Program for Veterans With Posttraumatic Stress Disorder:
The overall topic of Bolten et al.’s research in Evaluating a Cognitive-Behavioral Group Treatment Program for Veterans With Posttraumatic Stress Disorder is to examine the effect of group therapy in treating military veterans suffering from Posttraumatic Stress Disorder (PTSD). This topic is very pertinent to social work practice and policy because PTSD continues to be an issue that social workers and the population at large encounters due not only to past wars such as Vietnam, but also the current military activities overseas. A study such as Bolten et al.’s can assist in giving direction for social workers in recommending and providing treatment for veterans suffering from PTSD.
The primary research question of this study is to evaluate the effectiveness of cognitive-behavioral group therapy for veterans with PTSD. Additionally, the researchers sought to determine whether the results of their study would match those of previous studies. The research conducted was both comparative in respect to the previous studies and evaluative in its attempt to provide new data regarding the specific type of therapy provided to veterans with PTSD.
In the hypothesis for the study, the researchers “predicted that veterans would report improvements on measures assessing specific subsets of symptoms targeted by specific groups (i.e., reductions in aggressive behaviors after completion of the anger management group,” but that self-reports by the veterans would find “little change in the core symptoms of PTSD” (Bolten et al., 2004, p. 141). In other words, the researchers may observe significant positive change in the subjects even though the subjects themselves may not realize or report positive change.
The literature review focused on two particular studies concerning subjects with PTSD. The first, conducted by Foy et al. in 2000, included a review of studies of subjects with PTSD from a variety of sources such as female sexual assault survivors, multiple trauma survivors, male combat veterans who participated in group treatment (Bolten et al., 2004, p. 141). Foy et al.’s study “reported positive treatment options . . . in 13 out of 14 published (although largely uncontrolled) studies,” but pointed out the need to determine what kind of treatment, such as supportive, cognitive behavioral, or psychodynamic was most effective (Bolten et al., 2004, p. 141). The second study mentioned, by Repasky, Uddo, Franklin, and Thompson in 2001 was more specific in nature. Its subjects were veterans with PTSD who participated in a limited time cognitive-behavioral program. In this study, “veterans reported improvement on subjective measures with no corresponding change on self-reported symptom measures” (Bolten et al., 2004, p. 141). However, the researchers observed that in the group situation, the veterans found very positive support and feedback from each other, and that staff productivity at the location improved as well (Bolten et al., 2004, p. 141).
The literature review appears to be appropriate because this study was done in 2004, only three years after the beginning of the conflicts in Iraq and Afghanistan; therefore, not many studies, if any, were available concerning combat veterans of the current conflict. The current conflict likely highlighted the need for further research dealing with PTSD because of an increase in veterans suffering from the disorder, especially in “a climate of reduced mental health resources” (Bolten et al., 2004, p. 140). The previous studies and their results are thoroughly and succinctly described. The literature review supports the hypothesis of Bolten et al., and offers some direction and explanation for the results obtained in previous research. It is unclear exactly how much research for group treatment therapy options for veterans with PTSD was generally available at the time of Bolten et al.’s research, which would have been interesting to know.
The sampling technique used was probability based, including “male veterans who consented to be assessed while participating in one or more of three successive treatment groups at . . . the Behavioral Sciences Division of the National Center for Posttraumatic Stress Disorder (NCPTSD) and the Outpatient Clinic of the Boston Veterans Affairs Medical Center (OPC)” (Bolten et al., 2004, p. 141). In order to recruit for this study, the researchers selected subjects from the previously mentioned places whose primary psychological concern was PTSD and did not include those who had more “pressing concerns [that] were non-PTSD related, such as schizophrenia or drug and alcohol abuse (Bolten et al., 2004, p. 142). The limitations of NCPTSD and OPC as places of recruitment as well not including veterans who suffered from more prominent comorbid psychological conditions provided the sampling frame. The primary assessment of the subjects included whether or not group therapy was appropriate for individual participants. As mentioned above, veterans consented to be assessed, but the researchers mention that “the VA Boston Internal Review Board waived the requirement of informed consent for this study” because the results of the study “are archived data collected originally for clinical purposes” and “all data were stripped of identifying information to protect patient confidentiality” (Bolten et al., 2004, p. 142).
Because the veterans assessed by the researchers were “predominantly Vietnam era veterans, the majority were white, and all were male, there is some apparent bias in the study. Bolten et al. specifically state that “the generalizability of our results to women and nonveterans is limited by the fact that all of our study participants were male veterans” (2004, p. 145). Although diversity issues are not explicitly discussed beyond this, it is apparent that the sample is not racially diverse, the majority of the veterans participated in one particular war, and that most of the veterans were from either the Army or the Marines (Bolten et al., 2004, p. 142). Generalizability of the results in terms of the sample, despite attrition rates, appears to be appropriate because the results were consistent not only within the study, but also with the studies mentioned in the literature review. Reasons for attrition were not given by the researchers; the study included three 12-week groups including Understanding PTSD, Stress Management, and Anger Management. The Understanding PTSD group had 105 veterans complete the 12-week session, the Stress Management group had 62 veterans complete the 12-week session, and the Anger Management group had 30 veterans complete the 12-week session (Bolten et al., 2004, p. 144). It is not clear whether the 30 veterans who participated in the Anger Management group all also completed the previous two groups, whether there were some veterans who participated in Understanding PTSD and Anger Management but not Stress Management, and so forth. However, Bolten et al.’s Table 1 shows similar results for all groups regarding results, so the size of the sample, participation in just one or more than one group, and attrition rates do not appear to affect the outcome (2004, p. 144). The similarity of the results despite the differing sample sizes appears to support the researchers’ hypothesis.
The design of the research was straightforward and clearly described in the publication. First, the researchers screened and selected participants, who were given an initial assessment.
Bolten et al. Study Design
Next, the first 12-week session, Understanding PTSD, was conducted and followed by another assessment. The other two 12-week sessions, Stress Management and Anger Management, followed the first group-treatment session, each followed by another assessment. This straightforward design is a good choice because it involved treatment groups followed by individual assessment of the participants and an overall examination and assessment of group data. One problem with the design as reported by the researchers is that they “have little information on the clients who were referred to other modes of treatment, who chose not to participate in the groups, or who were not in attendance on the day the assessments were administered” (Bolten et al., 2004, p. 142). Another limitation reported by the researchers is that they “did not include control or comparison groups in our study” (Bolten et al., 2004, p. 144). The study best evaluates those veterans with PTSD who consented to and actually participated in the group sessions. It does not evaluate the reasons, problems, or other factors that caused some of the subjects to miss parts of the study such as group sessions or assessments. It does not compare the severity of PTSD of the subjects who actively participated and those who, for unknown reasons, chose to drop out or could not attend group sessions or assessments. Therefore, the study’s results reflect most accurately those of subjects who were willing to engage in active participation in group therapy, and does not address the issues of those who were either unwilling or unable to participate.
The independent variables (IVs) include the types of treatment offered, in this case, 12-week sessions of group therapy including Understanding PTSD, Stress Management, and Anger Management, as well as the assessments before and after the groups. The dependent variables (DVs) include several evaluation methods, including the Beck Depression Inventory, Life Satisfaction Inventory, General Health Scale, PTSD Checklist Total including made up of reexperiencing, avoidance, and hyperarousal, and a Violence Screen. Every assessment included the same DVs. The purpose of each of the measurements is discussed in depth on Bolten et al. pages 142-143, and appear to be reliable tests in regard to assessing PTSD symptoms. The DV variables operationalize the many symptoms of PTSD by providing an overview and rating typical life-areas affected by PTSD in the participants’ lives. While symptoms and severity may differ per person with PTSD, the DV tests provide a method of quantifying and examining pre- and post-treatment results for individuals as well as the group. The issue in this study is that not all the veterans who participated in the groups participated in the assessments and vice versa, although the results only include those who participated in both.
Ethical issues were not explicitly discussed in this article. However, the researchers write that 56% of the participants were “receiving some form of VA disability” (Bolten et al., 2004, p. 142). Citing other research, Bolten et al. write, “It has also been suggested that the absence or restriction in presorts of change in mental health by veterans may be due to symptom over-reporting on self-report measures in this population (Fairbank, Keane, & Malloy, 1983) or a hesitation to report improvement in symptoms because of compensation concerns” (2004, p. 144). In other words, the veterans receiving disability have concerns about what will happen if they improve enough that the VA determines they are no longer eligible for disability benefits such as medical care and payments. This is an ethical issue for the subjects and for future treatment providers because it is not only important to provide treatment for PTSD, but also to help adapt to possible lifestyle, financial, and medical conditions such as a reduction in VA benefits.
Descriptive statistics were provided in both a table and in narrative form. Details of the DV assessment results both before and after the 12-week group sessions were provided. The most interesting part found by examining the statistics and reading the correlating narrative is that although all the results were significant, the strongest results were reported in the group with the least participants, while the weakest results were reported in the group with the most participants. Whether this reflects on the sample size or the type of treatment being provided is not discussed by the researchers.
In general, Bolten et al.’s study showed that like other studies with PTSD patients, group therapy, cognitive-behavioral treatment specifically, is useful for the participants. Importantly, the researchers report that they found their “data indicate that interventions that target specific problematic behaviors are most effective” (Bolten et al., 2004, p. 145). The authors themselves provide some recommendations for future studies, including using “multiple methods of assessment based on self-report measures and clinician-administered interviews” and including a control group. Considering that Bolten et al.’s study was done in 2004, and in 2012 there is now a much higher population of veterans of the Iraqi and Afghanistan conflicts, it would be useful to include a sample including these veterans in any further research as well.
The overall summary was helpful in understanding results, limitations, comparisons with previous research, and ideas for further research.
Bolten et al.’s article provided interesting knowledge of methods, research design, and results in researching a population that is relatively difficult to study. The study was fairly specific, and does not hesitate to mention that it is not meant to be a comprehensive or exhaustive study of treatment methods for veterans with PTSD or even a study of cognitive-group therapy for veterans with PTSD. For social workers, ethical issues concerning dealing with lifestyle, financial, and medical benefit changes must be addressed as part of treatment. Further research on the subject or reading other research on the subject will be essential for other researchers that includes a more diverse population from the different armed forces branches, a better representative of race and ethnicity, inclusion of females, and a wider range of ages as the Iraqi and Afghanistan conflicts continue. Previous research also mentioned that group treatment made for a more efficient staff, and this should be explored as well because it will be valuable for social work organizations dealing with a large number of patients. Overall, the article presented many ideas and areas for further research and consideration by researchers and social workers alike.
Bolton, Elisa E., Lambert, Jennifer F., Wolf, Erika J., Raja Sheela, Varra Alethea A., & Fisher Lisa M. (2004). Evaluating a Cognitive-Behavioral Group Treatment Program for Veterans With Posttraumatic Stress Disorder. Psychological Services 1(2). 140-146. DOI: 10.1037/1541-1522.214.171.124