Randomized Trial of Trauma-Focused Group Therapy for Posttraumatic Stress Disorder: Results From a Department of Veterans Affairs Cooperative Study
Schnurr PP, Friedmann MJ, Foy DW, Shea T, Hsieh FY, Lavori PW, Glynn SM, et al.;
Commented by , 27 May 2003
Aim of the study
To determine the effectiveness of a method of exposure–based group therapy for treating posttraumatic stress disorder (PTSD) in male Vietnam veterans.
Method
360 male Vietnam veterans with combat-related PTSD were enrolled in a cooperative study, involving 10 centers, sponsored by the Department of Veterans Affairs (VA).
The diagnosis of PTSD as well as comorbid diagnoses were assessed using the Structured Clinical Interview for DSM-IV (SCID). The primary outcome measure was the Clinician-Administered PTSD Scale (CAPS). Additional outcome measures included a brief version of the General Health Questionnaire, an Addiction Severity Index, components from the 36-item Short-Form Health Survey, and the Quality of Life Inventory.
The exposure-based therapy provided in the study– Trauma-Focused Group Therapy – (TFGT) included exposure in a group context, together with other components of cognitive-behaviour therapy (CBT) such as psychoeducation, cognitive restructuring, and coping skills training.
TFGT was compared with a non-specific group therapy - Present-Centered Group Treatment (PCGT), which does not include any of the specific TFGT components. In particular, PCGT avoids exposure to trauma. Patients were randomly assigned to receive either TFGT or PCGT.
Results
In both the TFGT and the PCGT groups, there were modest, but still significant reductions from pre-treatment on the CAPS, PTSD Checklist, and General Health Questionnaire. However, intention-to-treat analyses found no significant differences between the two treatment groups on any outcome measure.
The authors reanalysed their data comparing TFGT and PCGT in two subsamples of patients who had participated in at least 24 active therapy sessions, i.e. in patients who had received what the authors consider “sufficient amounts of therapy”. There was a significant treatment effect, favoring TFGT, for avoidance and numbing, between the two subsamples.
Discussion
As stated by the authors themselves, “the short answer to the question of whether the VA should promote systemwide use of FTGT for Vietnam veterans seems to be no”. As such, the results of this study are disappointing, all the more since considerable time and effort went into the trial.
There are, however, several important questions that need to be discussed. First of all, there may be a problem in using trauma-focused therapy in group settings. Up to now, there is next to no evidence on the effectiveness of a group format for treating PTSD, whereas there is considerable evidence on the effectiveness of individual exposure therapy for the disorder. Secondly, each participant in the trial had only two sessions of therapy devoted to his own trauma. This is much less than is being currently proposed in individual exposure therapy for PTSD.
Thirdly, the therapists in the trial were not required to have formal training in exposure techniques or cognitive-behaviour therapy. This is contrary to what is usually being proposed by experts in exposure therapy for PTSD, who require that therapists have comprehensive training and experience before treating PTSD patients.