Group Therapy for Victims of Chronic Abuse

November 23rd, 2010
“Studies investigating the overall prevalence of traumatic events in the general population indicate surprisingly high rates for lifetime exposure to any type of traumatic event (Kessler, R., A. Sonnega, E. Bromet, et al. “Post-Traumatic Stress Disorder in the National Comorbidity Survey.” Archives of General Psychiatry 52 (1995): 1048–1060). 
Using sensitive screening instruments, Norris found in a normal population survey, that 69 percent of individuals experience at least one traumatic event in their lifetime (Norris, F.H., K.Z. Kaniasty, D.A. Scheer. “Use of Mental Health Services Among Victims of Crime: Frequency, Correlates, and Subsequent Recovery.” Journal of Consulting and Clinical Psychology 58 (1990): 538–547). 
An independent study conducted by Resnick, using an instrument that included a detailed assessment of trauma, found a lifetime exposure to trauma of 68.9 percent (Resnick, H., D.G. Kilpatrick, B. Dansky, et al. “Prevalence of Civilian Trauma and Post Traumatic Stress Disorder in a Representative National Sample of Women.” Journal of Consulting and Clinical Psychology 61 (1993): 984–991). 
Despite the variation in sensitivity of instruments and inclusion criteria, different demographic studies show only minor differences in the frequency of trauma-related symptoms; clearly indicating that exposure to traumatic events has become common in our society (Solomon, S.D., J.R.T. Davidson. “Trauma: Prevalence, Impairment, Service Use, and Cost." Journal of Clinical Psychiatry 58.9 (1997): 5–11). 
To qualify for a DSM-IV diagnosis of PTSD, patients exposed to a traumatic event need to satisfy two main criteria. 
The first is that the person has experienced, witnessed, or been confronted with an event that actually involves the threat of death or injury which evoked intense fear, helplessness, or horror (criteria A). 
The second is divided into three subcategories of symptoms: re-experiencing (such as flashbacks) (criteria B), avoidance (criteria C), and increased arousal such as hyper-vigilance or affect dysregulation (criteria D) (“DSM-IV.” American Psychiatric Association Diagnostic and Statistic Manual of Mental Disorders. Washington, DC: American Psychiatric Association, 2000).
The original body of literature that established the current PTSD construct evolved as a model around symptoms following exposure to a critical traumatic event.  
However, in 1992 Judith Herman (Trauma and Recovery. New York: Basic Books, 1992) described a more complex disorder in patients who had been victims of prolonged repeated interpersonal trauma. This syndrome included survivors of sexual abuse and victims of domestic violence who had suffered boundary violation for years (Herman, J.L. “Complex PTSD: A Syndrome in Survivors of Prolonged, Repeated Trauma.” Horowitz, M.J.,ed. Essential Papers on PTSD. New York: New York University Press, 1999).  
While Herman referred to this population of victims as suffering from “Complex Trauma,” the DSM Task Force adopted the term “Disorder of Extreme Stress Not Otherwise Specified” (DESNOS), a title which was not officially included in the DSM-IV. 
Many of these patients had been the victims of violence or abuse at the hands of their own caretakers. 
In cases of domestic abuse, the failure to provide critical caretaking function has a compounding effect, since the victim is deprived a safe haven to hide and recover. 
Such abuse victims, according to Herman, have symptoms that are much more far-reaching than the aforementioned symptom categories currently included in the DSM-IV under PTSD. 
In the handbook of PTSD, Trauma and Recovery, Herman describes the seven cardinal symptom groups which comprise complex trauma. (These are summarized in: Williams, M.B., S. Poijula. “Simple Effective Techniques for Overcoming Traumatic Stress Symptoms.” The PTSD Workbook. New Harbinger Publications, 2002.) 
• Alterations in the regulation of affect and impulses, including managing anger and self-destructive acts
• Alterations in attention or consciousness (such as amnesia, dissociation)
• Somatization (such as chronic pain, conversion, sexual dysfunction)
• Alterations in self-perception (such as shame, self-blame, feeling helpless)
• Alterations in perception of the perpetrator (such as when the victim adopts the perpetrator’s demeaning and distorted beliefs about oneself, or become obsessed with the perpetrator)
• Alterations in relationships with others (where victims show problems with trust, or inexplicably continue to reenact the role of being a victim)
• Alterations in the meaning of life (such as continuing to feel despairing, and losing belief that one’s fortune can ever change) 
Therefore, the patient with “complex trauma” has impairment in multiple areas of personality functioning. 
I prefer to use the term “complex PTSD” for those patients whose impairment in self-functioning coexist with PTSD symptoms.
In even the most conservative comorbidity studies, patients with PTSD are four times more likely than those without PTSD to have another psychiatric diagnosis (Kessler, R., A. Sonnega, E. Bromet, et al. “Post-Traumatic Stress Disorder in the National Comorbidity Survey.” Archives of General Psychiatry 52 (1995): 1048–1060).  
Breslau et al. showed that patients with histories and symptoms of abuse are almost eight times as likely to have three or more psychiatric disorders as those individuals without PTSD (Breslau, N., G.C. Davis, P. Andreski, et al. “Traumatic Events and Post Traumatic Stress Disorder in an Urban Population of Young Adults.” Archives of General Psychiatry 48 (1991): 216–222). 
I therefore decided to select a heterogeneous group of patients to study that shared a common history of chronic abuse. While their diagnoses varied, they all shared a common history of chronic abuse. Since prolonged trauma affects multiple areas of personality functioning, the goal was a targeted intervention for those symptoms deemed as trauma related.
As explained by Julian Ford, victims of prolonged trauma may not have PTSD symptoms unless they were also exposed to atrocities (Ford, J. “Disorders of Extreme Stress Following War-Zone Military Trauma: Associated Features of PTSD or Comorbid or Distinct Syndromes?” Journal of Consulting & Clinical Psychology, 67, 199).
In the field of “trauma recovery,” novel therapies have been developed to address the following symptoms: 
1. Affect dysregulation, especially involving fear and anger
2. Difficulty ‘‘staying in the present,’’‘‘spacing out,’’ or reliving the trauma as if it were constantly recurring
3. Isolating, feeling self-blame, and feeling vulnerable in relationships
4. Distortions of self resulting from the perpetrator imposing a distorted reality on the victim; or resulting from a paradoxical empathic bond and psychological dependence on the perpetrator
5. Distrust, isolation, or reenactment of abuse in subsequent relationships
6. A pervasive feeling of despair, emptiness, and guilt, or feelings that life is cruel or meaningless   
In her extensive clinical research in treating survivors of childhood abuse, Marylene Cloitre reported that individuals with repeated childhood trauma never develop the affect regulation or social skills that will enable them to resolve their traumatic experiences (Cloitre, M., L.R. Cohen, K.C. Koenen. Treating Survivors of Childhood Abuse. London: Guilford Press, 2006). 
Conventionally, such patients are treated using a modality known as “exposure therapy” (meaning “confronting one’s fear”), which is the cornerstone of cognitive behavior therapy. According to Cloitre however, only 20 percent of such complex trauma patients can benefit from this traditional form of therapy. 
Consequently, in order to prepare survivors of severe early traumatic abuse for eventual exposure therapy, Cloitre developed a two stage treatment therapy for such complex trauma patients. She has titled it the “STAIR Program,” an acronym for “Skill Training in Affect Regulation” (Cloitre, M., L.R. Cohen, K.C. Koenen. Treating Survivors of Childhood Abuse. London: Guilford Press, 2006).
The first stage of treatment, which takes a minimum of 12 weeks, includes the following treatment goals: 
1.  Helping patients identify their fears, triggers, thoughts, emotions, and behaviors
2.  Examining the patient’s usual maladaptive responses to trauma triggers
3.  Providing emotional regulation skills such as strategies in breathing, self-statements, and ‘‘mindfulness’’
4.  Identifying interpersonal schemas embedded in the patient’s psyche that leads to the repetition of trauma dynamics in other interpersonal relationships
5.  Promoting new behaviors that disrupt the abuse dynamic 
In the second stage, otherwise known as ‘‘Narrative Story Telling,’’ patients use the skills learned in the STAIR phase of treatment before being allowed to repeat in imaginative work or verbally recall the details of their traumatic experiences. 
During the second, or exposure phase, patients are constantly reminded how to use their newly acquired skills, particularly with regards to affect regulation and self-soothing.  
The co-therapists need skills in empathy as well as knowledge of group dynamics in order to create a safe “holding environment.” 
These strategies are constantly reinforced to prepare such victims with complex trauma to eventually process their trauma narrative. 
‘‘Emotional regulation’’ helps patients find an emotional ‘‘comfort zone’’ that is not overly intense, and thereby allows them to function, learn, and “stay connected with” their immediate environment. This replaces the dissociated state in which traumatized patients often function.  
Our study attempted to demonstrate that such skills can be effectively acquired, even in a chronically ill hospitalized population of patients. 
Upon admission to our 300-bed psychiatric unit, patients were routinely screened for a history of physical or sexual abuse, neglect, or chronic domestic violence. 
The screening process was performed independently by various disciplines comprising the treatment team, including Nursing, Psychology, and Social Work Departments.
Each of these services had its core evaluation instruments approved by the Quality of Care Committee. 
Patients who had significant trauma histories had not previously undergone individual or group therapy using the recovery methods described above.
A screening process was used to identify a cohort of 24 patients with a Major Axis I diagnosis and a significant history of trauma. 
A control group of 24 age-matched trauma patients was allocated to a 12 week period of weekly supportive group therapy. 
In the treatment group, trauma patients received bi-weekly cognitive behavior therapy (CBT) by therapists trained in the STAIR method of trauma management, while the comparison patients did not. 
Group-based CBT treatment consisted of the following components: 
• Establishing trust and boundaries
• Training in identifying feelings, triggers, thoughts, and mood regulation strategies
• Learning History: How did these patients deal with traumas in the past and present?
• Emotion Regulation Skills: Teaching skills such as controlled breathing, self-statements to reduce fear, and social skill training
• Behavior Strategies: Helping patients find calmer, more adaptive responses to trauma triggers
Throughout the 12 week course of trauma recovery, therapists consistently applied the following treatment strategies:
1. Patients were discouraged from discussing details about their own trauma history prior to learning self-soothing skills.
2. Patients were educated on concepts pertaining to trust and “boundary,” and these items were constantly reinforced by the therapist. (This skill deficiency is more likely to present in a more disturbed cohort of patients who have difficulty getting close or, alternatively, tend to be overly intrusive.)
3. During each session patients were reminded about the safety and confidentiality of the group experience, thereby ensuring a sense of calmness and safety.
4. Patients were taught a vocabulary to label their traumatic symptoms, which include flashbacks, dissociations, numbing, rage, reenactment, avoidance, and somatization.
5. Abuse-related interpersonal schemas were identified. The group experience lends itself to vicarious learning whereby patients attain new strategies when trained therapists confront acting out behaviors exhibited by other group members.
6. Trauma reenactment scenarios were identified by therapists who used role playing to introduce more adaptive alternatives in a real-life simulation.
7. Using techniques such as “empathy” and “soothing,” therapists provided a corrective ‘‘re-parenting’’ role, attempting to disrupt the reemergence of expected abuse dynamics.
8. Alternative schemas were built using an evolving safe “holding environment” based on mutual respect and positive regard.
9. Patients were encouraged, when necessary, to find soothing objects or imagery that would help reduce arousal levels.
10. Group members were later encouraged to identify and confront maladaptive behaviors (such as angry outbursts or other acting-out) themselves.
11. Patients were encouraged to select several alternative coping responses, such as controlled breathing, grounding techniques, and ‘‘mindfulness’’ (Williams, M.B., S. Poijula. “Simple Effective Techniques for Overcoming Traumatic Stress Symptoms.” The PTSD Workbook. New Harbinger Publications, 2002).
12. When able to control arousal without acting out, patients were encouraged to share their feelings and remain in the group.
13. However, when patients became agitated or became potentially violent, they would be encouraged to leave the session.
Treatment outcome was determined using the modified Impact of Events Scale (IES) (Horowitz, M.J., M. Wilner, W. Alvarez. “Impact of Events Scale: A Measure of Subjective Stress.” Psychosomatic Medicine 41 (1979): 209–218) and Brief Psychiatric Rating Scales (BPRS) (Overall, J.E. “The Brief Psychiatric Rating Scale (BPRS) Recent Developments in Ascertainment and Scaling.” Psychopharmacology Bulletin 24 (1988): 97–99) prior to the commencement and at the completion of the 12 week course of treatment.
Statistical analysis was performed with Wilcoxon Signed Rank Tests to examine treatment effect in each group. 
Our findings demonstrated that 12 weeks of group-based trauma recovery therapy using the STAIR method was more effective than traditional supportive therapy in reducing multiple items involving trust, safety, and arousal. 
For instance, patients in the STAIR group showed statistically significant reduction in somatic symptoms, anxiety, tension, depression, suspiciousness, hostility, and excitement.  
Our study indicates that this approach may be helpful even in clinically psychotic trauma survivors by reducing anxiety, emotional withdrawal, motor tension, suspiciousness, motor excitation, and level of hostility. 
Since patients with complex trauma or PTSD fail to respond to traditional CBT exposure in 80 percent of cases, this two-phased treatment approach appeared particularly prudent in a cohort of patients with extensive comorbidity. 
Without extensive preparation in areas of boundary, trust, and affect regulation, patients with chronic psychotic symptoms are vulnerable to exacerbation of distress and agitation. 
As a result, it is the author’s opinion that traditional “exposure therapy” in the form of “narrative storytelling” could be counterproductive in victims of chronic abuse. 
Improving coping strategies by the STAIR approach showed little spillover effect in reducing other core Axis I symptoms, consistent with the observations and those described by Resnick (Resnick, S.G., G.R. Bond, K.T. Mueser. “Trauma and PTSD in people with Schizophrenia.” Journal of  Abnormal Psychology 112.3 (2003): 415–423).
These findings were demonstrated by failure of the treatment group to show improvement in conceptual disorganization, mannerisms, hallucinatory behavior, or unusual thought content. 
Specific items of improved functioning on the Brief Psychiatric Rating Scale, such as reduction of anxiety, as well as emotional withdrawal, tension, motor excitation, and cooperative behavior, are consistent with a treatment approach focusing on trauma recovery strategies. 
Experts in the field of early trauma recovery emphasize the importance of creating an emotional comfort zone for victims by allowing them to connect with their environment in a nonthreatening way while facilitating the acquisition of new social skills (Williams, M.B., S. Poijula. “Simple Effective Techniques for Overcoming Traumatic Stress Symptoms.” The PTSD Workbook. New Harbinger Publications, 2002). 
Needless to say, this intervention represents only one facet of the treatment regimen, which includes appropriate use of psychopharmacological agents. 
All of my patients were treated simultaneously with appropriate neuroleptic agents and mood stabilizers. 
These findings are an encouraging first step and tentatively demonstrate the effective use of CBT-based trauma recovery groups by clinicians appropriately trained and supervised in trauma therapy for chronically hospitalized victims of trauma. 
This trauma recovery model appears highly suitable for very fragile patients who may only be receptive to recovery strategies under very safe conditions. 
This treatment philosophy has been deemed the cornerstone of early trauma recovery by other experts in the field of trauma (Gilchrist, P.A., P.L. Rainbow. “A Clinical Model of Group Treatment for Survivors of Trauma: The Trauma Safety Drop-in Group.” New York State Office of Mental Health: Trauma Initiative Publication, 1999; Rosenbloom, D., Williams M.B. Life After Trauma: A Workbook for Healing. New York: Guilford Press, 1999). 

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