A pilot study of a 12-week model of group-based exposure therapy for veterans with PTSD

Journal of Traumatic StressApril 2012, 25, 150–156

A Pilot Study of a 12-Week Model of Group-Based ExposureTherapy for Veterans With PTSD

Roy John Sutherland,1,2 Juliette M. Mott,1–4 Stacey Holmes Lanier,1,2 Wright Williams,1,2

David J. Ready,5,6 and Ellen J. Teng1–4

1Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA2Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, Houston, Texas, USA

3South Central Mental Illness Research, Education, and Clinical Center, Houston, Texas, USA4Houston Center for Quality of Care and Utilization Studies, Houston, Texas, USA

5Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA6Emory University School of Medicine, Atlanta, Georgia, USA

Group-based exposure therapy (GBET) is an intensive group treatment that targets posttraumatic stress disorder (PTSD) symptoms throughrepeated imaginal and in vivo exposure. The purpose of the present study was to assess the feasibility and acceptability of a modified12-week course of GBET (modified from the standard 16 weeks) and to examine its effectiveness in reducing veterans’ PTSD symptoms.Participants were 10 male Operation Iraqi Freedom and Vietnam-era veterans recruited from a PTSD specialty clinic at a large VeteransAffairs Medical Center. All participants were retained and demonstrated clinically significant reductions in PTSD symptoms (η2 = .84–.87) comparable to the standard protocol. The findings from this small sample indicate that the abbreviated 12-week GBET protocol is apotentially effective treatment for PTSD.

Although a large body of empirical evidence supports the ef-ficacy of individually-administered exposure therapy for post-traumatic stress disorder (PTSD; e.g., Rothbaum, Meadows,Resick, & Foy, 2000), there are few studies of group-based ap-proaches to exposure therapy. This may be due in part to concernthat exposing individuals to the details of other patient’s trau-matic experiences may cause secondary traumatization (e.g.,Resick & Schnicke, 1996), combined with previous resultsdemonstrating limited effectiveness for exposure delivered in agroup format (Monson, Rodriguez, & Warner, 2005; Schnurr etal., 2003). Schnurr et al. (2003) conducted the largest treatmenttrial testing a group exposure protocol to date. This multisitestudy compared an exposure-based treatment, trauma-focusedgroup therapy (TFGT), to a no-exposure control treatment.Although both treatments demonstrated modest effectivenessat treating PTSD in veterans, 23% of TFGT participants

Roy John Sutherland and Juliette M. Mott contributed equally to this work.

Roy John Sutherland is now at HealthEast Care System, St. Joseph’s Hospital,St. Paul, MN.

Correspondence concerning this article should be addressed to R. John Suther-land, HealthEast Care System, St. Joseph’s Hospital, Mental Health and Ad-diction Service Clinic, 45F 10th Street g7000, St. Paul, MN 55102. E-mail:[email protected]

Copyright C© 2012 International Society for Traumatic Stress Studies. Viewthis article online at wileyonlinelibrary.comDOI: 10.1002/jts.21679

dropped out of treatment, significantly more than droppedout of the control condition (9%). Given its strengths, includ-ing a large sample size (N = 360) and rigorous methodol-ogy, this study has been widely cited in the research liter-ature. Thus, the results of Schnurr et al.’s study likely dis-couraged the dissemination of group exposure for PTSD (Bis-son, 2003), despite the authors’ assertion that further researchwas needed before firm conclusions could be drawn about itseffectiveness.

A more recently developed treatment, group-based expo-sure therapy (GBET), has shown promising results in reduc-ing PTSD severity and maintaining high retention rates in aveteran population (Ready et al., 2008, 2012). A manualized,cognitive–behavioral treatment initially developed to treat com-bat veterans with severe PTSD, GBET employs in vivo andimaginal exposure techniques similar to those used in individ-ual prolonged exposure (PE) therapy (Foa, Hembree, & Roth-baum, 2007) and TFGT, in combination with elements designedto increase coping skills, reduce social withdrawal, and teachreappraisal of cognitions and behaviors (e.g., Donovan, Padin-Rivera, & Kowaliw, 2001; Humphreys, Westerink, Giarrantano,& Brooks, 1999).

GBET is similar to other exposure-based group treatments(e.g., PE, TFGT) in that patients participate in imaginal expo-sure exercises in session. In GBET, the group format providesveterans with the opportunity to give supportive feedback im-mediately before and after imaginal exposures and allows group

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Group-Based Exposure Therapy 151

members to model successful completion of exposure exercisesfor one another. Like TFGT, group members participate in twoin-session imaginal exposures. The GBET protocol, however,instructs patients to review audiotapes of each exposure 10–15 times (compared to 8 times in TFGT) and offers more op-portunities for vicarious exposure to other group members’traumatic memories due to its larger group size (10 veteranscompared to 6 in TFGT). Furthermore, although both PE andTFGT instruct patients to complete imaginal exposures on theirmost distressing trauma, GBET differs in that patients talk indetail about all of the traumatic events that occurred duringtheir combat tour during their first exposure.

Given that exposure-based treatments for PTSD have tradi-tionally been associated with high attrition rates, several as-pects of GBET are designed to increase group cohesion in theearly stages of treatment, thereby facilitating commitment tothe group. Group therapists place great emphasis on the impor-tance of working together to achieve a common goal, whichis highly consistent with military culture, and patients engagein group-building exercises adapted from an Australian PTSDprogram that demonstrated impressive rates of treatment reten-tion, reporting a 3% dropout rate in a sample of 2,223 veterans(Creamer, Elliott, Forbes, Biddle, & Hawthorne, 2006).

To date, two studies have examined the effectiveness ofGBET in treating PTSD. In an open trial of a 16-week course ofGBET with 102 war veterans, 81% of participants demonstratedclinically significant reductions in PTSD symptoms (Ready etal., 2008). These results were replicated in a second open trialwith 30 combat veterans, 54% of whom demonstrated reli-able reductions in PTSD symptoms from pre- to posttreatment(Ready et al., 2012). In addition, the observed dropout rates(3%, Ready et al., 2008; 0%, Ready et al., 2012) were lower thanthose reported with other group treatments for veterans withPTSD, which range from 14% (Beidel, Frueh, Uhde, Wong, &Mentrikowski, 2011) to 27% (Schnurr et al., 2003), indicatingthat GBET may be better able to engage veterans who wouldnot otherwise benefit from treatment.

Although initial results suggest that GBET may prove to bean effective and tolerable treatment for veterans with PTSD,the protocol in its current form is time intensive. The groupmeets for 32 three-hour sessions over the course of 16 weeks,totaling 96 hours of in-session time. The time commitment re-quired from patients to complete this program may serve as abarrier to initiating treatment. Similarly, mental health clinicsmay be reluctant to implement this treatment because it re-quires substantially more clinical hours than other empiricallysupported group treatments for PTSD, such as cognitive pro-cessing therapy, which typically entails 18 clinical hours. Thus,a briefer version of the GBET protocol, provided that it main-tains the effectiveness and retention rates associated with the16-week program, could increase the acceptability of GBET toboth patients and clinicians. The goal of the present study wasto test the feasibility of delivering a condensed, 12-week courseof GBET and to examine the preliminary effectiveness of thisintervention in reducing PTSD symptoms.

Method

Participants

Participants were 10 male Iraq (n = 3) and Vietnam (n = 7)veterans with combat-related PTSD. All participants were en-rolled in a PTSD specialty clinic at a large Veterans Affairs(VA) medical center and were recruited via clinician referral.Participants ranged in age from 27 to 65 years (M = 54.4, SD= 14.3). Forty percent of the sample self-identified as Latino,30% as African American, 20% as Caucasian, and 10% as other.Participants had an average of 13 years education, an averageannual income of $43,000, and 50% were married or partnered.Seven of 10 participants were receiving service-connected dis-ability compensation for PTSD at the time of study enrollment.Eight participants had previously received psychotherapy forPTSD at the VA.

Measures

The Clinician Administered PTSD Scale. (CAPS;Blake et al., 1995). The CAPS is a 30-item semistructuredclinical interview that assesses severity of each of the 17 PTSDsymptoms defined by the Diagnostic and Statistical Manualof Mental Disorders (4th ed., DSM-IV; American PsychiatricAssociation, 1994). Clinicians rate both the frequency and in-tensity of each symptom on a Likert-type scale ranging from0 to 4. Items are summed to yield a global severity score. Forthe purpose of the present study, we considered only symptomsoccurring in the past month and used the “1, 2 rule” (Weathers,Ruscio, & Keane, 1999), which requires that a symptom receivea frequency score of 1 or higher and an intensity score of 2 orhigher to be counted toward the diagnosis. The CAPS has well-established psychometric properties and is widely regardedas the gold standard measure for assessing PTSD (Weathers,Keane, & Davidson, 2001). The CAPS also has excellent diag-nostic accuracy in a veteran population (Hyer, Summers, Boyd,Litaker, & Boudewyns, 1996). Coefficient α at each assessmenttime point in the current study ranged from .92–.94.

The PTSD Checklist-Stressor Specific Version (PCL-S;Weathers, Litz, Herman, Huska, & Keane, 1993). The PCL-Sis a 17-item self-report measure that assesses the degree towhich the respondent has been impacted by PTSD symptomsin the past week. Each PTSD symptom is rated on a Likert-typescale ranging from 1 = Not all bothersome to 5 = Extremelybothersome, and items are summed to create a total score rang-ing from 17 to 85. A review of the psychometric propertiesof the PCL-S showed good internal consistency (consistentlyabove .75), high convergent validity with the CAPS, and goodsensitivity to change (Wilkins, Lang, & Norman, 2011). In thecurrent sample, α = .88–.92.

The Life Events Checklist. The Life Events Checklist(Gray, Litz, Hsu, & Lombardo, 2004) is a 17-item measureused to assess previous traumatic experiences. Each item lists

Copyright C© 2012 International Society for Traumatic Stress Studies Journal of Traumatic Stress, 2012, 25, 150–156

152 Sutherland et al.

a highly stressful event (e.g., combat, natural disaster), and re-spondents indicate their level of previous exposure by selectingone of the following options: “Happened to me,” “Witnessedit,” “Heard about it,” “Not sure,” and “Does not apply.” Itemsrated as “Happened to me” receive a score of 1, and all otherresponses receive a score of 0. Item scores are summed for atotal score. The internal reliability for the current sample wasgood (α = .92).

The Posttraumatic Cognitions Inventory. (PTCI; Foa,Ehlers, Clark, Tolin, & Orsillo, 1999). The PTCI consists of36 items that use a 7-point Likert scale to assess negativetrauma-related thoughts and beliefs. The PTCI yields a totalscore and three factor scores based on the means of items foreach subscale: Negative Cognitions about the Self (21 items),Negative Cognitions about the World (7 items), and Self-Blame(5 items). The PTCI subscales have good test–retest reliability(.75–.89), excellent internal consistency (Cronbach’s α rangingfrom .86–.97), and moderate-to-high correlations with PTSDsymptom severity (Foa et al., 1999). Internal consistency in thepresent sample across assessments was α = .96–.98.

The Client Satisfaction Questionnaire. (CSQ-8; Larsen,Attkisson, Hargreaves, & Nguyen, 1979). The CSQ-8 is an8-item measure that assesses satisfaction with treatment. Itemsuse a 4-point Likert scale. Total scores represent the sum ofindividual items and range from 8 to 32, with higher scoresindicating greater satisfaction with treatment. The CSQ-8 hasbeen widely studied and has been shown to correlate well withmeasures of global improvement, therapist ratings of patientprogress (Corcoran & Fischer, 1987). Several studies supportthe internal consistency of the CSQ-8, with Cronbach’s α rang-ing from .83 to .93 (Sederer, Dickey, & Hermann, 1996); inter-nal consistency in the current sample was α = .81.

The Saint Louis University Mental Status Exam. TheSaint Louis University Mental Status Exam (Tariq, Tumosa,Chibnall, Perry, & Morley, 2006) is a brief, 11-item screen-ing questionnaire that assesses orientation, memory, attention,and executive functioning. It has demonstrated good sensitivityand specificity in detecting dementia and mild neurocognitivedeficits in veterans (Tariq et al., 2006). Scores range from 0to 30, with lower scores indicating greater impairments. Al-though precise cutoff scores depend on the respondent’s levelof education, scores below 23.5–25.5, suggest mild cognitivedeficits, whereas scores below 19.5–21.5 suggest the presenceof a dementia process. In the present study, this measure wasused to screen participants for cognitive deficits that would beexpected to interfere with treatment.

Procedure

This study was approved by the Baylor College of MedicineInstitutional Review Board and the Michael E. DeBakey VAMedical Center Research and Development Committee.

Pretreatment Assessment. Participants were recruitedthrough clinician referrals from the PTSD specialty clinic at theVA medical center. Interested veterans were invited to partici-pate in an initial assessment conducted by two members of theresearch team who also served as the treating clinicians. Dur-ing this assessment, participants first learned about the studyand provided informed consent. Participants then completed theCAPS, PCL-S, PTCI, and Saint Louis University Mental StatusExam and were screened for study eligibility, which includeda diagnosis of combat-related PTSD, willingness to provide atelephone number to group members and to have sessions audiorecorded, and 1-month stability on psychotropic medications.Patients with current mania or psychosis, imminent suicidalideation, cognitive impairment (total score < 21 on the SaintLouis University Mental Status Exam), substance dependence,or previous participation in exposure-based PTSD treatmentwere excluded.

Course of Treatment. Participants received a modified,12-week course of GBET that was delivered in twice weekly,3-hour sessions (24 total sessions, as opposed to 32 sessionsin the original protocol).1 Similar to the original GBET proto-col, the 12-week model includes three treatment phases. Dur-ing Phase I (Build the Group: 3 weeks), participants receivedpsychoeducation about PTSD, learned coping skills, and wereprovided the opportunity to become more familiar with one an-other through assigned telephone calls and brief presentationsabout premilitary experiences. The treatment protocol calls forveterans who previously completed a course of GBET to orientnew participants to the group about what they might expect.Two veterans who recently completed individual PE were usedbecause no previous group had been conducted.

In Phase II (Exposure Phase: 7 weeks), each group mem-ber gave two trauma presentations (i.e., imaginal expo-sures). The first trauma presentation detailed the patient’s warexperiences from arrival in the combat zone until leaving(60 minutes, compared to up to 2.5 hours in the original proto-col). The second presentation (45–60 minutes, compared to 60minutes in the original protocol) focused on the participant’smost traumatic war-related event. Anxiety-level ratings weremade at 10-minute intervals throughout the exposure. Follow-ing the trauma presentation, a meal or snack was provided byone of the group members. The 12-week protocol also deviatesfrom the 16-week version in that it requires patients to giveone less in-session presentation during Phase II (veterans in the16-week model give a presentation on their life in the militarybefore their combat trauma).

Participants were instructed to listen to audio recordings ofeach of their own trauma presentations 15–20 times betweensessions (compared to 10 times in the original protocol) and tokeep a record of the date and time that they listened to it (partic-ipants did not review the audio recordings of group members’

1 The GBET treatment manual is available upon request from the fifth author

(DJR).



presentations.) In addition to in-session imaginal exposures,participants gave a brief (30-minute) homecoming presentationdetailing their experiences returning stateside after deploymentfollowing their initial trauma presentation. Group members alsoconstructed a hierarchy of safe, but anxiety-evoking situationsthey avoided (e.g., restaurants, movie theaters, etc.) and wereinstructed to gradually approach these situations during in vivoexposure exercises between sessions. Veterans practiced in vivoexposures throughout Phase II and Phase III of treatment.

Phase III (Closing the Wound: 2 weeks) included a guidedimagery exercise that led participants through the visualiza-tion of a fallen comrade’s funeral service and encouraged theprocessing of unresolved grief and guilt. In this ceremony, par-ticipants were asked to close their eyes as a VA chaplain readaloud a script that described a fallen comrade being laid to rest.Phase III also addressed trauma-related nightmares through anightmare rescripting exercise during which participants wroteout a trauma-related nightmare and revised upsetting aspects ofthe nightmare, and then rehearsed this new script each night.This exercise uses techniques similar to those in imagery re-hearsal therapy (Krakow, Kellner, Pathak, & Lambert, 1995),which has shown success in reducing nightmares in combat vet-erans (Long et al., 2011). During the final week of treatment,veterans participated in a healing ceremony during which theyread aloud healing letters addressed to themselves.

Treatment was administered by a postdoctoral fellow andpsychology intern under the supervision of a licensed clinicalpsychologist who had substantial experience in exposure-basedtreatments for PTSD and is a certified PE provider. The treatingclinicians also participated in weekly consultation calls withone of the developers of the GBET program (DJR).

Posttreatment and Follow-up Assessments. Participantsattended a posttreatment assessment with one of the treatingclinicians 2 weeks after the conclusion of treatment and afollow-up assessment 3 months later. Posttreatment and follow-

up assessments included the CAPS, PCL-S, and PTCI. TheCSQ-8 was administered at the follow-up assessment. Duringthe follow-up period, veterans were encouraged to continue touse the skills and strategies learned in the GBET group, but werenot given formal practice assignments; they also had the optionof attending a variety of treatment programs offered throughthe specialty clinic.

Data Analyses

We assessed our primary outcome, feasibility of implement-ing an abbreviated version of GBET, by examining retention,compliance, and treatment satisfaction. After calculating base-line clinical characteristics, we assessed our secondary out-come, effectiveness of the 12-week GBET model, by usingrepeated measures analyses of variance (ANOVA) to examinechange in mean scores on the CAPS, PCL-S, and PTCI acrossthe three assessment points: pre- and posttreatment, and at 3-month follow-up (see Table 1). In addition to evaluating thestatistical significance of changes in mean outcomes scores, wealso examined the number of participants who reported clini-cally significant change on measures of PTSD severity from pre-to posttreatment. To facilitate comparison between our resultsand those of the 16-week model, we applied the reliable changeindex (RCI; Jacobsen & Truax, 1991) calculated by Ready etal. (2012) for the PCL. Accordingly, we defined a change of7.82 points on the PCL-S as the minimum threshold for reliablechange and observed that all participants in the present studydemonstrated reliable change on the PCL-S. Clinically signif-icant improvement on the CAPS and PCL-S was defined as areduction of 10 or more points (Schnurr et al., 2007).

Results

The retention rate was 100%: All 10 participants enrolled inthe study completed the treatment, including posttreatment andfollow-up assessments. On average, participants attended 21.4

Table 1Repeated Measures Analyses of Variance on Outcome Measures

Assessment period

Pretreatment Posttreatment Follow-up

Measure M SD M SD M SD df F η2

CAPS 80.4 12.5 33.5 19.9 39.1 22.0 1.2, 11.0 48.53∗∗∗ .84PCL-S 63.4 9.2 32.5 11.3 33.0 12.6 1.1, 9.9 57.61∗∗∗ .87PTCI Total 154.8 34.6 98.3 28.0 102.4 34.5 2, 18 64.40∗∗∗ .88

PTCI Self 4.5 1.2 2.6 0.9 2.7 1.2 2, 18 13.39∗ .59PTCI World 6.2 0.7 4.8 1.3 5.1 1.4 2, 18 9.52∗ .51PTCI Self-Blame 3.3 1.7 1.8 1.0 1.8 1.1 1.1, 9.6 8.21∗ .48

Note. Follow-up was at 3 months. CAPS = Clinician Administered PTSD Scale; PCL-S = Posttraumatic Stress Disorder Checklist-Specific Stressor Version;PTCI = Posttraumatic Cognitions Inventory. When the assumption of sphericity was violated, degrees of freedom were corrected with the Greenhouse-Geisserestimate.∗p < .05. ∗∗∗p < .001.



(SD = 1.9) of 24 group sessions. All participants were in atten-dance for each of their scheduled in-session trauma presenta-tions, indicating that veterans did not skip sessions in an effortto avoid their trauma presentations. Veterans reported that theylistened to the recording of their initial trauma presentation anaverage of 21.5 (SD = 2.5) times and listened to their secondtrauma presentation an average of 6.6 (SD = 8.5) times. Allparticipants complied with the instruction to listen to their ini-tial presentation 15–20 times, although only three participantscomplied with the instruction to listen to their second traumapresentation 15–20 times. Patients indicated a high level oftreatment satisfaction (M = 29.5, SD = 2.37), as assessed withthe CSQ-8.

Participants reported experiencing an average of 7.6 (SD =1.5) distinct types of traumatic experiences, as assessed withthe Life Events Checklist. All participants endorsed combattrauma; the other most commonly reported trauma types werephysical assault (n = 8), transportation accident (n = 8), andassault with a weapon (n = 8). Analysis of baseline clinicalcharacteristics (a series of three independent-samples t tests)revealed that Iraq and Vietnam veterans were similar with re-spect to pretreatment scores on the CAPS (t = 1.63, p = .14),PCL (t = 1.05, p = .33), and PTCI (t = 0.60, p = .57).

There was a significant main effect of time for total scoreson the CAPS, PCL-S, and PTCI, such that participants demon-strated significant reductions from pre- to posttreatment on allmeasures. Differences between posttreatment and follow-upscores were nonsignficant (p > .05), indicating that partici-pants maintained their improvements at 3-months posttreat-ment. Similar results were observed for scores on each PTCIsubscale (Self, Self-Blame, World), with significant reductionsfrom pre- to posttreatment. All 10 participants demonstratedclinically significant improvement on the CAPS and 9 partici-pants on the PCL-S.

Discussion

The goal of this study was to examine the feasibility, accept-ability, and potential effectiveness of an abbreviated 12-weekGBET protocol. The retention rate (100%) in the present studyis consistent with previous findings (Ready et al., 2008, 2012).Factors associated with the structure and focus of the GBETprotocol may contribute to high retention. Like military train-ing, GBET stresses that the group serves as a unit that will startand complete the program together, and we hypothesize that thisuse of military culture increases participants’ willingness to en-gage in their own trauma memories and those of other groupmembers. Although not evaluated in this study, other unique as-pects of GBET that we believe facilitate group cohesion includethe expectations that group members call one another outsideof group time, take turns providing a meal for the group, andgive other group members individual feedback on their traumapresentations. These components are designed to encouragegroup members to connect and build trust, and may increasecommitment to treatment via commitment to one another. The

observed retention and attendance rates, combined with vet-erans’ scores on a self-report treatment satisfaction measure,support the acceptability of GBET.

Preliminary results show that the abbreviated GBET modelwas effective in reducing PTSD symptoms. Participants’ PTSDseverity significantly decreased over the course of treatment,and 7 of the 10 participants no longer met criteria for PTSDat posttreatment. GBET was also effective in reducing negativetrauma-related cognitions, as evidenced by significant reduc-tions on the PTCI. Overall, participants maintained their im-provements at 3-month follow-up. Veterans who participatedin the 12-week protocol demonstrated improvements that werecomparable to or greater than those in studies of the 16-weekprotocol. Although future study is needed to compare the bene-fits of a 12-week versus 16-week protocol directly, preliminaryresults from the current study indicate that veterans can expe-rience substantial symptom reduction with the 12-week model.This is important because the abbreviated model may be morepractical in busy clinical settings, as it requires less patient timeand fewer clinician hours.

In addition to shortening the overall length of the originalGBET protocol, the 12-week model departed from the 16-weekmodel in that it increased the amount of time patients spent re-viewing the audiotapes of their trauma presentations betweensessions. We observed that all participants were highly com-pliant with the assignment to listen to the audiotape of theirinitial trauma presentation 15–20 times; however, the major-ity of participants failed to comply with these same instruc-tions for the second trauma presentation. This is consistentwith Ready et al.’s (2012) report that tape review was the onlyaspect of the 16-week protocol where compliance issues wereevident. Several factors may have contributed to the observednoncompliance. Participants may have lost motivation due tothe repetitive nature of the assignment, may have more activelyavoided the second trauma presentation given its focus on theworst combat trauma, or may have habituated more quicklyto the second trauma presentation after experiencing symptomrelief from their initial trauma presentation. Future researchshould explore this issue, given that compliance with tape re-view directly impacts the dose of exposure received by GBETparticipants.

In this study we did not directly assess the potential mech-anisms of therapeutic change associated with GBET, but theseshould be considered in future research. One possible mech-anism of change is that incorporating feedback from groupmembers with similar experiences may enhance the benefits ofexposure therapy by facilitating change in trauma-related be-liefs (Shea, McDevitt-Murphy, Ready, & Schnurr, 2008). TheGBET protocol allows group members to offer supportive com-ments, new perspectives, and to ask questions immediately aftera veteran completes a trauma presentation. Additionally, audio-tapes of participants’ trauma presentations included this groupfeedback, and when participants reviewed these tapes, they alsorehearsed the supportive comments from group members. Wealso believe that modeling played a role in veterans’ treatment



success. Veterans who had completed an exposure-based treat-ment attested to its effectiveness, and those group members whovolunteered to be among the first to give the in-session traumapresentations modeled the tolerability of these exercises for therest of the group.

The structure of the initial trauma presentation may alsocontribute to GBETs success in reducing PTSD symptoms inveterans. In this presentation, veterans gave a narrative of thetraumatic events they experienced throughout their entire com-bat tour(s). This differs from other exposure-based protocols(e.g., PE) that instruct patients to select a single index traumafor imaginal exposures. The approach of GBET, which allowspatients to recount multiple combat related traumas, is partic-ularly amenable to combat veterans, who were often chroni-cally exposed to fear and threat throughout the duration of theirdeployment and rarely present with a single trauma. The in-creased dose of exposure (i.e., more assigned tape reviews) inthe 12-week model may have also contributed to the observedsymptom reductions.

Findings related to the potential effectiveness of a modified,12-week version of GBET should be interpreted with cautionbecause this was an open trial utilizing a small sample of vet-erans who were heterogeneous with respect to age and war era.Referring clinicians were aware of the rationale and proceduresfor GBET, and may have referred patients who were highly mo-tivated for treatment. In addition, unmasked assessments wereconducted by the treating clinicians, which may have biased vet-erans’ responses towards improvement. Although participantsin the present study had the option to attend other treatmentsthrough the VA PTSD specialty clinic (e.g., PTSD process andsupport groups) during the follow-up period and beyond, theymay have reported additional gains had they been formallyinstructed to continue using GBET techniques (e.g., tape re-view, in vivo exposure).

Our findings support the feasibility and effectiveness of anabbreviated, 12-week GBET protocol. In this study, two psy-chology trainees who were new to GBET successfully admin-istered the protocol, supporting the generalizability of the treat-ment. These findings related to the effectiveness of GBET areparticularly encouraging given that the study sample consistedof combat veterans who reported histories of multiple traumaevents; although we did not formally assess for mental healthdisorders other than PTSD, the presence of one or more psy-chiatric comorbidity was not an exclusionary criterion. Severalprevious treatment trials examining exposure-based treatmentsfor PTSD have excluded participants with multiple traumas,thereby creating a study sample that is unrepresentative oftreatment-seeking trauma survivors (Spinazzola, Blaustein, &van der Kolk, 2005). That a 12-week course of GBET was suc-cessful in reducing PTSD in the present sample suggests it maybe a viable treatment for veterans who present with complexhistories and diagnostic profiles. Further examination of GBET,including randomized controlled trials, is warranted by our pre-liminary findings which suggest that it is a promising treatmentfor veterans with PTSD.

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Documents

A pilot study of a 12-week model of group-based exposure therapy for veterans with PTSD