Do therapists need to give up efficiency for efficacy when it comes to treating posttraumatic stress disorder, or can the two go hand in hand? That is a key question asked by Patricia Resick, PhD, of the National Center for PTSD in Boston in a randomized clinical trial she is leading for STRONG STAR.

Dr. Resick developed Cognitive Processing Therapy (CPT), one of the two treatments with the most empirical support for efficacy in treating PTSD. It has proven to be highly successful with civilian PTSD patients. Now, in an effort to find treatment-delivery methods that best meet the needs of military patients, she has developed a STRONG STAR study to evaluate the efficacy of CPT in individual versus group settings.

Group therapy for PTSD is currently being used in both military and VA settings. If effective, this is an efficient way to treat the disorder. But the question remains: Is group therapy for PTSD effective?

Group vs. individual therapy

In 2007, the Institute of Medicine’s (IOM) Committee on the Treatment of Posttraumatic Stress Disorder published a report stating that there is insufficient evidence to support or refute the efficacy of group therapy for the treatment of PTSD because of a lack of well-designed studies comparing group and individual treatment formats. However, in examining individual treatment for PTSD, the IOM committee did find sufficient evidence on the efficacy of exposure therapies such as CPT.

It is interesting to note that CPT – which includes psychoeducation, cognitive therapy, and exposure in the form of rereading written accounts of trauma – was first developed as a group treatment. However, in the large randomized clinical trial to compare CPT with Prolonged Exposure therapy, it was necessary to test CPT with an individual therapy format. Later trials with CPT followed suit and examined the therapy either as an individual treatment or as a treatment that combined individual and group therapy. In a recent clinical trial to dismantle the components of CPT (Resick et al., 2008), Dr. Resick and her colleagues found that a cognitive-only version of CPT, called CPT-C, was equally effective to the full version of CPT and perhaps more efficient. CPT-C does not include the portion of CPT in which patients record and reread their account of their traumatic experience.

Currently, CPT is being rolled out nationally in a large dissemination project by the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) as one of the gold standard treatments for PTSD. In 2007, nearly 900 VA and DoD clinicians were trained in CPT. Given that CPT can be administered as either a group or individual treatment, it is important to determine whether the two are equivalent or whether one type of format is sufficiently superior to warrant recommendation either for or against group administration. This is the goal of STRONG STAR in the first-ever PTSD study to compare group versus individual therapy. Given that there are now multiple versions of group CPT being used in VA and military settings, Dr. Resick will use the CPT-C version of the therapy in this STRONG STAR clinical trial, which has several goals:

• To compare the efficacy of CPT-C in a group versus an individual setting.
• To compare group-administered CPT to another type of supportive group therapy.
• To test the efficacy of CPT for the first time with active-duty military personnel.
• To examine predictors of treatment outcome, such as gender, race/ethnicity, and comorbid conditions, along with the effect of multiple deployments and traumatic brain injury.

Potential impact

The significance of the study will be large no matter what the outcome because of the public health implications. If both individual and group CPT treatments are equivalent, then group treatment would be a much more efficient therapy modality in most cases. On the other hand, if there are large differences between the two modalities, the DoD and the VA may need to invest greater resources in individual therapy.