Revista

de la

Universidad

del Zulia

Fundada en 1947

por el Dr. Jesús Enrique Lossada

ANIVERSARIO

DEPÓSITO LEGAL ZU2020000153

ISSN 0041-8811

E-ISSN 2665-0428

Ciencias

Exactas,

Naturales

y de la Salud

Año 15 N° 43

Mayo - Agosto 2024

Tercera Época

Maracaibo-Venezuela

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DOI: https://doi.org/10.46925//rdluz.43.04

The Effect of Group Psychotherapy on the Mental Health of Servicemen

with Post-Traumatic Stress Disorder

Liudmyla Motoziuk*

Nataliia Chorna**

Maryna Lukashuk***

Volodymyr Vlasov****

Svitlana Sobkova*****

ABSTRACT

The aim of the article is to determine the conditions for the effective use of group

psychotherapy in working with servicemen with post-traumatic stress disorder (PTSD).

The research employed the methods of testing and formative experiment. The sample

consisted of the servicemen with PTSD symptoms. The group psychotherapy programme

demonstrated uneven effectiveness. The effectiveness of individual and group work in

reducing the symptoms of re-experiencing the event is moderate. Manifestations of

avoiding traumatic situations did not change significantly in the process of group influence,

while a moderate positive influence was recorded in the case of applying an individual

approach. Group psychotherapy is the most effective in working with symptoms of

emotional arousal of servicemen, which results from trauma. The significance of the

implementation of the obtained results lies in the development of effective programmes and

protocols of psychotherapy aimed at overcoming post-traumatic stress disorder of veterans

and combatants. Further research may focus on expanding the research sample and the

implementation of an experimental combination of individual and group psychotherapy in

the work with servicemen with PTSD.

KEYWORDS: Psychotherapy, mental health, stress, stress related diseases, military.



The Faculty of Pre-School Education and Psychology, Khmelnytskyi Humanitarian-Pedagogical Academy,

Khmelnytskyi, Ukraine. ORCID: https://orcid.org/0000-0002-6426-0261. E-mail: luynik29@gmail.com



The Faculty of Pre-School Education and Psychology, Khmelnytskyi Humanitarian-Pedagogical Academy,

Khmelnytskyi, Ukraine. ORCID: https://orcid.org/0000-0002-5324-7272. E-mail: natali_chorna@ukr.net



The Faculty of Pre-School Education and Psychology, Khmelnytskyi Humanitarian-Pedagogical Academy,

Khmelnytskyi, Ukraine. ORCID: https://orcid.org/0000-0002-6469-6831. E-mail: maryna.luk@gmail.com

   

Mykolaiv Institute of Human Development of University "Ukraine", Mykolaiv, Ukraine. ORCID:

https://orcid.org/0000-0001-8657-2840. E-mail: gelvetic.vv@gmail.com

    

Yuriy Fedkovych Chernivtsi National University, Chernivtsi, Ukraine. ORCID: https://orcid.org/0000-

0002-9496-581X. E-mail: si.sobkova@gmail.com

Recibido: 11/12/2023 Aceptado: 15/02/2024

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El efecto de la psicoterapia de grupo en la salud mental de los militares con

trastorno de estrés postraumático

RESUMEN

El objetivo del artículo es determinar las condiciones para el uso eficaz de la psicoterapia de

grupo en el trabajo con militares con trastorno de estrés postraumático (TEPT). La

investigación empleó los métodos de prueba y experimento formativo. La muestra estuvo

formada por militares con síntomas de trastorno de estrés postraumático. El programa de

psicoterapia de grupo demostró una eficacia desigual. La efectividad del trabajo individual y

grupal para reducir los síntomas de reexperimentar el evento es moderada. Las

manifestaciones de evitar situaciones traumáticas no cambiaron significativamente en el

proceso de influencia grupal, mientras que se registró una influencia positiva moderada en

el caso de aplicar un enfoque individual. La psicoterapia de grupo es la más eficaz para

trabajar con los síntomas de excitación emocional de los militares, que resultan de un

trauma. La importancia de la implementación de los resultados obtenidos radica en el

desarrollo de programas y protocolos de psicoterapia eficaces destinados a superar el

trastorno de estrés postraumático de los veteranos y combatientes. La investigación futura

puede centrarse en ampliar la muestra de investigación y la implementación de una

combinación experimental de psicoterapia individual y grupal en el trabajo con militares

con trastorno de estrés postraumático.

PALABRAS CLAVE: psicoterapia, salud mental, estrés, enfermedades relacionadas con el

estrés, militares.

Introduction

The mental health of Ukrainian citizens deteriorated significantly during the Russian-

Ukrainian war. In particular, indicators of anxiety, depression increased, while stress

resistance and life satisfaction decreased significantly (Kurapov et al., 2023). The main

factors in the deterioration of mental health during the Russian-Ukrainian war are the

unpredictability of conditions, deterioration of the economic component of life, and the

negative information background (Seleznova et al., 2023). The situation is complicated by

the traditional tendency to stigmatize mental health problems, which is typical for

Ukrainian society (Quirke et al., 2021). It is obvious that the changes in the mental health of

the civilian population and the servicemen have a different qualitative nature. In particular,

the US experience indicates that post-traumatic stress disorder and depression are the

most common problems of servicemen and combat veterans (Inoue et al., 2023; Trivedi et al.,

2015).

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In general, the problem of post-traumatic stress disorder manifestations among the

civilian population in the context of the Russian-Ukrainian war has only begun to be

studied (Zasiekina et al., 2023). At the same time, it was established that the post-

traumatic stress disorder of servicemen acquired in the combat zone significantly affects

the functioning of the individual (Romaniuk, 2021). It should be noted that the available

studies of the mechanisms of the Ukrainian servicemen’s PTSD mainly refer to the period

2014-2021, while this problem is poorly studied in the context of a full-scale invasion.

The issue of strategy for overcoming PTSD of servicemen deserves special attention. In

this context, the use of group psychotherapy is relevant: a method of influence that

demonstrates systemic effectiveness in the treatment of mental disorders (Rosendahl et al.,

2021). There are data confirming the positive impact of group psychotherapy on

overcoming post-traumatic stress disorder in the context of using cognitive processing

therapy (Schwartze et al., 2019). It was experimentally confirmed that group forms of work

are effective in improving mental health indicators of combat veterans, but these results

need clarification (Cowden et al., 2021). Before the full-scale invasion of Ukraine, there

were attempts to justify psychotherapeutic assistance to servicemen (Kokun et al., 2017).

However, such developments must be defined more exactly and experimentally

substantiated after February 24, 2022. The study of the impact of group psychotherapy on

post-traumatic stress disorder of servicemen participated in the Russian-Ukrainian war is

promising, which is almost not covered in the existing studies. These considerations

determine the relevance of the chosen topic.

The aim of the article

is to determine the conditions for the effective use of group

psychotherapy in working with servicemen with post-traumatic stress disorder.

Research objectives:

1) Analyse theoretical literature on the problems of organizing group psychotherapy,

the phenomenon of mental health, post-traumatic stress disorder in servicemen;

2) Empirically determine indicators of post-traumatic stress disorder of the

servicemen;

3) Experimentally study the possibilities of using group psychotherapy in working

with servicemen with post-traumatic stress disorder.

1. Literature review

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Post-traumatic stress disorder is a mental disorder that causes functional and

cognitive disorders as a result of a traumatic event (Mann & Marwaha, 2023). The main

PTSD symptoms include re-experiencing the traumatic event, obsessions, nightmares,

flashbacks, dissociation from reality, negative emotional and physiological response (Lok et

al., 2018). Furthermore, medicine distinguishes a complex post-traumatic stress disorder,

which is characterized by a more systemic and chronic impact of a traumatic event. ICD-11

(International Classification of Diseases 11th Revision) notes that complex post-traumatic

stress disorder is also characterized by difficulties in emotional regulation, negative

attitude towards oneself, and problems in establishing interpersonal contacts (Giourou et

al., 2018). PTSD symptoms must persist for more than one month, which distinguishes the

studied phenomenon from acute stress disorder (Bryant et al., 2011). PTSD is quite often

associated with sexual and physical abuse (Maercker et al., 2018). In addition to the

psychological and social indicators of the diagnosis of PTSD, attention has been paid to

biological indicators, such as hormonal and neurological changes (Jowf et al., 2023).

Systematic psychotherapy is recommended in cases of post-traumatic stress disorder,

which involves a focus on safety, active interaction between the psychologist and the

patient, trauma-focused intervention and the formation of self-control of the personality

(Maercker et al., 2022). Some researchers question the effectiveness of cognitive processing

therapy as a classic tool for overcoming post-traumatic stress disorder, as well as the

prolonged exposure in working with war veterans (Steenkamp et al., 2015), which requires

special attention to the category of servicemen.

The emergence and development of post-traumatic stress in servicemen is directly

related to combat mental trauma, which involves deformation of self-control and a decrease

in mental stability as a result of exposure to stressors during combat (Blinov, 2016). The

results of the study by Kang et al. (2023) demonstrate a correlation between the

development of PTSD symptoms and the degree of disability acquired during military

operations. Approximately 70% of veterans experience no reduction in PTSD symptoms

after completing treatment (Forbes et al., 2010). This is especially true of traumatic

memories of an event (Levi et al., 2022). At the same time, cognitive therapy and

pharmacological intervention demonstrate greater effectiveness in the treatment of anxiety

disorders (Springer et al., 2018) and depression (Thimm & Antonsen, 2014), compared to

the use of similar methods in case of PTSD. It should be remembered that approaches to

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treating PTSD in servicemen differ from those in the civilian population (Liu et al., 2021). In

particular, trauma-focused therapy, despite its proven effectiveness, has shown better

results in working with non-military citizens (Coventry et al., 2020). At the same time, it is

recommended to use prolonged exposure, cognitive processing therapy, desensitization,

and correction of eye movements in working with servicemen (US Department of Veteran

Affairs, 2020). These tools focus on the cognitive mechanisms of trauma assessment.

The study of the possibilities of group psychotherapy, the use of techniques and

methods of various psychotherapeutic approaches in specially organized communities is

promising in the current conditions. This form of influence is effective not only for the

correction of emotional symptoms — anxiety, depression, reaction to loss, eating disorders

(Burlingame & Strauss, 2021), but also for the formation of a characterological structure,

namely, humanity, rationality, endurance, etc.) (Marmarosh et al., 2022). A

psychotherapeutic group offers participants a sense of social belonging, an awareness of the

meaning of life, and a focus on mutual assistance (Yalom & Leszcz, 2020). A topical area of

research is the comparison of the results of individual and group psychotherapy

(Whittingham et al., 2021). Data on the effectiveness of group psychotherapy in reducing

the manifestations of PTSD in military personnel are encouraging (Cowden et al., 2021;

Morland et al., 2011). There is no significant difference in the effectiveness of both group

and individual CPT in the treatment of PTSD in servicemen (Spiller et al., 2023). According

to other data, the effectiveness of group work according to other data is about half as much

as that of individual work (Resick et al., 2017).

Therefore, the analysis of the problem of using group psychotherapy in the work with

PTSD of servicemen showed the existence of a large number of studies on this issue. At the

same time, the available results are often contradictory and require clarification in the

context of the Russian-Ukrainian war.

2. Methodology

Experimental work was carried out in the period from June to December 2023 and

included the following stages:

Problem statement involved determining the relevance and substantiating the

significance of the research in the context of academic and social trends. In addition, the

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problems of finding and using tools to influence PTSD correspond to the authors’ academic

interests.

The

theoretical analysis of the problem

is a study of the academic literature, which focused

on two aspects: “post-traumatic stress disorder in servicemen” and “group psychotherapy

in working with combatants”.

The hypothesis

was based on the analysis of theoretical sources and provided for the

statement that the use of a group form of psychotherapy in the treatment of PTSD of the

servicemen is effective and differs from the effect of individual psychotherapy.

Research planning is the development of a theoretically and methodologically grounded

algorithm of actions aimed at achieving the aim of the research and testing the hypothesis.

At this stage, the available resources (material, human, time) and the possibilities of using

them in the research were analysed. Planning is based on the systematicity principle.

Conducting research - carrying out two stages of diagnostics and formative influence:

group psychotherapeutic work with the servicemen.

Data analysis — the use of statistical methods aimed at identifying differences in PTSD

of the servicemen at the beginning and at the end of the study.

Data interpretation – explanation of the obtained results in order to clarify the

effectiveness of the formative experiment.

Drawing final research conclusions.

2.1. Instruments

The Clinician-Administered PTSD Scale (CAPS) was used to identify indicators of

post-traumatic stress disorder in servicemen. The proposed tool is valid and adapted to the

Ukrainian language (Kokun et al., 2017). The technique makes it possible to detect the level

of manifestation of various PTSD symptoms, namely, re-experiencing the event, avoiding

traumatic stimuli, and hyperarousal. The used scale is designed for working with

servicemen.

The formative experiment is planned for testing the research hypothesis. The

independent variable of the experiment is the system of cognitive processing therapy

classes implemented through group work. The dependent variable of the experiment is the

symptoms of post-traumatic stress disorder in the servicemen.

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The sample was formed from among the servicemen who participated in combat

operations, but temporarily or permanently ceased combat activity because of injuries.

Another criterion for selection for the study was pronounced PTSD symptoms, which

persisted for several months after the traumatic situation. Before the start of the study, the

attitude towards psychotherapy in general and the presence of serious mental disorders

were checked, which made further work impossible. The results of the observation were

defined more accurately by means of testing. The initial quantitative composition of the

experimental group (EG) and control group (CG) is 30 people each. The samples meet the

representativeness requirements. The study participants had no previous experience of

psychotherapy. The most common type of traumatic situation experienced by the sample

members is injury, loss of co-combatants. At the same time, loud noises, news, alcohol

intoxication, and a situation of social conflict can be factors that activate the PTSD

symptoms.

2.2. Data collection

The diagnostics took place in direct contact with the research participants. Methods

and techniques of cognitive processing therapy were chosen as an effective means of

working with PTSD. As already mentioned, the work was carried out in an individual

format in the CG, while it had a group format in the EG. The EG was divided into

subgroups of 6 people, where psychotherapeutic work was carried out. It was separately

discussed that the servicemen could withdraw from the experiment at any time. A total of 2

people in the CG and 3 people in the EG used this right during the experiment. Their

results are not taken into account in the final data processing. Qualified psychotherapists

with at least 5 years of experience working with PTSD were involved in both groups. The

experiment lasted for three months.

The data analysis was carried out through the use of percentage data analysis, the

Kolmogorov-Smirnov test to check the normality of the distribution of statistical series,

and the Wilcoxon signed-rank test to determine the effectiveness of the experiment. The

SPSS.22 statistics software was used.

The ethical criteria of the study provided for strict adherence to the principle of

confidentiality of the obtained data. The participation of the servicemen in the

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experimental programme was based on the voluntary consent of the military and detailed

familiarization with the course of the experiment.

3. Results

The results obtained in the process of providing psychotherapeutic assistance are

presented graphically. In the Figure 1, the EG stands for the experimental group, and CG —

for the control group. Accordingly, numbers 1 and 2 reflect the primary and repeated

diagnostic tests.

Figure 1. Changes in the symptoms of re-experiencing the event as a result of the

implementation of the experimental programme

Figure 1 shows the dynamics of changes in the recurrent experience of the event after

the end of the psychotherapeutic intervention. The initial diagnostics did not reveal

individuals with low indicators of these symptoms. This is understandable, because

according to the conditions of the experiment, the servicemen with pronounced post-

traumatic stress syndrome were included in the sample. More than 80% of respondents

demonstrated high rates of tendency to re-experience traumatic events. At the same time,

about 20% of the servicemen have medium manifestations of the specified symptoms.

Individual psychotherapy showed a 38.99% reduction in the number of individuals with a

high level of tendency to re-experiencing a traumatic situation. At the same time, this

indicator is 22.22% in the EG. Therefore, individual psychotherapy showed a slightly higher

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effectiveness than group therapy, however, the obtained data do not indicate high

effectiveness of both approaches.

The dynamics of individual manifestations of symptoms of re-experiencing a

traumatic situation is described below. In particular, almost no positive changes were

recorded in the manifestations of obsessive memories in both groups of servicemen. The

primary and secondary diagnostics demonstrated a rather intense and frequent experience

of this symptom. The experience of provoking factors is mostly recorded at the medium

level and slightly decreased in both groups after the psychotherapy. The level of

experiencing flashbacks in the absolute majority of the studied servicemen is high and

almost did not change after the end of the experimental programme. The only symptom of

the group that really significantly decreased after psychotherapy was the intensity and

frequency of nightmares. However, such dynamics are more positive in individual work

compared to group work.

Figure 2 presents the dynamics of symptoms of avoidance of traumatic factors. The

distribution of these PTSD manifestations of the servicemen is similar to the results of the

study of the previous group of reactions — high indicators, approaching 90%, dominate.

The percentage of the servicemen with high level of symptoms decreased by 28.58 in the

CG with individual psychotherapy. In group psychotherapy, the shift is 11.15% (3 people).

In other words, better results of psychotherapy were recorded in the CG than in the EG,

where the indicators did not change significantly.

The mechanism of avoidance of thoughts and conversations about a traumatic

situation in the subjects is at a medium level — the indicators did not change after the

experimental programme. A decreased interest in activities and social contacts is mainly

manifested in medium and high indicators and does not undergo significant changes in the

course of psychotherapy. Medium and high manifestations of memory selectivity in relation

to the traumatic situation remain unchanged. The servicemen with PTSD are characterized

by high indicators of detachment from the events of the outside world and activities — the

indicators were somewhat optimized in the course of psychotherapy. A significant

narrowing of the emotional attitude to reality was found in the studied groups, which

expanded after the psychotherapeutic intervention due to the realization of a wider range

of emotions. This parameter is the only one that clearly changed after the psychotherapy in

the studied group of symptoms. Pronounced tendencies to lose a sense of perspective and

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meaning in further life are characteristic for the servicemen with PTSD — the indicators

did not improve during psychotherapy.

Figure 2. Changes in the symptoms of avoidance of traumatic stimuli as a result of the

experimental programme

Figure 3 presents the dynamics of emotional excitability of the servicemen with PTSD

during the formative experiment. High indicators of this group of symptoms are typical for

70% of the subjects, which is somewhat lower compared to the previous types of symptoms.

High indicators in the course of individual psychotherapy decreased by 39.29%, and as a

result of group psychotherapy — by 44.44%. At the same time, working in groups

stimulated the growth of low indicators of hyperarousal up to 14.81%. Therefore, group

psychotherapy demonstrated the highest effectiveness in the context of working with

hyperarousal of the servicemen with PTSD.

The subjects had a medium level of sleep disturbance, but this parameter improved in

both groups after the psychotherapy. Before the start of the study, the servicemen with

PTSD had high rates of uncontrollable anger, which significantly decreased, especially

during group psychotherapy. The testing also recorded an improvement in the servicemen’s

concentration of attention as a result of the formative influence — this dynamic is more

pronounced in the EG. The medium indicators of somatic reactions to arousal factors did

not change significantly in both groups, which was recorded in the diagnostic interviews in

the results of repeated testing.

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Figure 3. Changes in the symptoms of hyperarousal as a result of the experimental

programme

Justified statistical procedures were carried out in order to confirm the preliminary

conclusions of the study. The Kolmogorov-Smirnov test confirmed the appropriateness of

using the non-parametric Wilcoxon test, as the statistical series do not conform to the

normal distribution law (see Table 1). All three groups of PTSD symptoms demonstrated

significance of changes at p=0.05, indicating moderate effectiveness of individual

psychotherapy in working with the servicemen. Significant changes in the re-experiencing

of the event (p = 0.05) and hyperarousal (p = 0.01) symptoms were recorded. The symptoms

of avoidance of traumatic situations do not show significant changes in group

psychotherapy.

4. Discussion

The study was carried out within a comparative strategy, which helps to clarify the

relevance of different forms of psychotherapy for the treatment of PTSD (Whittingham et

al., 2021). In general, differences between individual and group psychotherapy in

overcoming PTSD in the servicemen were found, which contradicts the available data

(Spiller et al., 2023). Such differences are explained by the sociocultural aspect of the study

and the strength of traumatic factors. Group psychotherapy demonstrated uneven

effectiveness in this study. In particular, the performance of the experimental programme in

improving re-experiencing symptoms is moderate. Information about the resistance of

traumatic flashbacks to psychotherapeutic influence in both groups is confirmed by

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previous studies (Levi et al., 2022). Both forms of psychotherapy do not differ in their effect

on the studied group of symptoms.

Table 1. The Wilcoxon test scores of PTSD symptoms in the servicemen after the individual

and group psychotherapy

Manifestations of avoiding traumatic situations did not change significantly in the

process of group exposure, while a moderate positive impact was recorded in individual

psychotherapy. Therefore, the phenomenon of emotional decline in attitude to reality is

more sensitive to changes in a situation of greater limitation of social interaction. Group

psychotherapy proved to be the most effective in reducing indicators of emotional arousal

in post-traumatic stress disorder of the servicemen. So, we can conclude that social

interaction and trusting relationships with people with similar combat experience

determine an increase in the level of emotional control of veterans. In general, the use of

cognitive processing therapy in a group form of psychotherapeutic work of group

psychotherapy to overcome PTSD confirms its effectiveness (Schwartze et al., 2019), but

has its own specifics. These features are related to the specific context of the Russian-

Ukrainian war and socio-cultural living conditions, in particular, Ukrainian society’s

tendency to stigmatize mental disorders (Quirke et al., 2021). Observation of the studied

subjects during psychotherapy revealed “classic symptoms” of PTSD, such as flashbacks,

obsessive thoughts, nightmares, and maladaptive emotional reactions (Lok et al., 2018). The

figure of 30% of military personnel experiencing improvement in the context of PTSD

treatment through psychotherapy remains relevant in our study (Forbes et al., 2010).

Observation of the servicemen during psychotherapy revealed “classic symptoms” of

PTSD, such as flashbacks, obsessive thoughts, nightmares, and maladaptive emotional

reactions (Lok et al., 2018). The figure of 30% of servicemen experiencing improvement in

Symptoms of post-traumatic stress

disorder

Wilcoxon’s t-test

Individual psychotherapy

Group psychotherapy

Re-experiencing of the event

119*

114*

Avoidance of traumatic situations

107*

189

Hyperarousal

125*

83**

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the context of PTSD treatment through psychotherapy remains relevant in our study

(Forbes et al., 2010).

The opinion on the differentiation of approaches to working with

PTSD

by civilians

and military is significant (Liu et al., 2021). Optimizing group psychotherapy also involves

preliminary individual work with the patient, which is of a preparatory nature (Kokun et

al., 2017). In our opinion, the possibility of biological substantiation of psychotherapy for

post-traumatic stress disorder (Jowf et al., 2023), in particular, in the context of fixing the

level of cortisol in the body, is promising. The atmosphere of mutual help and social

belonging that is characteristic of group psychotherapy opens up additional opportunities

for the treatment of PTSD (Yalom & Leszcz, 2020), which has its own specifics in the

context of working with the servicemen.

Conclusions

The conducted research revealed the differences between individual and group

psychotherapy in overcoming PTSD of the servicemen. It was found that the group

psychotherapy programme demonstrated uneven effectiveness. The effectiveness of

individual and group work in reducing the symptoms of re-experiencing the event is

moderate. Manifestations of avoiding traumatic situations did not change significantly in

the course of group influence, while a moderate positive influence was recorded in case of

applying an individual approach. Group psychotherapy is the most effective in working

with symptoms of emotional arousal of the servicemen manifested as a result of trauma.

Cognitive processing therapy in general has proven itself as an effective tool for working

with PTSD in the servicemen. The significance of the implementation of the obtained

results implies the development of effective programmes and protocols of psychotherapy

aimed at overcoming post-traumatic stress disorder of veterans and combatants. In

particular, the experience of psychological assistance to veterans and the research

verification of various psychotherapy strategies in the context of the Russian-Ukrainian

war are valuable. The prospects of further research may be the expansion of the research

sample and the implementation of an experimental combination of individual and group

psychotherapy in the work with PTSD of servicemen.

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Limitations

The results of the study on the group psychotherapy for working with the servicemen

with PTSD should be defined more exactly with a larger number of subjects.

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