Journal of Anxiety Disorders 30 (2015) 23–27
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Journal of Anxiety Disorders
Prolonged Exposure for PTSD in a Veteran group: A pilot effectiveness study Erin R. Smith a,b,∗ , Katherine E. Porter a,b , Michael G. Messina c,d , Jonathan A. Beyer e , Mahrie E. Defever a , Edna B. Foa f , Sheila A.M. Rauch a,b,1 a
Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States c Mental Health Service, William S. Middleton Memorial Veterans Hospital, Madison, WI, United States d Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States e Mental Health Service, Jesse Brown VA Medical Center, Chicago, IL, United States f University of Pennsylvania, Philadelphia, PA, United States b
a r t i c l e
i n f o
Article history: Received 23 July 2014 Received in revised form 26 November 2014 Accepted 15 December 2014 Available online 29 December 2014 Keywords: Prolonged Exposure therapy Group psychotherapy PTSD Veterans
a b s t r a c t Previous research has consistently demonstrated that Prolonged Exposure (PE) therapy is an effective treatment for posttraumatic stress disorder (PTSD). Traditionally, PE has been studied and delivered on an individual basis. However, the growing number of Veterans in need of PTSD treatment has led to increased interest in group therapies as an efficient way to provide access to care. The current study examined a group and individual hybrid treatment that was developed based on PE principles. Treatment was 12 weeks in length and consisted of 12 one-hour group sessions focused on in vivo exposures, and an average of approximately five-hour long individual imaginal exposure sessions. Data for this study were derived from 67 veterans who participated in 12 cohorts of the Group PE. Significant reductions in PTSD and depression symptoms were found in both completers and intent-to-treat sample analyses. The clinical implications of these findings are discussed. Published by Elsevier Ltd.
1. Introduction PTSD treatment guidelines support exposure therapy as a first line intervention (e.g., Friedman, 2006; IOM, 2007; VA/DoD Clinical Practice Guideline, 2010). Prolonged Exposure (PE) therapy, the most utilized exposure treatment program for PTSD, has consistently demonstrated efficacy in reducing the symptoms of PTSD and related psychopathology, such as depression, anger, and guilt for both veterans and non-veterans (Cahill, Rauch, Hembree, & Foa, 2003; Foa et al., 1999, 2005; Paunovic & Ost, 2001; Rauch et al., 2009; Resick, Nishith, Weaver, Astin, & Feuer, 2002; Rothbaum, Astin, & Marsteller, 2005; Schnurr et al., 2007; Tuerk et al., 2011). The Veterans Health Administration has conducted an
∗ Corresponding author at: VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States. Tel.: +1 734 845 5645. E-mail address: [email protected] (E.R. Smith). 1 Dr. Rauch’s contribution was based upon work supported by a CDA-2 Award from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Clinical Sciences Research and Development. http://dx.doi.org/10.1016/j.janxdis.2014.12.008 0887-6185/Published by Elsevier Ltd.
ongoing nationwide PE training initiative in the interest of making evidence-based treatment widely available for Veterans diagnosed with PTSD. To date over 1300 VA mental health professionals have attended training in the provision of individual PE as part of this formal implementation program (Rauch, Eftekhari, & Ruzek, 2012) and several additional hundreds were trained in delivering PE in other VA training programs. Examination of the effectiveness of these VA PE Roll Out trained clinicians using data from their training cases only, showed large effects on PTSD (d = 0.86; Eftekhari et al., 2013). The widespread training and dissemination of evidence-based psychotherapies for the treatment of PTSD within the VA system has been an important advance in providing the nation’s Veteran population with a pathway to improved mental health and well-being. However, the growing number of Veterans in need of PTSD treatment has placed emphasis on the need to facilitate access to these gold standard treatments. Empirical support for group interventions for PTSD is less established than for individual interventions. Recently, however, interest in group therapies for PTSD has increased in order to help meet the demand for treatment of PTSD among Veterans. The need for both effective and efficient treatments has led to the development
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of several new group protocols, as well as reviews of the existing group literature. For instance, in a recent meta-analysis of studies of cognitive behavioral groups for PTSD, the authors concluded that group CBT is an effective intervention for individuals with PTSD (Barrera, Mott, Hofstein, & Teng, 2013). Further, they reported no significant differences in the effect sizes between group CBT that included in-session exposure and those that did not include disclosure in groups. However, protocols that included exposure had large effects sizes (sizes (ES = 1.32; 95% CI: 0.89–1.75) while those without had small to moderate effects (ES = 0.49; 95% CI: −0.19 to 1.18) suggesting that the small number of trials for this comparison and significant heterogeneity in protocol effect may override the group versus individual difference. In addition, group CBT that included in-session exposure had slightly higher rates of attrition (26.4%) than groups without disclosure. Group interventions for PTSD may offer potential benefits over individual therapy. One potential benefit of group is the opportunity for positive social interaction and bonding. For patients with PTSD this can be an especially therapeutic feature due to the isolation and mistrust that often cluster with PTSD. Specifically, psychoeducation about PTSD symptoms within a group format may allow group members to interact with others while normalizing symptoms and challenging the assumption that individuals are alone in their experience of their symptoms. Additionally, when exposure protocols are used, group members can encourage each other to engage in the work of therapy, such as in vivo exposure exercises, in a manner that group leaders cannot because of the members’ shared symptoms and experiences of PTSD. Further, when provided with appropriate group size, group interventions can be an effective use of specialty trained staff resources (Sloan, Bovin, & Schnurr, 2012). In addition to the review outlined above, several recent articles have examined new group exposure protocols (e.g., Castillo, C’de Baca, Qualls, & Bornovalova, 2012; Mott et al., 2013; Ready et al., 2008; Ready, Sylvers et al., 2012a; Sutherland et al., 2012). The majority of these studies (Mott et al., 2013; Ready et al., 2008; Ready, Sylvers et al., 2012a; Sutherland et al., 2012) have relied on a similar manual (originally developed by Lorenz et al., 2006). In each of these studies, significant reductions in PTSD symptoms were noted, and in the case of Ready, Sylvers et al. (2012a) the effect size for this change was shown to be large (d = 0.89). However, the groups were very time intensive, meeting twice weekly for 3 hours per group, for between 12 and 18 weeks. Castillo et al. (2012) proposed an alternative to the aforementioned protocol. This protocol was much shorter, consisting of only 6 weekly 90-min sessions, and it included approximately 3 people in each group. Sessions focused on imaginal exposures and included time for processing. Results demonstrated that there was significant symptom reduction. However, the pre to post effect size on the PTSD checklist was small (d = 0.26). Indeed, both the Ready, Sylvers et al. (2012a), Ready, Vega, Worley, and Bradley (2012b), and Castillo et al. (2012) studies show effect sizes smaller than most trials with a full PE protocol. As such, concerns over whether these treatments are providing a full “dose” of exposure have been raised. Finally, Ready, Vega et al. (2012b), published a report on a mixed group and individual exposure treatment. Their version of the treatment was largely based on the 12-week group described previously. During the first and last 2 weeks of the treatment, the participants attended twice weekly group sessions, each lasting 4 hours in length. During the middle 8 weeks, there was 1 weekly group meeting and 6 individual sessions for a total of more than 50 hours of session time. As with the previous groups, significant reductions were noted across measures, and effect sizes were large (e.g., d = 1.63 on PCL from pre to post). In sum, the results of these studies suggest that group therapy for PTSD that included an exposure component can be effective, but
the models used tend to require more session time per Veteran. For instance, the studies by Ready and colleagues are extremely time intensive, requiring participants to commit to between 72 (in the standard 12-week protocol) and 96 hours (in the 16-week version). This time burden is considerably higher than the 18 hours of in-session work traditionally required in individual PE and would require that at least 8 participants complete each group in order to even match the efficiency of individual treatment delivery, as groups required two leaders. On the other hand, the protocol proposed by Castillo et al. (2012), was briefer, but produced a much smaller effect size and was only able to accommodate small number of patients per group. Overall, however, previous group studies reported positive findings both in terms of outcome, as well as retention, with reported rates of completion ranging between 87.5% and 100% (Castillo et al., 2012; Ready, Vega et al., 2012b; Sutherland et al., 2012). The purpose of this study was to develop and test a hybrid group and individual intervention protocol that would be both effective and efficient and would allow providers to make exposure based treatment more readily available to patients. The protocol that we developed aimed to minimally modify the traditional PE protocol, to ensure that clinicians trained in PE could implement the protocol easily and effectively. Indeed, we intended that the manual for this protocol be written as an addendum to the established PE manual (Foa et al., 2007). As such, this intervention includes all three primary components of PE: psychoeducation, in vivo exposure, and imaginal exposure followed by processing. No additional components were included. See below for additional details of the protocol. 2. Method 2.1. Participants and procedures The current study is based on a clinical sample of Veterans who presented for an evaluation and were enrolled for treatment at a PTSD Clinic within a midwestern VA Hospital. Based on the results of the initial clinical evaluation, individual providers collaboratively developed a treatment plan with the patient. Participants included in this sample were patients whose treatment plan recommended therapy for PTSD and had indicated interest in group. Specifically, data for this study were derived from 67 veterans who participated in 12 cohorts of the Group PE. The average age of the sample was 54.5 years of age (SD = 13.3), and was predominantly male (98.5%). The majority of participants were either Vietnam Veterans (67.2%) or OEF/OIF/OND Veterans (23.9%). Most participants were diagnosed with a co-morbid mental health disorder in addition to PTSD (88.0%) and were engaged in medication management in addition to this intervention (82.1%). Finally, the greatest number of patients identified a combat trauma as the index event (77.6%), although the groups included participants that had experienced various traumas (e.g., military accidents, military sexual assault, and civilian traumas). See Table 1 for full descriptive statistics. Prior to beginning the group, participants typically met with one of the group leaders individually to discuss the group. The ClinicianAdministered PTSD Scale, which was administered as part of the standard clinical intake, was readministered during this individual appointment in instances where the initial intake assessment took place more than 1 month before this pre-group appointment. 2.2. Exclusionary criteria Since Veterans were selected for the group in standard clinical care, enrollment in the group was determined based on clinic
E.R. Smith et al. / Journal of Anxiety Disorders 30 (2015) 23–27 Table 1 Sample characteristics (N = 67 total, 49 completers, 18 non-completers). Variable Pre-PTSD symptoms CAPS PCL-C Depression symptoms BDI-II Type of trauma Combat Military sexual trauma Other military Civilian Demographics Age Race Caucasian African American Other Period of service Vietnam OEF/OIF/OND Gulf War Other Comorbid axis I diagnoses No other diagnoses One other axis I Two or more additional Receiving psychotropic medications
Completers mean (SD) or N (%)
Non-completers mean (SD) or N (%)
65.69 (13.79)* 62.16 (10.08)*
74.69 (14.50)* 68.46 (7.15)*
29.22 (8.83)*
35.92 (8.39)*
44 (89.8%)* 1 (2.0%) 7 (14.3%) 1 (2.0%)
12 (66.7%)* 0 (0%) 2 (11.1%) 4 (22.2%)
54.71 (13.50)
54.00 (13.29)
39 (79.6%) 2 (4.1%) 8 (16.3%)
12 (66.7%) 3 (16.7%) 3 (16/7%)
34 (69.4%) 13 (26.5%) 1 (2.0%) 1 (2.0%)
11 (61.1%) 3 (16.7%) 3 (16.7%) 1 (5.6%)
6 (12.2%) 26 (53.1%) 16 (32.7%) 38 (77.6%)
2 (11.1%) 9 (50.0%) 7 (38.9%) 17 (94.4%)
OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom; OND, Operation New Dawn. All percentages are valid percent where the missing data have been removed. Other category under race also includes participants that refused to answer. * Indicates significant differences between completers and non-completers at p < 0.05.
evaluation and treatment planning with each Veteran. No specific exclusionary criteria were used to determine eligibility for the group. However, persons offered therapy in the clinic have PTSD or primary subthreshold PTSD symptoms that include significant intrusive symptoms and trauma-related avoidance. After enrollment, group leaders excluded patients from continuing in the group in circumstances when other diagnoses were clearly primary, and/or if risk factors indicated that trauma-focused treatment was not indicated. Typical examples of risk factors that resulted in participant exclusion included acute suicidality or homicidality; significant and uncontrolled active substance use, and/or the presence of active psychotic symptoms. 2.3. Measures Initial information regarding diagnoses and demographics were obtained during a standard clinical evaluation. All of the measures reported in this study are based on DSM-IV diagnostic criteria, as assessment and intervention took place prior to the publication of DSM-5. The Mini International Neuropsychological Interview (MINI; Sheehan, Lecrubier, & Sheehan, 1998), a semistructured diagnostic interview, was administered as part of the standard clinic intake procedure. The primary outcomes included the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1990), PTSD Check List-civilian version (PCL-C; Weathers, Litz, Herman, Huska, & Keane, 1993), and the Beck Depression Inventory-II (BDIII; Beck, Steer, & Brown, 1996). The CAPS is a semi-structured interview designed to assess the frequency and severity of PTSD symptoms, and to determine whether or not full diagnostic criteria for PTSD are met. CAPS has excellent reliability and validity (e.g., Blake et al., 1995). For the purposes of this study, the CAPS was used to establish diagnosis and served as the primary assessment for
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change in PTSD symptoms from pre- to post-treatment. The PCL-C is a self-report measure of PTSD symptoms with demonstrated strong psychometrics (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Weathers et al., 1993). Clinically, this questionnaire was utilized to assess change in PTSD symptoms over the course of treatment. Additionally, it served to verify that any changes noted on CAPS were also reflected on patient self-reports. Finally, the BDI-II is a widely used self-report measure of depressive symptoms with good reliability and validity (e.g., Beck et al., 1996; Dozois, Dobson, & Ahnberg, 1998). 2.4. Treatment overview Aspects of the group were developed and derived from the standard PE protocol (Foa et al., 2007). Authors created an addendum to use with the PE manual for this group protocol. The group consisted of 12 weekly, 1 hours group sessions that were focused on reviewing and developing in vivo exposures, and five 1 hours individual imaginal exposure sessions that occurred during the second half of group (beginning at week 6). In regards to the number of participants in each treatment cohort, group size ranged from four to nine participants in attendance during the first session of the group. On average, groups consisted of 5 or 6 members. The initial group sessions focused on material discussed in sessions 1 and 2 of traditional PE, including a review of the rationale for exposure, development of an in vivo hierarchy, introduction and development of the Subjective Units of Distress Scale (SUDS), and assignment of in vivo exercises. Sessions were structured to begin with a review of material and individual assignments from the previous week. Group discussions focused on reviewing patterns and experiences of in vivo exercises, highlighting factors related to habituation and problem solving difficulties that arose. Sessions concluded with the development of new assignments for the upcoming week. Final group session also included information about maintenance and a review of the original hierarchy as in traditional PE. Individual sessions included the traditional imaginal exposure, i.e., revisiting the most distressing traumatic memory in imagination and recounting it aloud, however, sessions were briefer in length (60 minutes) as content related to in vivo exposure was covered in group session. Sessions began with a review of imaginal exposure homework, followed by at least 30 minutes of exposure and approximately 10 minutes of processing. Exposures were recorded during the session and the participant was asked to listen to the recording daily between sessions. As this was a clinical protocol, in some instances, additional imaginal sessions could be added if it was determined that this would be beneficial, based on the participant’s progress with this part of the protocol. However, in the vast majority of cases 5 or fewer individual imaginal exposure sessions were provided (see results for more information). 2.4.1. Post-treatment Following the conclusion of the group and individual sessions, participants met with the group leader for a final individual session. 2.5. Data analytic strategy Change in symptoms over the course of treatment was examined using both an intent-to-treat (ITT) sample that included all participants that completed at least one pretreatment measure, and a completer only sample. For the purposes of the ITT analyses, the last recorded data point were carried forward and used as the postscore. Paired-sample t-tests were run to explore changes over the course of treatment on the primary symptom measures.
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3. Results 3.1. Descriptive statistics Prior to conducting analyses, participants were classified as completers and non-completers. Participants were considered completers if they attended at least six group sessions and two individual sessions. Using this definition, 49 participants (73.13%) from the total sample were considered completers. Of those who completed, the average number of group sessions attended was 10.00 (SD = 1.84), and the number of individual sessions was 4.67 (SD = 1.93). For non-completers the averages were 3.33 (SD = 2.06), and 0.22 (SD = 0.43), respectively. Initial analyses were run to determine if there were significant differences between completers and non-completers on any of the primary measures or demographic data. Results demonstrated that completers and non-completers differed significantly based on history of combat exposure (2 (1, N = 67) = 5.13, p = 0.02; 80.36% of those who had served in combat completed the group, compared to 45.45% without a combat history) and by the severity of their intake scores (CAPS (F(1,62) = 4.98, p = 0.03; completers M = 65.69, SD = 13.79, non-completers, M = 74.69, SD = 14.54), PCL-C (F(1,56) = 4.419, p = 0.04; completers M = 62.16, SD = 10.08, non-completers, M = 68.46, SD = 7.15), BDI-II (F(1,55) = 5.55, p = 0.02; completers M = 29.22, SD = 8.83, noncompleters, M = 35.92, SD = 8.39) such that patients with higher symptoms at pretreatment and those without combat exposure were more likely to be non-completers. 3.2. Primary analyses In the ITT sample, PTSD symptom severity was significantly reduced from pre to posttreatment (CAPS, t(63) = 6.91, p < 0.001, d = 0.87; PCL-C, t(57) = 5.47, p < 0.001, d = 0.76); as was depression severity (BDI-II, t(56) = 5.77, p < 0.001, d = 0.59). Means and standard deviations presented in Table 2. Results from the completer sample paralleled ITT with significant reduction in PTSD symptoms on CAPS (t(47) = 7.97, p < 0.001, d = 1.37) and PCL-C (t(44) = 6.15, p < 0.001, d = 1.00) (see Table 2). Additionally, a significant reduction in depressive symptoms was also noted on the BDI-II (t(44) = 6.23, p < 0.001, d = 0.79). To calculate provider time, efficiency of the group was examined from both a participant and a provider perspective. Based on an average 12-week, 90-minutes per session PE protocol, individual PE involves an estimated average of 18 hours of in-session participant time and an equal number of therapist hours per completer. This group exposure-based protocol included 12 hours of in-session group time and 5 hours of individual imaginal exposure sessions for a total of 17 hours of in-session time for the participants. To calculate provider time, in group time was multiplied by 2 as two providers were involved in each group (24 hours of in group time), Table 2 Change in PTSD severity with intent-to-treat sample (N = 67) and treatment completers (N = 49). Variable Intent-to-treat CAPS PCL-C BDI-II Completers CAPS PCL-C BDI-II * **
p < 0.05. p < 0.01.
Pre M (SD)
Post M (SD)
t
d
67.94 (14.40) 63.57 (9.81) 30.63 (9.10)
53.00 (19.60) 54.12 (14.49) 24.44 (11.79)
6.91** 5.47** 5.77**
0.87 0.76 0.59
65.69 (13.79) 62.16 (10.08) 29.22 (8.83)
45.77 (15.30) 50.33 (13.35) 21.44 (10.82)
7.97** 6.15** 6.23*
1.37 1.00 0.79
and individual pull outs were calculated using the mean number of participants that completed the group (4) and multiplying it by 5 hours. This produced an estimate of 20 hours of individual session time per group cohort (split across the two providers). In sum, approximately 44 hours of provider time (24 group and 20 individual) was required to complete a group. In order to provide individual PE to the same number of participants, 72 provider hours would be required. Given these calculations, it is estimated that the average Group PE completed saves participants approximately 1 hour of in-session time and represents an average time saving of 28 provider hours per group. The efficiency of the group, relative to individual treatment, was also examined based on group size,1 using the following equation: (Standard PE Hours − Group Protocol Hours)/Standard PE hours. Results from this analyses showed that any group with two or more completers had some benefit in terms of efficiency (2-person group is 6% more efficient, 3-person group is 28% more efficient, 4-person group is 39% more efficient, 5-person is 46%, and a 6-person group is 50% more efficient than individual PE). 4. Discussion Given the abundance of literature on the effectiveness of PE for the treatment of PTSD, and the increasing need for traumafocused therapy within the Veteran population, development of ways to increase access to exposure-based therapy is critical. The current study examined the effectiveness and efficiency of a hybrid group and individual intervention protocol utilizing all of the core PE components while building on the strengths of a group therapy model. Results from this study indicate that this treatment protocol constitutes an efficient and effective way to deliver PE in Veterans. Findings also suggest that this treatment was acceptable to Veterans as rates of drop were similar to other PTSD treatment interventions (Hembree et al., 2003). Given that the procedures are taken directly from the individual PE protocol, the model will require minimal training for providers trained in PE, and as such may facilitate implementation. In particular, analyses for completers and intent-to-treat samples revealed significant reductions in PTSD and depression symptoms. These reductions were moderate to large with effect sizes between 0.76 and 1.37 for PTSD symptoms and between 0.59 and 0.79 for depressive symptoms. The size of the effects found are similar to clinical care effect sizes reported in the VA’s implementation of individual PE and our own published individual therapy data (d = 0.86, Eftekhari et al., 2013; d = 1.13, Sripada et al., 2013), but are smaller than some of other recent reports in VA samples (e.g., d = 2.19, Rauch et al., 2009; d = 2.07, Tuerk et al., 2011). Differences in effect sizes between these studies likely related to the specific subsamples of study, as well as the level of experience with PE at various sites. However, it does provide a comparison for the effect sizes found in this study. In particular, results suggest that moderate to large effect sizes can be produced using a protocol that was essentially equivalent in terms of time demand for the participants and offered a significant time saving in terms of provider hours. Effects seen are comparable to many clinical samples of PE in VA settings, but is not necessary equivalent across the board. A primary benefit of this type of exposure approach is in the increased access to effective PTSD treatment. The group offering will allow more Veterans to be engaged in PE more quickly by freeing up clinician time with the option to provide a portion of the PE intervention in group rather than exclusively individual format.
1 For calculation purposed, both individual and group is calculated by number of completers and is based on the assumption of two providers regardless of number of participants.
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Additionally, some Veterans express a preference for group in order to increase interaction with other Veterans. In this way, the group context may allow for support and peer encouragement from group members. Indeed, clinical impressions suggest that many Veterans in Group PE were motivated by the improvement in their peers and felt more accountable to complete their in vivo exposure homework assignments knowing that they would be expected to report them in front of their peer group and not just their individual therapist as in traditional PE. While it is possible that this dynamic has an impact on motivation and outcome, the design of the current study does not allow for empirical examination of this hypothesis. While the findings of this study are quite encouraging, they are preliminary and should be interpreted in light of its limitations. The current study was designed to assess the viability/feasibility of Group PE therapy for PTSD in a VA outpatient specialty clinic. The lack of randomization to a control condition limits our ability to conclude that the observed outcome was due solely to the Group PE. However, as previously mentioned, effect sizes were large, clinically significant, and approached those found in the balance of individual PTSD treatment studies. Finally, while the results suggest that the majority of participants benefited from and tolerated the format well, since the data were collected in standard clinical care, all Veterans chose to receive the group intervention. As such, there is potential selection bias and it is likely that there is a portion of Veterans who may be avoidant of engaging in a group therapy. Finally, Veterans with higher initial CAPS were less likely to complete Group PE than those with lower CAPS. Thus, the most symptomatic and avoidant Veterans may find group therapy format difficult. Thus, results from this study DO NOT suggest that Group PE therapy should replace individual PE. Nevertheless, Group PE may be a useful alternative for many participants and can enhance access to PE. Additional research is needed to determine the level of pretreatment symptom severity that may warrant individual PE. In conclusion, this initial pilot study suggests that Group PE is an acceptable and effective mode for provision of PE for PTSD. Further, Group PE demonstrates a large reduction in PTSD severity with efficient use of therapist time compared to alternative exposurebased models of group PTSD treatment that require 50 or more hours of therapy time. Additional research including randomized controlled designs comparing Group PE to individual PE therapy, another group therapy such as cognitive processing therapy and/or present center therapy are needed to arrive at a strong conclusion about the efficacy of Group PE.
References Barrera, T. L., Mott, J. M., Hofstein, R. F., & Teng, E. J. (2013). A meta-analytic review of exposure in group cognitive behavioral therapy for posttraumatic stress disorder. Clinical Psychology Review, 33, 24–32. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression inventory manual (2nd ed.). San Antonio, TX: The Psychological Corporation. Blake, D. D., Weathers, F., Nagy, L. M., Kaloupek, D. G., Klauminzer, G., Charney, D. S., & Keane, T. M. (1990). A clinician rating scale for assessing current and lifetime PTSD: the CAPS-1. The Behavior Therapist, 13, 187–188. Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., et al. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 75–90. http://dx.doi.org/10.1002/jts.2490080106 Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric properties of the PTSD checklist (PCL). Behaviour Research and Therapy, 34, 669–673. Cahill, S. P., Rauch, S. A., Hembree, E. A., & Foa, E. B. (2003). Effect of cognitivebehavioral treatments for PTSD on anger. Journal of Cognitive Psychotherapy, 17, 113–131. Castillo, D. T., C’de Baca, J., Qualls, C., & Bornovalova, M. (2012). Group exposure therapy treatment for post-traumatic stress disorder in female veterans. Military Medicine, 177, 1486–1491. Dozois, D., Dobson, K., & Ahnberg, J. (1998). A psychometric evaluation of the beck depression inventory-II. Psychological Assessment, 10, 83–89.
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Eftekhari, A., Ruzek, J. I., Crowley, J. J., Rosen, C. S., Greenbaum, M. A., & Karlin, B. E. (2013). Effectiveness of national implementation of prolonged exposure therapy in veterans affairs care. JAMA Psychiatry, 70, 949–955. http://dx.doi.org/10.1001/jamapsychiatry.2013.36 Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67, 194–200. Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A. M., Riggs, D. S., Feeny, N. C., et al. (2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73(5), 953–964. Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: emotional processing of traumatic experiences therapist guide. USA: Oxford University Press. Friedman, M. J. (2006). Posttraumatic stress disorder among military returnees from Afghanistan and Iraq. The American Journal of Psychiatry, 163, 586–593. Hembree, E. A., Foa, E. B., Dorfan, N. M., Street, G. P., Kowalski, J., & Tu, X. (2003). Do patients drop out prematurely from exposure therapy for PTSD. Journal of Traumatic Stress, 16, 555–562. Institute of Medicine (IOM). (2007). Treatment of posttraumatic stress disorder: an assessment of the evidence. Washington, DC: The National Academies Press. Lorenz, A. R., Ready, D. J., Worley, V. M., Baltzell, D., Mozley, T. N., III, & BrownThomas, K. (2006). Group based exposure therapy (GBET): the Atlanta model for combat veterans with PTSD. Decatur, GA: Department of Veterans Affairs Medical Center-Atlanta. 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, and Policy, 5, 453–461. Paunovic, N., & Ost, L. G. (2001). Cognitive-behavior therapy versus exposure therapy in the treatment of PTSD in refugees. Behavioral Research Therapy, 39, 1183–1197. Rauch, S. A., Defever, E., Favorite, T., Duroe, A., Garrity, C., Martis, B., et al. (2009). Prolonged exposure for PTSD in a Veterans Health Administration PTSD clinic. Journal of Traumatic Stress, 22, 60–64. Rauch, S. A. M., Eftekhari, A., & Ruzek, J. I. (2012). Review of exposure therapy: a gold standard for PTSD treatment. Journal of Rehabilitation Research and Development, 49, 679–688. 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. Pyshcological Trauma: Theory, Research, and Policy, 4, 84–93. Ready, D. J., Thomas, K. R., Worley, V., Backscheider, A. G., Harvey, L. A. C., Baltzell, D., et al. (2008). A field test of group based exposure therapy with 102 veterans with war-related posttaumatic stress disorder. Journal of Traumatic Stress, 21, 150–157. Ready, D. J., Vega, E. M., Worley, V., & Bradley, B. (2012). Combining group-based exposure therapy with prolonged exposure to treat U.S. Vietnam veterans with PTSD: a case study. Journal of Traumatic Stress, 25, 574–577. 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. Rothbaum, B. O., Astin, M. C., & Marsteller, F. (2005). Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18, 607–616. Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M. T., Chow, B. K., et al. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial. The Journal of the American Medical Association, 297, 820–830. Sheehan, D., Lecrubier, Y., & Sheehan, K. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22–33. Sloan, D. M., Bovin, M. J., & Schnurr, P. P. (2012). Review of group treatment for PTSD. Journal of Rehabilitation Research and Development, 49, 689–702. Sripada, R. K., Rauch, S. A. M., Tuerk, P. W., Smith, E., Defever, A. M., Mayer, R. A., et al. (2013). Mild traumatic brain injury and treatment response in prolonged exposure for PTSD. Journal of Traumatic Stress, 26, 369–375. http://dx.doi.org/10.1002/jts.21813 Sutherland, R. J., Mott, M. J., Lanier, S. H., Williams, W., Ready, D. J., & Teng, E. J. (2012). A pilot study of a 12-week model of group-based exposure therapy for veterans with PTSD. Journal of Traumatic Stress, 25, 150–156. Tuerk, P. W., Yoder, M., Grubaugh, A. L., Myrick, H., Hamner, M., & Acierno, R. (2011). Prolonged exposure therapy for combat-related posttraumatic stress disorder: an examination of treatment effectiveness for veterans of the wars in Afghanistan and Iraq. Journal of Anxiety Disorders, 25, 397–403. VA/DoD. (2010). Clinical practice guidelines for the management of post-traumatic stress. Washington, DC: Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense. Office of Quality and Performance Publication 10Q-CPG/PTSD-04. Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (1993). The PTSD checklist: reliability, validity, & diagnostic utility. San Antonio, TX: Paper presented at the Annual Meeting of the International Society for Traumatic Stress Studies.
Contents lists available at ScienceDirect
Journal of Anxiety Disorders
Prolonged Exposure for PTSD in a Veteran group: A pilot effectiveness study Erin R. Smith a,b,∗ , Katherine E. Porter a,b , Michael G. Messina c,d , Jonathan A. Beyer e , Mahrie E. Defever a , Edna B. Foa f , Sheila A.M. Rauch a,b,1 a
Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States c Mental Health Service, William S. Middleton Memorial Veterans Hospital, Madison, WI, United States d Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States e Mental Health Service, Jesse Brown VA Medical Center, Chicago, IL, United States f University of Pennsylvania, Philadelphia, PA, United States b
a r t i c l e
i n f o
Article history: Received 23 July 2014 Received in revised form 26 November 2014 Accepted 15 December 2014 Available online 29 December 2014 Keywords: Prolonged Exposure therapy Group psychotherapy PTSD Veterans
a b s t r a c t Previous research has consistently demonstrated that Prolonged Exposure (PE) therapy is an effective treatment for posttraumatic stress disorder (PTSD). Traditionally, PE has been studied and delivered on an individual basis. However, the growing number of Veterans in need of PTSD treatment has led to increased interest in group therapies as an efficient way to provide access to care. The current study examined a group and individual hybrid treatment that was developed based on PE principles. Treatment was 12 weeks in length and consisted of 12 one-hour group sessions focused on in vivo exposures, and an average of approximately five-hour long individual imaginal exposure sessions. Data for this study were derived from 67 veterans who participated in 12 cohorts of the Group PE. Significant reductions in PTSD and depression symptoms were found in both completers and intent-to-treat sample analyses. The clinical implications of these findings are discussed. Published by Elsevier Ltd.
1. Introduction PTSD treatment guidelines support exposure therapy as a first line intervention (e.g., Friedman, 2006; IOM, 2007; VA/DoD Clinical Practice Guideline, 2010). Prolonged Exposure (PE) therapy, the most utilized exposure treatment program for PTSD, has consistently demonstrated efficacy in reducing the symptoms of PTSD and related psychopathology, such as depression, anger, and guilt for both veterans and non-veterans (Cahill, Rauch, Hembree, & Foa, 2003; Foa et al., 1999, 2005; Paunovic & Ost, 2001; Rauch et al., 2009; Resick, Nishith, Weaver, Astin, & Feuer, 2002; Rothbaum, Astin, & Marsteller, 2005; Schnurr et al., 2007; Tuerk et al., 2011). The Veterans Health Administration has conducted an
∗ Corresponding author at: VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States. Tel.: +1 734 845 5645. E-mail address: [email protected] (E.R. Smith). 1 Dr. Rauch’s contribution was based upon work supported by a CDA-2 Award from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Clinical Sciences Research and Development. http://dx.doi.org/10.1016/j.janxdis.2014.12.008 0887-6185/Published by Elsevier Ltd.
ongoing nationwide PE training initiative in the interest of making evidence-based treatment widely available for Veterans diagnosed with PTSD. To date over 1300 VA mental health professionals have attended training in the provision of individual PE as part of this formal implementation program (Rauch, Eftekhari, & Ruzek, 2012) and several additional hundreds were trained in delivering PE in other VA training programs. Examination of the effectiveness of these VA PE Roll Out trained clinicians using data from their training cases only, showed large effects on PTSD (d = 0.86; Eftekhari et al., 2013). The widespread training and dissemination of evidence-based psychotherapies for the treatment of PTSD within the VA system has been an important advance in providing the nation’s Veteran population with a pathway to improved mental health and well-being. However, the growing number of Veterans in need of PTSD treatment has placed emphasis on the need to facilitate access to these gold standard treatments. Empirical support for group interventions for PTSD is less established than for individual interventions. Recently, however, interest in group therapies for PTSD has increased in order to help meet the demand for treatment of PTSD among Veterans. The need for both effective and efficient treatments has led to the development
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of several new group protocols, as well as reviews of the existing group literature. For instance, in a recent meta-analysis of studies of cognitive behavioral groups for PTSD, the authors concluded that group CBT is an effective intervention for individuals with PTSD (Barrera, Mott, Hofstein, & Teng, 2013). Further, they reported no significant differences in the effect sizes between group CBT that included in-session exposure and those that did not include disclosure in groups. However, protocols that included exposure had large effects sizes (sizes (ES = 1.32; 95% CI: 0.89–1.75) while those without had small to moderate effects (ES = 0.49; 95% CI: −0.19 to 1.18) suggesting that the small number of trials for this comparison and significant heterogeneity in protocol effect may override the group versus individual difference. In addition, group CBT that included in-session exposure had slightly higher rates of attrition (26.4%) than groups without disclosure. Group interventions for PTSD may offer potential benefits over individual therapy. One potential benefit of group is the opportunity for positive social interaction and bonding. For patients with PTSD this can be an especially therapeutic feature due to the isolation and mistrust that often cluster with PTSD. Specifically, psychoeducation about PTSD symptoms within a group format may allow group members to interact with others while normalizing symptoms and challenging the assumption that individuals are alone in their experience of their symptoms. Additionally, when exposure protocols are used, group members can encourage each other to engage in the work of therapy, such as in vivo exposure exercises, in a manner that group leaders cannot because of the members’ shared symptoms and experiences of PTSD. Further, when provided with appropriate group size, group interventions can be an effective use of specialty trained staff resources (Sloan, Bovin, & Schnurr, 2012). In addition to the review outlined above, several recent articles have examined new group exposure protocols (e.g., Castillo, C’de Baca, Qualls, & Bornovalova, 2012; Mott et al., 2013; Ready et al., 2008; Ready, Sylvers et al., 2012a; Sutherland et al., 2012). The majority of these studies (Mott et al., 2013; Ready et al., 2008; Ready, Sylvers et al., 2012a; Sutherland et al., 2012) have relied on a similar manual (originally developed by Lorenz et al., 2006). In each of these studies, significant reductions in PTSD symptoms were noted, and in the case of Ready, Sylvers et al. (2012a) the effect size for this change was shown to be large (d = 0.89). However, the groups were very time intensive, meeting twice weekly for 3 hours per group, for between 12 and 18 weeks. Castillo et al. (2012) proposed an alternative to the aforementioned protocol. This protocol was much shorter, consisting of only 6 weekly 90-min sessions, and it included approximately 3 people in each group. Sessions focused on imaginal exposures and included time for processing. Results demonstrated that there was significant symptom reduction. However, the pre to post effect size on the PTSD checklist was small (d = 0.26). Indeed, both the Ready, Sylvers et al. (2012a), Ready, Vega, Worley, and Bradley (2012b), and Castillo et al. (2012) studies show effect sizes smaller than most trials with a full PE protocol. As such, concerns over whether these treatments are providing a full “dose” of exposure have been raised. Finally, Ready, Vega et al. (2012b), published a report on a mixed group and individual exposure treatment. Their version of the treatment was largely based on the 12-week group described previously. During the first and last 2 weeks of the treatment, the participants attended twice weekly group sessions, each lasting 4 hours in length. During the middle 8 weeks, there was 1 weekly group meeting and 6 individual sessions for a total of more than 50 hours of session time. As with the previous groups, significant reductions were noted across measures, and effect sizes were large (e.g., d = 1.63 on PCL from pre to post). In sum, the results of these studies suggest that group therapy for PTSD that included an exposure component can be effective, but
the models used tend to require more session time per Veteran. For instance, the studies by Ready and colleagues are extremely time intensive, requiring participants to commit to between 72 (in the standard 12-week protocol) and 96 hours (in the 16-week version). This time burden is considerably higher than the 18 hours of in-session work traditionally required in individual PE and would require that at least 8 participants complete each group in order to even match the efficiency of individual treatment delivery, as groups required two leaders. On the other hand, the protocol proposed by Castillo et al. (2012), was briefer, but produced a much smaller effect size and was only able to accommodate small number of patients per group. Overall, however, previous group studies reported positive findings both in terms of outcome, as well as retention, with reported rates of completion ranging between 87.5% and 100% (Castillo et al., 2012; Ready, Vega et al., 2012b; Sutherland et al., 2012). The purpose of this study was to develop and test a hybrid group and individual intervention protocol that would be both effective and efficient and would allow providers to make exposure based treatment more readily available to patients. The protocol that we developed aimed to minimally modify the traditional PE protocol, to ensure that clinicians trained in PE could implement the protocol easily and effectively. Indeed, we intended that the manual for this protocol be written as an addendum to the established PE manual (Foa et al., 2007). As such, this intervention includes all three primary components of PE: psychoeducation, in vivo exposure, and imaginal exposure followed by processing. No additional components were included. See below for additional details of the protocol. 2. Method 2.1. Participants and procedures The current study is based on a clinical sample of Veterans who presented for an evaluation and were enrolled for treatment at a PTSD Clinic within a midwestern VA Hospital. Based on the results of the initial clinical evaluation, individual providers collaboratively developed a treatment plan with the patient. Participants included in this sample were patients whose treatment plan recommended therapy for PTSD and had indicated interest in group. Specifically, data for this study were derived from 67 veterans who participated in 12 cohorts of the Group PE. The average age of the sample was 54.5 years of age (SD = 13.3), and was predominantly male (98.5%). The majority of participants were either Vietnam Veterans (67.2%) or OEF/OIF/OND Veterans (23.9%). Most participants were diagnosed with a co-morbid mental health disorder in addition to PTSD (88.0%) and were engaged in medication management in addition to this intervention (82.1%). Finally, the greatest number of patients identified a combat trauma as the index event (77.6%), although the groups included participants that had experienced various traumas (e.g., military accidents, military sexual assault, and civilian traumas). See Table 1 for full descriptive statistics. Prior to beginning the group, participants typically met with one of the group leaders individually to discuss the group. The ClinicianAdministered PTSD Scale, which was administered as part of the standard clinical intake, was readministered during this individual appointment in instances where the initial intake assessment took place more than 1 month before this pre-group appointment. 2.2. Exclusionary criteria Since Veterans were selected for the group in standard clinical care, enrollment in the group was determined based on clinic
E.R. Smith et al. / Journal of Anxiety Disorders 30 (2015) 23–27 Table 1 Sample characteristics (N = 67 total, 49 completers, 18 non-completers). Variable Pre-PTSD symptoms CAPS PCL-C Depression symptoms BDI-II Type of trauma Combat Military sexual trauma Other military Civilian Demographics Age Race Caucasian African American Other Period of service Vietnam OEF/OIF/OND Gulf War Other Comorbid axis I diagnoses No other diagnoses One other axis I Two or more additional Receiving psychotropic medications
Completers mean (SD) or N (%)
Non-completers mean (SD) or N (%)
65.69 (13.79)* 62.16 (10.08)*
74.69 (14.50)* 68.46 (7.15)*
29.22 (8.83)*
35.92 (8.39)*
44 (89.8%)* 1 (2.0%) 7 (14.3%) 1 (2.0%)
12 (66.7%)* 0 (0%) 2 (11.1%) 4 (22.2%)
54.71 (13.50)
54.00 (13.29)
39 (79.6%) 2 (4.1%) 8 (16.3%)
12 (66.7%) 3 (16.7%) 3 (16/7%)
34 (69.4%) 13 (26.5%) 1 (2.0%) 1 (2.0%)
11 (61.1%) 3 (16.7%) 3 (16.7%) 1 (5.6%)
6 (12.2%) 26 (53.1%) 16 (32.7%) 38 (77.6%)
2 (11.1%) 9 (50.0%) 7 (38.9%) 17 (94.4%)
OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom; OND, Operation New Dawn. All percentages are valid percent where the missing data have been removed. Other category under race also includes participants that refused to answer. * Indicates significant differences between completers and non-completers at p < 0.05.
evaluation and treatment planning with each Veteran. No specific exclusionary criteria were used to determine eligibility for the group. However, persons offered therapy in the clinic have PTSD or primary subthreshold PTSD symptoms that include significant intrusive symptoms and trauma-related avoidance. After enrollment, group leaders excluded patients from continuing in the group in circumstances when other diagnoses were clearly primary, and/or if risk factors indicated that trauma-focused treatment was not indicated. Typical examples of risk factors that resulted in participant exclusion included acute suicidality or homicidality; significant and uncontrolled active substance use, and/or the presence of active psychotic symptoms. 2.3. Measures Initial information regarding diagnoses and demographics were obtained during a standard clinical evaluation. All of the measures reported in this study are based on DSM-IV diagnostic criteria, as assessment and intervention took place prior to the publication of DSM-5. The Mini International Neuropsychological Interview (MINI; Sheehan, Lecrubier, & Sheehan, 1998), a semistructured diagnostic interview, was administered as part of the standard clinic intake procedure. The primary outcomes included the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1990), PTSD Check List-civilian version (PCL-C; Weathers, Litz, Herman, Huska, & Keane, 1993), and the Beck Depression Inventory-II (BDIII; Beck, Steer, & Brown, 1996). The CAPS is a semi-structured interview designed to assess the frequency and severity of PTSD symptoms, and to determine whether or not full diagnostic criteria for PTSD are met. CAPS has excellent reliability and validity (e.g., Blake et al., 1995). For the purposes of this study, the CAPS was used to establish diagnosis and served as the primary assessment for
25
change in PTSD symptoms from pre- to post-treatment. The PCL-C is a self-report measure of PTSD symptoms with demonstrated strong psychometrics (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Weathers et al., 1993). Clinically, this questionnaire was utilized to assess change in PTSD symptoms over the course of treatment. Additionally, it served to verify that any changes noted on CAPS were also reflected on patient self-reports. Finally, the BDI-II is a widely used self-report measure of depressive symptoms with good reliability and validity (e.g., Beck et al., 1996; Dozois, Dobson, & Ahnberg, 1998). 2.4. Treatment overview Aspects of the group were developed and derived from the standard PE protocol (Foa et al., 2007). Authors created an addendum to use with the PE manual for this group protocol. The group consisted of 12 weekly, 1 hours group sessions that were focused on reviewing and developing in vivo exposures, and five 1 hours individual imaginal exposure sessions that occurred during the second half of group (beginning at week 6). In regards to the number of participants in each treatment cohort, group size ranged from four to nine participants in attendance during the first session of the group. On average, groups consisted of 5 or 6 members. The initial group sessions focused on material discussed in sessions 1 and 2 of traditional PE, including a review of the rationale for exposure, development of an in vivo hierarchy, introduction and development of the Subjective Units of Distress Scale (SUDS), and assignment of in vivo exercises. Sessions were structured to begin with a review of material and individual assignments from the previous week. Group discussions focused on reviewing patterns and experiences of in vivo exercises, highlighting factors related to habituation and problem solving difficulties that arose. Sessions concluded with the development of new assignments for the upcoming week. Final group session also included information about maintenance and a review of the original hierarchy as in traditional PE. Individual sessions included the traditional imaginal exposure, i.e., revisiting the most distressing traumatic memory in imagination and recounting it aloud, however, sessions were briefer in length (60 minutes) as content related to in vivo exposure was covered in group session. Sessions began with a review of imaginal exposure homework, followed by at least 30 minutes of exposure and approximately 10 minutes of processing. Exposures were recorded during the session and the participant was asked to listen to the recording daily between sessions. As this was a clinical protocol, in some instances, additional imaginal sessions could be added if it was determined that this would be beneficial, based on the participant’s progress with this part of the protocol. However, in the vast majority of cases 5 or fewer individual imaginal exposure sessions were provided (see results for more information). 2.4.1. Post-treatment Following the conclusion of the group and individual sessions, participants met with the group leader for a final individual session. 2.5. Data analytic strategy Change in symptoms over the course of treatment was examined using both an intent-to-treat (ITT) sample that included all participants that completed at least one pretreatment measure, and a completer only sample. For the purposes of the ITT analyses, the last recorded data point were carried forward and used as the postscore. Paired-sample t-tests were run to explore changes over the course of treatment on the primary symptom measures.
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3. Results 3.1. Descriptive statistics Prior to conducting analyses, participants were classified as completers and non-completers. Participants were considered completers if they attended at least six group sessions and two individual sessions. Using this definition, 49 participants (73.13%) from the total sample were considered completers. Of those who completed, the average number of group sessions attended was 10.00 (SD = 1.84), and the number of individual sessions was 4.67 (SD = 1.93). For non-completers the averages were 3.33 (SD = 2.06), and 0.22 (SD = 0.43), respectively. Initial analyses were run to determine if there were significant differences between completers and non-completers on any of the primary measures or demographic data. Results demonstrated that completers and non-completers differed significantly based on history of combat exposure (2 (1, N = 67) = 5.13, p = 0.02; 80.36% of those who had served in combat completed the group, compared to 45.45% without a combat history) and by the severity of their intake scores (CAPS (F(1,62) = 4.98, p = 0.03; completers M = 65.69, SD = 13.79, non-completers, M = 74.69, SD = 14.54), PCL-C (F(1,56) = 4.419, p = 0.04; completers M = 62.16, SD = 10.08, non-completers, M = 68.46, SD = 7.15), BDI-II (F(1,55) = 5.55, p = 0.02; completers M = 29.22, SD = 8.83, noncompleters, M = 35.92, SD = 8.39) such that patients with higher symptoms at pretreatment and those without combat exposure were more likely to be non-completers. 3.2. Primary analyses In the ITT sample, PTSD symptom severity was significantly reduced from pre to posttreatment (CAPS, t(63) = 6.91, p < 0.001, d = 0.87; PCL-C, t(57) = 5.47, p < 0.001, d = 0.76); as was depression severity (BDI-II, t(56) = 5.77, p < 0.001, d = 0.59). Means and standard deviations presented in Table 2. Results from the completer sample paralleled ITT with significant reduction in PTSD symptoms on CAPS (t(47) = 7.97, p < 0.001, d = 1.37) and PCL-C (t(44) = 6.15, p < 0.001, d = 1.00) (see Table 2). Additionally, a significant reduction in depressive symptoms was also noted on the BDI-II (t(44) = 6.23, p < 0.001, d = 0.79). To calculate provider time, efficiency of the group was examined from both a participant and a provider perspective. Based on an average 12-week, 90-minutes per session PE protocol, individual PE involves an estimated average of 18 hours of in-session participant time and an equal number of therapist hours per completer. This group exposure-based protocol included 12 hours of in-session group time and 5 hours of individual imaginal exposure sessions for a total of 17 hours of in-session time for the participants. To calculate provider time, in group time was multiplied by 2 as two providers were involved in each group (24 hours of in group time), Table 2 Change in PTSD severity with intent-to-treat sample (N = 67) and treatment completers (N = 49). Variable Intent-to-treat CAPS PCL-C BDI-II Completers CAPS PCL-C BDI-II * **
p < 0.05. p < 0.01.
Pre M (SD)
Post M (SD)
t
d
67.94 (14.40) 63.57 (9.81) 30.63 (9.10)
53.00 (19.60) 54.12 (14.49) 24.44 (11.79)
6.91** 5.47** 5.77**
0.87 0.76 0.59
65.69 (13.79) 62.16 (10.08) 29.22 (8.83)
45.77 (15.30) 50.33 (13.35) 21.44 (10.82)
7.97** 6.15** 6.23*
1.37 1.00 0.79
and individual pull outs were calculated using the mean number of participants that completed the group (4) and multiplying it by 5 hours. This produced an estimate of 20 hours of individual session time per group cohort (split across the two providers). In sum, approximately 44 hours of provider time (24 group and 20 individual) was required to complete a group. In order to provide individual PE to the same number of participants, 72 provider hours would be required. Given these calculations, it is estimated that the average Group PE completed saves participants approximately 1 hour of in-session time and represents an average time saving of 28 provider hours per group. The efficiency of the group, relative to individual treatment, was also examined based on group size,1 using the following equation: (Standard PE Hours − Group Protocol Hours)/Standard PE hours. Results from this analyses showed that any group with two or more completers had some benefit in terms of efficiency (2-person group is 6% more efficient, 3-person group is 28% more efficient, 4-person group is 39% more efficient, 5-person is 46%, and a 6-person group is 50% more efficient than individual PE). 4. Discussion Given the abundance of literature on the effectiveness of PE for the treatment of PTSD, and the increasing need for traumafocused therapy within the Veteran population, development of ways to increase access to exposure-based therapy is critical. The current study examined the effectiveness and efficiency of a hybrid group and individual intervention protocol utilizing all of the core PE components while building on the strengths of a group therapy model. Results from this study indicate that this treatment protocol constitutes an efficient and effective way to deliver PE in Veterans. Findings also suggest that this treatment was acceptable to Veterans as rates of drop were similar to other PTSD treatment interventions (Hembree et al., 2003). Given that the procedures are taken directly from the individual PE protocol, the model will require minimal training for providers trained in PE, and as such may facilitate implementation. In particular, analyses for completers and intent-to-treat samples revealed significant reductions in PTSD and depression symptoms. These reductions were moderate to large with effect sizes between 0.76 and 1.37 for PTSD symptoms and between 0.59 and 0.79 for depressive symptoms. The size of the effects found are similar to clinical care effect sizes reported in the VA’s implementation of individual PE and our own published individual therapy data (d = 0.86, Eftekhari et al., 2013; d = 1.13, Sripada et al., 2013), but are smaller than some of other recent reports in VA samples (e.g., d = 2.19, Rauch et al., 2009; d = 2.07, Tuerk et al., 2011). Differences in effect sizes between these studies likely related to the specific subsamples of study, as well as the level of experience with PE at various sites. However, it does provide a comparison for the effect sizes found in this study. In particular, results suggest that moderate to large effect sizes can be produced using a protocol that was essentially equivalent in terms of time demand for the participants and offered a significant time saving in terms of provider hours. Effects seen are comparable to many clinical samples of PE in VA settings, but is not necessary equivalent across the board. A primary benefit of this type of exposure approach is in the increased access to effective PTSD treatment. The group offering will allow more Veterans to be engaged in PE more quickly by freeing up clinician time with the option to provide a portion of the PE intervention in group rather than exclusively individual format.
1 For calculation purposed, both individual and group is calculated by number of completers and is based on the assumption of two providers regardless of number of participants.
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Additionally, some Veterans express a preference for group in order to increase interaction with other Veterans. In this way, the group context may allow for support and peer encouragement from group members. Indeed, clinical impressions suggest that many Veterans in Group PE were motivated by the improvement in their peers and felt more accountable to complete their in vivo exposure homework assignments knowing that they would be expected to report them in front of their peer group and not just their individual therapist as in traditional PE. While it is possible that this dynamic has an impact on motivation and outcome, the design of the current study does not allow for empirical examination of this hypothesis. While the findings of this study are quite encouraging, they are preliminary and should be interpreted in light of its limitations. The current study was designed to assess the viability/feasibility of Group PE therapy for PTSD in a VA outpatient specialty clinic. The lack of randomization to a control condition limits our ability to conclude that the observed outcome was due solely to the Group PE. However, as previously mentioned, effect sizes were large, clinically significant, and approached those found in the balance of individual PTSD treatment studies. Finally, while the results suggest that the majority of participants benefited from and tolerated the format well, since the data were collected in standard clinical care, all Veterans chose to receive the group intervention. As such, there is potential selection bias and it is likely that there is a portion of Veterans who may be avoidant of engaging in a group therapy. Finally, Veterans with higher initial CAPS were less likely to complete Group PE than those with lower CAPS. Thus, the most symptomatic and avoidant Veterans may find group therapy format difficult. Thus, results from this study DO NOT suggest that Group PE therapy should replace individual PE. Nevertheless, Group PE may be a useful alternative for many participants and can enhance access to PE. Additional research is needed to determine the level of pretreatment symptom severity that may warrant individual PE. In conclusion, this initial pilot study suggests that Group PE is an acceptable and effective mode for provision of PE for PTSD. Further, Group PE demonstrates a large reduction in PTSD severity with efficient use of therapist time compared to alternative exposurebased models of group PTSD treatment that require 50 or more hours of therapy time. Additional research including randomized controlled designs comparing Group PE to individual PE therapy, another group therapy such as cognitive processing therapy and/or present center therapy are needed to arrive at a strong conclusion about the efficacy of Group PE.
References Barrera, T. L., Mott, J. M., Hofstein, R. F., & Teng, E. J. (2013). A meta-analytic review of exposure in group cognitive behavioral therapy for posttraumatic stress disorder. Clinical Psychology Review, 33, 24–32. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression inventory manual (2nd ed.). San Antonio, TX: The Psychological Corporation. Blake, D. D., Weathers, F., Nagy, L. M., Kaloupek, D. G., Klauminzer, G., Charney, D. S., & Keane, T. M. (1990). A clinician rating scale for assessing current and lifetime PTSD: the CAPS-1. The Behavior Therapist, 13, 187–188. Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., et al. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 75–90. http://dx.doi.org/10.1002/jts.2490080106 Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric properties of the PTSD checklist (PCL). Behaviour Research and Therapy, 34, 669–673. Cahill, S. P., Rauch, S. A., Hembree, E. A., & Foa, E. B. (2003). Effect of cognitivebehavioral treatments for PTSD on anger. Journal of Cognitive Psychotherapy, 17, 113–131. Castillo, D. T., C’de Baca, J., Qualls, C., & Bornovalova, M. (2012). Group exposure therapy treatment for post-traumatic stress disorder in female veterans. Military Medicine, 177, 1486–1491. Dozois, D., Dobson, K., & Ahnberg, J. (1998). A psychometric evaluation of the beck depression inventory-II. Psychological Assessment, 10, 83–89.
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Eftekhari, A., Ruzek, J. I., Crowley, J. J., Rosen, C. S., Greenbaum, M. A., & Karlin, B. E. (2013). Effectiveness of national implementation of prolonged exposure therapy in veterans affairs care. JAMA Psychiatry, 70, 949–955. http://dx.doi.org/10.1001/jamapsychiatry.2013.36 Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67, 194–200. Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A. M., Riggs, D. S., Feeny, N. C., et al. (2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73(5), 953–964. Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: emotional processing of traumatic experiences therapist guide. USA: Oxford University Press. Friedman, M. J. (2006). Posttraumatic stress disorder among military returnees from Afghanistan and Iraq. The American Journal of Psychiatry, 163, 586–593. Hembree, E. A., Foa, E. B., Dorfan, N. M., Street, G. P., Kowalski, J., & Tu, X. (2003). Do patients drop out prematurely from exposure therapy for PTSD. Journal of Traumatic Stress, 16, 555–562. Institute of Medicine (IOM). (2007). Treatment of posttraumatic stress disorder: an assessment of the evidence. Washington, DC: The National Academies Press. Lorenz, A. R., Ready, D. J., Worley, V. M., Baltzell, D., Mozley, T. N., III, & BrownThomas, K. (2006). Group based exposure therapy (GBET): the Atlanta model for combat veterans with PTSD. Decatur, GA: Department of Veterans Affairs Medical Center-Atlanta. 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, and Policy, 5, 453–461. Paunovic, N., & Ost, L. G. (2001). Cognitive-behavior therapy versus exposure therapy in the treatment of PTSD in refugees. Behavioral Research Therapy, 39, 1183–1197. Rauch, S. A., Defever, E., Favorite, T., Duroe, A., Garrity, C., Martis, B., et al. (2009). Prolonged exposure for PTSD in a Veterans Health Administration PTSD clinic. Journal of Traumatic Stress, 22, 60–64. Rauch, S. A. M., Eftekhari, A., & Ruzek, J. I. (2012). Review of exposure therapy: a gold standard for PTSD treatment. Journal of Rehabilitation Research and Development, 49, 679–688. 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. Pyshcological Trauma: Theory, Research, and Policy, 4, 84–93. Ready, D. J., Thomas, K. R., Worley, V., Backscheider, A. G., Harvey, L. A. C., Baltzell, D., et al. (2008). A field test of group based exposure therapy with 102 veterans with war-related posttaumatic stress disorder. Journal of Traumatic Stress, 21, 150–157. Ready, D. J., Vega, E. M., Worley, V., & Bradley, B. (2012). Combining group-based exposure therapy with prolonged exposure to treat U.S. Vietnam veterans with PTSD: a case study. Journal of Traumatic Stress, 25, 574–577. 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. Rothbaum, B. O., Astin, M. C., & Marsteller, F. (2005). Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18, 607–616. Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M. T., Chow, B. K., et al. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial. The Journal of the American Medical Association, 297, 820–830. Sheehan, D., Lecrubier, Y., & Sheehan, K. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22–33. Sloan, D. M., Bovin, M. J., & Schnurr, P. P. (2012). Review of group treatment for PTSD. Journal of Rehabilitation Research and Development, 49, 689–702. Sripada, R. K., Rauch, S. A. M., Tuerk, P. W., Smith, E., Defever, A. M., Mayer, R. A., et al. (2013). Mild traumatic brain injury and treatment response in prolonged exposure for PTSD. Journal of Traumatic Stress, 26, 369–375. http://dx.doi.org/10.1002/jts.21813 Sutherland, R. J., Mott, M. J., Lanier, S. H., Williams, W., Ready, D. J., & Teng, E. J. (2012). A pilot study of a 12-week model of group-based exposure therapy for veterans with PTSD. Journal of Traumatic Stress, 25, 150–156. Tuerk, P. W., Yoder, M., Grubaugh, A. L., Myrick, H., Hamner, M., & Acierno, R. (2011). Prolonged exposure therapy for combat-related posttraumatic stress disorder: an examination of treatment effectiveness for veterans of the wars in Afghanistan and Iraq. Journal of Anxiety Disorders, 25, 397–403. VA/DoD. (2010). Clinical practice guidelines for the management of post-traumatic stress. Washington, DC: Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense. Office of Quality and Performance Publication 10Q-CPG/PTSD-04. Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (1993). The PTSD checklist: reliability, validity, & diagnostic utility. San Antonio, TX: Paper presented at the Annual Meeting of the International Society for Traumatic Stress Studies.
