Abstract
The goal of this study is to ascertain whether the amount of people within a cognitive-behaviour therapy (CBT) session affects the severity of post-traumatic stress disorder (PTSD). 200 participants aged between 18 and 60 years, who have been clinically diagnosed with PTSD, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013) by a certified psychologist, but have not sought any formal treatment will be selected to participate in this study. It is hypothesised that adults with PTSD who participate in weekly group CBT sessions are more likely reduce both the frequency and severity of their symptoms than those who attend these weekly sessions alone. Pre-treatment, post-treatment and 6-month follow up tests will be conducted, examining the severity of the participants’ symptoms over the 12-week period of treatment. If the hypothesis can be supported, this study may suggest that the amount of people present during the therapy sessions has a significant effect on alleviating some of their symptoms. By understanding whether group sessions of CBT are more beneficial than individual sessions, future treatment for clients with PTSD can be improved.
Cognitive-Behaviour Therapy (CBT) has been used as a reliable form of treatment in an array of mental disorders such as obsessive compulsive disorder (OCD) (Cabedo et al., 2009), generalised anxiety disorders (GAD) (Linden, Zubraegel, Baer, Franke & Schlattmann, 2005), depressive disorders (Watson & Nathan, 2008) and post-traumatic stress disorder (PTSD) (Sannibale et al., 2013; Khoo, Dent & Oei, 2011). According to the DSM-5, PTSD is now classified as a separate category of mental disorders as opposed to previous editions of the DSM. PTSD is a ‘debilitating disorder’ (Sannibale et al., 2013), that is essentially characterised by dysfunction, mental and physical struggles in completing typically normal tasks, caused by a single or multiple distressing or traumatic events (e.g. military warfare, sexual abuse), that one witnesses or experiences (American Psychiatric Association, 2013). These difficulties are not caused by the use addictive substances such as illicit drugs and alcohol but excessive dependency on these substances has been linked to the disorder (Sannibale et al., 2013).
Many studies have looked at how both group and individual CBT sessions assist in reducing the severity and frequency of PTSD symptoms, but few have compared whether the group size impacts the efficacy, management and treatment of the disorder (Sannibale et al., 2013; Khoo, Dent & Oei, 2011). The objective of thus study is to determine if the amount of people within the therapy session can minimise the occurrence and the intensity of PTSD symptoms.
Unlike the research of Khoo, Dent and Oei (2011) who investigated military service-related PTSD in male veterans, this study focuses on adults, both men and women, who have been diagnosed with PTSD that have been triggered by a range of distressing events but who have not sought any formal treatment to ensure a roughly even baseline prior to the study. It is hoped that by expanding on not only the sample size but also the population of interest, the findings of this study will be more likely to be generalized to all adults with PTSD.
Based on the literature, it is expected that group CBT sessions, consisting of five individuals, will be more helpful in reducing PTSD symptoms over a 12-week period than if they attended therapy sessions alone. This finding may be attributed to the participants being able to relate to and identify with other like-minded individuals that share a similar experience, and thus more inclined to open up about the traumatising event and more motivated to seek help.
Method
Two hundred Australian citizens aged between 18-60 years with varying degrees and onsets of PTSD, such as military warfare and sexual abuse, will be asked to participate in the study. The sample will contain an even gender ratio, containing 100 men, will be randomly selected. All of the participants must be clinically diagnosed by a certified psychologist with PTSD, as per the set of criterion established in the DSM V, but have not sought any further treatment. All procedures will be approved by the Monash University Human Research Ethics Committee.
Design
The independent variable, the group size or the amount of people attending the therapy sessions, will have two levels; a group of five participants or just single participants. Severity of PTSD symptoms will be the dependent variable. An experimental independent-measures design will be employed in this study.
Materials
The PTSD Checklist for DSM-5 (PLC-5), a 20 item questionnaire that implements a Likert scale requiring participants to select options ranging from 0=not at all to 4=extremely, will be utilised as a tool to gage the severity of PTSD. It will be taken at several intervals throughout the study, as a pre-treatment, post-treatment and 6 month follow up test, with a higher total score indicating a more severe case of PTSD (Weathers et al., 2013).
Procedure
Participants will first sit the pre-treatment test before being randomly allocated via a randomised computer allocation program to either the experimental condition, attending a weekly 60-minute group session of CBT containing 5 individuals altogether, or to the control condition, attending a weekly 60-minute individual session of CBT over the same 12-week period, in the same clinical setting. At the conclusion of the 12-week period of CBT, participants will fill in the PLC-5 for a second time and then again for a final time six months after the last CBT session. Informed written consent will be obtained prior to the commencement of the study, participation will be voluntary and participants are allowed to withdraw at any point during the study.
Results
The mean scores for the pre-test for both groups are expected to be quite high, demonstrating the initial level of severity of the PTSD symptoms. In order for the hypothesis to be supported, the mean score on the PLC-5 of the group attending sessions of CBT as a group of five, would have to be lower than the mean score of the group attending CBT sessions individually. The results from post-test average score would also have to be lower than the initial pre-test average score, indicating that CBT is effective in the overall reduction of PTSD symptoms.
Discussion
This study aims to investigate the impact of the group size on the effectiveness of CBT for clients with PTSD. It is expected that larger groups of participants will report a greater reduction in their overall symptoms than those who attend the therapy sessions individually. However, if the findings are inconsistent with the hypothesis, it may suggest that individual therapy sessions are more beneficial in alleviating symptoms of PTSD. If there is little difference in the mean scores from both conditions, there may be no or a very weak relationship between group size and the efficacy of CBT for clients with PTSD.
Limitations of the study may include individual differences. Whether a participant is more or less extraverted may affect the degree to which the individual shares their experiences in the therapy sessions. Even the degree to which the participant relates or feels empathy or comfortable towards others within these sessions, may also affect how the symptoms of PTSD either increase or decrease. Additional assessment tools should be utilised in future trials to control these variables and ensure that they do not cause any unwanted changes in the severity of PTSD symptoms. As participants are being asked to fill in a self-report style questionnaire, results obtained may not be entirely accurate or indicative of their true feelings or experiences of the traumatic or distressing event. Participants may fill in answers of what they believe the experimenter wants to hear or may report fewer incidences of their symptoms if they wish to avoid future therapy, which may affect the generalizability of the results.
This study assumes that group therapy sessions consisting of five participants will be more beneficial than individual sessions in alleviating PTSD symptoms on the basis that these participants may relate to shared experience of a distressing event. However, there may be other explanations for this same conclusion and future research should focus more on why and how this might be the case. It will play a role in not only broadening current knowledge of PTSD, in describing and understanding the symptoms and the distressing events that trigger onset, but will also be useful in the overall treatment and management of the disorder. By understanding more about PTSD, the stigma in society surrounding clients with the disorder may also be reduced.
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