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Group Delivered Exposure,
Cognitive, and Skills
Therapies in Female OEF/OIF
Veterans: Data and Details
Diane T. Castillo, Ph.D.
Treatment Core Chief
Center of Excellence for Research on Returning War Veterans
Associate Professor, Texas A&M, College of Medicine
AMSUS December 2, 2015
Award Number(s): W81XWH-08-2-0022
Funding Agency: DoD CDMRP
Disclosures
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The presenter has no financial relationships to disclose.
This continuing education activity is managed and
accredited by Professional Education Services Group in
cooperation with AMSUS.
Neither PESG,AMSUS, nor any accrediting organization
support or endorse any product or service mentioned in this
activity.
PESG and AMSUS staff has no financial interest to disclose.
Commercial support was not received for this activity.
Learning Objectives:
At the conclusion of this activity, the participant will be able to:
1.
2.
3.
Participants will be able to identify the outcome measures for PTSD
which show improvement with group therapy for female veterans.
Participants will be able to identify the three group components in
the 16-week manualized group treatment for PTSD in female
veterans.
Participants will be able to identify 3 characteristics of the sample
of OEF/OIF female veterans in the manualized group treatment.
Acknowledgements
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Department of Defense (DoD) Grant
#PT074309, Award Number W81XWH-08-2-0022
Biomedical Research Institute of New Mexico (BRINM)—non
profit agency
Study Staff: Christine Chee, Ph.D., Study Coordinator, Jenna
Keller, BS, & Erica Nason, MS, Assessment Technicians, Clifford
Qualls, Ph.D., Statistician
Mentors/Consultants: Terry Keane, Ph.D., Mark W. Miller, Ph.D.,
Kathleen Haaland, Ph.D.
Overview
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Background Literature
Evidence-based treatments for PTSD
o Exposure & Cognitive
o Challenges to Group Treatment
Study Methodology
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Assessment
Three treatment modules
Measures
Results
Research on Treatments for PTSD—
Individual Protocols
Cahill, et.al., (2009). In Effective Treatments for PTSD by (2nd Ed.)
Foa, Keane, Friedman, & Cohen
2008 Institute of Medicine
1.
2.
Largest Effect Sizes:
o Exposure Therapy
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Prolonged Exposure (PE)—Foa (other models: Keane)
Cognitive Therapy
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Cognitive Processing Therapy (CPT)—Resick
Research on Treatments for PTSD—
Individual Protocols
Others treatments with smaller effect sizes:
o SIT
o Assertiveness training
o Biofeedback/relaxation training
o EMDR
o Medications (SSRIs, prazosin)
From: Cahill, et.al., (2009). In Effective Treatments for PTSD by (2nd Ed.) Foa, Keane,
Friedman, & Cohen
Impact of Findings
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Cognitive and Exposure Therapies recommended as the
1st line of treatment for PTSD by:
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VA/DoD PTSD Treatment Guidelines
ISTSS
VACO mandated dissemination of CPT and PE trainings to
all PTSD providers VA nationally
Standard of Care
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Prolonged Exposure—PE
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10 sessions, 90-minutes
In-session imaginal exposure
o 8 of 10 sessions
o Imaginal exposure—30-60 minutes
In-vivo exposure between sessions
Cognitive Processing Therapy—CPT
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Original 10-12 sessions, 60 minutes
Cognitive restructuring tailored to PTSD
Without Trauma, CPT-C
Cognitive Restructuring Therapy
General education:
o Thoughts create emotions
o “Distorted” thoughts cause problematic emotions (e.g., “I’m a
failure”  depression)
o Aware/challenge/modify distorted thoughts to improve feelings
(e.g., “I’m not a failure at everything; I’ve had some successes” 
hope, positive)
o Most common distortion in PTSD:
o Life/death from trauma applied to present
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CPT Components
Focus is on PTSD Symptoms
Education about rationale
& PTSD
12 Sessions, 60 minutes,
homework
Individual or Group format
Teaching Cognitive Skills to
evaluate trauma related
beliefs
Emotional Processing
Identifying Stuck Points
Assimilation
(about the
past/trauma)
Undoing, (“if only, should have”) guilt or
blame about trauma
Overaccommodation
(about present
and future)
Conclusions, implications of trauma
(“never, always, no one”, all re: 5 themes)
Progression Through Worksheets
Analyze,
Information
gathering, feelings
Challenge
Change (CBW)
Impact
statement
Challenging
questions
Challenging Beliefs
Worksheet
ABC sheets
Problematic
patterns
Themes
Written
Account
5 Cognitive Distortions in a Trauma
Safety
Trust
Power/Control
Esteem
Intimacy
Prolonged Exposure (PE): Emotional
Processing Treatment
Theory:
• TraumaLife-threatening situation
• Intense emotions (terror/fear)
• Survival requires suppression of emotions, suppression continues after
trauma is over
• PTSD symptoms result when emotions of trauma not processed
Emotional Processing:
• Addresses fear structure underlying the traumatic memory
• Directly challenges avoidance of memory & other situations
• “Allows” for corrective information to modify erroneous cognitions
PE Components
Focus is on PTSD Symptoms
SUDs and Breathing
retraining
Education about rationale &
common reactions to
trauma
10-12 Sessions, 90 minutes,
homework
Prolonged (repeated)
imaginal exposure
Repeated in vivo exposure
To trauma memories
To avoided situations
Exposure Therapy
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Gets to the heart of the problem—Trauma—in order to heal
Repeated imaginal exposure to memory of trauma
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Allows emotions
Allows processing of emotions and habituation
In SAFE environment
Example: Scary Movie
In-vivo exposure (real life)
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Repeated exposure to external situations
Example: Boy on Beach
Imaginal Exposure
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Target index trauma (worst)
30-60 min in-session imaginal
Present tense, SUDS ratings every 5 min
Recall the memory with eyes closed
Repeat the narrative as many times as necessary in allotted time
Engage feelings that the memory elicits
Recount as many details as possible
Anxiety
Habituation to Trauma Memory
Sessions
In Vivo Exposure
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Teach SUDs (Subjective Units of Distress)
Identify anchor points—0, 50, 100
Develop hierarchical list of avoided situations
Rate each on 1-100 scale (SUDS)
Select 2-3 in 40-60 range
At least one practice daily
Rate pre/peak/post SUDS for each exposure
Stay minimum of 30 min or ½ peak
Research on Treatments for PTSD—Group
Protocols
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Sloan (2013) Meta-analysis of 16 CBT Group RCTs
o Efficacy across all treatments, but not effectiveness
o No difference when compared to active control
o Better than no treatment
Other Group Characteristics:
o Smaller Effect Sizes than ind literature
o More & longer sessions (typical 90-minute group)
o Poorer methodology
o None comparable to PE or CPT—Combo of treatment interventions
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For PE: Only Schnurr (2003) conducted in-session imaginal exposure
(TFGT), but only 2/member, 30+ sessons; no difference to PCGT
Problems with Group Treatment Protocols
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Baldwin, et al. (2005)—Statistical problems in group
Evidence Supported Treatments (EST)
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Clustering within each group
Violation of assumption of independence of observations
 ICC in group
Inflation of type I errors
12-68% of EST studies no longer significant
Need larger N, use group as unit of analysis, not
individual
Why Group Therapy?
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Group offers:
o Currative Factors—Universality, Instillation of Hope,
Imparting Information, Catharsis, etc., (Yalom, 1975)
o For PTSD:
o Addresses Isolation
o Validation of traumatic experience
o Normalization of traumatic responses
o High satisfaction (Sloan, 2013)
o Other: efficiency & cost effectiveness
Challenges for Group Research
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Treatment comparable to ind standard of care (PE, CPT)
o Exposure—Dose of therapy: number of in-session exposures
(>2)
Need to address methodological issues unique to group
modality research (clustering, ICC)
Comparison of interventions—cog, exp, skills, etc.–to assess
contributions of each treatment component
Adequate control, active control (present centered therapy)
Group vs. Individual application of interventions
WSDTT Group Treatment Program
PsychEd
Cognitive
Skills
Sexual Intimacy
Exposure
*Castillo (2004). Systematic outpatient treatment of sexual trauma in women: Application of cognitive and
behavioral protocols. Cognitive and Behavioral Practice, 11, 352-365.
Clinic Findings
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Significant Improvement in Exposure, Cognitive, & Skills
Larger Effect Sizes for Exposure & Cognitive
Cumulative Improvement across treatments
See two papers:
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Exposure Group, 33 groups, N=77, Military Medicine, 2012
Cognitive Group, 47 groups, N=271, Behavioral Science, (2013)
DoD Aims & Hypotheses
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Aims:
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Add/extend Group Literature
Randomized Controlled Trial
Establish protocol for systematic exposure in group
o Beyond 2 in-session imaginal exposures
Comparison of treatment blocks
o Exposure, Cognitive, & Skills
Hypotheses:
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Group Tx > wait-list (PTSD—CAPS)—Efficacy
Exposure & Cognitive > Skills (PCL)
Study Design
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Participants = OEF/OIF female veterans with PTSD
Assessment:
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Descriptive: Demographics, SCID I/II, LEC, MSEQ
Outcome: CAPS, QOLI, SF-36—pre, post, 3-mo, & 6-mo. f/u
Additional: PCL (between tx blocks), Health Care Utilization
(+During active study treatment), Medication
Exclusion: Psychosis, BPAD, SI/HI, active substance
Randomized to:
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16-week Tx group (3 Tx Blocks, 3 Ss/group)
16-wait-list (minimal attention, ind support 2x/mo)
DOD Treatment Study
Arm 1: Treatment
(16 wks)
Post Tx Assessment
Initial Assessment &
Randomization
Arm 2: Waitlist (16
wks)
Post WL Assess—
refer to Tx
3-mo f/u
Assessment
6-mo f/u
Assessment
Treatment Blocks
Session 1 and 16—Orientation/Wrap Up
Exposure
Cognitive
Skills
5 sessions
5 sessions
4 sessions
Consort Diagram
97 screened
86 enrolled
44 Treatment
42 Wait List
32 completed
35 completed
14 Groups
14 Groups
Group Characteristics
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Randomization by 3
Three patients
Sessions = 90 min(16 wks)
Exposure Block—5 sessions
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Combo of PE (Foa) & Flooding (Keane)
Session 1: Rationale, SUDs, id worst trauma, breathing relaxation,
homework (write trauma)
Sessions 2-5: Repeated Imaginal Exposure
o Patients read aloud trauma
o Guided imaginal exposure (30 min/pt)
o Homework: Instructed to re-write same trauma, feedback on
what details to include
o After 3rd in-session exposure, patient reads completed
description daily at home for 2 weeks
Cognitive Block—5 sessions
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CPT model
Session 1: Didactics on cognitive restructuring, homework: 1 page
on beliefs 1st of 5 themes—safety
Session 2-5: Challenge irrational/distorted beliefs, homework—
writing 1 page on different theme each week
Each session writing/challenging beliefs on 5 themes: safety,
trust, power/control, esteem/intimacy in 4 sessions
Skills Block—4 sessions
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Session 1-2: Didactics
o Assertiveness training (passive, assertive, aggressive)
o Relaxation training—4 techniques, last ½ hr of group
Session 3-4: Practice
o Videotaped role-play: practice/review in session
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Passive, aggressive, assertive (fabricated situations)
Assertive only to personal situations,
Homework: observe self/other’s behaviors, practice
relaxation daily, & rate SUDs (1-100)
Demographics & Baseline
Characteristics
Demographics (N = 86)
Treatment Arm
n = 44
n (%)
Wait List Arm
n = 42
n (%)
36.7 (12.6)
35.1 (9.2)
Non-Hispanic White
12 (28.6)
15 (34.1)
Hispanic
18 (42.9)
19 (43.2)
Native American
7 (16.7)
8 (18.2)
14.5 (2.2)
14.9 (2.6)
Characteristics
Age, M years (SD)
Ethnicity
Education, M (SD)
Trauma Characteristics (N = 86)
Treatment Arm
n = 44 (%)
Wait List Arm
n = 42 (%)
> 8 trauma types (17 max)
31 (70.5)
29 (69.1)
> 25 trauma incid
28 (63.6)
29 (69.1)
> 1 mo comb env
34 (77.3)
34 (81.0)
> 1 milt sexual assault
21 (47.7)
19 (45.2)
> 1 X phys harass
26 (59.1)
28 (66.7)
> 1 X verb harass
39 (88.6)
38 (90.5)
Characteristics
Life Events Checklist
Military Stress Exposure Questionnaire
Diagnostic Characteristics (N = 86)
Treatment Arm
Characteristics
(n = 44)
SCID-I—Current co-morbid Axis I psychiatric disorder
Mood disorder
30 (68.2)
Anxiety disorder
Substance use/abuse
Wait List Arm
(n = 42)
23 (54.8)
29 (65.9)
23 (54.8)
2 (4.6)
1 (2.4)
SCID-II—Current co-morbid Axis II psychiatric disorder
Cluster A
24 (54.6)
18 (42.9)
Cluster B
10 (22.7)
7 (16.7)
Cluster C
8 (18.2)
8 (19.1)
Results
RM-ANOVA on CAPS
Tx Arm = 14 (27%); WL Arm = 14 (17%); *p < .001; ES = 1.72
PTSD Clinical Improvement (CAPS)
Response to
> 20-point
Treatment
Decrease
% (Mn)
% (Mn)
Post tx
77.4 (2.3)
3-month f/u
6-month f/u
Loss of Diagnosis
Total Remission
% (Mn)
% (Mn)
63.0 (1.9)
51.9 (1. 6)
13.52 (0.4)
67.7 (2.0)
54.3 (1.6)
43.8 (1.3)
18.19 (0.6)
73.1 (2.2)
54.6 (1.6)
46.3 (1.4)
12.62 (0.4)
Response to Treatment: > 10-point decrease on CAPS, Loss of Diagnosis: CAPS < 45; Total Remission: total current CAPS
< 20
SF36
Pre Tx
Post Tx
3-month
6-month
M (SD)
M (SD)
M (SD)
M (SD)
ES
Tx Arm
51.3 (14.2)
64.9 (18.0)***
59.7 (15.6)
62.6 (15.7)
1.08
WL
47.9 (16.2)
49.4 (15.0)
Tx Arm
34.3 (10.0)
54.7 (15.4)***
WL
31.5 (14.2)
38.3 (17.2)*
Physical
ns
Mental
48.6 (17.6)
48.9 (14.6)
1.31
0.56
*p < .05, **p < .01, ***p < .001
QOLI
Pre Tx
Post Tx
3-month
6-month
M (SD)
M (SD)
M (SD)
M (SD)
ES
Tx Arm
1.76 (0.56)
2.33 (0.52)***
2.05 (0.64)
2.33 (0.71)
1.01
WL
1.60 (0.60)
1.88 (0.82)*
0.63
*p < .05, ***p < .001
PCL for Treatment Blocks
Cognitive
Exposure
Skills
Pre
Post
M (SD)
M (SD)
ES
53.7 (9.2)
47.2 (8.9)*
0.90
52.2 (8.4)
44.8 (11.9) **
1.42
51.3 (9.8)
47.8 (9.0)
ns
*p
< .05, **p < .01
Conclusions
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RCT in young, educated, highly traumatized sample of female
OEF/OIF Veterans
Efficacy for a 16-week manualized group treatment protocol for
PTSD:
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Group-unit of analysis
Results sustained 6 months after treatment
Clinical improvement indicators comparable to ind PE (Schnurr, 2007)
Established group exposure therapy model, with safety & efficacy
{Exposure & Cognitive} > Skills
Future Research
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Castillo DoD Study:
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Comparison of 10-session PE individual to 10-session PE group
protocol
C’de Baca DoD Study:
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Effectiveness study—comparisons of Exposure Group to
Present Centered Therapy Group
References
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Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001). Current and lifetime comorbidity of the DSM-IV
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