Present-Centered Group Therapy for PTSD

Embracing Today

Melissa S. Wattenberg, Daniel Lee Gross, Barbara L. Niles, William S. Unger, M. Tracie Shea

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000398335
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychothérapie

Present-Centered Group Therapy for PTSD integrates theory, research, and practical perspectives on the manifestations of trauma, to provide an accessible, evidence-informed group treatment that validates survivors' experiences while restoring present-day focus.

An alternative to exposure-based therapies, present-centered group therapy provides practitioners with a highly implementable modality through which survivors of trauma can begin to reclaim and invest in their ongoing lives. Chapters describe the treatment's background, utility, relevant research, implementation, applications, and implications. Special attention is given to the intersection of group treatment and PTSD symptoms, including the advantages and challenges of group treatment for traumatized populations, and the importance of member-driven processes and solutions in trauma recovery.

Compatible with a broad range of theoretical orientations, this book offers clinicians, supervisors, mentors, and students a way to expand their clinical repertoire for effectively and flexibly addressing the impact of psychological trauma.

Part I

Origins, Evidence, and the Guide & Manual

1 Present-Centered Group Therapy: Origins, Theoretical Influences, and Overview of Components

M. Tracie Shea

Present-centered group therapy (PCGT) was originally developed to control for the “nonspecific” effects of group psychotherapy in order to test the specific benefits of trauma-focused group therapy (TFGT) for the treatment of PTSD in Vietnam veterans (VA Cooperative Studies Program 420 – CSP-420; Schnurr, Friedman, Lavori, & Hsieh, 2001; Schnurr et al., 2003). Subsequently, several additional studies have used PCGT for the same purpose in trials of other treatments. Although developed as a nonspecific therapy control, PCGT has performed better than expected in most of the trials that have used it (reviewed in chapter two). Of note, an individual format of present-centered therapy (PCT) was developed for the same purpose and has similarly shown better than expected results (Belsher et al., 2019; Schnurr et al., 2007). This chapter describes the origins of PCGT, including the context, purpose, and considerations influencing its development, theoretical influences, and key components.

CSP-420 was motivated by the large number of Vietnam veterans with chronic PTSD receiving care from the VA healthcare system, and the absence of clear guidelines for the treatment of these veterans. Cognitive behavioral approaches, including those using exposure, had the most empirical evidence for PTSD treatment in civilians, and to a lesser extent in veterans. While effective, exposure therapy was challenging and sometimes difficult to tolerate. Given concerns about the feasibility of using exposure in this population of veterans with chronic combat-related PTSD, the CSP-420 chose to use a group rather than individual format for delivering exposure therapy (TFGT; Foy, Glynn, Ruzek, Riney, & Gusman, 1997). This was based on the idea that the development of support and cohesion in the group setting would enhance tolerability and increase compliance with exposure (Schnurr et al., 2003).

Much has been written about the challenges of defining control conditions for psychotherapy. The randomized clinical trial (RCT) design, historically used for pharmacotherapy research, has provided many methodological benefits that have enhanced the rigor of psychotherapeutic treatment research. A limitation of the RCT for these studies, however, is that unlike drug studies that can use an inert pill as a control, there is no clear placebo for psychosocial treatment studies – a condition that would need to be both inert and credible (Parloff, 1986). As noted, the approach taken by the CSP-420 was to use a nonspecific comparison design; more specifically, using a comparison group that included features that are present in most forms of psychotherapy but excluded the hypothesized “active ingredients” of the treatment being tested (Borkovec, 1993; Schnurr, 2007; Schnurr et al., 2001). For CSP-420, this meant excluding exposure and other formal cognitive behavioral interventions from PCGT. The task was to develop a condition that would clarify and operationalize the “nonspecific” factors present in most forms of psychotherapy, provide good clinical care, and be credible to both therapists and veterans with PTSD, while excluding elements of cognitive behavioral therapy or other theoretically based interventions.

Non-Specific/Common Factors

Non-specific factors have also been referred to as common factors, and there is debate about the use of the term non-specific. It has been argued that nonspecific has additional meanings, and at times has been used to describe aspects of psychotherapy that are either unspecified or unspecifiable and thus not observable, and that the use of the term should be dropped (e.g., Castonguay, 1993). From this perspective, the term common factors more accurately describes the approach taken in developing PCGT.

Saul Rosenzweig (1936) first introduced the idea that factors common to different forms of psychotherapy may play an important role in outcome; an idea that was further developed by Jerome Frank. Frank (1971, 1986) proposed that all forms of psychotherapy introduce new concepts and information that help the individual in treatment to make connections between symptoms and experiences, and to change the meaning of the symptoms and problems in a way that increases their sense of hope, self-efficacy, and ability to tolerate their symptoms. “All forms of psychotherapy … include, first, an emotionally charged, confiding relationship with a helping person; second, a setting identified in the patient’s eyes as a place of healing; third, a therapeutic rationale that explains the causes of the patient’s symptoms, and fourth, prescribes a procedure for relieving them that requires active participation by both the patient and the therapist” (Frank, 1986, p. 342).

Over time, different conceptualizations of common factors have evolved; the most consistent factors include the therapeutic alliance (which involves both a confiding relationship, and active collaboration by the therapist and client), provision of a psychotherapeutic rationale, the experience of talking about problems in a safe environment, the acquisition and practice of new behaviors, creation of positive expectations and hope for improvement, and beneficial therapist qualities and interventions (Grencavage & Norcross, 1990). Beneficial therapist interventions that are common to most forms of psychotherapy include, for example, conveying interest through verbal and non-verbal reactions, providing appropriate praise, encouragement, and reassurance, and providing statements that help the client feel understood and validated.

Most of the literature on common factors has focused on individual therapy, but they play an important role in group therapy as well. Yalom’s classic book on group psychotherapy (Yalom, 1995) includes a description of therapeutic factors provided by groups (see chapter six for additional discussion of such therapeutic factors), and we drew upon aspects of this work in the development of the manual. One factor, instillation of hope, is described: “The instillation and maintenance of hope is crucial in any psychotherapy” (p. 4). Noting that faith in a treatment approach can itself be effective, Yalom discusses specific efforts to enhance belief and confidence in the efficacy of the group. This includes reinforcing positive expectations, removing negative preconceptions, providing a persuasive explanation of the beneficial effects of the group, and calling attention to the improvement that group members have made.

A second factor, universality, refers to the relief associated with discovering that others have similar experiences, helping the individual to feel less isolated and alone. This can be particularly relevant for those with PTSD, so often characterized by isolation and absence of social support. In addition to learning about PTSD symptoms (discussed next), hearing others in a group talk about similar experiences can help alleviate this sense of isolation.

Yalom (1995) also discusses the significance of psychoeducation as a therapeutic factor. Providing information about the symptoms and common associated features is an important source of validation of one’s experience, facilitates universality, and can help establish connections among members early on in the group. Yalom proposes that didactic information can also have a direct therapeutic effect – with increasing understanding of painful experiences comes reduced uncertainty and confusion and increased sense of control. This point regarding the significance of psycho-education is similar to Frank’s point that the introduction of new concepts and information that helps individuals connect their experiences with their symptoms and change the meaning of their problems can increase hope and self-efficacy.

An important difference for group therapy in the consideration of common factors is that rather than a single bond between a client and therapist, well-functioning groups involve the creation of bonds among group members (reflected in the term group cohesion). As noted by Yalom (1995) “… group cohesion is the analogue of relationship in individual therapy” (p. 47). Hearing about other group members’ experiences (universality) likely enhances the power of other common factors such as normalization and validation. Given the strong sense of isolation from society and people that is often present among those with PTSD, the creation of bonds within the group, as well as the experience of normalization and validation of their experiences, may be particularly therapeutic. Successful development of group cohesion, like the therapeutic alliance in individual therapy, creates the conditions that allow other therapeutic elements to occur. As noted, the strong sense of support that evolves in a group setting is what motivated the use of the group format for TFGT in the CSP-420 – with the idea that the bonds and support that develop might make the experience of exposure more tolerable. For the study to be able to draw conclusions about the effects of exposure, these common aspects of group therapy were critical to the development of PCGT as the active control.

Components and Session Content of PCGT

The broad objective of PCGT as developed for CSP-420 was to help veterans with PTSD to better understand and cope with current life problems and difficulties. The use of the term present-centered was intended to contrast with the focus on past (trauma) in TFGT, and is distinct from current mindfulness approaches that encourage being present and aware in the moment. As described in the original PCGT manual overview, “The central elements of the PCGT condition include: 1) psycho-education about the typical symptoms and features associated with PTSD in Vietnam veterans, particularly those affecting interpersonal relationships; and 2) the use of a group format to decrease isolation, normalize symptoms, provide the experience of giving and receiving support and feedback, and offer opportunities for positive interpersonal interactions.” These two components are particularly relevant to prominent themes that characterize PTSD – feeling overwhelmed and helpless, and feeling disconnected and isolated. Psycho-education directed at increased understanding of how overwhelming and confusing personal experiences may be connected to PTSD symptoms may reduce the sense of helplessness and increase a sense of efficacy, and the experience of positive interpersonal interactions in the group may decrease feelings of disconnection and isolation.

Early sessions of PCGT were designed to develop feelings of comfort, trust, and group cohesion. Session one includes presenting a rationale for PCGT, describing the structure and process of the group, presenting group rules and expectations of group members, discussing potential benefits and gains from the group, and encouraging positive expectations. In addition to providing the necessary information about the group, session one’s content encourages the mobilization of hope and motivation. The rationale provided in session one includes acknowledgement of the strong pull towards the past, specifically group members’ Vietnam experiences, at the expense of their current lives. By focusing on the present, the group is intended to help them shift the pull from the past to the present, for example, by investing in more meaningful relationships with the people in their lives, and engaging in meaningful activities. PCGT is also described as an opportunity to develop a clearer understanding of how their symptoms may be related to some of their problems, and to learn to identify, talk about, and deal with their problem areas. The importance of participation and support of each other to the benefits of the group, and the development of a feeling of support and trust among the members, are explicitly discussed in order to promote the process of group cohesion.

Two sessions are devoted to psycho-education about PTSD symptoms, associated disorders, and common problems areas. In addition to increasing understanding of their experiences and how their difficulties may be related to PTSD, these interactive discussions help to normalize their experiences, to provide a common framework for the group, and to increase the sense of connection and trust among group members by highlighting the experiences they have in common. It also helps to identify problems areas that they can work on in the group.

The fourth session focuses on helping group members to id...