingredient of therapy. There are many reasons why group support is indicated for trauma survivors with PTSD. Many of those who develop problems following trauma feel different from other people, alone with their distress, or misunderstood by those around them. Often, they doubt whether it is even possible that others can understand what they are experiencing. Trauma survivor support groups, being typically comprised of those who have undergone similar traumatic experiences, are well suited to challenging such perceptions. They may be especially useful in helping survivors address traumas that are difficult to talk about with family and friends (eg, sexual assault), due to perceived social stigma, embarrassment, shame, guilt, or fear of negative reactions from others.3
Some individuals with PTSD become socially isolated, in part because isolation often enables avoidance of trauma reminders and feelings of vulnerability. One effect of this isolation is to cut survivors off from others who might otherwise be of help to them, practically and emotionally. Isolation may enable avoidance of talking about the experience, but this may delay the potentially helpful processing of experience that survivors often require. Support groups provide a useful means to begin reducing social isolation, create an opportunity for contact with others in a safe and structured context, and give help in facing the many ongoing symptoms, stressors, and problems related to the traumatic experience.
Education is a component of all treatments for PTSD and may be usefully delivered in a group format. PTSD education is intended to improve understanding and recognition of symptoms, reduce fear and shame about symptoms, and, generally, “normalize” the experience of the survivor. Understanding how PTSD develops can make symptoms seem more predictable and less frightening. Recognizing symptom triggers can help individuals cope more effectively with them. Education should also aim to reduce negative forms of coping with symptoms, such as extreme avoidance or alcohol and drug use. In some settings, education should give participants information to help them better decide whether and when to seek further treatment. When PTSD-related education is provided to individuals as part of their formal PTSD treatment, it is important to give them a clear understanding of how recovery is thought to take place, what will happen in treatment, and, as appropriate, the role of medication.
Education includes didactic presentation of materials, but must be accompanied with active prompting of questions and discussion. Simple educational instruction is limited in its impact on more complex actions important to recovery. Whenever possible, presentation of information should be expanded to include opportunity to observe and practice coping behaviors to increase likelihood of behavior change.
Trauma-Related Coping Skills Training in Groups
Individuals diagnosed with PTSD have difficulty coping with everyday circumstances and problems.4 Patients often report feeling overwhelmed and are steeped in negative emotions such as shame, guilt, anxiety, and depression.5 PTSD symptoms interfere with healthy coping, interpersonal relationships, and role functioning. One main goal of PTSD treatment is to empower the patient to manage personal difficulties, and training in coping skills can foster its achievement.6
Whereas education groups focus on helping survivors understand their experience and know what to do about it, coping skills training focuses on teaching them know how to do the supportive recovery techniques. It relies on a cycle of instruction that includes education, demonstration, rehearsal with feedback and coaching, and repeated practice. Groups include regular between-session task assignments with diary self-monitoring and the real-world practice of skills. Coping skills can include a range of interpersonal and intrapersonal self-management strategies, such as problem-solving, management of distressing trauma-related thoughts, identification and management of personal trauma “triggers,” relaxation and breathing, anger management, assertion, emotional “grounding,” and use of social support. Skills are selected to target adaptive behaviors that may be new for the individual or may be impaired due to PTSD.
Group therapy is a particularly effective way to train patients diagnosed with PTSD in the use of coping skills. Many of their difficulties are associated with maladaptive patterns in relationships that can interfere with coping. Teaching coping skills in the group setting allows individuals to obtain direct feedback from others about their use of skills and their general interpersonal style. Coping skills training has a here-and-now focus and provides useful tools for change in the immediate environment. Active engagement in new coping behaviors that address current problems faced by patients can serve to lessen distress relatively quickly and help the patient to prepare for more intense therapy if needed.
Therapeutic Exposure and Cognitive Restructuring in Groups
The group methods outlined above have not included a detailed in-session exploration of traumatic experiences by participants, nor have they included a detailed review and rethinking of distressing trauma-related beliefs or concerns. However, exposure and cognitive restructuring methods are among the best-validated components of PTSD treatment.2,7 While most of the empirical evidence supporting exposure and cognitive therapy has been derived from examinations of individually-administered care, these treatments can be delivered in groups.
Therapeutic exposure groups include the repeated exploration of traumatic memories as the central treatment component. From a cognitive-behavioral perspective, repeated exposure to distressing aspects of traumatic memories can help reduce the fear and arousal associated with the trauma, and can also help correct faulty perceptions of danger, improve perceived self-control of memories and accompanying negative emotions, and strengthen adaptive coping responses under conditions of distress.6 In “imaginal” exposure, participants verbally recount the details of their experience. This is the primary vehicle for exposure, although it is often supplemented by real-world in vivo exposure to (objectively safe) situations associated with the trauma.
When this therapy is provided in groups, exposure itself is embedded in a range of other group processes and activities. Initial introductory sessions are intended to provide education about PTSD and the treatment process, teach and reinforce basic coping skills, and prepare members for their upcoming task of therapeutic re-experiencing of their traumatic memories. Preparation for exposure is accomplished by setting clear group rules and structure, building group cohesion, discussing realistic expectations for outcome, presenting a clear rationale for exposure treatment, and teaching and supporting coping skills to be consciously employed during and following exposure. After the introductory sessions, trauma scenes are selected and systematic exposure of each member to key individual trauma memories takes place. Finally, relapse prevention and termination sessions focus on helping members consolidate their experiences during exposure, plan for anticipated difficulties, and maintain coping skills.
Compared with individual treatment, the group setting limits the number of traumatic experiences to which an individual may be exposed. Therefore, therapists and group members discuss which traumatic experiences will be explored. Members are encouraged to select scenes that are especially distressing, related to current symptomatology (eg, nightmares), and associated with fear as the predominant affect.
In the group environment, exposure is conducted by focusing upon one member at a time to ensure a minimum of 30 minutes of exposure to important trauma-related reminders, and to prevent cognitive avoidance. In describing their experiences, members are instructed to emphasize their sensory perceptions, thoughts, and emotional reactions that occurred during the event. During recounting of the traumatic experience, the facilitators give minimal directions unless emotional avoidance is occurring; if avoidance is apparent, leaders can ask questions to direct the attention of the survivor to the avoided material. This in-session exposure is supplemented with self-exposure homework. The purpose of the exposure homework is to increase the number of times trauma scenes are re-experienced to ensure that fears are effectively reduced. Typically, cassette recordings of the individual trauma narratives are made, and members are asked to listen to their personal recordings at least once each week, noting distress levels and reporting on coping skills used to manage resultant distress. The goal of the process is to access painful memories but to prevent overwhelming negative emotion.
In order to be considered suitable candidates for this kind of group activity, prospective members should show understanding and acceptance of the rationale for trauma exposure work, willingness to disclose personal traumatic experiences, and ability to establish interpersonal trust with other group members and leaders. Prior group experience and completion of a preparatory course of individual therapy including coping skills training, are very desirable. It is recommended that practitioners not deliver group-administered exposure therapy unless they have received training in the method.
Group treatment can also be used as a vehicle for conducting cognitive restructuring of negative trauma-related beliefs. A range of negative thoughts troubles many trauma survivors, including thoughts of guilt and self-blame, negative views about self (eg, personal weakness) or performance in the traumatic situation, inaccurate concerns about symptoms, problematic views of other people and the world in general, and fears about the future. Group cognitive therapy focuses on educating participants about the relationships between thoughts and emotions, exploring common negative thoughts held by trauma survivors, identifying personal negative beliefs, developing alternative interpretations or judgments, and practicing new thinking. This is a systematic approach that goes well beyond simple discussion of beliefs to include individual assessment, self-monitoring of thoughts, homework assignments, and real-world practice. This kind of cognitive therapy in groups may be less emotionally provocative for participants than exposure therapy, but it may provide significant help to group members.
For more information on this approach, Resick and Schnicke8 incorporate extensive cognitive restructuring and limited exposure therapy in their manual on cognitive-processing therapy. In addition, Young and colleagues9 present a different group-administered combination of exposure and cognitive treatments in the context of disaster-related PTSD.
Manualized Group Treatments for Posttraumatic Stress Disorder and Related Problems
There are few manualized interventions that are specific to the treatment of trauma. There are several manuals that have received scientific support or are under investigation and that can guide the practitioner in effective and practical intervention.
• Seeking Safety. Developed by Najavits,5 this manualized group treatment for co-occurring PTSD and substance abuse focuses on trauma-related coping skills training. It is designed to help patients gain control over extreme symptoms, reduce risky behavior, reduce trauma-related distress, and reduce substance use. The manual addresses a wide range of interpersonal, behavioral, and cognitive coping skills that can be used with most trauma survivors (not just those with substance abuse problems).
• Acceptance and Commitment Therapy. This manualized treatment that has been shown to be effective with sexual abuse trauma survivors10 and is currently under investigation for use with survivors of war trauma.11 The intervention encourages acceptance of avoided internal experience and commitment to valued action in the service of enhancing life experience. Mindfulness exercises and experiential strategies are used to help the patient take action in the face of difficult emotional and
• Cognitive-Processing Therapy. This approach has been manualized for use with rape victims.8 However, the methods outlined can be easily adapted for other PTSD populations.
Matching Practitioners, Patients, and Group Methods
In deciding whether group therapy and what kind of group methods should be offered to trauma survivors, it is necessary that all potential participants be assessed prior to group participation. Practitioners must use clinical judgment in making these determinations because empirically-based criteria for matching individual patients to either group or individual forms of trauma treatment, or to varieties of group intervention, do not presently exist. Rationally-derived indications and contraindications for group therapy have been put forward, and key considerations include ability to establish trust with others and similarity in terms of traumatic experiences to other group members.1 Contraindications include limited cognitive capacity, active psychosis, and active suicidality or homicidality.
One consideration is how recently the survivor has experienced trauma. Group interventions during the acute phase of trauma response are often delivered to survivors of disaster or other events affecting multiple persons. In addition to supporting individual trauma survivors, they may assist with group cohesion and morale in groups whose members have enduring relationships (eg, firefighters, military units). One of the most common group interventions is “psychological debriefing,”12 the term for a family of interventions that involve bringing survivors together soon after a traumatic event to review the facts of what happened, explore thoughts and feelings associated with the event, and provide education. Overall, evidence for the utility of group debriefing is mixed, and methodologically rigorous studies have yet to be conducted. There has been some concern in the field that a single exploration of traumatic experience in a group or individual setting may exacerbate rather than reduce distress in some survivors. ISTSS practice guidelines recommend that the method should be conducted by experienced, well-trained practitioners, should not be mandatory, and should utilize some clinical assessment of potential participants.13 Studies of other group approaches to early intervention14 have yet to be conducted. Certainly, group support, education, and coping skills training constitute reasonable services to offer recent trauma survivors who want them, although their capacity to prevent development of PTSD has not been demonstrated.
In work with those whose trauma exposure occurred in the more distant past, a basic consideration is the degree to which the patient is likely to be able to tolerate the “opening up” of trauma-related emotions. If the patient does not wish to explore traumatic experiences in detail or is in some other way a poor candidate for trauma-focused therapies, or if the practitioner is not trained in managing the detailed exploration of traumatic experiences, potentially helpful treatment elements—education of participants about stress reactions, “normalization” of reactions to trauma, and instruction in coping—can still be delivered in groups.
Group-administered PTSD education and social support groups may be usefully delivered to most trauma survivors and can often be provided by practitioners who are not specialists in PTSD. However, even in such less emotionally provocative group formats, experience in assessing and treating trauma survivors is necessary in preparing the practitioner to respond to emergent issues. Similarly, clinicians who are familiar with coping skills training with other treatment populations can deliver skills-training groups, but basic clinical familiarity with PTSD is necessary.
Group Process Considerations
Evidenced-based reports describing the effectiveness of specific procedural considerations related to the delivery of group treatment for PTSD are lacking. Our clinical experience and the writings of others15-17 suggest some general guidelines. First, there are clear advantages to having two therapists conduct a treatment group for PTSD. While one therapist is presenting material or working more directly with a member, the other therapist can observe the group process and bring others into the discussion.15 This is particularly important in trauma-focused treatment where the account of one group member may trigger an emotional reaction in another. In addition, while group participants are often advised to not leave the group while it is in session, there is often no reasonable way to prevent a member from leaving. A second therapist can either accompany the member who is making his or her way toward the door or consult with the member outside the group room. Having two therapists also allows for postsession (and postgroup) discussions about what took place during the session, what seemed to be effective, what did not work, and what could be done differently the next time. There is the added potential that two therapists bring more clinical skills, experience, and knowledge to the group.
Second, concrete steps should be taken to establish and maintain group identity, cohesion, and trust. Group identity can be fostered by encouraging members to view themselves as survivors who have made a commitment to regaining control of their lives, helping members choose a name for the group, and eventually, if appropriate, encouraging supportive relationships to develop outside the group. Group cohesion and trust are essential to detailed discussions of traumatic experiences and can be achieved through a variety of introductory activities,17 group structures and rules,9 and efforts to maintain active involvement of all group members.
Therapists will need to actively manage relationships between members. When group trauma work addresses existential issues such as dying, exposure to death and horror, social responsibility, fear, and helplessness, group members may at some point “transfer” feelings of hostility toward one another or the group leaders. Group leaders can normalize such reactions and help members explore and understand them. Therapists may themselves also have strong emotional reactions to the issues encountered in trauma groups. It is important that these be anticipated and that group leaders engage in self-monitoring of their responses, take ongoing active coping steps, and seek formal collegial or supervisory support if they find themselves experiencing strong or surprising reactions to the group or its members.
A related responsibility for leaders is to manage difficult group members and those experiencing intense affective reactions. While the need to manage difficult patients is common across treatments and strategies for working with problem patients have been described in the general group literature,18 individuals in treatment for PTSD often have a high levels of irritability, alienation, mistrust, or difficulty in managing anger. When a group member becomes angry or enraged during a session, it is recommended that the leaders quickly intervene to demonstrate that the group remains under their control (thus upholding safety), while validating the survivor’s anger, and giving clear messages about what is permissible in the group (referring to previously established ground-rules).
Finally, it is important in any session to keep an active involvement of all group members. There may be a primary speaker, but routinely encouraging others to speak as well is recommended. When a participant is providing “too much” detail, is tangential, or is monopolizing group time, we recommend that the group leader(s) validate the survivor’s need to talk, while emphasizing the importance of hearing from other members during the limited group time. Depending on the spoken content, a group leader can ask the survivor to “hold that thought” while giving a commitment to later give the survivor more time. When returning, the therapist might say “Tom, you were thoughtful enough to give the floor to Allen. We have a few minutes left and I wanted to get back to you. Can you find a way to briefly tell us what you felt you needed to say, or should we talk after group, or do you want to wait till the next session to share with the group?”
Group treatments for PTSD may offer much of value to the trauma survivor, from emotional and practical support, to education about trauma and its impact, to training in more effective ways of coping. Groups can also be used to deliver therapeutic exposure and cognitive therapy, two of the best-validated forms of PTSD treatment. Selection of group approach must depend on time since traumatization, patient functioning and motivation, targets of treatment, and the experience and skills of the practitioner. Group services for trauma survivors are certain to remain a staple of clinical care. The effectiveness is suggested by clinical experience but requires empirical demonstration. PP
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