Sharing Traumatic Experiences in Group-Based Exposure Therapy for PTSD
Back when I was a psychology intern at the Portland VA Medical Center, I did my first rotation on the PTSD team. As part of the rotation, I helped out with or observed group-based treatments for PTSD. One of the cardinal rules of PTSD groups at the VA was: don’t let anyone describe their trauma, as it can trigger the other veterans.
This seemed like sound advice. Even talking abstractly about trauma was intense for many veterans. There were moments when I could feel the collective anxiety of the room rise when a veteran came close to talking about the details of his trauma. Even in a Cognitive Processing Therapy group I attended, the actual trauma narrative was only talked about with a therapist outside the group. No one talked about the details of the trauma. Describing a core trauma in a structured way is a form of exposure therapy (i.e., imaginal exposure), and this is typically done very carefully with an individual therapist.
For these reasons, I was intrigued when I came across a newly published study about an ongoing program at the Atlanta VA Medical Center that breaks this cardinal rule.
Group-Based Exposure Therapy
Talking about trauma in this group is not done lightly. In this program, 10 veterans with combat-related PTSD met for 3 hours twice a week for 16 weeks. The first 3 weeks involved building cohesion among group members. Group members learned about PTSD, practiced coping skills, and were required to give two 30 minute presentations on their lives before combat. They were also required to make telephone calls to each other outside of group, and were even supplied ice breaker questions, in order to build closeness.
The next 10 weeks involved talking about combat experiences and trauma in group. This was the exposure component. Veterans were required to give two presentations:
1.) a longer presentation on their war experiences from entering the war zone until the end of their tour;
2.) an hour-long presentation on their one or two most traumatic experiences.
The group leaders recorded these presentations and asked the veterans to listen to their own presentations at least 10 times each outside of group. In keeping with rapport building, one veteran signed up to present while another signed up to bring lunch to all the veterans.
The last 3 weeks (called “close the wound phase”) involved a number of techniques and activities to help bring some closure to the group.
How Well Did the Veterans Tolerate Treatment?
Perhaps the most impressive finding: out of three cohorts of 10 veterans—no one dropped out! Attendance was nearly 100% for the war trauma presentations, and no one indicated they found the presentation harmful. Although it’s worth noting that participants were carefully screened and asked to make a strong commitment, this is still pretty impressive. In the Discussion section of the article, the authors note that of the 267 people who have participated in the program so far, only 11 (4%) have dropped out, and these dropouts were largely due to health and financial reasons.
At the end the treatment, 73% of participants exhibited significant reductions in PTSD symptoms, and 36% no longer met PTSD criteria (at least according to a brief self-report measure). Additionally, 44% showed decreases in depression. Gains were maintained at a 7-9 month follow-up. The number of times group members listened to the audio recordings of their trauma presentations outside of group was positively related to improvements. Because of this latter finding, the authors write that they’ve increased the number of times they ask participants to listen to their recordings.
What About In Vivo Exposure?
As I mentioned above, talking about a trauma experience is what’s known as imaginal exposure. A common complement to imaginal exposure in exposure-based therapies for PTSD (e.g, Prolonged Exposure therapy) is in vivo exposure. In vivo exposure involves engaging experiences that tend to trigger PTSD symptoms (e.g., crowds, war movies). In Vivo exposure is absent in this particular program. This in itself is not a problem, but there is some evidence that in vivo exposure improves outcomes for PTSD above and beyond imaginal exposure alone (DeVilly & Foa, 2001; SalcIoglu et al., 2007).
A Qualified Success
What’s most impressive about this study is that it shows how a group treatment that breaks the rule about openly talking about trauma can be not only effective, but can have incredible rates of attendance when carefully and sensitively structured. At 32 total sessions total—twice a week meetings for 4 months—and outside assignments (e.g., listening to the trauma recording, preparing presentation), Group-Based Exposure Therapy is quite a time-commitment. Whether the outcomes justify it compared to briefer group treatments for PTSD (e.g., Cognitive Processing Therapy for groups) is another question. Regardless of the answer, I think the design of this group is an extremely inspiring achievement.