Copyright 2004 by the Educational Publishing Foundation
2004, Vol. 1, No. 2, 140–146
Evaluating a Cognitive–Behavioral Group Treatment
Program for Veterans With Posttraumatic Stress Disorder
Elisa E. Bolton, Jennifer F. Lambert, Erika J. Wolf, Sheela Raja, Alethea A. Varra, and
Lisa M. Fisher
Veterans Affairs Medical Center, Boston, Massachusetts, and Boston University School of Medicine
The need to develop and further refine efficient and effective treatments for individuals with
posttraumatic stress disorder (PTSD) in a climate of reduced mental health resources is critical.
This study examined the impact of a series of cognitive–behavioral groups administered in an
urban VA setting. The participants were veterans with chronic and severe PTSD, many of them
struggling with additional physical and mental health problems. The data indicate modest im-
provements in the distress level of the veterans. Additional research is needed to further isolate
the key elements of treatment that are most effective, palatable for patients, and cost-effective for
Posttraumatic stress disorder (PTSD) is a condition
eral medical population (Stein et al., 2000) to 20%
that is often chronic and quite debilitating. PTSD has
among VA ambulatory care patients (Hankin, Spiro,
been associated with decreased work productivity
Miller, & Kazis, 1999). These percentages corre-
(Kessler & Frank, 1997), with poor physical health
spond to a large number of people who are in need of
(Deykin et al., 2001; Zayfert, Dums, Ferguson, &
intervention in a health care climate characterized by
Hegel, 2002), and with a high comorbidity with other
cutbacks and downsizing. Given the growing recog-
psychiatric disorders (Breslau, 2001). As a result, pa-
nition of the severity of the distress caused by this
tients with PTSD use more health care resources than
disorder for the individual, the burden of this disorder
individuals without PTSD (Deykin et al., 2001; Stein,
on society, and the reduction in treatment resources
McQuaid, Pedrelli, Lenox, & McCahill, 2000).
(Breslau, 2001; Kessler, 2000), it is crucial that ef-
The lifetime prevalence of PTSD in the general
fective and efficient treatments be developed.
population has been estimated to be 5–6% for men
Current treatments for PTSD include psychotropic
and 10–11% for women (Breslau, Davis, Andreski, &
medications, individual psychotherapy, and group
Peterson, 1991; Kessler, Sonnega, Bromet, Hughes,
psychotherapy (see Foa, Keane, & Friedman, 2000,
& Nelson, 1995). Estimates of PTSD in medical set-
for a review). It is broadly recognized that medica-
tings are even higher, ranging from 12% in the gen-
tions are an efficient way to treat individuals with
PTSD. They have been found to have a wide range of
benefits, including reduction in the core symptoms of
Elisa E. Bolton, Jennifer F. Lambert, Erika J. Wolf,
PTSD, such as reexperiencing, avoidance, and
Sheela Raja, Alethea A. Varra, and Lisa M. Fisher, Veterans
arousal, and in secondary symptoms, such as depres-
Affairs Medical Center, Boston, Massachusetts, and Boston
sion, sleep disturbance, physical health problems, de-
University School of Medicine.
creased quality of life, and anger (Cyr & Farrar,
Elisa E. Bolton is now at the Dartmouth Psychiatric Re-
2000; Davidson, 2000; Pearlstein, 2000; Rapaport,
search Center; Jennifer F. Lambert is now at the Providence
Endicott, & Clary, 2002). However, with the range of
VA Hospital; Sheela Raja is now at the Edward Hines Jr.
VA Hospital; and Alethea A. Varra is now at the Depart-
social, interpersonal, occupational, and health prob-
ment of Psychology, University of Nevada, Reno.
lems frequently associated with chronic PTSD
We express gratitude to the following individuals for
(Breslau, 2001; Kessler, 2000), psychosocial inter-
their contributions to this study: Barbara Niles, Catherine
ventions often provide vital additional benefits not
Kutter, Victoria McKeever, Steve Quinn, Jim Munroe,
afforded from medication alone. The format of group
Maureen Grace, and the other clinicians who conducted the
treatment to target the range of problems stemming
groups. We are also appreciative of the veterans who par-
from PTSD has proven to be particularly popular
ticipated in this study.
given the increased demand for treatment for PTSD
Correspondence concerning this article should be ad-
and the reduction in treatment resources.
dressed to Elisa E. Bolton, PhD, who is now at the New
Ostensibly, the benefits of group therapy for PTSD
Hampshire–Dartmouth Psychiatric Research Center, State
Office Park South, 105 Pleasant Street, Concord, NH
are numerous. This treatment modality allows for the
03301. E-mail: firstname.lastname@example.org
provision of care for a large number of individuals
TREATMENT PROGRAM FOR VETERANS WITH PTSD
while decreasing the demands on clinicians’ time. It
ter, and includes a broad array of assessment mea-
also provides the unique benefit of allowing group
sures. This treatment program is composed of an ini-
members to confront several of the secondary prob-
tial assessment followed by a series of three 12-week
lems associated with PTSD, such as lack of trust in
structured groups: a psychoeducational group (“Un-
others, feelings of detachment, and diminished affect
derstanding PTSD”), an anxiety management group
(Allen & Bloom, 1994).
(“Stress Management”), and an anger management
Foy et al. (2000) conducted a review of group
group (“Anger Management”).
treatments with a variety of trauma populations (e.g.,
On the basis of previous findings (Foy et al., 2000;
female adult and childhood sexual assault survivors,
Telch, Schmidt, Jaimez, Jacquin, & Harrington,
male combat veterans, multiple trauma survivors,
1995) and our own clinical experience, we predicted
etc.), using a wide range of outcomes (e.g., self-
that veterans would report improvements in quality
report PTSD symptom scales, structured clinical in-
of life, and we expected to see improvements on
terviews for PTSD, depression inventories, and mea-
measures assessing specific subsets of symptoms tar-
sures assessing locus of control, self-esteem, and
geted by specific groups (i.e., reductions in aggres-
social adjustment). They reported that positive treat-
sive behaviors after completion of the Anger Man-
ment outcomes were found in 13 out of 14 published
agement group; see Peirce, Niles, Riggs, & Smith,
(although largely uncontrolled) studies. In their re-
2000, for related findings).
view, Foy and his colleagues emphasized the need for
In contrast, we expected that there would be little
further research to determine whether specific group
change in the core symptoms of PTSD as measured
formats (e.g., supportive, cognitive behavioral, psy-
by self-report. We did not expect significant changes
chodynamic) yield differential improvement and how
in core PTSD symptoms to emerge, given prior re-
best to generalize research findings to clinical prac-
search that suggests that (a) veterans may be hesitant
tice. Further, they noted that because most of the
to report improvement in symptoms of PTSD given
existing studies were conducted in research settings
compensation concerns (Freuh, Mirabella, Chobot, &
with strict control on participation and treatment
Fossey, 1994); (b) patients may make subjective rat-
implementation, research in clinical settings that em-
ings of improvement that may be clinically signifi-
phasize treatment in PTSD (such as VA hospitals)
cant but that may not be reflected when self-report
and that have few exclusionary criteria for study par-
measures are statistically analyzed (Creamer, Morris,
ticipation is crucial for developing and assessing the
Biddle, & Elliott, 1999; Forbes, Creamer, & Biddle,
effectiveness of these treatments.
2001); and (c) exposure-based treatments have the
Repasky, Uddo, Franklin, and Thompson (2001)
most success in reducing the hallmark symptoms of
conducted one such study of their time-limited, cog-
PTSD (Foa, Keane, & Friedman, 2000), and our
nitive–behavioral treatment program for veterans
groups did not include this component.
with PTSD. Across a wide variety of measures, the
veterans reported improvement on subjective mea-
sures with no corresponding change on self-reported
symptom measures. The authors argued that one pos-
sible explanation for this discrepancy is that veterans
The participants in this investigation were male
do not perceive their symptoms to have changed but
veterans who consented to be assessed while partici-
feel that they are better able to cope with their exist-
pating in one or more of three successive treatment
ing symptoms. Repasky and colleagues also reported
groups at one or both of the following centers: the
that cohorts progressing through the program became
Behavioral Science Division of the National Center
highly cohesive and were an excellent source of so-
for Posttraumatic Stress Disorder (NCPTSD) and the
cial support and feedback to each other. The staff
Outpatient Clinic of the Boston Veterans Affairs
noted improved staff productivity and more efficient
Medical Center (OPC). Patients were consecutively
service delivery as well. Thus, Repasky at al. con-
enrolled in group treatment between 1996 and 2001.
cluded that, overall, their comprehensive group treat-
Not all veterans who participated in the group treat-
ment program was beneficial to both patients and
ments completed the assessments for a variety of rea-
sons (e.g., veteran missed group the day assessments
The main goal of the current study was to assess
were administered). Therefore, these analyses reflect
the effectiveness of a treatment program, which con-
the number of individuals who completed the pre-
sists of a series of cognitive–behavioral groups. It
and postgroup assessments and not the number of
was established to treat veterans with PTSD at the
people who were actually enrolled in the group treat-
National Center for PTSD, Boston VA Medical Cen-
ment. There were 105 veterans who completed the
BOLTON, LAMBERT, WOLF, RAJA, VARRA, AND FISHER
assessments for an Understanding PTSD group, 62
group meetings, which allowed us to examine treat-
veterans who completed the assessments for a Stress
ment gains following each group.
Management group, and 30 veterans who completed
The Understanding PTSD group (Munroe, Bitman,
the assessments for an Anger Management group.
Hymen, & Makary, 1995) addresses issues of trust,
Given that assessments were completed for pro-
safety, self-care, effects of trauma, and treatment is-
gram evaluation purposes rather than as part of a
sues and options. The group’s goal is to provide pa-
controlled study, we have little information on the
tients with a working knowledge of the ways in
clients who were referred to other modes of treat-
which PTSD may affect their lives. The Stress Man-
ment, who chose not to participate in the groups, or
agement group (Grace & Niles, 1996) teaches veter-
who were not in attendance on the day the assess-
ans to alter their daily experiences through relaxation
ments were administered. However, Kutter, Wolf,
and cognitive restructuring. It works to reduce the
and McKeever (2004) reported from a related sample
impact of stress, hypervigilence, and the pervasive
that greater PTSD severity predicted initial enroll-
distrust of others. In this group, the veterans learn
ment and continued participation in the group treat-
cognitive coping strategies, such as self-talk, identi-
ment program. They also noted few differences in
fying and altering stress-inducing thoughts, and
background and symptom measures between those
adaptive problem solving. They are also taught re-
who entered into the groups and those who did not.
laxation and imagery techniques to facilitate lifestyle
Participants were predominately Vietnam era vet-
changes. The Anger Management group (Grace,
erans (80% Vietnam War era, 8% World War II era,
Niles, & Quinn, 1996) focuses on helping veterans to
5% Korean War era, 3% Gulf War era). Participants
better regulate their anger responses. The group fo-
had served with the Army (60%), Marines (28%),
cuses on increasing awareness of anger triggers and
Navy (6%), or Air Force (6%). The mean participant
applying adaptive anger management strategies to
age was 52.04 (SD
anger-provoking situations (e.g., time-outs, relax-
majority of participants were White, non-Hispanic
ation, cognitive restructuring, ventilation, and posi-
(88%); 9% were Black, non-Hispanic, and 1% was
tive distraction). In addition, the veterans work on
White Hispanic. Married veterans composed 51% of
strategies to help ensure that their feelings are com-
the sample; 37% of the participants were divorced or
municated with the least amount of damage to them-
separated. Most veterans had obtained at least a high
selves or others.
school degree or equivalent (93%). Forty-nine per-
All groups use didactic materials, group discus-
cent of the participants were working at least part-
sions, and skills-based exercises as part of the treat-
time; 49% were retired, disabled, or unemployed.
ment. Although the groups are manualized, clinical
Many participants (56%) were receiving some form
judgments about which components to emphasize in
of VA disability (M
22%), and 19%
each session are accommodated. In addition to the
of these men were receiving compensation for the
group treatment, each veteran is assigned a clinical
PTSD they acquired as a result of their service.
care coordinator. When appropriate, veterans are also
referred to one or both of the following: adjunct in-
dividual treatment and a psychiatrist for pharmaco-
Participants were referred to the Behavioral Sci-
Given that the data used in these analyses are ar-
ence Division for assessment and treatment recom-
chived data collected originally for clinical purposes,
mendations. Veterans whose most pressing concerns
the VA Boston Internal Review Board waived the
were non-PTSD related (i.e., veterans with severe
requirement of informed consent for this study. All
substance abuse or schizophrenia) were referred to
data were stripped of identifying information to pro-
other programs. Following a comprehensive assess-
tect patient confidentiality.
ment, veterans meeting Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV; American
Psychiatric Association, 1994) criteria for PTSD and
who were deemed appropriate for group therapy were
PTSD Checklist—Military (PCL–M; Weathers,
referred to the following treatment sequence: Under-
Litz, Herman, Huska, & Keane, 1993).
standing PTSD, Stress Management, and Anger
PCL–M is a brief, 17-item inventory designed to as-
Management. These manualized groups were in-
sess PTSD symptomatology in war veterans. Items
tended specifically for veterans with PTSD. Partici-
correspond with PTSD criterion: 5 items measure re-
pants were asked to complete assessment measures at
experiencing symptoms, 7 items measure numbing
the first (Week 1) and last (Week 12) of each of the
and avoidance symptoms, and 5 items measure hy-
TREATMENT PROGRAM FOR VETERANS WITH PTSD
perarousal symptoms. Respondents rate the extent to
has been normed for an ambulatory veteran popula-
which they have been bothered by symptoms over the
tion. The SF-12V was validated against the Medical
past month on a 5-point Likert scale ranging from 1
Outcomes Study SF-36 with correlations in the .93–
(not at all) to 5 (extremely). The PCL–M has been
.97 range (Ware et al., 1994). The SF-12V General
shown to have excellent concurrent validity (r
Health Scale is a single item which asks veterans to
Blanchard, Jones-Alexander, Buckley, & Forneris,
rate their general health on a 5-point scale ranging
1996) and test–retest reliability (r
.96; Weathers et
from excellent to poor. Lower scores indicate better
al., 1993). Items on the PCL–M were summed to
create a total score. Subscale scores were also com-
puted for each symptom cluster (reexperiencing,
avoidance, and arousal) by summing the items cor-
Pre- and postgroup means and standard deviations
responding to each.
for each of the outcome variables are presented in
Beck Depression Inventory (BDI; Beck, Rush,
Table 1. A series of correlated groups t tests were
Shaw, & Emery, 1979).
The BDI is a 21-item self-
used to compare the pre- with the postgroup scores
report checklist used to assess severity of depression
on each of the outcome measures for each group in
in clinical and nonclinical populations. Alpha coef-
the treatment series (i.e., Understanding PTSD,
ficients for the BDI of .86 and .81 have been reported
Stress Management, Anger Management). There was
in meta-analyses in psychiatric and nonpsychiatric
one significant change following the Understanding
samples, respectively (Beck, Steer, & Garbin, 1988).
PTSD group: reports of reexperiencing symptoms as
A mean concurrent validity of .72 has been reported
assessed by the PCL–M decreased following the
in analyses comparing the BDI to a variety of other
completion of the group, t(80)
2.20, p < .05. The
depression measures (Beck et al., 1988). Items on the
strength of the relationship was .06, as indexed by 2,
BDI were summed for the purposes of the current
indicating a weak effect (Rosenthal, 1995).
There were several statistically significant im-
Boston Life Satisfaction Inventory (BLSI; Smith,
provements following the Stress Management group.
Niles, King, & King, 2001).
The BLSI is a 26-item
Participants endorsed lower levels of depression on
self-report instrument designed to measure individu-
the BDI after attending Stress Management group
als’ satisfaction with life in a variety of areas, includ-
3.41, p < .001. The strength of the
ing living situations, relationships with friends and
relationship was .18, as indexed by
2, indicating a
family, work, safety, and well-being. Respondents
moderate effect. The clients also rated their overall
rate each item on a 7-point scale ranging from very
life satisfaction to be better than it had been prior to
dissatisfied to very satisfied. The BLSI has demon-
the group, t(46)
?2.14, p < ?2.14. The strength of
strated acceptable psychometric properties with an
the relationship was .09, as indexed by 2, indicating
alpha coefficient of .91, test–retest reliability over 4
a moderate effect.
months of .67, and a correlation of .67 with the Frish
There also were statistically significant changes
Quality of Life Measure (Smith et al., 2001). Items
following the Anger Management group. Specifi-
on the BLSI were summed; higher scores indicate
cally, participants reported that they were less violent
increased life satisfaction.
at the conclusion of the Anger Management group
Violence Screen (V-Screen).
The V-Screen is an
than they had been prior to the group, t(21)
unpublished instrument developed at the Behavioral
p < .001. The strength of the relationship was .45, as
Science Division of the National Center for PTSD to
2, revealing a strong effect. These same
assess aggressive behaviors over the past 4 months.
clients also rated their general health to be better than
Items ask about both relatively minor acts of aggres-
it had been before the group started, t(21)
sion (“I broke off contact with someone out of anger
< .05. The strength of the relationship was .20, as
or fear of losing control”) and severe acts of aggres-
2, indicating a strong effect.
sion (“I used a weapon against someone”). Item re-
sponses range from 0 (never) to 6 (more than 20
times). Items on the V-Screen were summed; higher
scores indicate an increased number of violent
In this study, we examined whether a series of
cognitive–behavioral groups to address symptoms of
General Health Scale from the Veterans SF-12
PTSD and to improve coping skills for managing
(SF-12V; Kazis et al., 1994).
The SF-12V is de-
these symptoms were effective at reducing reports of
rived from the commonly used Medical Outcomes
psychological distress. Although the effects of the
Study SF-12 (Ware, Kosinski, & Keller, 1994) and
Understanding PTSD group were small, the group
BOLTON, LAMBERT, WOLF, RAJA, VARRA, AND FISHER
focused on increasing awareness of anger triggers
Means and Standard Deviations for Each Measure
and the application of adaptive anger management
Given at Pre- and Postassessment
skills, produced strong declines in reports of recent
violent behavior and improvements in self-reports of
overall physical health.
These results were consistent with our predictions
that changes would be most evident on measures as-
sessing specific behavioral change and on life satis-
faction and less likely to be demonstrated on the self-
reported distress associated with the core features of
PTSD. Our results are consistent with results reported
in other studies. For example, Telch et al. (1995)
General Health Scale
reported improvements in ratings of quality of life
PTSD Checklist Total
following cognitive–behavioral treatment in anxious
patients, and Forbes, Creamer, and Biddle (2001)
noted that the PCL is relatively insensitive to detect-
ing changes following treatment in comparison to the
“gold standard” of the Clinician Administered PTSD
Scale (CAPS; Blake et al., 1990).
Although the extent of our findings is limited, this
is not surprising given the nature of our data and the
challenges of conducting treatment outcomes studies,
General Health Scale
especially with veterans. As mentioned earlier, it has
PTSD Checklist Total
been suggested that patients may anecdotally report
improvements that may be clinically significant but
that may not be detected when these self-report mea-
sures are statistically analyzed (Creamer et al., 1999;
Forbes et al., 2001). It also has been suggested that
the absence or restriction in reports of change in men-
tal health by veterans may be due to symptom over-
reporting on self-report measures in this population
General Health Scale*
(Fairbank, Keane, & Malloy, 1983) or a hesitation to
PTSD Checklist Total
report improvement in symptoms because of com-
pensation concerns. Alternatively, the amount of
change may have been limited by the fact that the
groups are not trauma focused (Rogers, 1998), or it
may instead be a genuine reflection of the severe and
The Violence Screen was added to assessment pack-
chronic nature of the problem (Freuh et al., 1994).
ets during later group iterations, resulting in a lower n for
this measure. PTSD
posttraumatic stress disorder; PCL
There are also methodological limitations to this
study. For example, we did not include control or
aOne hundred and five participants completed assessments
comparison groups in our study. Thus, it is possible
prior to and upon completion of the Understanding PTSD
that factors other than the active treatment variables
may have contributed to our findings. For instance, it
Sixty-two veterans had completed assessments for the
Stress Management group.
may be that the veterans improved over the course of
cThirty individuals completed pre- and postassessments for
a group because of the additional social support pro-
the Anger Management group.
vided by being in a group. In addition, our data are
*p < .05.
**p < .001.
based exclusively on self-reported assessments of
psychological distress, and, thus, our ability to draw
treatment reduced the reported distress associated
conclusions is limited by the validity and reliability
with reexperiencing symptoms. The Stress Manage-
of this methodology. In general, self-report data are
ment group, which focused on relaxation and cogni-
subject to threats to validity such as social desirabil-
tive-restructuring skills, had a moderate impact on
ity and response-style biases. Thus, as suggested
the reports of depression and overall life satisfaction.
above, it may be that the veterans in the treatment
Furthermore, the Anger Management group, which
groups were hesitant to acknowledge much change in
TREATMENT PROGRAM FOR VETERANS WITH PTSD
the status of their distress as they may fear that to do
ments in symptoms of PTSD but may be willing to
so would impact their service connection or their
report improvements in health status, quality of life,
identity associated with being a traumatized veteran.
and so forth. By using a broad range of measures,
Further, the generalizability of our results to women
researchers are likely to capture the genuine changes
and nonveterans is limited by the fact that all of our
described by the veterans that might not otherwise be
study participants were male veterans.
captured by a mono-method approach focused only
Despite these limitations, our study is based on the
on assessing the core symptoms of PTSD.
use of a manualized, and therefore standardized,
Although our findings are modest, the clinical im-
treatment. We used psychometrically sound assess-
plications are broad. Specifically, our data indicate
ment measures of PTSD and a commonly comorbid
that interventions that target specific problematic be-
disorder—depression. All of our participants re-
haviors are most effective. In addition, psychoeduca-
ported significantly high levels of distress at the onset
tion appears to have a function in reducing the dis-
of the groups and, although not formally assessed, a
tress associated with reexperiencing symptoms,
large proportion of our participants have additional
possibly by normalizing these experiences as com-
mental and physical problems. Finally, we were able
mon responses to traumatic events. Further, our data
to demonstrate some improvement in a group of in-
indicate that standard behavioral arousal reduction
dividuals who suffer from severe and longstanding
and cognitive-restructuring techniques can be taught
symptoms of PTSD.
in a group format and are helpful in decreasing vet-
In sum, we found that the groups produced modest
erans’ experiences of stress and anxiety. It is our
improvements in the distress level of the veterans,
speculation that treatment effects are likely to be
which is consistent with our clinical experience and
greater if veterans’ functional goals were incorpo-
with results from prior research studies. Although the
rated into the course of treatment and if potential
documented gains were modest, both veterans and
movement on these goals were tied to the skills
clinicians have been highly satisfied with the out-
taught in the group.
comes. The veterans in the groups reported that they
liked the groups, as evidenced by the fact that 98% of
our patients reported being highly satisfied with the
treatment. In addition, the clinicians have reported
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