Group Interventions in PSTD Treatment
Group interventions in PSTD are preferred to individual treatments due to the benefits of group therapy. The group environment provides safety, cohesion and empathy. The individuals get an opportunity to form trusting relationships. There is no single treatment strategy of the condition due to the nature of its complexity. There are four main group interventions known as cognitive behavioural therapy, psychodynamic therapy, art therapy and psychological debriefing. Cognitive behaviour therapy which involves exposure and stress inoculation therapy has been proven to be quite effective. It is used to treat fear and cognitive distortions. It is a lengthy and intensive treatment.
There are also behavioural treatments such as psychodynamic therapy that yields results within a shorter time period. There are those clients who are not able to express their traumatic events in a coherent narrative manner. The introduction of art therapy has greatly helped these clients as they narrate their stories through visual imagery. There is also the debriefing treatment especially after the traumatic event where the individuals narrate the event when it is quite fresh in their minds. The individuals get to connect with others who have gone through the same experiences. In group set-ups, the individuals get to interact with each other and overcome the fear of social interaction. The system of support and affirmation that they receive from the group members and the therapists is crucial for their journey towards recovery.
As others share their experiences, clients have mirror reflections of the experiences and feelings that they have every day. It also aids them to know that they are not the only ones going through the terrible experience.
There are others who are going through treatment and yet others who have overcome and become contributing members in the society. Group therapy however is sensitive and the therapists have to be trained on how to handle the clients. There needs to be an environment of safety and security for the clients to openly share their fears and insecurities.
Post-traumatic stress disorder (PTSD) refers to an anxiety disorder that occurs when an individual is exposed to a terrifying event. It refers to events that occur that expose an individual to feelings of intense fear, horror and helplessness. The individuals will find themselves re-experiencing the traumatic events either through flashbacks, nightmares or intense memories of the event. Advanced or chronic PSTD is resistant to treatment as it has already caused a physiological imprint in the brain. Anti-depressants are administered for symptom reduction in clients with PSTD.
Cognitive Behaviour Therapy
There are several interventions in posttraumatic stress disorder. Cognitive behaviour therapy has been noted to be quite successful. It can also be conducted in a group set-up however there are certain things that have to be considered. First of all, it is important to achieve group cohesion and social support among the members. The individuals who would do well in a group are those who are isolated and cannot cope well emotionally.
The group setting causes them to come out of their shell and deal with their fears and anxieties. The individuals are able to get emotional support from people who have gone through the same experiences. The PSTD clients may suffer from intimate aggression or violence. At times they may experience diminished intimacy and relationship satisfaction (Monson,
Rodriguez & Warner, 2004). The inter-personal relationships in group therapy may greatly assist them overcome certain social barriers. In order to maximise on the group set-up there are certain strategies that can be applied. The pacing of the interventions may be slower in order to allow the individuals to understand and appreciate the various techniques.
During the group sessions, there may be exposure therapy which reduces the fear in the trauma clients. The client is exposed to anxiety-stimulating environment either in imagination or vivo during the group sessions. It aids the client to reduce the anxious reactions whenever they are exposed to threatening stimuli. It assists in counter-conditioning of the client. The exposure allows the client experience the anxiety building, reaching a peak and subsiding. It encourages emotional habitation and mastery of feelings. However, there are studies that have shown that there is a high drop-out level when exposure therapy is used among PSTD clients (Schnurr, et al, 2003). Relaxation is an important technique where the clients are taught to relax their muscles in order to reduce the physiological arousal levels.
There are therapists who are a bit reluctant to utilize exposure therapy either due to lack of training or they are afraid of asking the clients to conduct activities that would increase their anxiety. The group session can have two therapists who will manage the therapeutic environment (Beck, & Coffey, 2005). The clients are encouraged to tackle their anxieties by harnessing their own resources. It promotes the client to reflect on the meaning attached to a certain traumatic event.
The client is able to desire behavioural changes that will put him or her on the path to recovery. He or she therefore notes his or her improvement and is able to link it to his or her own efforts. The clients are encouraged to reward themselves when they have succeeded in any given exercise. There is systematic positive and negative re-enforcement. Positive behaviour is praised while negative behaviour is highlighted and advice given on the way forward.
The therapist is usually concerned with behaviour such as avoidance and reduced activity which is considered to be unhealthy as the individual is not facing his phobias or fears. Clients are asked to state the beliefs they have concerning themselves, the world around them and situations and events in their lives. The therapist and clients explore alternate beliefs and behaviours and there is encouragement to try out the alternate behaviours and note the effects that the alternative action has on their fears, insecurities and anxieties.
It is therefore an opportunity for the client to acquire or adopt new ways of perceiving and acting. The therapist helps the client identify maladaptive automatic thoughts where the client belittles himself and positive thoughts can be established. They are also trained in being assertive where they participate in exercises where they refuse unreasonable requests and state their rights in a mature manner. This intervention may be applied with or without psychopharmacological medication as it depends on the seriousness of the client’s condition. The duration of the sessions usually lasts between 10 to 20 sessions. The intervention has been assessed and found to be effective when it comes to the modification of dysfunctional beliefs in the clients. Studies have shown that the group treatment alleviates symptoms of PSTD after the traumatic events (Shooshtray, Panaghi & Moghadam, 2008).
Cognitive therapy has also been found to be effective in the treatment of PSTD in children and young adults (Kar, 2011). Despite the fact that the children have not yet fully developed the capabilities to self-reflect and co-operate well in treatment, with structured exercises with exposure therapy and relaxation, they have improved in their condition (Scheeringa, 2007).
Another alternate intervention strategy in group therapy is psychodynamic group therapy. It is an intervention strategy that occurs on an interpretive-supportive continuum. The client is made aware of repetitive conflicts that serve to sustain his or her problems. The supportive interventions aid the clients to tackle their problems where they may not be able to due to acute stress or traumatic events. These supportive activities are at times are described as ego-building functions especially for the clients with borderline personality disorders.
The therapist working together with the client set goals and work on accomplishing them. The intensity of the supportive strategies depends on the seriousness of the client’s condition. It is a process that utilizes certain strategies. The main difference between cognitive behaviour therapy and psychodynamic group therapy lies on the technical aspect of transference. Transference is a key technique in this intervention strategy. There is a technique where the clients takes the memory of past experience and projects it to the current situation however he or she seeks a new experience from what occurred previously. The therapist is trained not to get involved in counter-transference where the therapist has resistance to the issues being discussed (Foy, Unger & Wattenburg, 2004). There is interpretive or sight-enhancing approach where the therapist causes the client to understand why they behave in a certain manner (Leichsenring, Hiller, Weissburg & Leibing, 2006).
A client may not want to perform well in an exam as they are afraid of what would happen in the likelihood that they become successful. There is confrontation where the client has to be forced to address and identify his fears. It helps address avoidance and blockage. There are certain things that a person does to avoid talking about the topic such as coming late for therapy or changing the discussion topic which the therapist should be trained to identify.
The therapist questions the client to get a clarification on what the client is feeling. In the clients describing their feelings, they get clarification on what is actually troubling them.
There is a lot of encouragement for the client to speak up. The therapist also validates the client’s feelings in order to cause him or her to open up and not shy off. The therapist advices the client on what they should do and praises him or her for any action that he or she took that was correct. It is a process that is repetitive or cyclic as the client identifies his fears, confronts and is encouraged to take action.
The therapist helps the client go through the processes in a smooth fashion. The therapist learns to behave in a neutral manner and does not judge the client in order to create a rapport and environment where the client works with the therapist to be a better person. There are free style sessions where the client decides what he or she wants to talk about. The therapy session is more effective when the client is able to talk about all that is troubling them.
As the topics being discussed are highly sensitive, it may come to a time where the client exhibits a lot of resistance. The therapist deals with the resistant behaviour through the cyclic methods of clarification, confrontation and interpretation. The sessions last between 7 to 40 sessions.
A common group therapy intervention strategy is acute debriefing after a traumatic event. The process is aimed at reducing the risk of the traumatic stress or disorder effects increasing in the client (Wethington, et al, 2008). The debriefing process relies on three basic principles. The clients get an opportunity to ventilate or air out or share their experiences in the context of a supportive group framework.
There is the normalization of the responses and the clients are now educated on the psychological events that may occur after the disaster. Each client is invited to share his or her experience and describe where he or she was when the incident occurred and the subsequent events leading to him or her being in the room with the others. The client is guided by the facilitator to share about the experience in its cognitive, behavioural and affective context. The facilitator acknowledged the intensity of the event however he emphasizes on the commonness or the universality of the people’s reactions so that no one feels the odd one out.
On what the clients perceive as failure, the facilitator assures the clients that their feelings of helplessness are to be expected when a disaster strikes. This is done to address feelings of self-condemnation, self-judgement and worthlessness and overcome the negative feelings.
The debriefing may occur in an individual setting however it may occur in a group setting where it has been judged by certain scholars to offer technical and economic advantages and offers a maternal environment.
There are several advantages of group therapy. There is a higher possibility of reaching more clients and the costs are reduced. The workload is reduced for each therapist and the therapists are able to work together to increase their skills.
The effectiveness of the debriefing intervention has been widely scrutinized and the results are inconsistent. There are scholars who have found that debriefing is associated with lower levels of acute PSTD however in these same clients there were higher delayed reactions of PSTD. In other studies, the debriefing has been found to aggravate PSTD (Rose, Bisson, Churchill & Wessely, 2009).
In other studies, debriefing has worked to help the clients overcome their feelings of helplessness and guilt over being the ones who survived the ordeal while their loved ones died in the incident. There are also studies that have shown that there was no difference between the
people who had gone through debriefing and those who had not.
It has been suggested that the success of the debriefing depends on several individual factors thus the inconsistent results when it comes to the success of the exercise in clients. The individual may be dealing with factors such as different coping mechanisms and defensive styles and previous trauma in their life which was not addressed or treated. He or she could also have dissociative attributes. The aspects of loss and separation also increase the trauma in clients Immediacy has been found to increase the chances of success of the debriefing.
The earlier it is after the disaster, the higher the chances of a speedy recovery. The therapists love immediacy as they feel that there will be less time for disruptive and maladaptive cognitive and behavioural changes or patterns to take place which will slow down or block the success of the debriefing session.
Group Art therapy
Art therapy is increasingly being utilized in the group treatment of PSTD. It began in the 1970s and it was found to be quite effective. It involves the clients using writing, drawings, painting and even music to communicate about their experiences. It is used by the clients who find it hard to communicate using words alone. The clients get a way to master their feelings and recall and re-enact their experiences and share it with others.
Art therapy has been used frequently in the treatment of trauma associated with sexual abuse, domestic abuse, war, terrorism and medical trauma. In studies conducted on veteran clients, clients exposed to art therapy showed significant improvement compared to the others
who had been exposed to other group therapy interventions. The improvement was noted mostly in the clients with the severe PSTD.
Researchers have noted that art provides a pleasurable distraction for the clients and they are not forced to deal with the negative short-term effects of verbal introspective interventions. It enables the clients to process the difficult content in a pleasurable manner. In another study of war veterans who had PSTD, it was found that those who participated in drawing exercises had fewer and intense nightmares than those who participated in writing exercises (Collie, Backos, Malchiodi & Spiegel, 2006). There are several approaches that are utilized in art therapy. First of all, art helps the client reconsolidate their memories.
PSTD clients usually have difficulty remembering all the details of a traumatic event and narrating it to others in words alone. There is also progressive exposure to alarming memories. It helps tackle the threatening memories at a slower pace than verbal expression. As the client confronts the traumatic events through drawing, there is a lot of symbolism which can be modulated.
There is externalization strategy which occurs as the client draws the images, he becomes an external observer to the traumatic event and can distance himself from the traumatic event. It enables the client to give a coherent account of the traumatic event. There is reduction of arousal as art expression generally allows a lot of meditation and relaxation. In PSTD, there is emotional numbing and art expression helps the client address this issue.
Art expression awakens positive emotions and as the group members appreciate the artistic expression there is reward-driven motivation. The client feels more in control and Art therapy has been welcomed as a great alternative in treatment of PSTD in certain clients compared to the use of cognitive behaviour therapy, psychodynamic therapy and acute debriefing. The memories of the traumatic event most of the times occur involuntarily, outside the control of the individual.
There is therefore need to engage the traumatic event in order to release the client from PSTD. In clients who experience nightmares and flashbacks, drawing of the images is powerful since the memories are in visual medium (Collie, Backos, Malchiodi & Spiegel, 2006).
Group therapy interventions are effective for different kind of clients. It depends on different factors and further research may have to be carried out to assist the therapists to be effective as possible.
Beck, J., & Coffey, S. (2005). Group Cognitive Behavioural Treatment for PTSD:
Treatment of Motor Vehicle Accident Survivors. Cognitive and Behavioural Practice, 12, 267-277.
Collie, K., Backos, A., Malchiodi, C., & Spiegel, D. (2006). Art Therapy for Combat-
Related PTSD: Recommendations for Research and Practice .Journal of the American Art Therapy Association, 23(4): 157-164.
Foy, D., Unger, W., & Wattenburg, S. (2004). Group Interventions for Treatment
of Psychological Trauma. Module 4: An Overview of Evidence-Based
Group Approaches to Trauma with Adults. American Group Psychotherapy Association, 116-166.
Hinton, D., Safren, S., & Pollack, M. (2006).Cognitive-Behaviour Therapy for
Vietnamese Refugees with PTSD and Comorbid Panic Attacks. Cognitive and Behavioural Practice, 13: 271–281.
Kar, N. (2011). Cognitive behavioural therapy for the treatment of post-traumatic stress
disorder: a review. Neuropsychiatric Disease and Treatment,7, 167–181.
Leichsenring, F., Hiller, W., Weissburg, M., & Leibing, E. (2006). Cognitive-
Behavioural Therapy and Psychodynamic Psychotherapy: Techniques, Efficacy, and Indications. American Journal of Psychotherapy, 60(3), 233-259.
Monson, C., Rodriguez, B., & Warner, R. (2004). Cognitive-Behavioural Therapy for PTSD
in the Real World: Do Interpersonal Relationships Make a Real Difference? Journal Of Clinical Psychology, 61(6), 751–761.
Rose, S., Bisson, J., Churchill, R. & Wessely, S. (2009). Psychological debrieﬁng for
Preventing Post-traumatic Stress Disorder (PTSD). Cochrane Database System Review, 1, 1-46.
Scheeringa, M., et al (2007). Feasibility and Effectiveness of
Cognitive–Behavioural Therapy for Posttraumatic Stress Disorder in Preschool Children:
Two Case Reports. Journal of Traumatic Stress, 20(4):631–636.
Schnurr, P. et al (2003). Randomized Trial of Trauma-Focused Group
Therapy for Posttraumatic Stress Disorder. Arch General Psychiatry, 60, 481-489.
Shooshtray, M., Panaghi, L. & Moghadam, J. (2008). Outcome of Cognitive Behavioural
Therapy in Adolescents after Natural Disaster. Journal of Adolescent Health, 42, 466–472.
Wethington, H. et al. (2008). The Effectiveness of Interventions to Reduce Psychological
Harm from Traumatic Events Among Children and Adolescents. American Journal of Preventive Medicine, 35(3), 287-313.