A STUDY IN GROUP THERAPY FOR VETERANS WITH

POST-TRAUMATIC STRESS DISORDER

by
Jack M. Freedman
**INTRO TO ABNORMAL PSYCH**NPSY 3501A**PROF. MARY CAROL MAZZA**

A STUDY IN GROUP THERAPY FOR VETERANS WITH POST-TRAUMATIC STRESS DISORDER

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5,
APA, 2013), changes have been made in the criteria for diagnosing Post-Traumatic Stress Disorder
(PTSD). Whereas PTSD was once classified as an anxiety disorder, the diagnosis is now part of a new
chapter known as Trauma- and Stressor-Related Disorders. It is also noted that the diagnostic criteria
emphasizes that the triggers of PTSD must be related to the direct exposure or connection to a
traumatic event (ie military combat). There are four distinct behaviors that can identify an onset of
PTSD. These include flashbacks, anguish, blackouts, and aggression surrounding the traumatic event.
Even though a person may not be in danger, they may experience emotions and physical feelings that
occurred during the traumatic incident. If at least one of these behaviors continue for a span exceeding
one month, one could be potentially diagnosed with PTSD. Arguments were made by members of the
American Psychiatric Association (APA) about the continued classification of PTSD as a disorder, due
to the perceived stigma in the military. The change implemented would have referred to the disorder as
a stress injury. However, PTSD maintains the status of a disorder, as psychologists believe the military
paradigm needs to change and not the psychiatric classification.
In a study by Hannah Fischer (Congressional Research Service, 2014), a total of 34,157 cases of
PTSD occurred over a span of 15 years (2000-2014). This was among military veterans who were
never deployed. As Operation New Dawn (OND), Operation Iraqi Freedom (OIF), and Operation
Enduring Freedom (OEF) progressed, the incidence of PTSD significantly rose year after year. It
wasn't until 2013 when the total number of cases decreased. This was most likely due to the end of
military intervention in Iraq. In total, there have been 118,829 documented cases of PTSD among
deployed veterans. These are high numbers. However, the number may be higher, as many veterans
would be adamant about not disclosing their symptoms or experiences.
In this study (Ellis et. al., International Journal of Group Psychotherapy, 2014), a cross-section

A STUDY IN GROUP THERAPY FOR VETERANS WITH POST-TRAUMATIC STRESS DISORDER

of 38 military veterans from across the country were placed in an inpatient facility. Included in this
study were group therapy sessions that lasted between 2-4 hours per day, implementing cognitive
processing therapy (CPT), as well as individual therapy sessions by unit staff. Also included were
programs for those battling co-morbidities of substance abuse disorders. Self-assessment and activities
encouraging group cohesion were essential aspects of the treatment. Ellis' study was conducted over a
28-day period.
The purpose of this study was to determine the benefits of group inpatient treatment of veterans
with PTSD. The participants were current members of the military who had served in OEF and OIF.
The study used both pre-treatment and post-treatment analysis through the use of specific selfassessments.
Upon intake, several self-assessments were used to measure the severity of the symptoms
presented by this population. These included the PTSD Check List- Military Version (PCL-M), the
Outcome Rating Scale (ORS), the Deployment Risk and Resilience Inventory (DRRI), and the
Personality Assessment Inventory (PAI). Upon discharge from the inpatient setting, the PCL-M, ORS,
and the California Psychotherapy Alliance Scale-Group Version (CALPAS-G) were administered.
Without the use of psychological intervention, these tests were completed solely by the veterans. The
purpose of these treatment tests was to evaluate symptom improvement at the completion of the
inpatient stay. These tests were designed to measure symptomatology, improvement, and effectiveness
of both individual and group therapy.
In terms of demographic data, the group consisted of 37 men and 1 woman, primarily members
of the Army. Other participants were in the Air Force and the Marine Corp. They were primarily
Caucasian, and 68.4% also had an alcohol related diagnosis, and 24.3% had a chemical dependency
diagnosis. The average age of the participants was 31 and the average length of service was

A STUDY IN GROUP THERAPY FOR VETERANS WITH POST-TRAUMATIC STRESS DISORDER

approximately 20 months. Other demographic information included family structure and ethnicity.
The results of the study showed that there was a dramatic change. Baseline studies were
significantly exceeded by the time that treatment ended. Scores ranged from good to excellent on all of
these assessments. The strongest correlations were made between pre-scores and post-scores related to
the symptomatology of PTSD and the outcome. These were the most significant augmentations in their
functioning. There were also improvements in the attachment issues of the subjects and the sense of
group cohesion among the subjects. Certain questions posed in the CALPAS-G showed strong
correlations, especially as they related to deepening understanding of their symptoms, disclosing their
feelings, and remaining secretive about their conditions.
In this individual study, Ellis and colleagues proved that group cohesion is essential in helping
military veterans overcome their symptoms. Support was a key component to this study, as many who
suffer from PTSD feel alone. In an inpatient setting, the veterans were able to relate to each other. In
this context, the use of CPT in an inpatient group setting is a predictor of how future treatments may
conclude. One of the most telling aspect of this study was the freedom that these veterans felt while
discussing their experiences with other members of the cross-section. There was comfort present in the
group setting, as they may not have shared their deepest emotions in another setting. Had this study
only focused on working with a veteran on an individual basis, it may have hindered its success as well
as hindered the recovery of the subject.
In addition to cognitive based therapy, medication can also be recommended. Selective
serotonin reuptake inhibitors (SSRIs) have been found valuable in treating the depressive aspects of
PTSD. Examples of SSRIs include Paxil, Zoloft, and Prozac. Effexor, which is a serotonin
noreprinephrine reuptake inhibitor (SNRI), can also be used as a first line medication for PTSD. It is
essential for the psychiatrist to consider the possible side-effects of the medication prescribed.

A STUDY IN GROUP THERAPY FOR VETERANS WITH POST-TRAUMATIC STRESS DISORDER

Comorbidities, such as bipolar disorder (BPD) may affect treatment decisions, as SSRIs can increase
the risk of a manic episode. Other medications may be considered if a patient has a comorbitiy of a
substance abuse disorder.
Some patients may refuse pharmacological treatment and instead choose complimentary and
alternative medicine (CAM). Examples of CAM approaches include acupuncture, body manipulation,
herbs, yoga, and Reiki. Although there is no significant evidence of the efficacy of these techniques,
there is also little information about potential harm or side effects.
Preventing PTSD is a significant goal of military psychiatrists. Combat stress control teams
assist soldiers by counseling them as soon as possible after combat missions. In addition, the military
has made great strides in improving living conditions for soldiers. Air conditioning, regular mail
delivery, and good food are obvious improvements over the experience of soldiers during the Korean
and Vietnam Wars. As we often see on television, soldiers can now communicate with their families
via the Internet (ie Skype), and this has proven to be a strong and effective morale builder, both for
the soldiers and their families.
Whether this study would apply to another cross-section of individuals afflicted with PTSD
remains unclear. In order to improve the study, subjects would need to come back for a series followups to determine whether the study was truly effective on a long term basis. While this study was
effective in the moment of treatment, further steps would need to be taken in order to measure the
symptomatology and correlations between the inpatient setting and living in the community. There are
other factors to take into consideration. Demographic data regarding location and environment would
be an important factor. One question that needs to be posed is whether the present location of a veteran
would be conducive to symptomatology or whether the location would be detrimental to the psyche of
the veteran. Would urban environments present a more stressful condition for a veteran rather than a

A STUDY IN GROUP THERAPY FOR VETERANS WITH POST-TRAUMATIC STRESS DISORDER

rural setting or vice versa?

Historically, women are more likely to admit to having symptoms of PTSD. This is to be
expected. since more women, in general, seek treatment for psychological issues. Another critique of
this study is that there was a disparity among gender diversity. Since there was only one woman
involved in the study, there was not enough empirical data to test the differences between the way
people of different genders experience PTSD.
Religion might have also played a factor in demographic data. Many people turn to a higher
power when they are under insurmountable levels of stress. It would have been interesting to test the
correlations between religious affiliation and PTSD recovery. It would also be interesting to test how
the coping skills of people of those believing in a higher power compared to those with no religious or
spiritual identity or affiliation.
In conclusion, the results of this study by Ellis and colleagues are promising. However, there
are additional avenues of treatment to explore. Little mention is made of the individual therapy
approaches used. There is also no mention of family involvement. It is imperative that spouses,
parents, siblings, and children play a role in the treatment process. Educating them about PTSD in
general and the specific problems faced by the patients is paramount. With the additional attention this
diagnosis is receiving in the psychiatric community, the government, and the media, there is hope that
this disorder can be effectively treated and prevented.

-----

A STUDY IN GROUP THERAPY FOR VETERANS WITH POST-TRAUMATIC STRESS DISORDER

WORKS CITED
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.) Washington, D.C.:Author.
Butcher, James N., Hooley, Jill M., & Mineka, Susan. (2014). Abnormal Psychology
Boston:Pearson. 154-155.
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. (2014).
PTSD Treatment Options.
Ellis, Carilyn C., Peterson, Mary, Bufford, Rodger & Benson, Jon. (2014) The Importance
of Group Cohesion in Inpatient Treatment of Combat-Related PTSD.
International Journal of Group Psychotherapy, 64 (2), 209-226.
Fischer, Hannah. (2014). A Guide to U.S. Military Casualty Statistics: Operation New Dawn,
Operation Iraqi Freedom and Operation Enduring Freedom. Congressional
Research Service, 1-2.
National Institute of Health. (2009). PTSD: A Growing Epidemic. Medline Plus,
Winter 2009, 4 (1) 10-14.