Psychotherapeutic treatment program for posttraumatic stress disorder:
prospective study of 70 war veterans
Dolores Britvić, M.D.
Vesna Antičević, psychologist
Ivan Urlić, M.D., Ph.D.
Goran Dodig, M.D., Ph.D.
Branka Lapenda, M.D.
Vesna Kekez, psychologist
Department of psychiatry, Clinical hospital Split, Split University School of Medicine,
Split, Croatia
Correspondence:
Britvić Dolores
Klinička bolnica Split
Šoltanska 1
21 000 Split
Tel. 00 385 21 557 411
00 385 21 220-586
Fax 00385 21 557 507
dbritvic@globalnet.hr
Short title:
Outpatient psychotherapeutic program for PTSD
Key words (not in title).
Combat, outcome, group psychotherapy, depression, quality of life.
Abstract:
Aim. To assess the effectiveness of psychotherapeutic model of treatment of war
veterans with posttraumatic stress disorder (PTSD), by evaluating the symptoms of
PTSD, associated neurotic symptoms, ways of coping with stress, and indicators of
quality of life and depressiveness.
Methods. Prospective cohort study included 77 war veterans who took part in a
psychotherapeutic model of treatment lasting 40 weeks. On each visit, there were
three types of group sessions: socio-therapeutic, psycho-educative, and traumafocused groups. Groups consisted of 10-12 veterans, and each session lasted 60
minutes. Mississippi scale for PTSD was used for assessing the intensity of PTSD,
Crown-Crisp Index for neurotic symptoms, Inventory of dispositional and situational
coping with stress for ways of coping with stress, Quality of Life Scale for indicators
of quality of life, and Beck Depression Inventory for depression at the beginning and
the end of psychotherapeutic program.
Results. Seventy veterans finished the whole course of treatment. After the
completed psychotherapeutic treatment program, there was an increase in problemoriented coping with stress (t=-2.073, p=0.042), and coping by avoidance (t=-2.803,
p=0.007). BDI scores at the end of treatment were significantly lower than at the
beginning (t=4.563, p=0.000). There were no significant changes in symptoms of
PTSD (t=1.730, p=0.088), neurotic symptoms and scores on the QLS (t=-1.825,
p=0.072).
Conclusion. Revealing and working through the traumatic events facilitated gradual
ending of the process of pathologic grief, which resulted in reduction of depression.
Other therapeutic factors (altruism, giving hope, developing social skills) contributed
to the achieved therapeutic effects.
Introduction
Ten years after the end of war in Croatia, there are still many patients showing a
complex posttraumatic response to traumatic experiences (1, 2). Brutality and
repetitive nature of traumatic battlefield experience profoundly changes motives,
spiritual and existential views on life, as well as the individual feeling of meaning and
purpose (3). An inner world of deeply repressed emotions reflects itself on the totality
of intrapsychic and interpersonal layers of personality, causing changes in biological
functions, strong anxiety, and often depression and changes in quality of life (4-7).
Group psychotherapy, which goes deep into intrapsychic and interpersonal spheres,
is a necessary part of integral approach to treatment of psychotrauma (8,9).
Literature on group therapy of posttraumatic stress disorder (PTSD) gives
descriptions of different therapeutic techniques, each of them mostly focusing on a
particular psychological disturbance such as anxiety, fear or avoidance behavior (10,
11). The majority of recent studies suggests multidimensional approach using
psychoeducation, support, anxiety relief, and life-style modification, all of which have
a goal of normalizing the stress reactions and reducing the maladaptive
psychobiological processes (8-10). Various models are recommended for this
purpose, but there is still no common stand on how these integral techniques should
be applied. The fact that only a few studies evaluated the effect of such treatment
(12-15) contributes to the problem.
Aiming towards the above mentioned in treatment of PTSP, we implemented a
psychotherapeutic program consisting of socio-therapeutic, psycho-educative and
dynamic-oriented group approach. The purpose of this study was to assess the
effectiveness of such psychotherapeutic program by evaluating the symptoms of
PTSD, neurotic symptoms, ways of coping with stress, depressiveness and indicators
of quality of life.
Patients and methods
Participants
The study included war veterans who came for treatment in the Regional Center for
Psychotrauma at the Department of Psychiatry of the Clinical Hospital Split, from
January 2003 to October 2005. Detailed screening procedure was performed prior to
admission to identify the veterans with PTSD according to the International
Classification of Diseases, 10th revision (16). For this purpose, we used clinical
interview and patients’ medical records (findings of psychiatrist and psychologist,
including intelligence test results). Inclusion criteria were age between 25 and 65
years and the diagnosis of PTSD as a consequence of traumatic experiences while
serving in the Croatian Army units. Exclusion criteria were central nervous system
disease, alcohol and drug addiction, acute psychosis, severe form of PTSP which
precludes participation in the treatment program, and subnormal intelligence. Data on
participants' intelligence were obtained from their psychological findings.
Therapeutic technique
Therapeutic program was carried out for 40 weeks. At each meeting, patients
participated in three types of groups: 1) socio-therapeutic, 2) psycho-educative, and
3) dynamic-oriented group for working through traumatic experience. Groups
consisted of 10-12 veterans, and each session lasted 60 minutes. On each occasion,
participants would stay in the Center for a total of 5 hours. The socio-therapeutic
group was led by a social worker, psycho-educative group by a psychiatrist or
psychologist, and dynamic-oriented group by group therapists (psychiatrist or
psychologist). The primary goal was to help war veterans establish a feeling of trust,
security and reciprocity. The way of conducting the group sessions was active,
supporting, facilitating and stimulating.
Socio-therapeutic group. Supportive techniques were used to foster reciprocity,
acceptance, altruism, universality and better communication. At the beginning of the
program, the most recurring themes were reality's problems such as obtaining the
status of military war invalid and the right to pension. Later on, focus was transferred
on solving current problems at work, in family and society. The participants were
encouraged to improve the communication with their family members, to take up their
family duties more actively, and to strengthen their male roles. Positive transfers of
the group members were crucial in facilitating acceptance of new patterns of behavior
(3, 8- 10).
Psycho-educative group. Participants were informed about the symptoms of PTSD,
its consequences on the family, professional and social functioning, as well as the
ways of coping with mental disturbances by using the techniques of conflict resolution
and other social skills. Participants were able to recognize the symptoms and face
the fact that their everyday problems in interpersonal relationships were the result of
disorder caused by a traumatic experience. These insights were well received by the
members of the group, and brought them a sense of relief.
Mirroring with other group members who had the similar or same symptoms
stimulated self-discovering and self-acceptance, and contributed to the feeling of
unity, connection and acceptance by others (3, 10).
Trauma focused group. Participants were stimulated to disclose their traumatic
experiences and reconstruct them in detail, describing location, period of the day,
fellow soldiers, enemies, as well as their emotional reactions at the time and after the
traumatic event. Especially at the beginning of the program, but also during the whole
course of treatment, there was a strong resistance to disclosure and working through
traumatic experience. A valuable signpost in revealing the trauma was bringing up
dreams of the traumatic event, dreams with content very similar to the traumatic
event, or with strong emotions of fear and panic. Presentment of traumatic memories
would provoke strong feelings in the whole group, and some of participants would be
moved to open up, while others would react by acting out and leaving the session,
becoming verbally aggressive towards the therapist, or missing the next session.
Opening traumatic memories threatened intrapsychic balance, so we often heard
complaints about intensified symptoms, sleep disturbances, isolation and withdrawal
from family members. In the beginning phases, participants primarily revealed
traumatic events associated with the fear for their own existence, grief for fellow
soldiers who were killed, and the guilt of surviving. As confidence in the group and
therapists increased, revealing expanded to the traumatic events associated with
strong feelings of guilt (17, 18).
At the very beginning of the program, the emphasis was on establishing basic
security and trust in the group and the therapist. Here we often encountered issues
related to distrust in the staff and group leaders. After approximately 15 meetings,
cohesion and connections between the group members would develop, which helped
to overcome the resistance and to disclose traumatic experiences as well as the
problems in social relations and in family. With increased closeness and connections
between the group members, the act of revealing traumatic memories was
accompanied by feelings of sadness and grief. Group members would become very
vulnerable due to the grief for killed fellow soldiers and due to the loss of ego
idealizations because of what happened on the battlefield. Opening up of painful
traumatic memories in some participants provoked worsening of the clinical picture,
which in two cases required hospitalization. In this stage of group work, participants
sometimes expressed suicidal phantasies, or described the attempts of suicide,
either their own or of their friends and fellow combatants. The atmosphere was much
more comfortable and easier in the last third of the program.
Outcome measures
Mental state of participants was evaluated by the following self-assessment
instruments:
A) Mississippi scale for assessing the symptoms of post-traumatic stress disorder
(MPTSD), B) the Crown-Crisp Experiential Index, C) Inventory of dispositional and
situational coping with stress, D) Quality of Life Questionnaire, E) Beck Depression
Inventory. Evaluation was done in two time points: before the beginning of treatment,
and at the end of the program.
The study was approved by the Ethics Committee of the Split University School of
Medicine and the Clinical Hospital Split. Patients were informed about the study and
gave a written consent.
Mississippi scale for assessing the symptoms of post-traumatic stress disorder
(MPTSD) is considered one of the best instruments for assessing the intensity of
PTSD in war veterans, and correlates highly with other measures for PTSD. It
consists of 35 items with a series of 5-point Likert-type responses ranging from
„totally incorrect“ to „completely correct“. The sum of individual responses gives a
continuous result as a measure of the intensity of PTSD symptoms. The scale has a
good reliability and validity, as well as the sensitivity and specificity (19).
Crown Crisp Experiential Index (CCEI) is used to assess neurotic symptoms and
measure changes before and after an intervention (20). Index is objective and
satisfactorily meets two basic psychometric criteria: reliability and validity (20,21).
Inventory of dispositional and situational coping with stress (COPE) consists of 17
theoretically derived scales which describe three factors of the higher order: problemoriented coping, emotions-oriented coping, and coping by avoidance. The inventory
is a Croatian version of original COPE questionnaire, from which 15 scales were
taken, and two more were added to include the answers specific for this area (22,
23).
Quality of Life Scale consists of 21 items which measure various aspects of quality of
life. The scale is used: 1) as a synthetical, global indicator of the state of an
individual, 2) for assessing effects of various medical or psychotherapeutic
interventions on the quality of life of individual, and 3) for assessing the quality of life
as a dependant variable in scientific research (24).
Beck Depression Inventory (BDI) consists of 21 items by which the intensity and
structure of the symptoms of depression is evaluated. Symptoms are defined
according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders
(DSM IV). The questionnaire is sensitive to the changes which are the result of
psychotherapy or pharmacotherapy. It well discriminates mild, medium and severe
depression. The reliability coefficient is 0.80 (25).
Statistics
The variables are evaluated descriptively (mean and standard deviation), and
analyzed with T-test for dependant samples. Software program SPSS 12.0 for
Windows (Chicago, IL: SPSS Inc., 2003) was used for data analysis; significance
level was set at 0.05.
Results
A total of 151 war veterans were examined (Figure 1). Forty-four veterans did not
meet inclusion criteria: diagnosis of PTSD was not confirmed in 30 veterans, 2 were
addicted to psychoactive drugs, 3 were diagnosed with acute psychosis, 4 were of
subnormal intelligence, and 5 had a severe disorder that required hospital rather than
outpatient treatment. Sixteen veterans refused to participate in the study and 14 did
not answer the invitation for group psychotherapy.
Seventy-seven patients began the psychotherapy, and 70 completed the whole
course of treatment. All patients were men. In the group of veterans who completed
the psychotherapy, more than a half (n=37) were in the 30-40 age group, and 24
were in the 40-50 age group. Mean age was 39.5±6.09 years. Most of the
participants (n=57) had high school education (10-12 years of school). The majority
(n=54) was married, 14 were single, and no one was divorced. Most of the
participants (n=60) spent less than 3 years on the battlefield (Table 1).
Out of 7 patients who quit therapy, 4 did it at the very beginning. They stated
complexity and long duration of the program as the reasons for quitting. Two patients
got jobs after three months and decided to stop coming to the therapy. One quit
without explanation.
Total score of symptoms of PTSD as measured by the MPTSD were lower at the end
than at the beginning of the program, but the difference was not significant (t=1.730,
p=0.088).
On the CCI scales of anxiety, phobia, obsession, somatization, depression and
hysteria, there were no significant differences between the results at the beginning
and end of the program (Table 2.)
Results of Inventory of dispositional and situational coping with stress showed
significant differences in two out of three categories: problem-oriented coping and
coping by avoidance. Problem-oriented coping significantly increased from the
beginning (M=45.9917.85) to the end (M=49.5315.95) of the program (t=-2.073,
p=0.042). Emotions-oriented coping also increased, but not significantly (t=-0.833,
p=0.408). Coping by avoidance increased from the beginning (M=79.7726.22) to the
end (M=88.5426.52) of program, and the difference was significant (t=-2.803,
p=0.007).
Results of the Quality of Life Scale at the beginning of the program (M=57.6111.39)
were lower than at the end (M=59.9110.37), but the difference was not significant
(t=-1.825, p=0.072).
Significant difference was observed on the results of Beck's Depression Inventory
(t=4.563, p=0.000). Depressiveness decreased from the beginning of the program
(M=38.4110.23) to the end of it (M=29.198.49) (Table 2).
Discussion
The results of this study show that the psychotherapeutic treatment program leads to
changes in ways of coping with stress and reduces depressiveness, but it does not
bring significant changes in symptoms of PTSD, neurotic symptoms and scores on
QLS.
Guidelines for treatment of PTSD recommend the combined use of therapeutic
techniques, but the results of available studies are varying. Hence there is a need for
evaluation of the multidimensional approach also on the population of Croatian war
veterans suffering from the chronic PTSD. In such an evaluation, it is not possible to
assess the effect of each individual technique. The limitation of the study is a
relatively small number of participants, which is resulting from the very nature of
therapeutic process. In assessing the effect of treatment, the problem of control
group arises. The use of control group in psychotherapy is questionable, because it is
very difficult to find a group which would be similar to the treated group in all relevant
characteristics. This study did not include follow-up data collected a year after the
end of treatment. This, together with a comparison with war veterans on the waiting
list, will be analyzed in the continuation of this study.
Several studies evaluated treatment programs consisting of psychoeducative groups,
thematic groups, and in some instances groups for working through traumatic
experience (26,27). Described programs were very diverse, conducted in-hospital or
out-of-hospital, lasting for 90 days, 12 weeks and up to 4 months. Such a diversity
does not allow appropriate comparing with the results of our study. Furthermore, the
results of previous studies are unequal. Some reported reduction in the intensity of
the PTSD symptoms, while others found no change (12-15, 26, 27). Most studies
showed improvement in interpersonal relationships and family functioning, and some
observed an attenuation in feelings of guilt, shame and loneliness (13, 14, 28).
Our study did not find a significant reduction of the PTSD symptoms measured by the
MPTSD and neurotic symptoms, and no increase in the QLS scores, which is in
accordance with the results of some previous studies (13,29,30). An earlier study by
this group found that a long-term dynamic-oriented group psychotherapy reduces the
symptoms of PTSD in war veterans, which is an indication that such a method is
more effective than a combined psychotherapeutic treatment program lasting only 40
weeks. These findings confirm the conclusions by this group about the need of longterm group psychotherapy of chronic PTSD to reduce the symptoms of this disorder
(10, 31).
Results of the Inventory of coping with stress (COPE), conducted at the end of
treatment, showed an increase in problem-oriented coping, but also in coping by
avoidance. The increase in problem-oriented coping indicate an improvement in
communication with environment, more active taking of roles within the family and
work place, and less difficulties in controlling aggression, all of which is consistent
with the findings of previous studies (14). Beside the more frequent use of this
positive way of coping with stress, there is also an increase in coping by avoidance.
This finding can be a sign of a tendency to avoid conflicts, which results from the
therapeutic efforts to acquire these skills. The results demonstrate the importance of
psychoeducational and sociotherapeutic aspect of treatment, which includes
receiving information about the PTSD symptoms, understanding the reasons behind
the intrapsychic and interpersonal problems, but also acquiring the new
communication skills and conflict resolution skills in an atmosphere of trust,
universality and connection with others (8,9,10).
Data on depression were obtained by two tests. Results of the CCI depression scale
showed no change in depression when compared with the level from the beginning of
treatment. A reduction of depression was observed when measured by the BDI. This
discrepancy can be explained by different sensitivity of two tests, out of which CCI
evaluates depression as a personality trait, and BDI the present emotional state.
Observed improvement can be explained from the viewpoint of resolving the process
of pathologic grief, but also the positive effects of other therapeutic factors during the
group treatment (32,33).
In the dynamic-oriented group trauma-focused group, patients are able to reveal and
work through long-suppressed, emotionally invested memories of traumatic
experiences. Psychotherapeutic interventions enabled patients to re-live the
emotions of guilt and shame in a new context of group setting (18, 33, 34). Revealing
and working through the traumatic events facilitated gradual ending of the process of
pathologic grief, which resulted in reduction of depression. Other therapeutic factors
(altruism, giving hope, cohesion and acceptance, leading and directing, developing
social skills, discovering and understanding oneself) undoubtedly contributed to the
achieved therapeutic effects (14).
References
1. Tocilj ŠG, Urlić I. War Truma: Emotional responses and psychological
defenses of displaced persons. Croatian Med J. 1995;36:253-61.
2. Lončar M, Medved V, Jovanović N, Hotujac Lj. Psychological consequences of
rape on women in1991-1995 war in Croatia and Bosna and Herzegovina.
Croatian Med J. 2006;47:67-75.
3. Willson JP, Friedman MJ, Lindy JD, editors. Treathing psychological trauma
and PTSD. New York, London: Guilford Press; 2004.
4. Elsesser K, Sartory G, Tackenberg A. Initial symptoms and reactions to
trauma-related stimuli and the development of posttraumatic stress disorder.
Depress Anxiety. 2005;21:61-70.
5. Gudmundsdottir B, Beck JG, Coffey SF, Miller L, Palyo SA. Quality of life and
post trauma symptomatology in motor vehicle accident survivors: the
mediating effects of depression and anxiety. Depress Anxiety. 2004;20(4):1879.
6. Cox BJ, Clara IP, Enns Mw. Posttraumatic stress disorder and the structure of
common mental disorders. Depress Anxiety. 2002;15(4):168-71.
7. Golier JA, Yehuda R, Schmeidler J. Siever LJ. Variability and severity of
depression and anxiety in post traumatic stress disorder and major depressive
disorder. Depress Anxiety. 2001;13(2):97-100.
8. Shalev AY, Bonne O, Eth S. Treatment of posttraumatic stress disorder: a
review. Psychosom Med. 1996;58:165-82.
9. Foa EB, Terence MK, Friedman MJ. Guidelines for treatment of PTSD. J
Traum Stress. 2000;13:539-85.
10. Marmar CR. An Integrated approach for treating posttraumatic stress. In:
Pynoos RS, editor. Posttraumatic stress disorder. A clinical review. Lutherville:
The Sidran Press; 1994.p.99-132.
11. Gregurek R. Countertransference problems in the treatment of mixed group of
war veterans and female partners of war veterans. Croat Med J. 1999;40:493497.
12. Hammarberg M, Silver SM. Outcome of treatment for post-traumatic stress
disorder in a primary care unit serving Vietnam veterans. J Trauma Stress.
1994;7:195-216.
13. Ragsdale KG, Cox RD, Finn P. Effectiveness of short-term specialized
inpatient treatment for war-related posttraumatic stress disorder: a role for
adventure-based counseling and psychodrama. J Tram Stress. 1996;9:269283.
14. Johnson DR, Rosenheck MD, Fontana A. Outcome of intensive inpatient
treatment for combat-related posttraumatic stress disorder. Am J Psychiatry.
1996;153:771-7.
15. Schnurr PP, Friedman MJ, Foy DW. Randomized trial of trauma-focused
group therapy for posttraumatic stress disorder: results from a Department of
Veterans affairs cooperative study. Arch Gen Psychiatry, 2003;60:481-89.
16. International Classification of Diseases, 10th revision. [in Croatian] Zagreb:
Medicinska naklada; 1994.
17. Weinberg H, Nuttman-Shwartz O, Gilmore M. Trauma groups: an overview.
Group Analysis. 2005;38:187-202
18. Urlić I. Aftermath of war experience: impact of anxiety and aggressive feelings
on the group and the therapist. Croatian Med J. 1999;40:486-492.
19. Keane TM, Wolfe J, Taylor KL. Post-traumatic stress disorder: evidence for
diagnostic validity and methods of psychological assessment. J of Clin
Psychol. 1987;43:32-43.
20. Crown S, Crisp AH. Manual of the Crown-Crisp Experiental Index. London:
Hodder and Stoughton; 1979.
21. Crown S, Crisp AH. Handook for Crown-Crisp Experiential Index. [in Croatian]
Jastrebarsko: Naklada Slap; 1994.
22. Lazarus RS, Folkman S. Stress, appraisal and coping. New York: Springer
Publishing; 1984.
23. Hudek-Knezević
J,
Kardum
I,
Vukmirović
Z.
The
structure
of
coping styles: A comparative study of Croatian sample. European Journal of
Personality, 1999;13:149-161.
24. Krizmanić M, Kolesarić V. Quality of Life scales (in Croatian). Jastrebarsko:
Naklada Slap; 1992.
25. Beck TA. Beck Depression Inventory. (in Croatian). Jastrebarsko: Naklada
Slap; 2000.
26. Elliot P, Biddle D, Hawthorne G. Patterns of treatment response in chronic
posttraumatic stress disorder: an application of latent growth mixture
modeling. J Trauma Stress. 2005;18:303-11.
27. Lubin H, Loris M, Burt J. Efficacy of psychoeducational group therapy in
reducing symptoms of posttraumatic stress disorder among multiply
traumatized women. Am J Psychiatry. 1998;155:1172-1177.
28. Scurfield RM, Kenderdine SK, Pollard RJ. Inpatient treatment for war- related
post-traumatic stress disorder: initial findings on a longer-term outcome study.
J Traum Stress. 1990;3:185-201.
29. Munley PH, Bains DS, Frazee J, Schwartz LT. Inpatient PTSD treatment: A
study of pretreatment measures, treatment dropout, and therapist ratings of
response to treatment. J Traum Stress. 1994;7:319-25.
30. Fontana A, Rosenheck R, Horvath T. Social support and psychopathology in
the war zone. J Nerv Ment Dis. 1997;185:675-681.
31. Britvić D, Radelić N, Urlić I. Long-term dynamic oriented group psychotherapy
of posttraumatic stress disorder: prospective study of five-years treatment of
war veterans. Croatian Med J. 2006;47:76-84.
32. Urlić I. Recognizing inner and outer realities as a process: on some
countertransferential issues of the group conductor. Group Analysis.
2005;38:249-63.
33. Urlić I. Trauma and reparation, mourning and forgiveness: the healing
potential of the group. Group Analysis. 2004;37:453-71.
Table 1. Demographic characteristics of 70 war veterans who participated in the
psychotherapeutic treatment program in the day hospital of the Regional Center for
Psychotrauma Split.
n = 70
Characteristic
s
Years
30
0
30-39
37
40-49
24
50-59
9
> 60
0
Education
Elementary
7
school
High school
57
College and
6
university
Marital status
54
Married
Single
14
Divorced
0
Time spent on
the battlefield
< 3 years
60
3 - 4 years
7
> 4 years
3
Table 2. Results of assessment of 70 war veterans who participated in the
psychotherapeutic treatment program in the day hospital of the Regional Center for
Psychotrauma Split.
Admission
Discharge
MPTSD*
134.4816.328
132.0416.377
Anxiety
12.632.240
Phobia
T
P
1.730
0.088
13.01.985
- 1.564
0.122
7.87 2.718
8.403.246
- 1.637
0.106
Obsession
8.092.653
8.703.085
- 1.875
0.065
Somatization
12.163.300
12.912.739
- 1.968
0.053
Depression
11.833.026
11.812.666
0.049
0.961
Hysteria
3.092.339
3.272.359
- 0.714
0.478
Problem-
45.9917.858
49.5315.958
- 2.073
0.042†
18.5610.459)
19.378.131
- 0.833
0.408
88.5426.524
- 2.803
0.007†
oriented
coping
Emotionsoriented
coping
Coping
by 79.7726.224
avoidance
Quality of life
57.6111.398
59.9110.374
- 1.825
0.072
Becks
38.4110.231
29.198.496
4.563
0.000†
Depression
Inventory
* Mississippi scale for assessing the symptoms of post-traumatic stress disorder.
† Statistically significant difference between two time points (p<0.005).
Figure 1. Flow of patients through the study.
151 war veterans
examined
44 did not
meet inclusion
criteria
16 refused to
participate in the study
14 did not
answer the
invitation for
group
psychotherapy
77 began the
treatment
program
7 quit the
program
70 completed
the treatment
program