Appendix 2
Review of PTSD Group Treatment Programs:
Phase 2 In-depth Quantitative and Qualitative
Analyses
Co-ordinating Author: Katrina Bredhauer
Dr Renee Anderson, Dr Annabel McGuire, Professor Peter Warfe, Michael Waller and
Jeeva Kanesaraja
June 2011
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Research team
Dr Annabel McGuire
Professor Peter Warfe
Katrina Bredhauer
Dr Renee Anderson
Michael Waller
Jeeva Kanesaraja
Consultants and advisors
Professor Justin Kenardy
Dr Len Lambeth
Professor Helen Lapsley
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Contents
Research team ........................................................................................................................................... ii
Consultants and advisors .......................................................................................................................... ii
Introduction...................................................................................................................................................1
Structure of this report .............................................................................................................................1
Background to the review .........................................................................................................................1
Methodology .................................................................................................................................................2
Program data .............................................................................................................................................2
Financial data ............................................................................................................................................2
DVA and VVCS interviews ..........................................................................................................................3
Site visits ....................................................................................................................................................3
Written information requested from sites................................................................................................3
Additional information from DVA and VVCS .............................................................................................3
Research questions: ..................................................................................................................................3
Section 1: About the PTSD Group Treatment Programs ...............................................................................5
Site snap shots...........................................................................................................................................5
Hyson Green Calvary (ACT)....................................................................................................................5
Northside Cremorne (NSW) ..................................................................................................................6
St John of God Richmond (NSW) ...........................................................................................................6
Greenslopes (QLD).................................................................................................................................7
Mater Townsville (QLD) .........................................................................................................................8
Toowong (QLD) ......................................................................................................................................8
Palm Beach Currumbin (QLD)................................................................................................................9
Geelong (VIC) .........................................................................................................................................9
Heidelberg (VIC) ....................................................................................................................................9
Hollywood (WA) ................................................................................................................................. 10
Daw Park (SA) ..................................................................................................................................... 11
Overall sample ........................................................................................................................................ 16
Section 2: Referrals and demand ............................................................................................................... 18
Declining demand: What do we know? ................................................................................................. 18
Prevalence .......................................................................................................................................... 18
Referrals ................................................................................................................................................. 20
Sources of Referrals............................................................................................................................ 20
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Benefits of knowing where referrals come from ............................................................................... 21
Referrals from VVCS ........................................................................................................................... 21
Barriers to accessing PTSD programs ..................................................................................................... 22
Section 2 Discussion of referrals and demand ....................................................................................... 23
Section 3: Evidence base for the PTSD group treatment programs........................................................... 24
What is the evidence base of the group treatment programs? ............................................................. 24
Establishing an evidence-base for group PTSD programs ...................................................................... 25
Section 4: About the quantitative data analyses ....................................................................................... 26
Raw scores .............................................................................................................................................. 26
Predictors ............................................................................................................................................... 26
Interactions ............................................................................................................................................ 27
Section 5: Effectiveness of the group PTSD programs: overall results ...................................................... 28
Results: PCL-M overall (PTSD) ................................................................................................................ 28
Changes in raw scores on the PCL-M ................................................................................................. 28
Movement between diagnostic categories on the PCL-M ................................................................. 29
Reliable change on the PCL-M............................................................................................................ 30
Predictors of PCL-M ............................................................................................................................ 32
Interactions for PCL-M ....................................................................................................................... 33
Discussion: PCL-M overall................................................................................................................... 35
Results: WHOQOL-BREF (Quality of Life) overall ................................................................................... 36
WHOQOL-BREF Physical scale ............................................................................................................ 36
WHOQOL-BREF Psychological scale ................................................................................................... 38
WHOQOL-BREF Social Relationships scale ......................................................................................... 41
WHOQOL-BREF Environment scale .................................................................................................... 43
Discussion: WHOQOL-BREF overall .................................................................................................... 45
Results: DAR (Anger) overall .................................................................................................................. 46
Predictors of DAR (Anger) .................................................................................................................. 46
Interactions for DAR (Anger) .............................................................................................................. 46
Discussion: DAR (Anger) overall ......................................................................................................... 48
Results: DAS (Family Function) overall ................................................................................................... 49
Predictors of DAS (Family Function) ................................................................................................... 49
Interactions for DAS (Family Function) .............................................................................................. 49
Discussion: DAS (Family Function) overall.......................................................................................... 50
Results: HADS (Anxiety) overall .............................................................................................................. 50
Predictors of HADS (Anxiety) .............................................................................................................. 51
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Interactions for HADS (Anxiety) ......................................................................................................... 52
Discussion: HADS (Anxiety) overall..................................................................................................... 54
Results: HADS (Depression) overall ........................................................................................................ 55
Predictors: HADS (Depression) ........................................................................................................... 56
Interactions: HADS (Depression) ........................................................................................................ 56
Discussion: HADS (Depression) overall............................................................................................... 58
Qualitative Data...................................................................................................................................... 59
Qualitative Data for 2007/08 ............................................................................................................. 59
Qualitative Data for 2008/09 ............................................................................................................. 63
Section 5 Discussion of the effectiveness of the group PTSD programs overall .................................... 67
PTSD.................................................................................................................................................... 67
Age ...................................................................................................................................................... 68
Trauma focus ...................................................................................................................................... 68
Partner involvement........................................................................................................................... 68
Mixed cohorts..................................................................................................................................... 69
Employment category ........................................................................................................................ 69
Satisfaction ......................................................................................................................................... 69
Measures of functional improvement are needed ............................................................................ 69
Review of measures ........................................................................................................................... 70
Section 6: Effectiveness of the group PTSD programs: differences by site................................................ 71
Results: PCL-M for each site ................................................................................................................... 72
Raw scores .......................................................................................................................................... 72
Statistical modelling ........................................................................................................................... 73
Results: WHOQOL-BREF Physical for each site....................................................................................... 74
Statistical modelling ........................................................................................................................... 74
Results: WHOQOL-BREF Psychological for each site .............................................................................. 76
Statistical modelling ........................................................................................................................... 76
Results: DAR (Anger) for each site ......................................................................................................... 77
Statistical modelling ........................................................................................................................... 77
Results: DAS (Family Function) for each site .......................................................................................... 79
Statistical modelling ........................................................................................................................... 79
Results: HADS (Anxiety) for each site ..................................................................................................... 80
Statistical modelling ........................................................................................................................... 80
Section 6 Discussion of differences by site ............................................................................................ 82
Section 7: Effectiveness of group PTSD treatments for contemporary veterans ...................................... 83
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Overall data ............................................................................................................................................ 83
Selected sites .......................................................................................................................................... 83
Changes to programs for contemporary veterans ............................................................................. 84
Comparison site...................................................................................................................................... 84
Results: PCL (PTSD) for contemporary veterans .................................................................................... 84
Results: WHOQOL-BREF (Quality of Life) for contemporary veterans ................................................... 85
WHOQOL-BREF Physical ..................................................................................................................... 85
WHOQOL-BREF Psychological ............................................................................................................ 85
Results: HADS (Anxiety) for contemporary veterans ............................................................................. 86
Results: DAR (Anger) for contemporary veterans .................................................................................. 86
Section 7 Discussion of the effectiveness of group treatments for contemporary veterans ................ 86
Section 8: The needs of different participants with respect to age ........................................................... 88
Contemporary veterans: more acute symptoms ............................................................................... 88
Contemporary veterans: slightly different symptom profile ............................................................. 89
Contemporary veterans: different deployment experiences ............................................................ 89
Contemporary veterans: different family needs ................................................................................ 89
Contemporary veterans: demands and stage of life are different .................................................... 89
Contemporary veterans: focus is rehabilitation rather than retirement ........................................... 90
Contemporary veterans: potentially different experience of camaraderie ....................................... 90
Veterans aged 50 and over: long-term symptoms and behaviour .................................................... 90
Veterans aged 50 and over: stage of life ............................................................................................ 90
Veterans aged 50 and over: issues to do with ageing ........................................................................ 90
Different triggers and level of commitment ...................................................................................... 90
Different generational attitudes ........................................................................................................ 91
Section 9: Outcomes unique to group treatments .................................................................................... 92
Improved social skills, relationships and support .............................................................................. 93
Normalisation and validation ............................................................................................................. 93
Camaraderie ....................................................................................................................................... 93
Incentive to attend ............................................................................................................................. 93
Help each other to process, understand and change ........................................................................ 93
Modelling and application .................................................................................................................. 94
Enhances and assists trauma-focused work ...................................................................................... 94
Contributes something the therapist can’t ........................................................................................ 94
Groups create efficiencies of time ..................................................................................................... 94
Staff are skilled and experienced and receive regular supervision and support ............................... 94
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Section 9 Discussion of outcomes unique to group treatments ............................................................ 95
Section 10: After the programs .................................................................................................................. 96
Discharge planning ............................................................................................................................. 96
VVCS ................................................................................................................................................... 97
Does follow-up care have any impact on outcomes? ............................................................................ 98
Differences between sites .................................................................................................................. 98
Section 10 Discussion regarding what happens after the programs ..................................................... 98
Section 11: Economic analysis .................................................................................................................. 100
Issues with the data.............................................................................................................................. 100
Analysis of the data .............................................................................................................................. 101
Future economic analysis ..................................................................................................................... 101
Section 12: Recommended treatment model/option.............................................................................. 103
References ................................................................................................................................................ 104
Reports consulted for the review ............................................................................................................. 104
Appendix 1: PCL-M results for each site................................................................................................... 105
Appendix 2: WHOQOL-BREF (Psychological) results for each site ........................................................... 111
Appendix 3: WHOQOL-BREF (Physical) results for each site .................................................................... 117
Appendix 4: DAR (Anger) results for each site ......................................................................................... 123
Appendix 5: DAS (Family Function) results for each site.......................................................................... 129
Appendix 6: HADS (Anxiety) results for each site .................................................................................... 135
Appendix 7: WHOQOL-BREF Physical results for contemporary veterans............................................... 141
Appendix 8: WHOQOL-BREF Psychological results for contemporary veterans ...................................... 143
Appendix 9: HADS (Anxiety) results for contemporary veterans ............................................................. 145
Appendix 10: Predictors for each scale .................................................................................................... 147
Appendix 11: PCL-M results for contemporary veterans ......................................................................... 156
Appendix 12: DAR (Anger) results for contemporary veterans ............................................................... 158
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Introduction
Structure of this report
This Appendix contains the full indepth quantitative and qualitative analyses conducted as Phase Two of
the review of DVA funded PTSD programs. A summary of the key analyses, conclusions and findings of
the review, along with recommendations based on the critical analysis, can be found in the Final Report
(main document). The literature review of evidence-based best practice treatment for PTSD (Phase
One) can be found in Appendix 1.
Background to the review
The Independent Study into Suicide in the Ex-Service Community by Professor Dunt in 2009
recommended a strategic review of PTSD programs as a matter of urgency. In response, DVA released a
tender in 2010 and CMVH was the successful tenderer. The review commenced in November 2010 and
comprised two phases:


Phase One: a literature review of evidence-based best practice treatment of PTSD with specific
reference to the Australian Guidelines for the Treatment of Adults with Acute Stress Disorder
and Posttraumatic Stress Disorder, released by ACPMH in 2007. Phase One was completed in
February 2011, culminating in a workshop with key DVA and VVCS staff to discuss the findings
and outline the methodology for Phase Two (see “Review of PTSD programs: International
literature review of evidence-based best practice treatments for PTSD”).
Phase Two: a critical review and analysis of the PTSD group treatment programs, including the
role and function of VVCS in referral, discharge planning and follow-up. Specifically, the tasks of
Phase Two were to:
o Analyse the existing treatment programs against the key findings of the literature
review
o Identify recommended treatment model(s) and options(s)
o Detail cost benefit analysis of recommended treatment model(s)
o Identify strategies to ensure effective linkages into ongoing, sustainable community
based support where required.
The methodology for Phase Two was outlined and discussed at the February 2011 workshop with
representatives from DVA and VVCS, as follows:
Table 1: Agreed methodology for Phase Two
Preparation



Cost-benefit



Consult with ACPMH and VVCS
Review most recent reports
Short paper-based questionnaire based on self-assessment and research
questions
Collate data from DVA on costs per participant at each site (e.g. cost centre data
re who is paid, rent costs, staff costs etc; number of people treated and utilisation
data such as number of sessions; contracting arrangements)
Commence cost-benefit analysis
(concurrent with other activities)
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Site visits





Compare and
evaluate
Report**
Additional to
contract:






Site visits will occur for all 12 sites listed by DVA and will commence in QLD
Format is semi-structured interview providing personnel opportunities to answer
specific questions and provide more details on key points as required
Katrina Bredhauer will attend all site visits
Prof Kenardy and Prof Warfe will provide expert support during initial visits to
refine protocol as necessary
Based on outcomes of first visits compared with later visits some iteration may be
necessary
Data from ACPMH/DVA, site visits and cost benefit research will be analysed
Efficacy of programs at different sites will be evaluated
Comparison with potential alternative models will be conducted
Complete draft report for DVA (due 12/05/2011)
Complete final report for DVA (due 31/05/2011 and reflecting DVA’s feedback on
the draft report)
In addition to the outlined methodology, CMVH was asked to interview several
nominated DVA and VVCS staff.
**Due to a two month delay in receiving data from ACPMH and DVA, the due date for the final report
was extended to 27 June 2011. DVA requested an additional workshop on 31 May 2011 to discuss the
preliminary findings of Phase Two. A further contract extension was requested by DVA to 30 August
2011.
Methodology
The following data were made available to CMVH for the purposes of the review:
Program data



Annual PTSD Program Quality Assurance Accreditation reports from 05/06 to 09/10.
Five years of quantitative outcome data, collected by site staff at four time points: entry,
discharge, three month follow-up and nine month follow-up. The data were provided to CMVH
in March 2011.
Three years of quantitative and qualitative satisfaction data, collected at time of accreditation
from past participants of the PTSD programs. This dataset, particularly the free-text comments,
provided invaluable insights to the participant experience. These data were provided to CMVH
in March 2011.
It should be noted that program outcome data only includes those who have returned their protocols
and does not represent the total throughput of the program or participation in follow-up days: that is,
attrition in data may not equal attrition in program participation at different points in time. For sites
operating mixed cohorts of veterans and non-veterans, program data are not collected for non-veteran
participants.
Financial data
The financial data were received by CMVH towards the end of March 2011. CMVH acknowledge that
the financial data were difficult for DVA to collate and involved extracting information from multiple
databases. It was further complicated by the different arrangements for public and private hospitals
and the transition some hospitals underwent from repatriation to private hospitals. Perhaps because of
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
these factors, the quality of the data varied by site, with seemingly complete data for some sites and
patchy, incomplete data for others. There were no valid conclusions possible on the basis of these data.
DVA and VVCS interviews
At the workshop in February 2011, CMVH was asked to interview selected DVA and VVCS staff. Halfhour phone interviews were conducted in April 2011 with:


15 VVCS staff, including Directors and Group Program Coordinators
8 DVA staff
These interviews were semi-structured, with questions based upon the agreed research questions and
the aims of the review.
Site visits
Semi structured face-to-face interviews were conducted during March and April 2011 with program staff
at each site included in the review. The interviews were two to three-and-a-half hours in length, with
questions based on the research questions agreed upon in the February workshop. Due to the short
timeframes of the project these visits were arranged at occasionally short notice, and CMVH
appreciated the full cooperation of sites in this process.
Written information requested from sites
Most sites provided a small amount of written information as requested by CMVH, and several provided
additional useful information of their own volition.
Additional information from DVA and VVCS
DVA provided data to CMVH on pension claims by deployment, state and age. VVCS provided data to
CMVH on issues at intake and counselling.
Research questions:
Based on the issues raised by the tender and the literature review, the overarching research questions
presented and agreed upon at the February workshop were:
Table 2: Guide to research questions and report sections
Research question:
See report section:
1. The number of referrals to group treatment
programs is declining – why?
 Section 2: Referrals and demand
2. Who ends up in the group programs, and how
do they get there?
 Section 1: About the group PTSD programs
3. Are there differential outcomes between
programs? If so, why?
 Section 6: Effectiveness of the group PTSD
programs: Differences by site
4. Are there any outcomes unique to group
treatments?
 Section 9: Outcomes unique to group
treatments
5. How can the needs of younger veterans be
better met by group treatments?
 Section 7: Effectiveness of the group PTSD
treatments for contemporary veterans
 Section 2: Referrals and demand
 Section 8: The needs of different participants
with respect to age
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Research question:
See report section:
6. What happens once they leave the program?  Section 10: After the programs
7. How evidence-based are the group
treatments?
 Section 3: Evidence base for the PTSD group
treatment programs
8. How effective are the group treatments?
 Section 5: Effectiveness of the group PTSD
programs: Overall results
 Section 6: Effectiveness of the group PTSD
programs: Differences by site
 Section 7: Effectiveness of the group PTSD
treatments for contemporary veterans
9. What are the outcomes of a cost-benefit
analysis of the (group) treatments?
 Section 11: Economic analysis
10. Are there differential outcomes between
veteran groups (pre- and post-1975)? If so,
why?
 Section 7: Effectiveness of the group PTSD
treatments for contemporary veterans
11. What are the most effective treatments, for
whom?
 Section 5: Effectiveness of the group PTSD
programs: Overall results
 Section 6: Effectiveness of the group PTSD
programs: Differences by site
 Section 7: Effectiveness of the group PTSD
treatments for contemporary veterans
 Section 12: Recommended treatment model/
option
These research questions formed the basis of the semi-structured interviews with sites, DVA and VVCS
and guided the quantitative analyses.
The research questions were not used as section headings as they are not mutually exclusive – the
overlap between them would create large amounts of repetition. Instead, the report has been
structured to best explain the results of the analyses. Table 2 indicates which research question is
addressed in each section.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Section 1: About the PTSD Group Treatment Programs
Research question:
This section answers the first part of the research question: “Who ends up in the group treatment
programs, and how do they get there?”
This review examined 12 DVA-funded group treatment programs for PTSD, based in the following
locations:











Hyson Green Calvary (ACT)
Northside Cremorne (NSW)
St John of God Richmond (NSW)
Greenslopes (QLD)
Mater Townsville (QLD)
Toowong (QLD)
Palm Beach Currumbin (QLD)
Geelong (VIC)
Heidelberg (VIC) (2 programs)
Hollywood (WA)
Daw Park (SA)
Hyson Green Calvary and Palm Beach Currumbin no longer operate a DVA-funded group treatment
program, and Heidelberg ceased the program it offered for WWII and Korean veterans.
Site snap shots
While each site is accredited under the ACPMH guidelines, they differ according to demographics,
context and program approach. This section provides the following information about each site:
location, demographics, key details of program approach, trauma focus, partner involvement, and
follow-up structure. This information provides a useful context for understanding the results of the
analyses, later in this report.
1. Two types of demographic information have been included in this section: The first is from the
annual accreditation reports and details numbers of participants and partners. These data were
only available from 06/07 to 09/10 and can be found in Tables 3 to 13.
2. Detailed demographic data for each site were calculated from the program outcome dataset
provided to CMVH, based on five years of data (05/06 – 09/10). This can be found in Table 14
(Note: “NK” means “not known” and these numbers are not included in the calculated
percentage because missing values were excluded from the statistical modelling).
A summary of the key program details by site can be found in Table 15 at the end of this section.
Hyson Green Calvary (ACT)
The PTSD program in the ACT was delivered by the Hyson Green Unit of the Little Company of Mary
Calvary Private Hospital. It provides mental health services to the general population, including veterans
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
and current serving members of the ADF. The PTSD program was small, running one cohort in 06/07
and 07/08, and ceased in 08/09 (see Table 3).
Table 3: Participation data for Hyson Green Calvary
Year
Cohorts
06/07
1
07/08
1
08/09
1
09/10
0
Source: Annual accreditation reports.
Participants
10
7
6
0
Non-completers
0
0
0
0
Partners involved
6
5
2
0
The PTSD program was run by a small staff team for veterans only, three days per week for 12 weeks.
Trauma work was choice-based within the group, incorporating non-specific exposure and voluntary
disclosure. Partners were invited to the beginning of the program, and could attend the general carer
group provided at the hospital.
Staff reported that demand for the program has reduced over recent years. Few contemporary
veterans accessed the program, and staff stated that older veterans may have had difficulty travelling to
Canberra for a day program. The site operates several other programs, such as groups for anxiety and
depression and a men’s group for veterans and police that provides support for PTSD. Veterans
requiring a group PTSD program have been referred to St John of God at Richmond, NSW.
Northside Cremorne (NSW)
One of the two PTSD programs in NSW is operated by Ramsay Health Care at the Northside Clinic,
Cremorne. It provides mental health services to the general population, including veterans. Throughput
has remained relatively steady, and the site comfortably operates three cohorts per year (see Table 4).
Table 4: Participation data for Northside Cremorne
Year
Cohorts
06/07
4
07/08
3
08/09
3
09/10
3
Source: Annual accreditation reports.
Participants
27
20
22
28
Non-completers
1
0
0
1
Partners involved
16
14
14
18
The PTSD program is run by a small number of core staff for veterans only. It has an intensive phase of
three days per week for seven weeks, then a taper of two days per week for four weeks. Veterans and
partners come back for one day at three months and nine months post-program. Trauma work is
choice-based, incorporating non-specific exposure and voluntary disclosure. Partners and adult children
have the opportunity to be involved throughout the program, with 10 days of separate content and
several shared communication sessions with veterans.
The clinic conducts two different PTSD programs – one is inpatient and open format, and the other is
the closed outpatient program funded by DVA. Veterans can do both, although only a very small
number do.
St John of God Richmond (NSW)
The second of the two PTSD programs in NSW is operated by St John of God Health Care, North
Richmond Private Hospital. It provides mental health services to the general population, including
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
veterans. Throughput has declined over past years, and the site operates two cohorts per year (see
Table 5).
Table 5: Participation data for St John of God Richmond
Year
Cohorts
06/07
4
07/08
3
08/09
2
09/10
2
Source: Annual accreditation reports.
Participants
22
15
7
7
Non-completers
3
1
0
1
Partners involved
Unknown
7
4
4
The PTSD program is run by a small number of staff for non-veterans, who are mainly emergency
services personnel, and veterans. It has an intensive phase of five days per week for four weeks, then a
long taper of one day per month for nine months. This includes a day at three months and nine months
after the intensive phase. The program has an explicit and intensive focus on trauma using a structured
interactional process. Support people may attend the two-day orientation at the beginning of the
program, a family day at the end of the intensive phase, and the follow-up days, sharing sessions with
veterans.
The site conducts two different PTSD programs – one is a three-week inpatient format for those with
simpler presentations; the other is the outpatient program funded by DVA, which is generally for those
with complex PTSD. Many people will do both programs, as the inpatient program assists with
stabilisation and symptom management and thus prepares people for the intensive trauma work in the
outpatient program.
Greenslopes (QLD)
One of the four Queensland programs is run at the Keith Payne Unit of the Greenslopes Private Hospital,
which is a former Repatriation Hospital. The Keith Payne Unit provides mental health services to
veterans. Throughput has declined overall and in 09/10 four cohorts were run (see Table 6).
Table 6: Participation data for Greenslopes
Year
Cohorts
06/07
5
07/08
5
08/09
6
09/10
4
Source: Annual accreditation reports.
Participants
25
29
34
22
Non-completers
0
2
0
2
Partners involved
20
20
25
12
The PTSD program is run by a large, multi-disciplinary team for veterans only. It was offered at five days
per week for four weeks but was changed to two days per week for 10 weeks to reduce the intensity.
Veterans and partners return for one day at both three and nine months. There is no explicit traumafocused work, although some may seek this in individual sessions. Partners have four partner-only
sessions and five shared sessions with veterans.
The Greenslopes PTSD program is long-standing and will run its 100th cohort in 2011. The Unit provides
many other programs, which veterans may access before or after the PTSD program.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Mater Townsville (QLD)
The second of four Queensland PTSD programs is based in Townsville and is operated by Mater Health
Services North Queensland. Located behind the hospital, this unit’s sole focus is providing PTSD group
treatment programs for the general population, including veterans. Throughput has declined slightly
and the team comfortably run four to five cohorts per year (see Table 7).
Table 7: Participation data for Mater Townsville
Year
Cohorts
06/07
5
07/08
5
08/09
5
09/10
4
Source: Annual accreditation reports.
Participants
36
43
36
30
Non-completers
1
4
3
0
Partners involved
25
29
15
22
The PTSD program is conducted by a large, multi-disciplinary team for veterans and non-veterans
(mainly comprising other uniformed services such as police). The program has an ease-in period of two
days per week for two weeks, an intensive period of four days per week for four weeks, then an ease
out of two days per week for two weeks. Veterans come back for one day at both three months and
nine months post-program. Trauma-focused work is explicit, with 12 group sessions focusing on
preparation and trauma narratives. Partners are welcome to attend most of the program and there are
several partner-only sessions, which can be run out of hours.
The program staff report strong demand. They work with high numbers of contemporary veterans.
Many ex-participants use the unit as a drop-in centre once the program has finished.
Toowong (QLD)
The third of four Queensland PTSD programs is delivered by Toowong Private Hospital. The day
program unit provides mental health programs for the general population, including veterans.
Throughput has declined only slightly over time, with six cohorts run in 09/10 (see Table 8).
Table 8: Participation data for Toowong
Year
Cohorts
06/07
8
07/08
6
08/09
6
09/10
6
Source: Annual accreditation reports.
Participants
47
45
39
38
Non-completers
1
2
0
3
Partners involved
25
28
26
27
The PTSD program is conducted by a large, multi-disciplinary team and includes contractors and guest
speakers. Cohorts are for veterans only and begin with an intensive phase of four days per weeks for six
weeks, followed by a taper of two days per fortnight for 12 weeks. Veterans and partners come back for
one day at three months and nine months. The site previously offered a one day per week program but
ceased this due to low demand. Trauma-focused work in the group is via imaginal and in vivo general
exposure, and specific trauma work can be undertaken in individual sessions. Partners are involved
towards the end of the intensive phase and have shared sessions with veterans as well as partner-only
sessions.
The site conducts several other veteran-only group programs, and veterans can also access other group
programs with civilians.
8
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Palm Beach Currumbin (QLD)
The last of the four Queensland PTSD programs was operated by the Currumbin Clinic at Palm Beach.
The clinic provides mental health services to the general population, including veterans. The PTSD
program ran two cohorts in 06/07 and 07/08 and ceased operation in 08/09 (see Table 9).
Table 9: Participation data for Palm Beach Currumbin
Year
Cohorts
06/07
2
07/08
2
08/09
0
09/10
0
Source: Annual accreditation reports.
Participants
14
11
0
0
Non-completers
0
1
0
0
Partners involved
12
8
0
0
The PTSD program was conducted by a small team for veterans only (although the last cohort was mixed
with other uniformed services). It ran four days per week for six weeks, and veterans and support
people returned for one day at three months and nine months. Trauma-focused work was explicit, with
two group sessions each week. Support people were involved one day per week, but when
contemporary veterans began accessing the program this was changed to three workshops as this was
perceived to be more suited to their needs.
The site offered two different PTSD programs: the intensive DVA-funded program and a day program for
PTSD for one day per week for 12 weeks, which veterans were able to access before or after the
intensive program. A large number did both, particularly if they were waiting for a place in the intensive
program. The day program still operates.
Geelong (VIC)
One of the two PTSD programs in Victoria is operated by Healthscope at the Geelong Clinic. The clinic
provides mental health services to the general population, including veterans. Throughput has
remained relatively steady, and the site likes to run two cohorts per year (see Table 10).
Table 10: Participation data for Geelong
Year
Cohorts
06/07
1
07/08
2
08/09
1
09/10
2
Source: Annual accreditation reports.
Participants
8
13
8
16
Non-completers
0
0
0
1
Partners involved
8
9
6
10
The PTSD program is operated by a large multi-disciplinary team comprising three core staff and several
sessional staff, and is for veterans only. It runs for two days per week for 12 weeks, with a live-in in
week five. There is no follow-up, apart from mailing the ACPMH booklets to veterans. Trauma focus is
explicit, including narrative deliveries in the live-in phase. Support people are involved throughout, with
weekly support groups and several shared sessions with veterans.
The clinic offers a variety of other programs that veterans can access.
Heidelberg (VIC)
The second of the two PTSD programs in Victoria is operated by the Austin Health Heidelberg
Repatriation Hospital. The hospital provides services to the general population, with a strong focus on
9
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
veterans. Throughput is high but has declined in recent years, with five cohorts run in 09/10 (see Table
11).
Table 11: Participation data for Heidelberg VPU and OVPP programs
Year
Cohorts
06/07
9
07/08
8
08/09
5
09/10
5
Source: Annual accreditation reports.
Participants
31
54
38
35
Non-completers
1
1
1
2
Partners involved
35
22
27
29
The PTSD program is operated by a large multi-disciplinary team for veterans only. Four different
program formats have been offered, including some in regional areas. The most common format in
recent times is an intensive phase of three days per week for six weeks, with a taper of one day per
week for six weeks. Partners and veterans come back for half a day at three and nine months postprogram. Trauma focus in the group is indirect, incorporating psycho-education, triggers and memory
network, with veterans able to use individual sessions for trauma-focused work. Partners are involved
throughout the program, with a weekly partner-only group and several shared sessions with veterans.
There was a separate program for older veterans but this has ceased.
The site works with a large number of veterans across all services.
Hollywood (WA)
The PTSD program in Western Australia is run by the Ramsay Health Care Hollywood Clinic. The clinic
provides mental health services to the general population, including veterans. Throughput is high but
has declined over recent years, with four cohorts run in 09/10 (see Table 12).
Table 12: Participation data for Hollywood
Year
Cohorts
06/07
7
07/08
6
08/09
6
09/10
4
Source: Annual accreditation reports.
Participants
59
42
39
25
Non-completers
7
0
3
2
Partners involved
38
29
26
16
A large multi-disciplinary team provides two PTSD programs for veterans and non-veterans. The PTSD
program for veterans over approximately 50 years of age has an intensive phase of five days per week
for four weeks, then a taper of one day per week for eight weeks. The Trauma Recovery Program for
under 50s has an intensive phase of five days per week for two weeks, then a long taper of generally
two days per week for 16 weeks. In both programs veterans come back for one day at three and nine
months. Trauma focus is explicit, with several group sessions throughout both programs. Partners are
involved throughout the PTSD program, with a partner-only group and several sessions shared with
veterans. Support people have six sessions throughout the Trauma Recovery Program, as well as a kids’
fun day and two psycho-education sessions for family and friends.
The site works with high numbers of contemporary veterans and the Trauma Recovery Program has
been systematically developed and trialled to meet the needs of this younger demographic.
10
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Daw Park (SA)
The PTSD program in South Australia is operated by the Repatriation General Hospital at Daw Park. The
hospital provides services to the general population with a strong focus on veterans. Throughput has
declined slowly over recent years, with four cohorts run in 09/10 (see Table 13).
Table 13: Participation data for Daw Park
Year
Cohorts
06/07
4
07/08
3
08/09
4
09/10
4
Source: Annual accreditation reports.
Participants
21
18
20
14
Non-completers
0
1
0
0
Partners involved
18
10
10
11
The PTSD program is operated by a small multi-disciplinary team for veterans and non-veterans (who
are primarily from the SA police). It runs for three days per week for eight weeks, with partners and
veterans returning for half a day at three and nine months post-program. Trauma focus is choice-based,
with group exposure work and the option of further exploring trauma in individual sessions. Support
people are involved throughout, with separate sessions as well as shared sessions with veterans. There
was a program specifically for older veterans but this has ceased.
The site has predominantly worked with Vietnam veterans, although numbers of contemporary
veterans have increased in recent years.
11
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
12
Table 14: Demographic characteristics for program participants from 05/06 to 09/10
Heidelberg
n
Gender:
 Male
 Female
Age:
 <50
 50+
Ed.:
 Primary
 Second.
 Post-second.
 Tertiary
Marital status:
 Single
 Married
 De-facto
 Sep/div
 Widow.
Employ. Status:
 FT
 PT
 Not work
 Retired
 Unable
 Other
Service:
 Navy
 Army
 NK*
Deployed:
 Pre-‘72
 Post-‘72
%
Geelong
n
%
Greenslopes
n
%
Toowong
n
%
Townsville
N
Palm Beach
St John
%
n
%
n
%
Cremorne
n
Calvary
%
N
%
Daw Park
n
%
Hollywood
n
%
253
0
(100)
(0)
58
2
(97)
(3)
161
1
(99)
(1)
228
4
(98)
(2)
186
6
(97)
(3)
31
0
(100)
(0)
68
1
(99)
(1)
141
1
(99)
(1)
30
0
(100)
(0)
132
1
(99)
(1)
171
3
(98)
(2)
40
213
(16)
(84)
14
46
(23)
(77)
21
141
(13)
(87)
58
175
(25)
(75)
123
68
(64)
(36)
11
20
(35)
(65)
14
63
(18)
(82)
9
133
(6)
(94)
7
23
(23)
(77)
15
118
(11)
(89)
61
113
(35)
(65)
11
128
93
16
(4)
(52)
(38)
(6)
1
32
19
7
(2)
(54)
(32)
(12)
8
83
58
11
(5)
(52)
(36)
(7)
15
119
81
16
(6)
(52)
(35)
(7)
7
106
66
13
(4)
(55)
(34)
(7)
0
21
8
1
(0)
(70)
(27)
(3)
2
37
27
2
(3)
(54)
(40)
(3)
5
72
50
14
(4)
(51)
(35)
(10)
0
14
12
4
(0)
(47)
(40)
(13)
5
74
46
7
(4)
(56)
(35)
(5)
10
80
67
16
(6)
(46)
(39)
(9)
10
174
19
35
14
(4)
(69)
(8)
(14)
(6)
4
46
3
6
1
(7)
(77)
(5)
(10)
(2)
3
129
8
21
0
(2)
(80)
(5)
(13)
(0)
13
154
17
43
2
(6)
(67)
(7)
(19)
(1)
25
107
25
32
0
(13)
(57)
(13)
(17)
(0)
1
20
2
6
1
(3)
(67)
(7)
(20)
(3)
0
51
6
11
0
(0)
(75)
(9)
(16)
(0)
6
105
8
20
0
(4)
(76)
(6)
(14)
(0)
1
21
2
2
4
(3)
(70)
(7)
(7)
(13)
3
89
11
26
4
(2)
(67)
(8)
(20)
(3)
9
108
16
37
2
(5)
(63)
(9)
(22)
(1)
34
12
11
68
116
6
(14)
(5)
(5)
(28)
(47)
(2)
10
3
4
18
24
1
(17)
(5)
(7)
(30)
(40)
(2)
14
6
8
36
95
3
(9)
(4)
(5)
(22)
(59)
(2)
44
3
16
53
106
7
(19)
(1)
(7)
(23)
(46)
(3)
88
10
8
20
63
3
(45)
(5)
(4)
(10)
(32)
(2)
1
0
2
4
21
2
(3)
(0)
(7)
(13)
(70)
(7)
7
1
7
12
39
1
(10)
(1)
(10)
(18)
(58)
(1)
0
1
5
30
103
1
(0)
(1)
(4)
(21)
(74)
(1)
5
2
0
7
15
1
(17)
(7)
(0)
(23)
(50)
(3)
15
10
6
21
78
2
(11)
(8)
(5)
(16)
(59)
(2)
25
1
9
31
103
3
(15)
(1)
(5)
(18)
(60)
(2)
34
191
28
(15)
(85)
13
42
5
(23)
(76)
44
116
(28)
(73)
61
167
4
(27)
(73)
29
155
8
(16)
(84)
6
24
1
(20)
(80)
20
48
1
(29)
(71)
38
101
3
(27)
(73)
7
21
2
(25)
(75)
23
108
2
(18)
(82)
45
124
5
(27)
(73)
210
43
(83)
(17)
46
14
(77)
(23)
135
27
(83)
(17)
174
58
(75)
(25)
65
127
(34)
(66)
20
11
(65)
(35)
54
15
(78)
(22)
93
7
(93)
(7)
23
7
(77)
(23)
119
14
(89)
(11)
108
66
(62)
(38)
Note: Numbers in rows do not always match the total as not all participants completed every question (i.e. there are missing data)
* NK means "not known" and these numbers are not included in the percentages as they were excluded from the statistical analyses.
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Table 15: Program details across key variables by site
Structure
of days
Partner/
other
Partner
structure
Follow-up
structure
Context
of cohorts
Staffing
structure
Trauma
focus
Heidelberg
Geelong
Greenslopes
Toowong
Townsville
Palm Beach
St John of
God
Northside
Cremorne
Calvary
Daw Park
Hollywood
4d/wk for 4
weeks, 1d/wk
for 8 wks OR
3d/wk for
6wks, 1d/wk
for 6wks OR
2d/wk for 12
wks
Partner
2d/wk +
live-in wk 5
5d/wk for
4wks OR
2d/wk for
10wks
1d/week OR
4d/wk for
6wks,
2d/f’night
for 12 wks
2d/wk for
2wks, 4d/wk
for 4wks,
2d/wk for
2wks
4d/wk for
6wks
5d/wk for 4
wks,1d/m for
9m
3d/wk for
7wks, 2d/wk
for 4wks
3d/wk for 12
wks
3d/wk for
8wks
Anyone
Partner
Partner
Partner
Anyone
Anyone
Anyone
Partner
Anyone
Weekly
partner
group, 2x
communication skills w
veterans, 6
ed. Sessions
Weekly
family group
(9x1hr).
Shared
communication group,
review, &
relaxation.
None.
Just post
ACPMH
booklets.
5 days.
5x2hr couple
sessions in
group, 4x1hr
women
sessions.
Follow-up
sessions 5+6
incl. partner,
partner only
sessions and
some shared
w veterans.
Was 1d/wk
for 6wks,
then changed
to 3
workshops.
Meet
together at
start. Can
attend
general carer
group.
Referred for
support.
Shared
sessions with
veterans plus
partner-only
group.
Come back
for 1d @ 3m
& 9m.
2 day orient.
pre-program,
family day
last wk of
residential,
follow-up
days. Shared
w veterans.
Come back
1d/m for 9m.
10 partner
days incl. @
follow-up
4 comm.
sessions w
veterans.
Come back for
1d @ 3m and
9m. Partners
invited.
Partner
groups,
sessions w
veterans on
comm.,
invited to
several other
sessions
Come back
for 1d @ 3m
& 9m.
TR: 5d/wk for
2wks then
2d/wk for
16wks
PTSD: 5d/wk
for 4wks then
1d/wk for 8
wks
PTSD: partner
TR: anyone
PTSD – shared
sessions and
partner-only
grp. 1d/wk for
12 wks. TR – 6
sessions, kids’
day, friends’
session
Come back for
1d at 3m and
9m.
Veteran-only.
Old + young.
Veteran only.
Old + young,
PK only did not
work.
Veterans +
non-veterans.
Old + young,
mainly
young.
Veteran only.
Old + young.
Veterans +
non-veterans.
Mainly older.
Veteran only.
Mainly older.
Veteran-only.
Old + young,
mainly older.
Veterans +
non-veterans.
Mainly older.
Had WWIIonly.
Veterans +
non-veterans.
Old only +
young only (not
mix ages)
3 + guests +
contractors.
Multi-disc
Explicit
7 + guests
Multi-disc.
Veteran
only.
Old + young,
young only
did not
work.
7 + guests
+contractors
Multi-disc
Indirect
Multi-disc,
large-ish
Smaller team
Smaller team
3 + guests
Nurses + psyc
Smaller team
Smaller team
8 + psychiatrist
Multi-disc
Explicit
Explicit
Explicit
Choice-based
Explicit
Choice-based
Explicit
Come back
for ½ day
@3m and
9m. Partners
invited.
Veteran only.
Old + young,
& old only.
Young only
did not work.
9 + guests
and others
Multi-disc
Indirect
Indirect
Come back
1d @ 3m and
9m. Partners
invited.
Come back
1d @3m &
9m. Partners
invited.
Come back ½
day @ 3m &
9m. Partners
invited.
14
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Source: Qualitative interviews with site staff
15
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Overall sample
Two types of demographic information have been included in this section. The first is from the Annual
Accreditation reports, which state that program numbers peaked in 2000/2001 at 567 participants and
have been steadily declining since that time:




06/07 – 330 participants
07/08 – 297 participants
08/09 – 249 participants
09/10 – 215 participants
The second is the detailed demographics calculated from the outcome dataset provided to CMVH. This
is based on five years of information and can be found in Table 16.
The sample included only 19 women, which means analysis of results by gender was not possible.
Intake data includes service and regular or conscript status, but does not indicate reservist status.
Table 16 lists the demographic characteristics of the overall sample by year (based on the outcome data
provided to CMVH). It can be seen that:





Numbers of women accessing the programs has remained low.
There are different trends according to age:
o A dramatic fall in the number of participants aged 50-59, from 199 in 2005 to 15 in 2010.
o A jump in the number of participants aged 60+ in 2006, with a gradual decline since.
o Relatively unchanged numbers of participants aged under 50 (i.e. contemporary veterans),
except for a jump in 2007 and 2008.
The percentage of participants in the workforce has doubled, although the number has largely
remained the same, and an increasing percentage of participants are retired.
Numbers of participants that deployed before 1972 is steadily decreasing, while numbers of
participants that deployed after the Vietnam War (i.e. contemporary veterans) has remained
relatively stable.
Other demographic characteristics such as education level and marital status have remained
relatively unchanged over time.
It is important to mention that these overall demographic trends may be quite different at each site.
16
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Table 16: Overall demographics by year
2005
N
Gender:
 Male
 Female
Age:
 20-49
 50-59
 60+
Ed.:
 Primary
 Second.
 Postsecond.
 Tertiary
 NK*
Marital
status:
 Single
 Married
 De-facto
 Sep/div
 Widow.
 NK*
Employ.
Status:
 FT
 PT
 Not
work
 Retired
 Unable
 Other
 NK*
Service:
 Navy
 Army
 NK*
Deployed:
 Pre-‘72
 Post-‘72
%
2006
N
%
2007
N
%
2008
N
%
2009
N
2010
%
n
Total
%
(96)
(4)
N
310
2
(98)
(1)
318
1
(99)
(1)
269
4
(99)
(1)
253
3
(99)
(1)
176
3
(98)
(2)
133
6
1459
19
55
199
58
(18)
(64)
(19)
58
158
103
(18)
(50)
(32)
74
98
101
(27)
(36)
(37)
76
69
111
(30)
(27)
(43)
58
28
93
(32)
(16)
(52)
52
15
70
(38)
(11)
(51)
373
567
236
16
164
105
(5)
(54)
(34)
20
146
133
(6)
(46)
(42)
13
141
94
(5)
(52)
(34)
8
137
93
(3)
(54)
(36)
3
100
57
(2)
(56)
(32)
4
78
45
(3)
(56)
(32)
64
766
530
21
6
(7)
15
5
(5)
23
2
(8)
17
1
(7)
19
-
(11)
12
-
(9)
107
14
11
214
20
58
5
6
(4)
(69)
(6)
(19)
(2)
13
220
20
55
5
6
(4)
(70)
(6)
(18)
(2)
11
191
21
42
7
1
(4)
(70)
(8)
(15)
(3)
21
167
20
42
4
2
(8)
(66)
(8)
(17)
(2)
9
121
18
27
3
1
(5)
(68)
(10)
(15)
(2)
10
91
18
17
2
1
(7)
(66)
(13)
(12)
(1)
75
1004
117
241
26
15
33
11
12
(11)
(4)
(4)
36
14
16
(11)
(4)
(5)
58
11
19
(22)
(4)
(7)
54
4
10
(21)
(2)
(4)
30
8
10
(17)
(5)
(6)
32
1
9
(23)
(1)
(7)
243
49
76
43
203
5
5
(14)
(66)
(2)
75
168
8
2
(24)
(53)
(3)
52
122
6
5
(19)
(46)
(2)
50
128
8
2
(20)
(50)
(3)
44
83
2
2
(25)
(47)
(1)
36
59
1
1
(26)
(43)
(1)
300
763
30
17
70
234
8
(23)
(77)
64
247
8
(21)
(79)
53
210
10
(20)
(80)
66
187
3
(26)
(74)
40
128
11
(24)
(76)
27
91
21
(23)
(77)
320
1097
61
255
57
(82)
(18)
256
63
(80)
(20)
198
75
(73)
(27)
172
84
(67)
(33)
120
59
(67)
(33)
85
54
(61)
(39)
1086
392
Note: Numbers in rows do not always match the total as not all participants completed every question
(i.e. there are missing data)
* NK means "not known" and these numbers are not included in the percentages as they were excluded
from the statistical analyses.
17
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Section 2: Referrals and demand
Research question:
This section answers the question, “The number of referrals to group treatment programs are declining –
why?” and the second part of the research question, “Who ends up in the group treatment programs,
and how do they get there?”
Declining demand: What do we know?
The number of people accessing the PTSD programs has decreased in the past five years. This has raised
questions about why this is happening. Indeed, if the numbers are declining, what does this represent?
Is there a reduced demand for the programs? Is it a problem with referrals or bottlenecks? Or is there
inadequate understanding, knowledge about, or information available about these programs?
Prevalence
In order to understand the current and projected demand for PTSD programs for veterans, it is
important to consider Australian prevalence rates of PTSD.
Older veteran PTSD prevalence rates
PTSD prevalence rates for older Australian veterans are estimated at 15% (or 17% when comorbid
depression is included) for veterans involved in the Korean War. This estimate is limited by reliance on
self-report and retrospective measures. The lifetime prevalence of PTSD for Vietnam veterans is
estimated at 21%, with current prevalence rates sitting at 12% (10,000 from 50,000), when assessed 2025 years after deployment (Dunt, 2009).
Contemporary veteran PTSD prevalence rates
For Australian Gulf War veterans, current PTSD rates assessed at 10-15 years post-deployment are
estimated at 5.4% and were obtained using structured clinical interviews. Estimates of PTSD in ADF
ground forces serving in Iraq and Afghanistan remain unpublished. The Royal Australian Navy estimated
that PTSD in sailors deployed to the Middle East Area of Operations (MEAO) between 2001 and 2005
was 1.6%. However, PTSD rates in Navy and Air Force personnel are usually lower than ground forces or
Army populations. Comparatively, the prevalence rate for PTSD in the general Australian population is
estimated at 6.4% (Australian National Survey of Mental Health and Wellbeing, 2007).
Australian prevalence rates for PTSD are lower than in the US. For example, US Vietnam veterans have
30.9% lifetime and 15.2% current prevalence for PTSD. Estimates for US Iraq veterans are 12.2% –
16.6%; 4% for UK Iraq veterans; 6.2% US Afghanistan veterans; and 9% for US Afghanistan and Iraq
veterans (Dunt, 2009).
Current demand for PTSD programs in Australia
Data from VVCS indicated that counselling was provided to an average of 10,000 clients in each financial
year from 2005 to 2010. Of the 50,279 clients seen by VVCS during this period, 8280 (16.5%) people
nominated PTSD as their primary presenting problem. Of these, 6920 (84%) had a military background.
The majority (85.2%) of VVCS clients with a military background who reported having PTSD were
veterans, 8.6% were peace keepers and 5.4% were ex-ADF with accepted mental health disabilities
under DVA legislation.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Data were also provided for veterans who presented at the VVCS through intake from 17 December
2007 (when electronic intake forms commenced) to 21 March 2011. The information indicated that
VVCS supplied intake counselling to 45,034 clients during this period. Of these clients, 3903 (8.7%)
identified PTSD as one of their three main presenting problems. Of these, 3015 (6.7%) were individuals
with a military background. Of the people with a military background and who had nominated PTSD as
one of three primary presenting problems, the majority (83.8%) were veterans, 8.8% were peace
keepers, and 6.1% were ex-ADF with DVA accepted mental health disabilities.
It is important to note that a self-reported indication of the presence of PTSD is not as accurate as a
clinician-diagnosed PTSD condition. Therefore, the above data supplied from VVCS must be interpreted
with caution. The data suggest self-reported prevalence of around seven percent.
Data from DVA show that as of 31 December 2010, the total number of veterans with accepted PTSD
claims was recorded at 30,179. Of these, 342 were listed as being accepted as a service related
disability under MRCA and 2497 were listed as accepted under the VEA for treatment only (Non Service
Related). The data were broken down by state and territory and shown in Table 17.
The data received from DVA represent the total distribution of veterans that have an accepted service
related disability under the VEA. It is important to note that veterans who have PTSD attributed to more
than one conflict (e.g., both Afghanistan and Iraq) have been counted in the data under each relevant
conflict. The data did not indicate the number of veterans that were counted on more than one
occasion, therefore the data must be interpreted with this caveat in mind. Thus, the total number of
actual persons is likely to be less than the total indicated.
Table 17: DVA data of veterans with PTSD as of 31 December 2010 by state/territory
State/Territory
Queensland
New South Wales
Victoria
Western Australia
South Australia
ACT
Tasmania
Overseas
Northern Territory
Source: DVA data.
N
9497
8809
4527
3029
2651
500
728
229
209
%
31.5
29.2
15.0
10.0
8.8
1.7
2.4
0.8
0.7
In order to understand the distribution of veterans by key demographic variables, the data were broken
down by age group and gender (see Table 18). The data from DVA show that the majority of individuals
with an accepted service related disability were male and in the age range of 55 to 74 years, many of
whom may be Vietnam veterans.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Table 18: Numbers of veterans with PTSD known to DVA by gender and age group
Age Group
Under 55
55 to 74
75 and over
Total
Gender
Total
Male
Female
2353
23114
4449
29916
185
51
27
263
2538
23165
4476
30179
PTSD and the Dunt Suicide Study
The Dunt Suicide Study (2009) indicated that it was too early to make any judgements about the likely
future number of PTSD claims in Australia. The consensus is that with the introduction of better policies
in response to the post-Vietnam veterans’ experience, large numbers of claims will be prevented in the
period 20-29 years after the end of the current conflicts. Thus, whilst projected numbers for future
PTSD cases remains unknown, the importance of developing new policies and modernised, evidencebased treatment programs is undeniable.
Estimates suggest that as few as 30% of people with early-onset PTSD receive evidence-based
treatment. There are a number of ethical and therapeutic problems with this statistic. There is a
significant body of evidence that outlines numerous evidence based treatments for PTSD, and without
empirically based interventions being used for all people, the potential to cause or exacerbate existing
damage is great. Consequences may include, for example, no improvement or a worsening of
symptoms, which can lead to distrust or lack of confidence in health professionals, as well as other
physical, psychological, and psychosocial implications (e.g. relationship distress, increased reliance on
substances such as alcohol etc.). This can have long-term help-seeking consequences, such as
discouraging people to consult health professionals. People with late-stage PSTD are at a disadvantage
by the advanced, often chronic, stage of their presentation. Little is known about how effective
treatments are for late-stage presentations. Certainly, some treatments are no longer suitable (Dunt,
2009). Taken together, the evidence then suggests that early, empirically-based PTSD interventions are
crucial for long-term gains for suffers and to avoid people “falling through the cracks” and entering the
later stages of the disorder.
Referrals
The number of people participating in PTSD group treatment programs has steadily declined in the past
five years. As described earlier in the report, program numbers peaked at 567 participants in
2000/2001, but have steadily declined since then with only 215 people participating in PTSD programs in
2009/2010. This represents a 38% decrease in participant numbers over five years.
Sources of Referrals
According to program outcome data for all the sites, an average of 70% of referrals come from
Psychiatrists, 8% Psychologists, 8% General Practitioners (GP), 5% self or family, and 10% from a mix of
other sources (e.g. ESOs, welfare organisations).
However, the number and distribution of referral sources differed considerably between sites, as did the
accuracy of the data on referral sources. Qualitative data (site interviews) and quantitative sources (site
questionnaire data) revealed that some sites were able to provide comprehensive data on where
participant referrals came from, whilst other sites knew much less about referral sources and
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
procedures. This was often a reflection of where the program was situated within the hospital or clinic.
In some sites, like Geelong, program staff liaise directly with referral sources and the associated data
can be considered accurate. In other sites, e.g. St John of God or Hyson Green Calvary, the program is
situated within the hospital and referrals are internal, primarily from the associated psychiatrist. In
these cases, little was known about the referral pathway to the psychiatrist, e.g. whether the participant
was initially referred to from a psychologist, ESO, self-referred, or from a GP.
Benefits of knowing where referrals come from
Sources of referrals are an important piece of information, with data analyses suggesting that on
average self-referred participants did better on treatment outcomes compared to other referral sources
(i.e. psychiatrist, psychologist, GP). This suggests that self-referred participants may be in a more
advanced stage of ‘readiness for change’ and thus respond better to the intervention.
Developing a greater understanding of referral sources and procedures can be advantageous for
program sites for other reasons too. Understanding referral sources can inform sites on who knows
about the program, it can help identify good referral sources, and also where problems or blockages
may lie for participants who may otherwise benefit from accessing the program. This type of
information can be used to monitor and improve referral procedures and processes. This knowledge
may assist in diversifying referral sources and thus increase the number of participants able to access
the PTSD programs. This may also be achieved by improving sites’ ability to identify “holes” in the
referral process and subsequently up-skill the organisations identified as being in need of more
knowledge about the suitability, availability, and accessibility of the PTSD programs. Overall,
understanding referral sources may increase accessibility to the programs, reduce perceived barriers to
starting the program, and consequently increase participant numbers. This is important, because the
literature shows that as little as 30% of veterans with PTSD are receiving adequate, evidence-based
treatment.
Some sites receive referrals from a wide variety of sources e.g. Mater Townsville: 42% Psychiatrist, 25%
Psychologist, 20% GP; Geelong: 18% Psychiatrist, 27% Psychologist, 22% Self/family, 13% ESO, 13%
Health welfare agency.
In other sites there are potential referral bottlenecks. For example, in Hyson Green Calvary participants
are only able to be referred, and therefore access the PTSD program, via one psychiatrist. However, due
to high demand this psychiatrist occasionally had to “close his books” to new clients, which
subsequently created a bottleneck. Situations such as these may act as a barrier to participants
receiving treatment when they need it and when they are ready to receive it. This factor may be
contributing to fewer numbers of participants accessing programs in certain sites.
Referrals from VVCS
Interviews with sites and VVCS revealed that the quality of the relationship with VVCS varied by site.
Some sites have a close and positive working relationship, while others seem to have little to no contact
with VVCS. However, even where the relationship was strong, it seems there were very few referrals to
the programs from VVCS. This seems to be related to two factors:


A perceived level of competition, in that VVCS offers their own treatments for PTSD and may not
see the relevance of referring to an alternative provider.
A different understanding between sites and VVCS of what the group treatment programs do
and for whom they are suitable. Some VVCS staff stated that they would be most likely to refer
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
someone to a group PTSD program if they were acute or severe enough to require an inpatient
stay. However, the PTSD programs include participants with a much broader range of
presentations.
In a very small number of locations, VVCS staff said they had reservations about referring clients to PTSD
group treatments because they did not believe that trauma-focused work was appropriate.
There is a high level of agreement amongst sites and VVCS that the referral mechanisms currently in
place may need to be improved and streamlined. A key to this process would seem to be a better
understanding of the programs – the approaches used, the targeted participants and the anticipated
(and demonstrated) outcomes.
It is important to mention that in some sites this is already happening – sites and VVCS work closely
together and have a good understanding of the different services offered by each e.g. Hollywood,
Northside Cremorne. Where this type of relationship does not exist it should be developed/improved as
a matter of priority, as VVCS and the PTSD group treatment programs are both valuable resources for
veterans and current serving members, are often complementary, and should be fully utilised wherever
possible.
Barriers to accessing PTSD programs
The literature review in Phase 1 identified a number of barriers to treatment for Australian veterans
wanting (or considering) access to PTSD treatment programs (see Appendix 1 of the Final Report). The
literature review identified several barriers to accessing care that were relevant for those suffering
PTSD. The most commonly cited barriers to care included:








uncertainty about what help was available
difficulty accepting the presence of a problem
economic or time constraints
insufficient numbers of mental health professionals
stigma and concerns about privacy
career concerns
previous unsuccessful treatment
lack of confidence in mental health professionals
A salient barrier and one amenable to change relates to access to helpful information, including
websites.
The process of finding appropriate help for combat-related PTSD in Australia is unclear. Whilst
information factsheets about PTSD are available on Defence and DVA websites, the path of obtaining
specialist help is obscure. For people with a mental health or stress related condition, this is likely to be
discouraging and may be a barrier to obtaining adequate treatment. In order to improve the throughput
of participants in PTSD programs, and to improve access for those who would benefit from the
programs, it is paramount that the path they follow be user friendly, simple to navigate, and available
when needed.
The DVA website carries some information on PTSD in the form of factsheets, but generally veterans are
directed to either to the ACPMH or the VVCS websites. In one of its factsheets, DVA advises that after
the diagnosis of PTSD is made, DVA will cover the cost of psychological or psychiatric treatment sought
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
outside the veteran health system. Whilst useful in one capacity, people seeking help may require more
information on how to contact a psychiatrist, which treatment options are available and other process
(i.e. concrete “how to” information).
Section 2 Discussion of referrals and demand
To improve referral rates and participant throughput, a variety of referral sources are required. In order
to achieve this, organisations and medical/mental health providers need to be aware of the programs
and have a good understanding of who may benefit from them. Greater dissemination of information
may be needed, for some PTSD program sites more than others.
When considering referral sources, it is important to address referrals from self and family as
participants referred through this channel have been found to receive the greatest magnitude of benefit
on the PCL-M. People who self-refer may be more ready to change, and thus their benefit from the
programs may be greater. It would be beneficial for information about the PTSD group treatment
programs to be made available to veterans and their families, and to consider broadening referral
pathways into the programs to enable and facilitate self-referral.
Given the relatively unchanging numbers of contemporary veterans accessing the programs, their needs
in terms of referral and information should be considered separately. Prominent, clear, easy-to-follow
information online may be particularly useful, based on the assumption that the internet would be a key
source of information for this group. Site interviews indicated that help-seeking in contemporary
veterans is likely to be triggered by a crisis; accordingly, it is important that the path for finding help is
obvious and easy.
Both VVCS and the PTSD group treatment programs are high quality, effective resources for veterans
and their families. It would be beneficial to explore strategies to maximise the benefit of these
resources, particularly in sites where the relationship with VVCS is not as strong.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Section 3: Evidence base for the PTSD group treatment programs
Research question:
This section answers the research question: “How evidence-based are the group treatments?”
What is the evidence base of the group treatment programs?
ACMPH are responsible for accrediting the PTSD group treatment program at each site. In order for
sites to be accredited, each has to meet defined criteria, which are:





A multidisciplinary team
A cognitive behavioural orientation
A program with core components including:
o Psychoeducation about PTSD and its treatment
o Trauma focused work
o Symptom management in areas such as anxiety and depression
o Anger management groups
o Substance abuse and addictive behaviours
o Interpersonal, problem-solving, and communication skills
o Physical health and lifestyle issues
o Relapse prevention
o Education and support to veterans partners
Individual therapy
Attention to discharge planning and appropriate follow-up
Sites are required to maintain a minimum cohort size (i.e. no less than five participants in each cohort)
and cohort frequency (i.e. equal to or greater than three programs per year, or five in two years). If the
participant numbers and cohort frequency drop below these guidelines, then the feasibility of the
program must be questioned. Further, the level of staff experience for those taking the programs must
be maintained (i.e. minimum 3.0 effective full time clinical positions).
Although each site was accredited and therefore deemed to be operating within an evidence-based
approach to therapy, there are considerable differences between the PTSD programs. For example,
some sites have a strong, explicit trauma focus whilst other sites have little to no trauma focus and only
address trauma if it is brought up specifically by a group participant. Similarly, programs differed on the
level of partner involvement and program structure (i.e. number of days, focus on additional modules
such as anger management and substance use, etc.). Some sites had different programs for older and
younger participants, whilst other sites had made little change to the program structure to
accommodate demographic changes.
In the past, the accreditation process involved face-to-face visits by ACPMH and DVA staff, and regular
face-to-face gatherings of site staff from around the country. This has since been changed to a paperbased accreditation process. The credibility and integrity of sites and ACPMH in this process is not in
question, however several sites said they receive less feedback under this model, and they felt the
interaction and practice-based discussions with staff from other sites was a particular loss. It was
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
evident during the site interviews that staff are generally experienced, passionate clinicians who seek
out information and evidence in order to improve the treatment they offer to participants; in this
context, a reduction in the information provided is an opportunity lost, and may be detrimental to the
overall outcomes of the programs.
Establishing an evidence-base for group PTSD programs
It is important to note that there is currently no available evidence to suggest what a best-practice
approach is for group-based PTSD programs. Based on the available data, we do not and cannot know
how the current PTSD group treatment programs compare to no treatment or to alternative treatment
approaches. To date, there is insufficient evidence in the PTSD treatment literature on group programs,
and this represents a significant gap in the knowledge base. This gap could be closed by taking
advantage of opportunities to publish the findings of research such as this.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Section 4: About the quantitative data analyses
The following five key outcome measures were selected for the quantitative analyses to evaluate
whether the programs result in improvement for participants:





PTSD Check List, Military Version (PCL-M): PTSD symptoms
Brief World Health Organisation Quality of Life Instrument (WHOQOL-BREF): quality of life
(physical, psychological, social relationships and environmental scales)
Dimensions of Anger Reaction (DAR): anger
Dyadic Adjustment Scale (Abbreviated) (DAS): family functioning, focusing primarily on the
partner relationship
Hospital Anxiety and Depression Scale (HADS): anxiety and depression
These measures represent the severity of the participants’ PTSD symptoms, how it influences their
overall quality of life, its impact on family relationships and the extent of comorbidities like anger,
anxiety and depression. Evaluating these measures provides the best overall picture of the effects of
the programs on the participants’ lives. It should be noted that the measures listed above are all selfreport; clinician-rated measures such as the CAPS are only collected at one point in time (intake) and
thus are not suited to the current analyses.
In analysing these measures, CMVH looked at raw scores, predictors, and interactions.
Raw scores
Raw scores were examined on each measure in order to understand change at different points in time,
and to compare with clinical cut-offs and community norms, where available.
Predictors
In these analyses, there are programs, cohorts within programs, people within cohorts and repeated
measures for each person.
A multilevel model allowed us to account for these cluster groups (programs, cohorts and people) in the
modelling. The model structure chosen allowed “random intercepts” by program, cohort and person
and assumed an “unstructured” variance-covariance structure.
For each of the outcomes of interest we started with a model with the for time points (entry, discharge,
three month and nine month follow-up) and as dichotomous fixed effect independent predictors. For
this model, the outcome at entry is treated as the baseline, and three predictors calculate the difference
between the measurement at entry and those at discharge, three month and nine month follow-up.
From here demographic characteristics of the participants were built into the model one by one to
determine which characteristics predicted overall levels of each outcome. If the term was significant or
approaching significance at the 5% level it was retained in the final model. This final model was used to
make predictions of the expected outcomes for each program based on the demographic characteristics
of that program.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
The results of the multi-level modelling for the different measures can be found under the “Predictors”
heading in the relevant section. The tables associated with these analyses can be found in Appendix 10.
Interactions
Interactions were also investigated as part of the model building process. Interaction tests assessed
whether the change in the scores over time varied by the characteristics of the participants.
Based on the literature review and questions raised in the tender, interactions were also used to assess
whether particular variables of interest (trauma focus, partner focus, mixed cohorts and age range) had
improved results. These variables were built into the statistical model in the following way:




Age: three age ranges –
o 20-49: Deployed after Vietnam. Represents contemporary veterans.
o 50-59: Includes Vietnam veterans and also some older peacekeepers e.g. Rwanda.
o 60+: Includes veterans from Vietnam, WWII and other deployments.
Trauma focus: three categories defined on qualitative information collected from sites (see
Table 15 for specific details) –
o Low: trauma focus is indirect, focusing on symptom management psycho-education,
triggers and restoration of affect, but no exposure or direct trauma work. Sites:
Greenslopes and Heidelberg.
o Medium: trauma focus in group work incorporates some exposure work, including
imaginal and in vivo, but participation is choice-based and varies with participant and
cohort. Sites: Toowong, Northside Cremorne, Hyson Green Calvary, and Daw Park.
o High: trauma focus is explicit and structured, incorporating several group sessions.
Sites: Geelong, Townsville, Palm Beach Currumbin, St John of God and Hollywood.
Partner focus: as we were unable to match individual partner involvement with individual
participant outcomes, programs were grouped according to the opportunities offered to
partners and families to be involved (see Table 15 for specific details of partner focus in each
program). This is a blunt analysis as opportunity does not equal attendance. Three categories –
o Low. Sites: St John of God, Hyson Green Calvary
o Medium. Sites: Greenslopes, Toowong, Palm Beach Currumbin
o High. Sites: Heidelberg, Geelong, Townsville, Northside Cremorne, Daw Park and
Hollywood
Mixed cohorts: two categories –
o Veteran-only. Sites: Heidelberg, Geelong, Greenslopes, Toowong, Palm Beach,
Northside Cremorne, and Hyson Green Calvary.
o Mixed (includes civilians, typically from other uniformed services such as police). Sites:
Townsville, St John of God, Daw Park and Hollywood.
It was not possible to compare inpatient with day programs as in many sites this has changed over time
(i.e. an inpatient program has become a day program), and in some sites the program is largely offered
as a day program but includes an inpatient phase.
The results of the interactions for the different measures can be found under the “Interactions” heading
in the relevant section. The graphs associated with these analyses can be found in the relevant
appendices.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Section 5: Effectiveness of the group PTSD programs: overall results
Research question:
This section answers the research question: “How effective are the group treatments?”
This section contains the results and a brief discussion of the analyses (raw scores, predictors and
interactions) for the PCL-M (PTSD), WHOQOL-BREF (Quality of Life), DAR (Anger), DAS (Family
Functioning) and HADS (Anxiety and Depression). At the end of the section is an in depth discussion of
the overall conclusions regarding effectiveness, along with the relevant recommendations.
The tables of predictors have been included in Appendix 10. Some graphs have been included in-text
and the remainder can be found in the relevant appendix.
Results: PCL-M overall (PTSD)
The military version of the PTSD Check List (PCL-M) is a self-report measure of PTSD symptoms in line
with the DSM-IV criteria. It is a 17 item scale, with a score range of 17 to 85. Participants in the PTSD
group treatment programs were asked to complete the PCL-M, along with a range of other measures, at
four points in time – entry, discharge, three month follow-up and nine month follow-up.
The PCL-M is a key measure of effectiveness for the PTSD programs. Five different types of analysis have
been conducted on the PCL-M:





Changes in raw scores: what is the average amount of change?
Movement between screening categories: are changes in PCL-M scores reflected by shifts
between positive and negative screens?
Reliable change: are changes in PCL-M scores of sufficient magnitude that they may be
classified as reliable change?
Predictors: do age, gender, employment status etc predict PCL-M scores?
Interactions: are changes in PCL-M scores influenced by different variables? For example do
scores change differently for contemporary versus older veterans?
As with any dataset, there is attrition over time in data as some participants do not complete and return
measures. However, it can be seen in Table 20 that there is almost no difference in results between the
overall dataset and participants who completed measures at all four points in time. This indicates that
participants who dropped out are not significantly different to those who completed data collection.
Changes in raw scores on the PCL-M
Overall a clear, statistically significant reduction in PCL-M scores is observed between entry (mean =
61.5, SD = 11.2) and nine month follow-up (mean = 53.7, SD = 13). The largest drop occurs between
entry and discharge (from a mean of 61.5 to a mean of 55.5) and further small reductions in PCL score
occur at three month and nine month follow-up (see Table 19).
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Table 19: PCL-M scores by time point
Entry
Discharge
3 months
9 months
N
1470
1303
1159
984
Mean
61.5
55.5
54.4
53.7
95% CI
(60.9, 62.1)
(54.7, 56.2)
(53.7, 55.1)
(52.9, 54.5)
p-values
-
DIFFERENCES:
Entry to Discharge
Entry to 9 months
Discharge to 9 months
1296
1155
940
-6.1
-6.9
-1.9
(-6.7, -5.5)
(-7.6, -6.4)
(-2.6, -1.2)
<0.0001
<0.0001
<0.0001
Movement between diagnostic categories on the PCL-M
Scores above 50 on the PCL-M indicate a positive screen for PTSD, although there is some debate about
the most appropriate cut-off point and clinical review is required for diagnosis. In the PTSD group
treatment programs, average PCL-M scores remain above 50 at discharge and follow-up (see Table 19).
However, raw scores show that the number of participants scoring above 50 on the PCL-M falls from
86% at entry to 64% by nine month follow-up, meaning that 36% of scores are below the clinical range
at this point in time (see Table 20). Table 20 also demonstrates that there are no significant differences
on the PCL-M between participants who completed measures at all four time points and those who did
not – the proportions scoring above 50 are almost the same.
Table 20: Numbers scoring ≥50 on the PCL-M by time-point
Including all PCL-M records
Entry
Discharge
3 months
9 months
N
PCL-M 50 (%)
Including subjects who completed
questionnaire at all four time-points
N
PCL-M 50 (%)
1470
1303
1159
984
1261 (86%)
902 (69%)
748 (65%)
627 (64%)
878
878
878
878
749 (85%)
610 (69%)
564 (64%)
559 (64%)
An in depth analysis (see Table 21) of the movement of individuals between diagnostic categories (as
opposed to changes in overall raw scores) revealed that 72% (n = 707; i.e. 113+594) of participants
scored in the same PCL-M category at both entry and nine month follow-up, 25% (n = 241) moved out of
the clinical range and 3% (n = 30) moved into the clinical range (i.e. worsened). Although the majority of
participants remained in the same category (72%), McNemar’s test indicated that the number who
changed from one category to another was significant.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Table 21: Movement between PCL-M categories from entry to nine month follow-up
Entry
PCL-M 50 (%)
PCL-M 50 (%)
Total
PCL-M 50 (%)
113 (12%)
241 (25%)
354
N
Entry to discharge
Entry to 9 months
1296
978
9 months
PCL-M 50 (%)
30 (3%)
594 (61%)
624
Difference
PCL-C 50
16.9 %
21.6%
95% CI of difference
[15.1%,18.7%]
[19.5%, 23.6%]
Total
143
835
978
McNemar’s Pvalue
< 0.0001
< 0.0001
However, due to the severity of the symptoms in this population, 61% of participants (n=594) scored
above 50 at both entry and discharge; a further analysis was undertaken in order to understand more
about what was happening for these participants (see Table 22). Scores above 50 were broken into two
categories: 50-59 and ≥ 60. This analysis found that 54% of participants (n = 495; i.e. 113+84+298)
stayed in the same category between entry and nine months, 39% (n = 358; i.e. 121+120+117) improved
(i.e. dropped a category) and 7% (n = 67; i.e. 24+6+37) worsened (i.e. went up a category). Of
participants who scored above 60 on entry, 40% (n = 237; i.e. 120+117) improved, compared to 50% of
those who scored 50-59 at entry, and 30% of participants scored above 60 at both entry and nine
months. These findings suggest that symptoms at this high level of severity may be more difficult to
improve.
Table 22: Movement between three PCL-M categories from entry to nine month follow-up
Entry
9 months
Total
PCL < 50
PCL 50 - 59
PCL ≥ 60
PCL < 50
113
24
6
143
PCL 50 – 59
121
84
37
242
PCL ≥ 60
120
117
298
535
Total
354
225
341
920
NB: Black cells indicate an improvement, grey cells indicate a deterioration and white cells suggest no
change between entry and nine months.
Reliable change on the PCL-M
The Reliable Change Index (RCI) was used to determine the degree to which individuals had changed,
and whether this change was both reliable (i.e. large enough to be due to more than measurement
error) and clinically significant. This type of analysis is different from statistical significance and
diagnostic categories and focuses on change for individual participants.
An RCI of 1.96 indicates significance. The RCI calculated for PCL-M scores from entry to discharge was
6.23, confirming that the change for participants between entry and discharge is significant. Breaking
this down:

53% (681 from 1296) of participants reliably changed between entry and discharge. Of these:
o 43% (554 from 1296) of participants reliably improved
o 10% (127 from 1296) of participants reliably worsened
30
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
The finding that 43% of participants reliably improved is positive, given the severity of symptoms within
this population.
RCIs were also calculated for two key variables of interest: levels of trauma focus and age.
RCIs by level of trauma focus
RCIs calculated between entry and discharge for participants found slightly stronger results for programs
with a medium/high trauma focus (see Table 23):



Reliable improvements for 37% (n = 131) of participants in low and 45% (n = 423) of participants
in medium/high trauma focus programs
Reliable worsening for 10% (n = 37) of participants in low and 10% (n = 90) of participants in
medium/high trauma focus programs
No reliable change (either positive or negative) for 53% (n = 186) of participants in low and 46%
(n = 429) of participants in medium/high trauma focus programs
Table 23: Reliable change on the PCL-M by level of trauma focus from entry to discharge
Reliable change
No
Yes – Improve
Yes – Worsen
Total
Low
186
131
37
354
Trauma focus
Medium or High
429
423
90
942
Total
615
554
127
1296
RCIs were also calculated between entry and nine month follow-up. This analysis found that by this
time, differences between levels of trauma focus had largely disappeared (see Table 24):



Reliable improvement for 53% (n = 147) of participants in low and 50% (n = 353) of participants
in medium/high trauma focus programs
Reliable worsening for 7% (n = 18) of participants in low and 7% (n = 51) of participants in
medium/high trauma focus programs
No reliable change for 40% (n = 110) of participants in low and 43% (n=299) of participants in
medium/high trauma focus programs
Table 24: Reliable change on the PCL-M by level of trauma focus from entry to nine month follow-up
Reliable change
No
Yes – Improve
Yes – Worsen
Total
Low
110
147
18
275
Trauma focus
Medium or High
299
353
51
703
Total
409
500
69
978
RCIs by age
RCIs calculated between entry and discharge found slightly stronger results for participants aged 50 and
over (see Table 25):
31
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses



No reliable change (either positive or negative) for 51% (n = 154) of contemporary veterans and
46% (n = 460) of veterans aged 50 and over
Reliable improvement for 38% (n = 114) of contemporary veterans and 44% (n = 439) of
veterans aged 50 and over
Reliable worsening for 12% (n = 35) of contemporary veterans and 9% (n = 92) of veterans aged
50 and over
These results suggest that, between entry and discharge, more contemporary veterans stayed the same,
slightly fewer improved and slightly more worsened.
Table 25: Reliable change on the PCL-M by age from entry to discharge
Reliable change
No
Yes – Improve
Yes – Worsen
Total
Age
Contemporary veterans
Veterans aged 50 and
over
154
460
114
439
35
92
303
991
Total
614
553
127
1294
RCIs calculated between entry and nine month follow-up found that differences between age persisted
(see Table 26):



No reliable change for 44% (n = 84) of contemporary veterans and 41% (n = 325) of veterans
aged 50 and over
Reliable improvement for 46% (n = 88) of contemporary veterans and 52% (n = 412) of veterans
aged 50 and over
Reliable worsening for 10% (n = 20) of contemporary veterans and 6% (n = 49) of veterans aged
50 and over
These results suggest that while there are further improvements by nine month follow-up, the
differences in improvement between age groups are still evident.
Table 26: Reliable change on the PCL-M by age from entry to nine month follow-up
Reliable change
No
Yes – Improve
Yes – Worsen
Total
Age
Contemporary veterans
Veterans aged 50 and
over
84
325
88
412
20
49
192
786
Total
409
500
69
978
Predictors of PCL-M
Other than time-point (entry, discharge, three months, nine months), age, education, marital status,
employment, service (Army, Navy and Air Force) and service type (Regular or Conscript) were all
important predictors of overall PCL-M scores. Adjusting for all the demographics in the model,
contemporary veterans reported more symptoms of PTSD. Being single, having a post high school
qualification, being retired or unable to work or being from the Army or a conscript were all associated
with lower (improved) scores on the PCL-M.
32
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Interactions for PCL-M
Age group
There was no clear indication that the improvement in PCL-M scores differed by age group.
Contemporary veterans had the highest PCL-M scores at entry and discharge, however the reduction
observed in PCL-M scores was of a similar magnitude for all age groups, indicating that participants
received a similar improvement in PTSD symptoms regardless of age.
Employment category
Reductions in the PCL-M did differ by employment category. As shown in Figure 1, overall those who
were unable to work had the largest adjusted reduction in the PCL-M between entry and nine months.
This suggests that participants who are retired or unable to work gained the most benefit in terms of
reductions in PCL-M scores, and that participants who are employed may be receiving less benefit from
the programs on the PCL-M.
Figure 1.
PCL-M scores by employment category
Trauma focus
There was a significant difference in the reduction in PCL-M scores from entry and discharge by the level
of trauma focus (see Figure 2). The initial reduction in PCL-M scores was greatest in the programs with
a medium trauma focus, although these differences were less noticeable at nine month follow-up. This
suggests programs with some trauma focus achieve slightly better results on the PCL-M at discharge,
although by nine months these differences have largely disappeared.
33
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 2.
PCL-M scores by trauma focus
Partner focus
There was no indication that programs with a different level of partner focus achieved different
outcomes on the PCL-M. However, as detailed above, our analysis of partner involvement was blunt. A
more precise analysis would need to be conducted before drawing firm conclusions about the impact of
partner involvement on PCL-M scores.
Veteran-only or mixed cohorts
Veteran-only cohorts had a slightly larger reduction in PCL-M between entry and discharge, but mixed
cohorts had a larger reduction in PCL-M scores between discharge and nine month follow-up (see Figure
3), suggesting that results are very similar on this measure.
34
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 3.
PCL-M scores by veteran-only or mixed cohorts
Discussion: PCL-M overall
Overall, the PTSD programs achieved a statistically significant reduction (improvement) on the PCL-M of
6.1 points between entry and discharge, and a further 1.7 points from discharge to nine month followup, providing clear evidence of effectiveness.
It is less clear what this reduction means in terms of functional change in a person’s life – how well are
participants, and how meaningful is this change for them? Functional improvement is not directly
measured in the data to which CMVH had access, and inclusion of measures of function should be
considered in future data collection.
Contemporary veterans achieved a similar magnitude of change on the PCL-M as other age groups.
However, they finished with higher scores because they entered with higher scores, and may therefore
be less well than other age groups on discharge. This age group is benefitting from the programs but
may require something additional, such as higher intensity treatment or additional follow-up. Some of
this may be delivered using promising new technologically-based interventions highlighted in the Phase
1 literature review (see Appendix 1), such as internet based therapy.
Participants who were retired or unable to work achieved a higher reduction on the PCL-M than those
who were working or looking for work. Though this may also be related to age, it is possible that the
programs are achieving a smaller benefit for participants who are in the workforce. This may be due to
different demands for this subgroup, or other, as yet unknown, variables. This area would benefit from
further investigation.
Programs with some trauma focus achieved slightly better results on the PCL-M between entry and
discharge than programs with a low trauma focus. Although this difference largely disappeared by nine
months, it suggests that participants in programs with some trauma focus are receiving slightly more
benefit at discharge.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
No effect on the PCL-M was observed for level of partner involvement, but as discussed this may be due
to the blunt analysis. The qualitative interviews found overwhelming support for the involvement of
partners and families, and the consulting psychiatrist, Dr Len Lambeth, believes family involvement is
critical in the treatment of PTSD.
There have been some questions about the appropriateness of including non-veterans in the PTSD
cohorts. Sites who include non-veterans report benefits; sites who operate veteran-only cohorts
sometimes express reservations about mixing cohorts. The quantitative analyses showed no
detrimental effect on PCL-M scores for mixed cohorts, suggesting that inclusion of non-veterans in PTSD
programs was not detrimental to outcomes, although it should be noted that these participants are
from other uniformed services such as police. This finding has important implications for the
sustainability of the programs if demand from veterans continues to decline.
Results: WHOQOL-BREF (Quality of Life) overall
The WHOQOL-BREF is an abbreviated 26-item version of the WHOQOL-100. The self-report measure
reflects four quality of life (QOL) domains: physical, psychological, social and environment. Domain
scores are scaled in a positive direction, such that higher scores denote higher QOL. Participants in the
PTSD group treatment programs were asked to complete the WHOQOL-BREF, along with other
measures, at four points in time – entry, discharge, three month follow-up, and nine month follow-up.
The World Health Organisation (WHO) define QOL as “an individual’s perception of their position in life
in the context of the culture and value systems in which they live, and in relation to their goals,
expectations, standards, and concerns” (WHOQOL Group, 1994). This measure captures changes in
personal meaning and functioning in daily life. Therefore, the outcomes observed for this measure may
be more likely to capture meaningful functional improvements in participants’ lives, compared to a
measure such as the PCL-M which is designed to measure symptomatology.
The four scales – physical, psychological, social and environment – will be addressed separately.
WHOQOL-BREF Physical scale
The Physical scale of the WHOQOL-BREF asks participants to respond to questions concerning activities
of daily living; dependence on medicinal substances and aids; energy and fatigue; mobility; pain and
discomfort; sleep and rest; and work capacity. The measure taps into how heavily participants rely on
medical treatment to function in their daily life, to what extent they experience pain, and if this
interferes with their ability to do the things they wish to do. This is an important measure because it
offers some quantifiable indication of changes in functioning.
Overall, there is a clear and significant improvement on the WHOQOL-BREF Physical scale between entry
and discharge. These gains were maintained at nine month follow-up (see Table 27). The data suggest
that overall, participants who completed the PTSD programs experienced significant improvements in
their physical QOL.
36
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Table 27: WHOQOL-BREF Physical scores by time point
Entry
Discharge
3 months
9 months
n
1476
1309
1161
984
Mean
39.7
46.3
45.4
46.4
95% CI
(38.9, 40.4)
(45.4, 47.1)
(44.5, 46.3)
(43.4, 47.4)
p-values
-
DIFFERENCES:
Entry to Discharge
Entry to 9 months
Discharge to 9 months
1307
982
944
6.6
6.5
-0.01
(6.0, 7.2)
(5.6, 7.3)
(-0.8, 0.8)
<0.0001
<0.0001
0.98
Improvements on the physical scale suggest that participants, on average, were significantly less reliant
on medical treatments to function in their daily life, were sleeping better, and experiencing less pain. In
contrast to the WHOQOL-BREF norms, however, participants were still functioning with lower
satisfaction at nine month follow-up compared to population norms (PTSD program mean of 46.4
compared to population means of 61.6 for outpatients and 51.8 for inpatients). Therefore, physical QOL
remained lower than the population level, despite the significant improvements observed.
Predictors of WHOQOL-BREF Physical
Other than time-point (entry, discharge, three months, and nine months), the variables age, marital
status, employment, service (Army, Navy or Air Force) and service type (Regular or Conscript) were all
important predictors of the WHOQOL-BREF Physical scale. Adjusting for all the demographics in the
model, contemporary veterans were found to have lower (worse) scores, overall. This is consistent with
general trends for contemporary veterans that suggest they are experiencing more severe problems at
entry and at follow-up. In contrast, participants who were working, from the Army or a conscript were
found to have higher scores on the WHOQOL-BREF physical scale.
Interactions for WHOQOL-BREF Physical
Age group
There was no clear indication that the improvement in WHOQOL-BREF Physical scores differed by age
group, indicating that participants improved at a similar rate regardless of age.
Employment category
Improvements in the WHOQOL-BREF Physical scale did differ by employment category (see Figure 4).
Overall those who were unable to work had the greatest adjusted improvement in the WHOQOL-BREF
Physical between entry and nine month follow-up.
37
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 4.
WHOQOL-BREF Physical results by employment category
Trauma focus
The changes in the WHOQOL-BREF Physical scale did not vary by the level of trauma focus.
Partner focus
The changes in the WHOQOL-BREF Physical scale did not vary by the level of partner focus.
Veteran-only or mixed cohorts
The changes in the WHOQOL-BREF Physical scale did not vary between veteran-only and mixed cohorts.
WHOQOL-BREF Psychological scale
The Psychological scale of the WHOQOL-BREF asks participants to respond to questions concerning body
image and appearance; negative and positive feelings; self-esteem; spirituality, religion, personal beliefs;
and thinking, learning, memory, and concentration. This scale taps into how satisfied people feel about
themselves, their sense of self worth, and to what extent their life has meaning. Higher scores indicate
higher satisfaction.
Overall, there is a clear improvement on the WHOQOL-BREF Psychological scale between entry and
discharge for people who participated in the PTSD programs (see Table 28). Between discharge and
nine month follow-up, the average score of the WHOQOL-BREF Psychological falls back slightly.
However, overall the gain is significant and is maintained from entry to nine month follow-up.
38
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Table 28: WHOQOL-BREF Psychological scores by time point
Entry
Discharge
3 months
9 months
n
1476
1309
1161
985
Mean
36.5
45.5
43.9
44.3
95% CI
(35.8, 37.3)
(44.7, 46.4)
(43.1, 44.8)
(43.3, 45.4)
p-values
-
DIFFERENCES:
Entry to Discharge
Entry to 9 months
Discharge to 9 months
1307
983
945
8.9
7.2
-1.4
(8.2, 9.7)
(6.2, 8.1)
(-2.3, -0.6)
<0.0001
<0.0001
0.0009
This finding suggests that after participating in a PTSD group treatment program, participants have
significantly greater satisfaction regarding the quality of their life, self-worth, and meaningfulness.
However, the average score for participants at nine month follow-up (mean = 44.3) is below the
population norms for outpatients (mean = 65.3, SD = 17.9) and inpatients (mean = 64.1, SD = 18.4). This
suggests that participants may continue to experience lower psychological quality of life at follow-up
compared to norms, despite significant improvements after treatment.
Predictors of WHOQOL-BREF Psychological
Other than time-point (entry, discharge, three months and nine months), the variables age, education,
employment, service (Army, Navy or Air Force) and service type (Regular or Conscript) were all
important predictors of the WHOQOL-BREF Psychological scale. Adjusting for all the demographics in
the model, contemporary veterans were found to have lower (worse) scores, whereas having a post
high school qualification, being retired, or being from the Army or a conscript were all associated with
higher (improved) scores on the WHOQOL-BREF Psychological scale.
Interactions for WHOQOL-BREF Psychological
Age group
There was no clear indication that the improvement in WHOQOL-BREF Psychological scores differed by
age group, indicating that participants improved at a similar rate regardless of age.
Employment category
Improvement in WHOQOL-BREF Psychological scores did differ by employment category (see Figure 5).
Overall, those who were working or looking for work had the smallest adjusted improvement in the
WHOQOL-BREF Psychological scale between entry and nine month follow-up.
39
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 5.
WHOQOL-BREF Psychological results by employment category
Trauma focus
The changes in the WHOQOL-BREF Psychological scale did vary by the level of trauma focus (see Figure
6). Specifically, the improvement between entry and discharge was greatest in the programs with a high
trauma focus. However, it appears that by nine month follow-up these differences had largely
disappeared.
Figure 6.
WHOQOL-BREF Psychological results by trauma focus
Partner focus
The changes in the WHOQOL-BREF Psychological scale did not vary by the level of partner focus.
40
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Veteran-only or mixed cohorts
The changes in the WHOQOL-BREF Psychological scale did not vary between veteran-only and mixed
cohorts.
WHOQOL-BREF Social Relationships scale
The Social Relationships scale of the WHOQOL-BREF asks participants to respond to questions
concerning how satisfied they are with their personal relationships; social support from friends; and
sexual activity. Positive changes on this scale represent improvements in the quality of personal
relationships, friendships, social support, and intimate relationships. Higher scores indicate higher
satisfaction.
Overall, there is a significant improvement in the WHOQOL-BREF Social Relationships scale between
entry and discharge. Between discharge and three month follow-up the scores decline slightly and then
remain steady until nine month follow-up (see Table 29).
Table 29: WHOQOL-BREF Social Relationships scores by time point
Entry
Discharge
3 months
9 months
n
1472
1304
1160
982
Mean
37.8
47.3
45.6
45.8
95% CI
(36.8, 38.8)
(46.2, 48.4)
(44.4, 46.7)
(44.5, 47.1)
p-values
-
DIFFERENCES:
Entry to Discharge
Entry to 9 months
Discharge to 9 months
1298
977
941
9.6
7.7
-1.5
(8.6, 10.6)
(6.5, 8.9)
(-2.6, 0.3)
<0.0001
<0.0001
0.01
Whilst participants’ scores, on average, significantly improved from entry to nine month follow-up, it is
important to note that ratings are still below population norms for outpatients (PTSD program mean of
45.8 compared to population outpatient mean of 62.9). This finding suggests that participants in the
program continue to experience less satisfaction with their social relationships compared to norms for
outpatient populations.
Predictors of WHOQOL-BREF Social Relationships
Age, gender, marital status, employment, and service type (Regular or Conscript) were all important
predictors of the WHOQOL-BREF Social Relationship scale. Adjusting for all the demographics in the
model, contemporary veterans were found to have lower (worse) scores, whereas females, those who
were retired, and conscripts all had higher (improved) scores on the WHOQOL-BREF Social Relationship
scale.
Interactions for WHOQOL-BREF Social Relationships
Age group
There was no difference in the improvement on the WHOQOL-BREF Social Relationships scale by age
group.
41
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Employment category
Examining the scores by employment category, those who were retired or unable to work had the
largest improvement in the WHOQOL-BREF Social Relationship scale between entry and discharge (see
Figure 7).
Figure 7.
WHOQOL-BREF Social Relationships results by employment category
Trauma focus
The changes in the WHOQOL-BREF Social Relationships scale did not vary by the level of trauma focus.
Partner focus
The changes in the WHOQOL-BREF Social Relationships scale did not vary by the level of partner focus.
Veteran-only or mixed cohorts
The changes in the WHOQOL-BREF Social Relationships scale did not vary between veteran-only and
mixed cohorts.
Gender
The patterns of improvement on the WHOQOL-BREF Social Relationships were found to vary by gender
(see Figure 8). Women’s scores continued to improve after discharge, whereas men’s scores remained
steady. It is important to note, however, that this comparison is based on 19 women, and therefore
only tentative conclusions can be drawn based on such a small number of women.
42
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 8.
WHOQOL-BREF Social Relationships results by gender
WHOQOL-BREF Environment scale
The Environment scale of the WHOQOL-BREF asks participants to respond to questions concerning
financial resources; freedom, safety, and security; health and social care; home environment;
opportunities for recreation activities; the physical environment in which they live; and access to
transport. This scale determines the quality of participants’ ability to function and act within their
environment.
On the Environment scale of the WHOQOL-BREF, statistically significant improvements were found
between entry and discharge and entry to nine month follow-up, although there was a slight decline
between three months and nine months (see Table 30). This suggests that people who participated in
the PTSD programs made significant improvements in their environmental QOL and that these gains
were maintained at nine month follow-up. Increases in the environment scale indicate that participants
felt more satisfied with the environment in which they live.
Table 30: WHOQOL-BREF Environment scores by time point
Entry
Discharge
3 months
9 months
n
1476
1309
1161
985
Mean
56.5
60.8
59.8
60.6
95% CI
(55.8, 57.3)
(60.0, 61.5)
(59.0, 60.6)
(59.7, 61.5)
p-values
-
DIFFERENCES:
Entry to Discharge
Entry to 9 months
Discharge to 9 months
1307
983
944
4.0
3.3
-0.4
(3.3, 4.6)
(2.5, 4.1)
(-1.2, 0.3)
<0.0001
<0.0001
0.28
Although participants improved from entry to discharge on this scale, the mean score at nine month
follow-up (mean = 60.6) was lower than the population norms for outpatients (mean = 68.2) and
43
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
inpatients (mean = 67.1). This suggests that whilst participants significantly improved, their quality of
life remains below the population’s average on this scale.
Predictors of WHOQOL-BREF Environment
Age, marital status, employment, education, service (Army, Navy or Air Force) and service type (Regular
or Conscript) were all important predictors of the WHOQOL-BREF Environment scale. Adjusting for all
the demographics in the model, contemporary veterans were found to have lower scores overall. In
contrast, participants who were retired, from the Army, or a conscript all had higher (improved) scores
on the WHOQOL-BREF Environment scale.
Interactions for WHOQOL-BREF Environment
Age group
There was no clear indication that the improvement in WHOQOL-BREF Environment scores differed by
age group, indicating that participants improved at a similar rate regardless of age.
Trauma focus
Between entry and discharge, the improvement in the WHOQOL-BREF Environment scale was greatest
in programs with a high trauma focus, however this improvement was not sustained to nine month
follow-up (see Figure 9).
Figure 9.
WHOQOL-BREF Environment results by trauma focus
Partner focus
The changes in the WHOQOL-BREF Environment scale did not vary by the level of partner focus.
Veteran-only or mixed cohorts
The changes in the WHOQOL-BREF Environment scale did not vary between veteran-only and mixed
cohorts.
44
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Discussion: WHOQOL-BREF overall
Trends in the data were consistent with other measures (e.g., PCL-M), indicating the greatest
improvements are made between entry and discharge, and improvements are generally maintained
through to three month and nine month follow-up. This indicates that overall the programs are
effective at improving quality of life for participants.
Contemporary veterans consistently report experiencing a lower quality of life on entry to the PTSD
programs. This was found across the four domains of the WHOQOL-BREF measure. However, although
they have lower baseline WHOQOL-BREF scores on all domains, there are no differences between this
group and veterans aged 50 and over on the magnitude of improvements observed related to quality of
life. Greater distress for contemporary veterans is a finding that is consistent with the results from
other measures.
Significant interactions with employment status were found on the psychological, social relationships,
and physical scales of the WHOQOL-BREF, suggesting that employment status has a significant impact
on improvements to quality of life for participants completing PTSD programs.



Overall, participants who were working or looking for work had the smallest adjusted
improvement on the psychological scale between entry and nine month follow-up. Typically,
people actively seeking work or who are in the work force are most likely to be in the younger
age group bracket. This finding is consistent with other results suggesting that the symptoms of
contemporary veterans are more severe at entry, discharge, and the two follow-up time points.
Therefore, they may require a more intensive or longer-term treatment approach.
Those participants who indicated that they were unable to work had the greatest adjusted
improvement on the physical scale. This suggests that participating in the program significantly
improved this subgroup of participants’ activities of daily living, reliance on medications, energy,
mobility, pain/discomfort, sleep, and work capacity. Therefore, this would suggest a clinically
meaningful QOL improvement for this subgroup of participants.
The retired subgroup of participants generally showed larger improvements from entry to
follow-up compared to other groups, across the range of WHOQOL-BREF domains. The retired
and unable to work subgroups showed significantly greater improvements on the social
relationships subscale. This finding suggests that clinically meaningful improvements in QOL
relating to personal relationships, social support, and sexual activity were made.
Having a high trauma focused PTSD program produced a greater magnitude of improvements in
WHOQOL-BREF Psychological and Environmental scales between entry and discharge.
Partner focus was found to have little to no significant impact on any of the WHOQOL-BREF domains,
although, as previously explained, the analysis of partner involvement was blunt. A more precise
analysis would need to be conducted in order to make firm conclusions about the impact of partner
involvement on quality of life improvements from the PTSD programs.
An interesting outcome was that women demonstrated a greater level of improvement in WHOQOLBREF scores on the social relationships scale compared to men. Although the number of women for
whom data were available was small (n=19), the results point towards an interesting trend that could be
explored in future research.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
The inclusion of mixed cohorts had no significant impact on ratings on the WHOQOL-BREF domains. This
suggests that having mixed or veteran-only cohorts did not increase or decrease quality of life
improvements for PTSD program participants.
Results: DAR (Anger) overall
The Dimensions of Anger Reaction (DAR) is a seven-item self-report scale that measures anger reactions.
It has a score range of zero to 56, with higher scores indicating worse symptomatology.
Overall, a clear, statistically significant reduction is observed in the DAR (Anger) scale between entry and
discharge (from a mean of 31.0 to a mean of 26.1), with a further marginal improvement from discharge
to nine month follow-up (from a mean of 26.1 to a mean of 24.3) (see Table 31).
Table 31: DAR (Anger) scores by time point
Entry
Discharge
3 months
9 months
n
1474
1304
1159
981
Mean
31.0
26.1
25.1
24.3
95% CI
(30.3, 31.7)
(25.3, 26.9)
(24.3, 25.9)
(23.4, 25.2)
p-values
-
DIFFERENCES:
Entry to Discharge
Entry to 9 months
Discharge to 9 months
1300
978
939
-5.0
-6.3
-1.6
(-5.6, -4.3)
(-7.1, -5.5)
(-2.3, -0.9)
<0.0001
<0.0001
<0.0001
Predictors of DAR (Anger)
Age, marital status, employment category, service (Army, Navy or Air Force) and service type (Regular or
Conscript) were all important predictors of the DAR anger scale. Adjusting for all the demographics in
the model, contemporary veterans had more symptoms of anger, as did married participants. Those
who were retired, unable to work, from the Army or conscripts all exhibited a lower level of anger.
Interactions for DAR (Anger)
Age group
Although contemporary veterans had higher baseline severity, there was no difference in improvement
on the DAR (Anger) scale by age group, suggesting that reduction in anger does not vary by age.
Employment category
Looking at the scores by employment categories, those unable to work or who were retired had the
largest reduction on the DAR (Anger) scale, particularly between entry and discharge (see Figure 10).
This suggests that participants who are retired or unable to work gain the most benefit in terms of
reductions in DAR scores, and that participants who are in the labour market (employed or looking for
work) may be receiving less benefit from the programs on the DAR.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 10.
DAR (Anger) scores by employment category
Trauma focus
The improvements on the DAR (Anger) scale were not shown to vary by the level of trauma focus.
Partner focus
Programs with some partner focus had larger reductions on the DAR (Anger) scale compared to
programs with a low partner focus (see Figure 11). Despite the blunt analyses, clear differences are
evident, such that medium to high partner focus significantly decreases participants’ levels of anger,
compared to a low partner focus. This difference is still evident at nine month followup.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 11.
DAR (Anger) scores by level of partner focus
Veteran-only or mixed cohorts
Veteran-only cohorts had a slightly larger reduction in the DAR anger scale between entry and discharge
compared to mixed cohorts (see Figure 12). However, this distinction was less clear at nine month
follow-up. This suggests that veteran-only cohorts achieve a slightly larger reduction in anger between
entry and discharge, although the difference has largely disappeared at three month and nine month
follow-up.
Figure 12.
DAR (Anger) scores by veteran-only or mixed cohorts
Discussion: DAR (Anger) overall
The trends found in the DAR (Anger) are very similar to the trends in other measures. Overall, the
programs achieved a statistically significant reduction in the DAR between entry and discharge, with a
further small improvement between discharge and nine months. This is clear evidence of effectiveness.
With respect to age, contemporary veterans entered the programs with more acute anger but received
the same magnitude of benefit as veterans aged 50 and over. This suggests that the programs are
equally effective across all age groups in reducing anger, but also indicates that as with the PCL,
contemporary veterans have higher levels of anger on discharge and thus require either higher intensity
treatment or additional follow-up.
Participants who are retired or unable to work gained the most benefit with respect to anger, with
smaller gains for those in the labour force (working or looking for work). This suggests the programs
may not be as beneficial for participants in the labour force, as measured by the DAR, and it may be
important to investigate this further.
Despite the blunt analysis, the level of partner focus had a clear impact on anger, with programs with
medium and high partner focus achieving significantly greater reductions in anger than programs with a
low partner focus across all post-treatment measures.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
There was no impact on the DAR (Anger) by the level of trauma focus, and veteran-only and mixed
cohorts had comparable results.
Results: DAS (Family Function) overall
The Dyadic Adjustment Scale (DAS) is a self-report scale measuring the general quality of marital/cohabiting relationships. It has seven items, and the score ranges from zero to 36, with higher scores
indicating better functioning. A mean of 22.5 (SD 5.4) indicates a high incidence of happily married
couples.
Overall, there was an improvement in the DAS (Family Function) scale between entry and discharge
(from a mean of 18.4 to a mean of 20.3), before the scores fall back slightly at three month and nine
month follow-up (from a mean of 20.3 on discharge to a mean of 19.8 at nine months) (see Table 32).
Note: fewer participants completed the DAS as those without current partners were instructed to skip
the scale.
Table 32: DAS (Family Function) scores by time point
Entry
Discharge
3 months
9 months
n
1184
1055
921
764
Mean
18.4 (6.5)
20.3 (6.2)
20.1 (6.2)
19.8 (6.2)
95% CI
(18.0, 18.7)
(19.9, 20.7)
(19.7, 20.5)
(19.4, 20.3)
p-values
-
DIFFERENCES:
Entry to Discharge
Entry to 9 months
Discharge to 9 months
1011
728
715
1.9
1.3
-0.7
(1.6, 2.2)
(0.9, 1.7)
(-1.0, -0.3)
<0.0001
<0.0001
0.0004
Predictors of DAS (Family Function)
Gender, employment status and education level were all important predictors of the DAS family
function scale. Adjusting for all the demographics in the model, female and retired participants had
better family function scores. Those with post high school qualifications had slightly higher family
functioning scores.
Interactions for DAS (Family Function)
Age group
There was no difference in the improvement in the DAS (Family Function) scale by age group, suggesting
that improvement in family function does not vary by age.
Trauma focus
The improvements on the family function scale were not shown to clearly vary by the level of trauma
focus.
Partner focus
Programs with medium or high partner focus also had larger improvements on the family function scale
between entry and discharge compared to programs with a low partner focus, although this difference
was less marked at nine month follow-up (see Figure 13). Although a more precise analysis of partner
involvement could be conducted, as previously discussed, this result suggests that programs with some
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
partner focus (medium or high) achieve larger improvements in family function than those with low
partner focus, which might be expected.
Figure 13.
DAS (Family Function) by level of partner focus
Veteran-only or mixed cohorts
The improvements on the DAS (Family Function) scale were not shown to clearly vary between mixed or
veteran-only cohorts.
Discussion: DAS (Family Function) overall
Overall there is a small improvement on the DAS (Family Function) between intake and discharge.
As might be expected, the level of partner focus impacts the magnitude of improvement in the DAS,
with medium and high partner focus achieving greater improvements than a low partner focus between
entry and discharge. Improvements were not affected by mixed cohorts or the level of trauma focus,
which is also consistent with expectations.
As with many mental illnesses, PTSD can have an impact on the entire family system, taking a toll on
relationships with partners and children. In considering the overall benefit from the programs,
improvements for families are vitally important as this can influence the level of support received by the
veteran, as well as the ongoing functionality and happiness of the family unit.
Results: HADS (Anxiety) overall
The Hospital Anxiety and Depression (HADS) is a 14 item self-report scale that incrementally measures
states of anxiety or depression. This first section reports the analysis of the anxiety scale. Seven items
relate to anxiety, with a score range of zero to 21. Lower scores represent less anxiety.
Overall a statistically significant reduction in HADS (Anxiety) scores is observed between entry (mean =
13.7, SD = 3.5) and nine month follow-up (mean = 11.6, SD = 3.8). The largest drop occurs between
entry and discharge (from a mean of 13.7 to a mean of 11.9) and further small reductions in HADS
(anxiety) score occur at three month and nine month follow-up (see Table 33).
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Table 33: HADS (Anxiety) scores by time point
Entry
Discharge
3 months
9 months
n
1469
1309
1158
980
Mean
13.7 (3.5)
11.9 (3.7)
11.7 (3.7)
11.6 (3.8)
95% CI
(13.5, 13.9)
(11.7, 12.1)
(11.5, 11.9)
(11.4, 11.8)
p-values
-
DIFFERENCES:
Entry to Discharge
Entry to 9 months
Discharge to 9 months
1300
971
939
-1.8
-2.1
-0.3
(-2.0, -1.6)
(-2.3, -1.9)
(-0.5, -0.1)
<0.0001
<0.0001
0.004
As with any dataset, there is attrition over time in data as some participants do not complete and return
measures. However, it can be seen in Table 34 that there is almost no difference in results between the
overall dataset and participants who completed measures at all four points in time. This indicates that
participants who dropped out are not significantly different to those who completed data collection.
Table 34: Numbers scoring ≥11 on the HADS (Anxiety) by time point
Including all HADS (Anxiety) records
Entry
Discharge
3 months
9 months
n
HADS Anxiety 11 (%)
1469
1309
1158
980
1261 (86)
902 (69)
748 (65)
627 (64)
Including subjects who completed
questionnaire at all four timepoints
n
HADS Anxiety 11
(%)
874
730 (84)
874
547 (63)
874
554 (63)
874
538 (62)
Scores above eight on the HADS indicate possible pathology, with scores above 11 indicating more
definite cases. Seventy-one percent of participants scored in the same HADS category at both entry and
nine month follow-up, 26% moved from scoring above to below this cut-off (i.e. improving) and 4% of
participants scored below 11 at entry but above 11 at nine months (i.e. worsening) (see Table 35). This
suggests that most participants stayed in the same category, a pattern of results that is very similar to
those on the PCL-M. Note: the more stringent cut-off of 11 has been used for this analysis.
Table 35: Movement between HADS (Anxiety) categories from entry to nine month follow-up
Entry
HADS Anxiety 11 (%)
HADS Anxiety 11 (%)
Total
9 months
HADS Anxiety 11 (%)
HADS Anxiety 11
(%)
116 (12)
39 (4)
248 (26)
568 (59)
364
607
Total
155
816
971
Predictors of HADS (Anxiety)
Age, marital status, employment category, education level, service (Army, Navy or Air Force) and service
type (Regular or Conscript) were all important predictors of the HADS Anxiety scale. Adjusting for all the
51
Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
demographics in the model, retired, single and Army participants had better (lower) anxiety levels.
Those without a qualification post high school, regulars and contemporary veterans had higher levels of
anxiety.
Interactions for HADS (Anxiety)
Age group
There was a difference in the HADS (Anxiety) by age group, with contemporary veterans receiving less
improvement than other age groups (see Figure 14). This suggests that contemporary veterans received
less benefit on anxiety than veterans aged over 50, even though their initial level of severity was similar
to veterans aged 50-59.
Figure 14.
HADS (Anxiety) scores by age
Employment category
Looking at the scores by employment categories, those unable to work or who were retired had the
largest reduction on the HADS (Anxiety) scale, particularly between entry and discharge (see Figure 15).
This suggests that participants who are retired or unable to work gain the most benefit in terms of
reductions in HADS (Anxiety) scores, and that participants who are in the labour market (employed or
looking for work) may be receiving less benefit from the programs on anxiety, even though they enter
with similar severity to those who are unable to work.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 15.
HADS (Anxiety) scores by employment category
Trauma focus
There was a difference in the reduction in HADS (Anxiety) scores from entry and discharge by the level
of trauma focus (see Figure 16). Programs with medium or high trauma focus had larger improvements
on the HADS (Anxiety) scale between entry and discharge compared to programs with a low trauma
focus, although this difference was less marked at nine month follow-up. This suggests programs with
some trauma focus (medium or high) achieve slightly better results on anxiety at discharge, although by
nine months these differences have largely disappeared.
Figure 16.
HADS (Anxiety) scores by trauma focus
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Partner focus
There was no clear indication that programs with a different level of partner focus achieved different
improvements on the HADS (Anxiety) scale. However, as detailed above, our analysis of partner
involvement was blunt. A more precise analysis would need to be conducted before drawing firm
conclusions about the impact of partner involvement on anxiety.
Veteran-only or mixed cohorts
Veteran-only and mixed cohorts had a similar reduction in anxiety from entry to discharge, but in the
mixed cohort anxiety continued to decline up to nine months whereas scores in the veteran-only group
remained steady after discharge (see Figure 17).
Figure 17.
HADS (Anxiety) scores by veteran-only or mixed cohorts
Discussion: HADS (Anxiety) overall
Contemporary veterans received less benefit on the HADS (Anxiety) than veterans aged 50 and over.
This is a different pattern to that seen on other measures such as the PCL-M, where the magnitude of
improvement was similar across all age groups. This result may indicate that the programs are less
effective at reducing anxiety in contemporary veterans.
The level of trauma focus in the program does influence the result – more trauma focus resulted in
greater improvements between entry and discharge, although this improvement levelled off during the
follow-up period.
The same pattern is seen for employment category as was found on other measures – participants in the
workforce (working or looking for work) seemed to gain less benefit on anxiety than those participants
who were retired or unable to work. This may indicate that the programs are not working as well for
participants in the workforce.
The results for veteran-only and mixed cohorts were comparable, suggesting that it is not detrimental to
include non-veterans in cohorts.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Results: HADS (Depression) overall
Please note this section reports the results of the depression subscale of the HADS. The Hospital
Anxiety and Depression (HADS) is a 14 item self-report scale that incrementally measures states of
anxiety or depression. Seven items relate to depression, with a score range of zero to 21.
Overall a statistically significant reduction in HADS (Depression) scores is observed between entry
(mean = 11.3, SD = 3.7) and discharge (mean = 9.4, SD = 4.0). Scores worsen slightly after discharge,
from a mean of 9.4 on discharge to a mean of 9.8 at nine month follow-up (see Table 36).
Table 36: HADS (Depression) scores by time point
Entry
Discharge
3 months
9 months
n
1469
1308
1157
980
Mean
11.3 (3.7)
9.4 (4.0)
9.7 (3.9)
9.8 (4.1)
95% CI
(11.1, 11.5)
(9.2, 9.6)
(9.5, 9.9)
(9.5, 10.0)
p-values
-
DIFFERENCES:
Entry to Discharge
Entry to 9 months
Discharge to 9 months
1299
971
939
-1.9
-1.5
0.4
(-2.1, -1.7)
(-1.7, -1.2)
(0.1, 0.6)
<0.0001
<0.0001
0.002
As with any dataset, there is attrition over time in data as some participants do not complete and return
measures. However, it can be seen in Table 37 that there is almost no difference in results between the
overall dataset and participants who completed measures at all four points in time. This indicates that
participants who dropped out are not significantly different to those who completed data collection.
Table 37: Numbers scoring ≥11 on the HADS (Depression) by time point
Including all HADS (Depression) records
Entry
Discharge
3 months
9 months
n
HADS Depression 11 (%)
1469
1308
1157
980
853 (58)
491 (38)
453 (39)
393(40)
Including subjects who completed
questionnaire at all four timepoints
n
HADS Depression 11
(%)
874
497 (84)
874
322 (37)
874
336 (38)
874
346 (40)
Scores above eight on the HADS (depression) indicate possible pathology, with scores above 11
indicating more definite cases. Seventy percent of participants scored in the same HADS category at
both entry and at nine month follow-up, 23% moved from scoring above the HADS (Depression) cut-off
of 11 to below this cut-off and 7% scored below 11 at entry but above 11 at nine month (see Table 38).
This suggests that most participants stayed in the same category, with 23% dropping below the clinical
range (improving on depression scores) and 7% moving above it (worsening on depression scores).
Note: the more stringent cut-off of 11 has been used for this analysis.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Table 38: Movement between HADS (Depression) categories from entry to nine month follow-up
Entry
HADS Depression 11 (%)
HADS Depression 11 (%)
Total
9 months
HADS Depression 11
HADS Depression 11
(%)
(%)
352 (36)
64 (7)
228 (23)
327 (34)
580
391
Total
416
555
971
Predictors: HADS (Depression)
Age, marital status, employment status, education level, service (Army, Navy or Air Force) and service
type (Regular or Conscript) were all important predictors of the HADS (Depression) scale. Adjusting for
all the demographics in the model, retired, single and Army participants had lower (better) depression
levels. Those without a qualification post high school, regulars and contemporary veterans had higher
levels of depression.
Interactions: HADS (Depression)
Age group
There was a difference in the HADS (Depression) by age group, with contemporary veterans receiving
slightly less improvement than veterans aged 50 and over (see Figure 18).
Figure 18.
HADS (Depression) scores by age
Employment category
Looking at the scores by employment category, those unable to work or who were retired had the
largest reduction on the HADS (Depression) scale, particularly between entry and discharge (see Figure
19). This suggests that participants who are retired or unable to work improved on ratings of depression
compared to participants who are in the labour market (employed or looking for work), even though the
level of severity on entry is similar between those who are working/looking for work and those who are
unable to work.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 19.
HADS (Depression) scores by employment category
Trauma focus
The reduction in depression at discharge was not shown to vary by different levels of trauma focus.
Partner focus
Programs with a medium or high partner focus achieved the greatest reduction in HADS (Depression)
scores between entry and discharge (see Figure 20). This suggests participants in programs with more
partner focus achieve a greater reduction in depressive symptoms than programs with a low partner
focus. The improvement compared to low partner focus was also maintained through to nine month
follow-up. This is encouraging, particularly given the blunt partner analyses available.
Figure 20.
HADS (Depression) scores by level of partner focus
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Veteran-only or mixed cohorts
The reduction in depression at discharge was not shown to vary between veteran-only or mixed
cohorts.
Discussion: HADS (Depression) overall
There was a statistically significant improvement on the HADS (Depression) from entry to discharge,
then a slight reduction at three month and nine month follow-up. This is evidence that the programs
effectively reduce the symptoms of depression for program participants, with 23% moving out of the
clinical range.
Contemporary veterans showed less improvement on the HADS (Depression) than veterans aged 50 and
over. This is a different trend to other measures, where the magnitude of improvement has been the
same across age groups. It may indicate that the programs are less effective at reducing the symptoms
of depression for contemporary veterans.
Consistent with other measures, participants in the workforce (working or looking for work) remained
slightly more depressed compared to participants who were retired or unable to work. Again, this may
indicate that the programs are slightly less effective for improving depressive symptoms, as measured
by the HADS, for participants in the workforce.
Despite the blunt analysis, the level of partner focus was shown to be important, with slightly greater
improvements in medium and high partner focused programs compared to a low partner focus.
No impact was seen for the HADS (Depression) based on trauma focus or mixed cohorts.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Qualitative Data
Participants were sent a questionnaire that assessed satisfaction with the PTSD program at the point of
accreditation for each site. Accreditation generally occurred between one to three years after programs
were completed. Whilst qualitative data were obtained by site, participant responses remained
anonymous.
Qualitative Data for 2007/08
Satisfaction
PTSD review veteran satisfaction data were analysed for the 2007/08 period. The current figures are
based on the available data from five program sites: Calvary, Daw Park, Victor Harbour (a regional
program provided by Daw Park), Greenslopes, and Palm Beach Currumbin. In total, 116 participants
responded to the satisfaction survey in this period. Satisfaction rates were very high – as shown in
Figure 21, over 95% of participants who responded to the questionnaire, across the five sites, indicated
that they were satisfied or very satisfied with the program.
Figure 21.
Overall participant satisfaction ratings of the PTSD programs in 2007/2008
Most important assistance received
Participants were also asked what they thought was the most important assistance they received during
the program. Participants’ free-text qualitative responses were analysed and the frequencies are
represented in Figure 22.
As the figure suggests, participants across sites indicated that receiving strategies to manage PTSD
symptoms (e.g., CBT strategies) was the most important assistance received from the program. One
participant stated that he benefited by, “learning new strategies to manage my anger, frustration, and
sleep disorder.” This was followed by developing a greater understanding of PTSD as a condition,
including symptoms and normalising PTSD responses, with one participant stating, “Accepting that PTSD
does not mean that I am mental...I am normal.” A number of respondents reported benefiting from the
group program because they realised “I was not alone” and that there were other people experiencing
similar problems to themselves. Other participants indicated that receiving strategies specifically
targeting alcohol and anger problems were highly valued, as was increasing knowledge on accessing
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
help (outside the program). Participants also indicated that the combination of group work and
individual-based work were beneficial, which provides support for anecdotal reports by staff that
participants generally gain benefits over-and-above doing one-on-one therapy only. Improvements in
relationships (partners or families) were also noted, as was learning relaxation strategies.
One participant made the following statement regarding what he gained most out of the program,
“Understanding what PTSD actually was and how the symptoms were affecting my family and my own
life. The symptoms were with me for many years, which I thought was normal behaviour.”
Figure 22.
Participants’ qualitative responses for the most important assistance received (07/08)
Improvements
Participants were also asked to indicate what they would improve, if anything, about the PTSD program
they participated in. The data presented in the following graph (see Figure 23) were obtained from the
same sites and individuals as above.
The majority of participants across the five sites indicated that they thought no improvement of the
PTSD program was needed. One participant stated, “I could not fault the staff on the running of this so
very important program.” The next most frequent recommendation was to improve the structure of the
program, which included suggestions regarding session structure, ordering of material presented, and
problems/suggestions regarding staff (e.g., type, experience). For example, “some of the material is
outdated, however, the presenters tried to adjust the context to match our time and experiences” and “I
came out feeling half-baked; a few more days on trauma may be beneficial.” Similarly, respondents
recommended changes to program content, including having smaller/bigger group discussions, more
physical activities and relaxation, increased provision of specialists (e.g., pharmacists) or specialised
treatment focus (e.g., anger management), and high care/acute treatment options. Increasing partner
involvement was also indicated as an area requiring improvement in a number of sites. For example,
“more time for partners and perhaps a day for children if possible, regardless of age” and “more
participation from partners, both with vets and in partner groups.” Respondents indicated that they felt
they would benefit from better follow-up to consolidate program learning. For example, “a revision or
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
follow-up course, say 6 to 12 months later, to reinforce the effects of the course, to address programs
and the mistakes made” and “no provisions for follow-up periods of consolidation, this was the
program’s weakness.” Improving facilities, modernising the program, and better management of
“problematic” participants in programs was also identified. F or example, “better overseeing of group
discussions (some people wanted to take the floor all the time!)” and “firmer with ‘problem children’ who
always seem to disrupt the group.”
Figure 23.
Areas of the PTSD programs indicated as needing improvement
Partner participation
Partner participation data were available in the period of 2007/08 for 114 people (missing = 3).
Questionnaire responders were asked to indicate if partners participated in the program and the results
are shown in Figure 24.
Differences in the level of partner participation were observed between sites. Overall, based on
responses from the five sites from which qualitative data were obtained in the period of 2007/08, the
majority of participants had at least some participation from their partner. What is not known is the
level and intensity of the partner participation.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 24.
Frequency of partner participation in 2007/2008
Partner satisfaction
Partners were asked to indicate their overall satisfaction with the partner component of the PTSD
program. Response numbers were fairly low (n=76) with a large amount of missing data (missing = 41),
and is described in Figure 25. Approximately 88% of partners were satisfied with the partner aspects of
the PTSD program. Approximately 12% indicated that they had no opinion or were dissatisfied with the
partner aspects of the program.
Figure 25.
Partner satisfaction with the PTSD program (2007/2008)
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Qualitative Data for 2008/09
Satisfaction
PTSD review veteran satisfaction data were analysed for the 2008/09 period. The PTSD review
satisfaction questionnaires were sent to program participants as part of the accreditation for sites. The
current figures are based on the available data from six program sites: Geelong, Hollywood, Mater
Townsville, St John of God at Richmond, Toowong, and Heidelberg. In total, 224 participants responded
to the satisfaction survey and all responses were anonymous. Again, satisfaction rates were very high,
with approximately 97% of participants who responded to the questionnaire indicating they were
satisfied or very satisfied with the PTSD program in which they participated.
Figure 26.
Overall participant satisfaction ratings of the PTSD programs (08/09)
Most important assistance received
The qualitative free-text satisfaction data were obtained from participants at the point of accreditation
for each site and is presented in Figure 27.
As the figure shows, participants indicated that receiving strategies to manage PTSD and comorbid
disorders (e.g., depression, anxiety, sleep) was the most valuable assistance received from the program.
For example, one participant stated they benefited from receiving “information on how to deal with
issues and emotional distress.” This was followed by developing an understanding of PTSD, for example,
“realising that I had PTSD.” The 2008/09 qualitative data are consistent with the 2007/08 data. The
2008/09 data differ from the earlier satisfaction data in that there was less mention of alcohol and
anger management and a greater emphasis on the value of group work and the friendships and
camaraderie that ensued for some as a result of participating in the group program. One person said
the following about the program, “it gave me the courage to get back into and engage with the
community; it made me believe in myself again.”
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 27.
Participants’ qualitative responses for the most important assistance received
(2008/2009)
Improvements
Participants were also asked to indicate what they would improve, if anything, about the PTSD program
in which they participated. The data presented in Figure 28 were obtained from the same six sites for
the 2008/09 period. Qualitative data on suggested improvements were available for 213 respondents.
Of the participants that provided a response for this free-text question, the majority indicated that they
thought no improvement of the program was needed. The next most frequent recommendation was to
improve the structure of the program, which included suggestions regarding session structure (e.g.,
programs need to be longer/shorter) and problems/suggestions regarding staff (e.g., type, experience,
more time needed with counsellor or psychologist). Similarly, questionnaire respondents recommended
changes to program content, including having smaller/bigger group discussions, different types of
activities, and/or more or less program content/materials. Participants indicated a need for better or
more regular follow-up to consolidate treatment gains. Many indicated the need for more than one
follow-up session. Increasing partner involvement was also indicated as an area in need of
improvement across sites, as was improving program facilities, and modernising the program. Specific
mentions were made regarding the need to group contemporary veterans together (e.g., “group
younger vets where possible”) and to have more specific focus for this group (e.g., “group dynamics are
changing; there are less Vietnam veterans and more recent veterans coming through”). Questionnaire
respondents also suggested that improved communication and information from DVA, VVCS, and other
groups would be beneficial for participants. This was not indicated in the previous year’s suggestions on
areas to improve.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 28.
Areas suggested for improvement in the PTSD programs for 2008/2009
Partner participation
Partner participation data were available in the period of 2008/09 for 208 people (missing = 16).
Questionnaire responders were asked to indicate if partners were involved during the program and the
results are shown in Figure 29.
Differences in the level of partner participation were observed between sites. Overall, based on
responses from the six sites from which qualitative data were obtained in the period of 2008/09, the
majority of participants had at least some participation from their partner. What is not known is the
level and intensity of the partner participation (i.e. attended one day or every day).
Figure 29.
Frequency of partner participation in 2008/2009
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Partner satisfaction
Data regarding overall satisfaction with the partner component of the PTSD program were available for
116 participants (missing = 108) and is described in Figure 30.
Almost 84% of partners reported being satisfied or very satisfied with the partner aspects of the PTSD
program. In the 2008/09 period, there were 9.5% of people who were dissatisfied with the partner
programs. The percentage of dissatisfaction with the PTSD program was slightly greater in this period
compared to 2007/08. Importantly, however, the vast majority of partners were satisfied.
Figure 30.
Partner satisfaction with the program (2008/2009)
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Section 5 Discussion of the effectiveness of the group PTSD programs overall
Research question:
This section answers the research question: “How effective are the group treatments?”
The PTSD group treatment programs achieved a clear, statistically significant reduction on all measures,
indicating that they effectively reduce symptoms of PTSD, anger, anxiety and depression and improve
quality of life and family relationships for participants. This finding is not unexpected – site visits found
that staff working in the programs are generally highly-experienced, passionate professionals who seek
out evidence and endeavour to deliver the best treatment possible for their participants. Furthermore,
the programs are designed according to evidence-based guidelines and regularly accredited. This is
strong evidence that the system DVA has in place is working well.
It is not possible to say whether these programs are any more or less effective than any other
treatments as there is very little evidence available on group treatments for PTSD, and valid
comparisons with the effectiveness of one-to-one treatments in the literature are not possible because
they use different outcome measures.
Table 39 summarises whether key variables of interest, such as age or trauma focus, influenced results
on the measures examined, and these are further discussed in the sections below.
Table 39: Interactions found for key variables
Age
Measure
PCL (PTSD)
WHOQOL Physical
WHOQOL Psychological
WHOQOL Social R’ships
WHOQOL Environmental
DAR (Anger)
DAS (Family Function)
HADS (Anxiety)
HADS (Depression)







 (<50)
 (<50)
Key variables of interest
Employment Trauma focus
Partner
involvement

(med. focus) 




 (high focus) 




 (high focus) 


 (med+high)


 (med+high)

 (med+high) 


 (med+high)
Mixed/veteranonly cohorts
 (both)




 (veteran)

 (mixed)

PTSD
As a measure of PTSD symptomatology, the PCL was considered a key variable. By nine month followup, 25% of participants had moved out of the clinical range on the PCL-M. Fifty-four percent of
participants (n = 495) stayed in the same category between entry and nine months, 39% (n = 358)
improved (i.e. dropped a category) and 7% (n = 67) worsened (i.e. went up a category). Participants
with the most severe symptoms were the most difficult to shift: 40% of participants scoring above 60 at
entry improved, compared to 50% of those scoring 50-59. This suggests that participants with worse
symptoms may need something additional, such as treatment that is of a higher intensity or longer
duration in order to receive the same benefit from the program. Moving beyond diagnostic categories,
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43% of participants reliably improved, which is a positive finding given the severity of symptoms within
this population. However, ten percent of participants reliably worsened.
Age
Contemporary veterans achieved a similar magnitude of change as veterans aged 50 and over on PTSD,
quality of life, anger and family functioning (see Table 39). On anxiety and depression, the magnitude of
change for contemporary veterans was smaller. Analyses on the PCL-M revealed that more
contemporary veterans remained the same, slightly fewer reliably improved and slightly more reliably
worsened. These differences between age groups were apparent at both discharge and nine month
follow-up.
Although they generally received a similar magnitude of change, raw scores for contemporary veterans
were generally higher on all measures on entry and exit, meaning that these veterans are likely to be
less well when they leave the programs.
It appears that contemporary veterans benefit from the programs but may require additional support,
such as higher intensity treatment or additional follow-up. Some of this may be delivered using
promising new technologically-based interventions highlighted in the Phase One literature review, such
as internet based therapy. As discussed in Section 7, three of the programs have made specific and
considered changes to more effectively meet the needs of this younger demographic, and it would be
worthwhile investigating this further, especially in light of potential future demand from this age group.
Trauma focus
The evidence base for the treatment of PTSD states that some level of trauma focus is necessary for
effectiveness. Overall analyses found that between entry and discharge, programs with a medium or
high trauma focus achieved slightly stronger results on PTSD, quality of life and anxiety than programs
with a low trauma focus (see Table 39). Analyses also found that between entry and discharge more
participants reliably improved and fewer remained the same (i.e. did not reliably change) in programs
with a medium/high trauma focus. However, these differences in outcomes had largely disappeared by
nine months. The number of participants who reliably worsened was the same. These findings suggest
that programs with a medium or high trauma focus achieved slightly stronger outcomes between entry
and discharge. Several programs were concerned that a trauma focus may actually be detrimental to
participants: this concern was not supported by the data.
Partner involvement
The level of partner involvement was shown to influence outcomes on depression, family functioning
and anger but no effect was observed on other measures (see Table 39). As previously discussed, this
may be due to the blunt analysis. The qualitative interviews found overwhelming support for the
involvement of partners and families, and the consulting psychiatrist, Dr Len Lambeth, believes family
involvement is critical in the treatment of PTSD. It would be possible to investigate partner involvement
more precisely by linking individual veteran outcomes to individual partner involvement. This could be
done retrospectively if records of partner involvement exist. Alternatively, this information could be
collected for a period of 12 months to enable a more accurate analysis. This information has clear
implications for the future structure of the programs, including the funding structure, as it seems that
the cost of working with partners and families is not funded separately but is absorbed by sites.
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Mixed cohorts
Overall analyses found that programs operating veteran-only cohorts achieved a slightly higher
magnitude of change on PTSD and anger between entry and discharge, and programs operating mixed
cohorts achieved a slightly higher magnitude of change on anxiety between discharge and nine months
(see Table 39). All differences were relatively small, and there were no interactions on any other
variable. These results suggest that it has not been detrimental to include non-veteran participants in
PTSD group treatment programs, which may be an important factor to consider if demand from
veterans continues to decrease.
Employment category
Employment status was shown to influence every variable except family functioning. Participants who
were in the labour force (working or looking for work) received consistently lower benefits on PTSD,
quality of life, anger, anxiety and depression than those who were retired or unable to work (see Table
39). This may indicate that the programs are currently most suited to participants who are retired or
unable to work, and may be less effective for participants in the workforce. It may be important to
investigate this further as contemporary veterans are more likely to be working and future demand for
programs may be more likely to arise from this demographic.
Satisfaction
The level of participant satisfaction with the programs is very high. While high satisfaction does not
always translate to high outcomes, it is a good reflection of the quality of the programs and the staff
who conduct them. Additionally, the level of satisfaction may influence the level of engagement, which
has clear implications for treatment effectiveness.
Measures of functional improvement are needed
Although improvements on the measures discussed are statistically significant, what this means in terms
of meaningful change in a person’s life is less clear. Comprehensive measurement of outcomes has
been conducted by sites and ACPMH over several years, and they are commended on the quality of this
data. For any program it is impossible to measure every outcome, and some outcomes cannot be
measured. However, inclusion of measures that directly target functional improvement is important to
be able to demonstrate that improvements are both statistically significant as well as meaningful in
someone’s life.
The HONOS is currently collected and is an adequate measure of functioning, but this seems to be
completed only on entry; similarly, the CAPS is currently collected and would provide a clinician-rated
measure of PTSD change but this is also only measured on entry. This review provides an opportunity to
examine and reflect on the measures collected and how this may be changed in the future. It would be
useful to have clinician-rated measures at the four points in time, using scales such as the CAPS and
HONOS, in addition to the current self-rated measures. Annual accreditation reports generally show
high correlation between the clinician-rated and self-rated measures, but having both at all four points
in time would enable a more robust understanding of the outcomes being achieved by the programs. It
would also better enable comparison with the literature, as most studies in this area measure change
with the CAPS.
It would be worthwhile considering the introduction of measures of functional change such as the SF6D,
which would also better enable a cost-effectiveness analysis.
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Review of measures
Not all measures collected through the accreditation process are regularly analysed and discussed
(examples include family functioning, health service usage, medication usage) and there are two
different quality of life measures in use. It may be possible to discontinue collection of some measures
and introduce a small number of new measures, with an emphasis on clinician-rated measures and
measures of function. This would need to be done with clear consideration of future information needs,
and in a way that did not significantly impact the power of the existing dataset.
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Section 6: Effectiveness of the group PTSD programs: differences by site
Research question:
This section answers the research question: “Are there differential outcomes between programs?”
This section compares results between sites on the PCL-M (PTSD), WHOQOL-BREF (Physical and
Psychological scales), DAR (Anger), DAS (Family Functioning) and HADS (Anxiety scale). At the end of the
section is an in depth discussion of the overall conclusions regarding differences in outcomes, along with
the relevant recommendations.
Comparing results between sites must be done with caution due to large differences in demographic
profiles (see Table 14 for details). For example, it would be inappropriate to compare the raw scores of
Mater Townville with those of Northside Cremorne, as 64% of participants in Townville were
contemporary veterans, compared to only 6% of participants at Northside Cremorne. To make fair
comparisons, statistical modelling has been used to adjust for level of severity on intake. Baseline
severity (at intake) significantly predicted scores at discharge and the two follow-up time points (i.e.
being more severe at baseline predicted being more severe at nine month follow-up), therefore, this
variable needed to be controlled for in the analyses in order to make comparisons fair and accurate.
The resulting graphs plot the raw scores for each site compared to the overall expected results,
accounting for differences in demographic profiles (e.g. differences with the age profile of each site). In
other words, given the characteristics of each site, how did they perform compared to how we would
expect them to perform?
It should be noted that in some cases the differences discussed are slight i.e. a one or two point
difference between the observed and expected. In these cases, it is important not to over-interpret
results, particularly when the clinical meaning of this difference is unclear.
Some graphs have been included in-text, but the majority can be found in the appendices.
To interpret the graphs:




The thick purple line represents the adjusted overall change in what we have observed in all
sites, adjusted for differences between sites. It can be thought of as what we would expect the
site to achieve based on the results being achieved overall for those with similar levels of
severity on intake.
The solid gold line is the observed result – what the site did achieve i.e. raw score.
The dotted gold lines represent the confidence intervals – if multiple samples were taken from
this site we would expect the “true” mean to lie within this confidence interval in 95% of the
samples we observe. Note: confidence intervals are related to sample size. For sites with large
numbers the confidence intervals are narrower. For sites where there is attrition in data over
time, the confidence interval widens. Tighter (narrower) CI’s are preferable because the range
of scores that the “true” score lies within is more precise.
If the adjusted overall (the thick purple line) is within the confidence interval (dotted gold lines)
then the program has performed as expected at that point in time.
Example: Northside Cremorne
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
The graph and interpretation of the PCL-M results for Northside Cremorne have been included here as
an example (Figure 31).
Figure 31.
PCL-M results for Northside Cremorne (n=141)
For Northside Cremorne:




On entry: PCL-M severity is as expected given demographic characteristics (n=141).
At discharge: the improvement in PCL-M scores was better than expected (the decline in the
gold line is sharper than the decline in the purple line) (n=138, 98%). Therefore, Northside
Cremorne is performing better than the adjusted overall scores at discharge.
At three month follow-up: PCL scores are similar to the predicted level (n=118, 84%). However,
in contrast to the overall results there was a slight increase in PCL-M scores between discharge
and three months follow-up.
At nine month follow-up: PCL scores are as expected (n=97, 69%), as the adjusted and
observed scores are the same
In summary, on the PCL-M, Northside Cremorne performed significantly better than expected at
discharge, but by nine months PCL-M scores were at the predicted level based on the data from all sites.
Results: PCL-M for each site
This section contains the graph and interpretation for raw scores on the PCL-M at individual sites, as
well as the interpretation of the statistical modelling for each site (the graphs representing the results of
the modelling for each site can be found in Appendix 1).
Raw scores
Raw scores on the PCL-M demonstrate that each site reduces PCL-M scores from entry to discharge and
this reduction is statistically significant in all sites but one (see Figure 32). The exception was Palm
Beach Currumbin but it should be noted there were only 30 participants at this site. Therefore, if any
positive treatment effects truly existed for this site, it may not have been detectable due to the lack of
power available for the analysis. To increase power and therefore detect any true treatment effects, a
larger sample size is needed.
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Figure 32.
PCL-M raw scores overall and by site
The raw PCL-M scores represented in Figure 32 show a similar downward trend across all sites between
entry (baseline) and discharge, but some apparent variation between sites from discharge to nine
month follow-up which is worthy of further exploration and comparison.
Notes:



Most sites invite participants to return at three months and nine months follow up for a full or
half day.
St John of God have a unique follow-up model of one day per month for nine months after
discharge, which may contribute to the large drop in PCL scores post-discharge, and the low
attrition in data.
Geelong participants do not return to the site at three months and nine months, but are sent
the program questionnaires for completion. This may account for the high attrition in data.
Statistical modelling
The PCL-M measures self-reported symptoms of PTSD in line with the DSM-IV criteria.
Graphs are included in Appendix 1, with Northside Cremorne presented as an example below.
Statistical modelling on the PCL-M found:



Northside Cremorne performed better than expected between entry and discharge on the PCLM, but by 9 months follow-up the scores on the PCL-M were similar to the predicted level (see
Figure 33 below and Appendix 1).
On the PCL-M, Mater Townsville had a slightly greater improvement than expected. This was
due in part to a clear reduction between discharge and 3 months follow-up (see Appendix 1).
Hollywood performed better than expected on the PCL-M between entry and discharge.
Consistent with the combined results, there was a further small improvement between
discharge and nine months (see Appendix 1).
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses






PCL-M scores at St John of God Richmond and Daw Park improved less than expected between
entry and discharge. However, in contrast to the results from other sites, clear improvements
were sustained after discharge and by nine months these sites had achieved the expected
reductions in PCL-M scores (see Appendix 1).
Toowong performed as expected between entry and discharge, after which PCL-M scores
worsened slightly between discharge and 3 months. This contrasted with the expected pattern
of a slight improvement.
PCL-M scores at Palm Beach Currumbin improved slightly less than expected between entry and
discharge and in contrast to the expected results, the PCL-M score worsened between 3 months
and 9 months follow-up. These result are only based on 30 participants at entry and should be
interpreted with caution (see Appendix 1).
The strong gains achieved by Geelong on the PCL-M between entry and discharge were not
maintained between discharge and nine months, however there was 58% attrition between
entry and 9 months so these results should be interpreted with caution (see Appendix 1).
Calvary took participants who were more severe than expected on the PCL-M on entry and got
them to the expected score at discharge and three months, although treatment gains weakened
between three months and nine months. However, these observations are based on 30
participants at entry so these results should be interpreted with caution (see Appendix 1).
Heidelberg and Greenslopes results were broadly consistent with the expected results based on
the data from all sites (see Appendix 1).
Figure 33.
Example - PCL-M results for Northside Cremorne (n=141)
Results: WHOQOL-BREF Physical for each site
This section contains the interpretation of the statistical modelling of the Physical scale of the WHOQOLBREF for each site (the graphs for each site can be found in Appendix 3).
Statistical modelling
The Physical scale of the WHOQOL-BREF measures how heavily participants rely on medical treatment
to function in their daily life, to what extent they experience pain, and if this interferes with their ability
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
to do the things they wish to do. This is an important measure because it offers some quantifiable
indication of changes in functioning. Higher scores indicate higher satisfaction.
Statistical modelling on the physical subscale of the WHOQOL-BREF found:









On the WHOQOL-BREF Physical, Northside Cremorne achieved a slightly greater improvement
than expected between entry and discharge, but by nine month follow-up the scores were
similar to the predicted level (see Appendix 3).
Hollywood achieved a slightly greater improvement on the WHOQOL-BREF Physical between
entry and discharge. Scores were similar to predicted levels at all other points in time (see
Figure 34 and Appendix 3).
Palm Beach Currumbin performs as expected on the WHOQOL-BREF Physical between entry
and discharge, although the treatment gains had almost disappeared by nine months. These
results are based on only 30 participants at entry and so must be interpreted with caution) (see
Appendix 3).
Toowong performs as expected on the WHOQOL-BREF Physical between entry and three
months. Between three and nine months scores improve slightly more than expected (see
Appendix 3).
On the WHOQOL-BREF Physical, Geelong performs as expected between entry and discharge. In
contrast to the results from other sites, treatment gains are slightly reduced between discharge
and three months, however there was 58% attrition in data between entry and nine months so
these results should be interpreted with caution (see Appendix 3).
On the WHOQOL-BREF Physical, Calvary performs generally as expected between discharge and
three months, however in contrast to the results from other sites scores reduce slightly
between three and nine months. However, these observations are based on 30 participants at
entry and should be interpreted with caution (see Appendix 3).
WHOQOL-BREF Physical scores at Daw Park improved less than expected between entry and
discharge. However, in contrast to results from other sites, there was a continued small
improvement between discharge and nine months (see Appendix 3).
Although the expected scores on the WHOQOL-BREF Physical are outside of the confidence
interval for St John of God Richmond at discharge, the almost parallel lines for the raw and
adjusted scores indicate that, once the lower scores at entry are taken into account, this site
performs in line with expectations (see Appendix 3).
Results at Mater Townsville, Heidelberg and Greenslopes were broadly consistent with the
expected results on the WHOQOL-BREF Physical, based on the data from all sites (see Appendix
3).
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Figure 34.
Example: WHOQOL-BREF Physical results for Hollywood (n=173)
Results: WHOQOL-BREF Psychological for each site
This section contains the interpretation of the statistical modelling of the Psychological scale of the
WHOQOL-BREF for each site (the graphs for each site can be found in Appendix 2).
Statistical modelling
The Psychological scale of the WHOQOL-BREF measures how satisfied people feel about themselves,
their sense of self worth, and to what extent their life has meaning. Higher scores indicate higher
psychological quality of life.
Statistical modelling on the Psychological scale of the WHOQOL-BREF found:




Although the adjusted line is outside the confidence intervals for Mater Townsville and St John
of God Richmond at discharge and three months, the almost parallel lines for the raw and
adjusted scores indicate that these sites performed generally as expected on the WHOQOL-BREF
Psychological (see Figure 35 and Appendix 2).
Northside Cremorne achieved a slightly greater improvement than expected between entry and
discharge on the WHOQOL-BREF Psychological, although by nine months scores were similar to
the predicted levels (see Appendix 2).
On the WHOQOL-BREF Psychological, Hollywood and Calvary achieved a slightly greater
improvement than expected between entry and discharge. At Hollywood treatment gains were
maintained as expected, although at Calvary scores worsened slightly between three months
and nine months (see Appendix 2).
WHOQOL-BREF Psychological scores at Daw Park improved less than expected between entry
and discharge, and treatment gains reduced between discharge and nine months (see Appendix
2).
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses




WHOQOL-BREF Psychological scores at Heidelberg improved slightly less than expected
between entry and discharge, although scores had reached the expected level by nine months
(see Appendix 2).
On the WHOQOL-BREF Psychological, Geelong achieved a slightly greater improvement than
expected between entry and discharge. In contrast to the results from other sites, treatment
gains reduced between discharge and three months. However, there was 58% attrition in data
between entry and nine months so these results should be interpreted with caution (see
Appendix 2).
Palm Beach Currumbin performed as expected on the WHOQOL-BREF Psychological, but all
treatment gains were lost by nine months. However, these results are based on only 30
participants at entry and so must be interpreted with caution (see Appendix 2).
Results at Toowong and Greenslopes were broadly consistent with the expected results on the
WHOQOL-BREF Psychological, based on the data from all sites (see Appendix 2).
Figure 35.
Example: WHOQOL-BREF Psychological results for Mater Townsville (n=192)
Results: DAR (Anger) for each site
This section contains the interpretation of the statistical modelling of the DAR (Anger) for each site (the
graphs for each site can be found in Appendix 4).
Statistical modelling
The DAR measures anger reactions. Lower scores are better, indicating less anger.
Statistical modelling on the DAR (Anger) found:


On the DAR (Anger) St John of God Richmond achieved a smaller improvement than expected
between entry and nine months follow-up (see Figure 36 and Appendix 4).
On the DAR (Anger), Northside Cremorne achieved a greater improvement between entry and
discharge than expected, although there was a very slight reduction in treatment effect
between three and nine months (see Appendix 4).
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses







On the DAR (Anger), Hollywood achieved a greater improvement than expected between entry
and discharge, and treatment gains were maintained in line with predictions between discharge
and nine months (see Appendix 4).
Improvements on the DAR (Anger) at Palm Beach Currumbin were greater than expected
between entry and three months, although treatment gains greatly reduced between three and
nine months. However, these results are based on only 30 participants at entry and so must be
interpreted with caution (see Appendix 4).
Although the expected scores on the DAR (Anger) were outside the confidence intervals for
Greenslopes between entry and three months, the almost parallel lines for the raw and
adjusted scores indicate that, once the lower scores at entry are taken into account, this site
performed in line with expectations (see Appendix 4).
On the DAR (Anger), Calvary achieved a slightly greater improvement than expected between
entry and discharge. In contrast to other sites, treatment gains reduced slightly between
discharge and nine months. However, these results are based on 30 participants at entry and
must be interpreted with caution (see Appendix 4).
The slightly stronger gains achieved by Geelong on the DAR (Anger) between entry and
discharge reduced between discharge and three months, but were similar to predicted scores at
nine months (see Appendix 4).
On the DAR (Anger), Daw Park had a slightly smaller improvement between entry and nine
months than expected. This was due in part to a smaller than expected reduction between entry
and discharge (see Appendix 4).
Results on the DAR (Anger) at Mater Townsville, Toowong and Heidelberg were broadly
consistent with the expected results based on the data from all sites (see Appendix 4).
Figure 36.
Example - DAR (Anger) results for St John of God Richmond (n=69)
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Review of PTSD group treatment programs: Phase 2 In-depth quantitative and qualitative analyses
Results: DAS (Family Function) for each site
This section contains the interpretation of the statistical modelling of the DAS (Family Function) for each
site (the graphs for each site can be found in Appendix 5).
Statistical modelling
The DAS measures the general quality of marital/ co-habiting relationships. Higher scores are better.
Note that sample sizes are smaller because veterans without a current partner were instructed to skip
this measure.
Statistical modelling on the DAS (Family Function) found:







Greenslopes achieved a greater than expected improvement on the DAS (Family Function)
between discharge and three months, but by nine months the scores were similar to the
predicted level (see Figure 37 and Appendix 5).
On the DAS (Family Function), Hollywood achieved a slightly greater than expected
improvement between entry and discharge and then, in contrast to results at other sites,
achieved a continuing small improvement between discharge and nine months (see Appendix
5).
St John of God Richmond did not achieve the expected improvement on the DAS (Family
Function) between entry and three months, however an improvement between three and nine
months left scores close to the expected level (see Appendix 5).
On the DAS (Family Function) Geelong performed broadly as expected between entry and
discharge. In contrast to results from other sites there was a slight reduction of treatment gains
between discharge and nine months. However, there was 58% attrition in data so these results
should be interpreted with caution (see Appendix 5).
Improvements on the DAS (Family Function) at Palm Beach Currumbin were greater than
expected between entry and three months, although treatment gains greatly reduced between
three and nine months. However, these results are based on only 30 participants at entry and
so must be interpreted with caution (see Appendix 5).
Mater Townsville had a slightly greater improvement on the DAS (Family Function) than
expected. This was due in part to a slightly larger improvement between discharge and three
months (see Appendix 5).
Results on the DAS (Family Function) for Northside Cremorne, Toowong, Heidelberg, Daw Park
and Calvary were broadly consistent with the expected results based on the data from all sites
(see Appendix 5).
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Figure 37.
Example - DAS (Family Function) results for Greenslopes (n=145)
Results: HADS (Anxiety) for each site
This section contains the interpretation of the statistical modelling of the HADS (Anxiety) for each site
(the graphs for each site can be found in Appendix 6)
Statistical modelling
The HADS (Anxiety) provides an incremental measure of states of anxiety. Lower scores indicate less
anxiety, with a score of eight to 10 indicating possible pathology (sub- to clinical-levels of anxiety) and
scores above 11 indicating more definite cases (clinical anxiety).
Statistical modelling on the HADS (Anxiety) found:




Northside Cremorne achieved a greater improvement than expected between entry and
discharge the HADS (Anxiety). But in contrast to other sites, treatment gains reduced after
discharge, with scores similar to the predicted level at nine months. At discharge the average
score was below 11, although this increased (worsened) slightly between discharge and nine
months (see Appendix 6).
Mater Townsville had a slightly greater improvement on the HADS (Anxiety) than expected.
This was due in part to a slightly larger than expected improvement between discharge and
three months (see Appendix 6). On average, participants remain above 11 (see Appendix 6).
On the HADS (Anxiety), Hollywood achieved a slightly greater improvement than expected
between entry and discharge. Scores were similar to predicted levels between discharge and
nine months. On average, participants remain above 11 (see Appendix 6).
Palm Beach Currumbin performed as expected on the HADS (Anxiety) between entry and
discharge, although treatment gains largely disappeared between discharge and nine months.
These results are based on only 30 participants and must be interpreted with caution.
Participants’ scores remained above 11 (see Figure 38 and Appendix 6).
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



On the HADS (Anxiety), Calvary achieved a slightly greater improvement than expected between
entry and discharge. In contrast to other sites, treatment gains reduced slightly between three
and nine months. However, these results are based on 30 participants at entry and must be
interpreted with caution. On average, participants’ scores remained above 11 (see Appendix 6).
HADS (Anxiety) scores at St John of God Richmond improved less than expected between entry
and discharge. However, in contrast to the results from other sites, further improvements
occurred after discharge and by nine months the site had achieved the expected improvements
(see Appendix 6).
Results on the HADS (Anxiety) for Toowong, Heidelberg, Daw Park and Greenslopes were
broadly consistent with the expected results based on the data from all sites (see Appendix 6).
Average scores remained above 11 at St John of God Richmond, Heidelberg, Daw Park,
Greenslopes, Palm Beach Currumbin, Mater Townsville, Hollywood, Toowong, and Calvary. At
Geelong and Northside Cremorne, participants’ scores dropped below an average of 11 on
discharge but increased slightly between discharge and nine months.
Figure 38.
Example - HADS (Anxiety) results for Palm Beach Currumbin (n=31)
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Section 6 Discussion of differences by site
Research question:
This section answers the research question: “Are there differential outcomes between programs?”
All sites except one achieved statistically significant change on outcome measures such as the PCL-M.
This similarity in results between sites provides further indication that the system DVA has in place is
working – skilled professionals working in accordance with evidence-based guidelines and monitored by
regular accreditation.
However, just as there are variations in program approaches and demographics between sites, there are
also variations in outcomes across different measures.
There was a strong improvement on each measure in each site between entry and discharge, although
the magnitude of change varied between sites. Some sites had a consistently larger improvement
between entry and discharge, and in some sites the improvement was less than expected.
A variation in trends was evident between discharge and nine month follow-up. This indicates different
maintenance of program effects but also must be interpreted with caution. The full effect of complex
programs utilising cognitive-behavioural therapy should not be measured only on discharge, as
participants need time to practice new skills in their everyday environments and family systems and
relationships need time to adjust. The current system of measuring results post-discharge takes this
into account and is a strength of the monitoring system. However, attribution for results in the followup period is not straightforward because participants may have undergone other treatment during this
time and this would influence any improvements or worsening of results. The current review did not
include data about follow-up treatments accessed by participants, but it would be possible to collect this
data either retrospectively or for a period of 12 months in order to better interpret the results postdischarge.
For many sites, results levelled-off after discharge, indicating maintenance of program effect. In some
sites there was a regression, meaning that program effects may not be maintained. And in other sites,
results continue to improve throughout the follow-up period. It could be worth investigating
mechanisms to increase program gains post-discharge, particularly for contemporary veterans who are
likely to leave the programs with higher symptoms across several scales. Two sites who show this
continued downward trend are St John of God Richmond, who have an extended follow-up period of
one day per month for nine months, and Hollywood, who have an extended taper.
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Section 7: Effectiveness of group PTSD treatments for contemporary
veterans
Research question:
This section partly addresses the research question: “How can the needs of younger veterans be better
met by group treatments?”
Contemporary veterans are those who deployed after the Vietnam war i.e. post-1972. Many of this
group have had multiple deployments and served in several different areas of operations.
There has been some concern over recent years that the PTSD group treatment programs are not
meeting the needs of contemporary veterans and may be less effective for this demographic. This is an
issue of priority as decreasing numbers of Vietnam veterans access the programs and in light of
potential future need by contemporary veterans.
Overall data
Overall analyses of raw scores found that contemporary veterans received a similar magnitude of
change as other age groups on the PCL-M, the WHOQOL-BREF, the DAR and the DAS. Analysis of
reliable change at an individual level found that on the PCL-M more contemporary veterans stayed the
same, slightly fewer improved and slightly more worsened, as compared to veterans aged 50 and over
(see Table 24, Section 5).
Although contemporary veterans received similar improvements on most measures, their scores are
higher on entry and thus on discharge, suggesting they may be less well when they leave the programs.
Selected sites
Three sites work with higher numbers of contemporary veterans and, based on their expertise and
experience, have made changes to their program to better work with this demographic. These sites are
Mater Townsville, Toowong and Hollywood.
The Townsville site has the highest number and proportion (n=123, 64%) of contemporary veterans and
the highest number and proportion of working participants (n=98). Data attrition by nine months was
35%.
The outcome data for Toowong include 58 contemporary veterans over the last five years – 25% of their
sample. Twenty percent of their participants were working. Data attrition by nine months was 53%.
The outcome data for Hollywood include 61 contemporary veterans over the last five years – 35% of
their sample. Sixteen percent of their participants were working. The Hollywood site has developed a
specific program for contemporary veterans called the Trauma Recovery Program. It has an intensive
inpatient phase for two weeks then an extended taper of two days per week for 16 weeks. There is
considerable flexibility in the structure and content of the program, which is modular, and the
involvement of support people. This analysis focuses only on the Trauma Recovery cohorts, not all
contemporary veterans at Hollywood. Data attrition was 57% by nine months.
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Changes to programs for contemporary veterans
The programs discussed in this section have made a range of deliberate adjustments to their group
treatment program in order to better work with contemporary veterans. These include:

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






Greater focus on acute symptoms, particularly nightmares, anger, sleep, and anxiety
Greater focus on partner communication
Partner sessions opened up to any significant other, flexible days, BBQ/ family fun day for kids,
psycho-education sessions for family and friends
More peacekeeper-friendly: reviewed the manual, connected with peacekeeper organisations,
invite both a Vietnam veteran and a peacekeeper from past programs as guest speakers
Inpatient phase and teambuilding activities to build a cohesive group
Flexibility: modules that can be moved forward/ back/ left out, content within modules that can
be changed, structure that can change on the day according to needs and reactions
Focus on rehabilitation not retirement, with an emphasis on quality of life
Extra liaison with other treating professionals
Intensive supervision and support of staff due to the intensity of the work
Comparison site
Heidelberg has had reasonable numbers of contemporary veterans over the past five years (n=40),
although this is only 16 percent of their sample. They have been included as a comparison site because
they have not made large scale changes to their program for contemporary veterans (which is
reasonable at this point in time, given they make up a low proportion of their sample), and because they
are the only other site with sufficient numbers in this demographic. Data attrition was 65% by nine
months.
CMVH examined four key areas with regards to contemporary veterans: PTSD symptoms, quality of life,
anxiety and anger. It should be noted that in some cases the differences discussed are slight i.e. a two
point difference between the observed and expected. In these cases, it is important not to overinterpret results.
Results: PCL (PTSD) for contemporary veterans
As detailed in Section 5, the analysis of the PCL-M found that the group treatment programs are
similarly effective across age groups. Contemporary veterans received the same magnitude of change in
PTSD symptoms as veterans aged 50 and over, meaning that on the PCL-M the programs are equally
effective for all age groups (see Table 40).
Table 40: Drop in PCL-M raw scores between entry and discharge by age group
Age
No. at intake
PCL-M at
intake
No. at
discharge
PCL-M at
discharge
Decrease in
raw score
20-49
(375)
64.5
(304)
59.3
5.2
50-59
(570)
62.3
(537)
55.8
6.5
60
(537)
58.5
(473)
52.5
6
However, because PCL-M scores are higher on entry for contemporary veterans they are also higher on
exit. This raises the question: what else do contemporary veterans need?
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Statistical modelling on the PCL-M found:




Townsville achieved a slightly greater reduction than expected on the PCL-M, mainly due to a
sharper than expected reduction in scores between discharge and nine months. Compared to
all ages, scores were slightly higher for contemporary veterans at all points in time (see
Appendix 11).
On the PCL-M at Toowong, there was a slightly greater than expected improvement between
entry and discharge for contemporary veterans. The PCL-M scores then worsened slightly
between discharge and nine months, in contrast to the expected pattern of a continuing slight
improvement. In line with overall trends, contemporary veterans have higher scores at all
points in time (see Appendix 11).
On the PCL-M, the Hollywood Trauma Recovery program achieved a slightly greater reduction
than expected, which was largely due to a sharper than expected improvement between three
and nine months. In line with broader trends, scores for contemporary veterans were higher at
all points in time (see Appendix 11).
The comparison site, Heidelberg, performed as expected at all points in time for contemporary
veterans. The pattern of results is slightly different than for the other programs discussed in this
section, with the observed scores higher than the adjusted overall, but this likely reflects higher
scores on entry. In contrast to the expected pattern, results improved more than expected
between three and nine months (see Appendix 11). However, there was 65% data attrition
between entry and nine months and so these results must be interpreted with caution.
Results: WHOQOL-BREF (Quality of Life) for contemporary veterans
The Physical and Psychological scales of the WHOQOL-BREF were examined for contemporary veterans.
WHOQOL-BREF Physical
Statistical modelling on the WHOQOL-BREF Physical found that Mater Townsville, Toowong and
Hollywood all performed as expected at all points in time for contemporary veterans. The comparison
site, Heidelberg, also performed as expected on this scale at all points in time. (For graphs, see
Appendix 7).
WHOQOL-BREF Psychological
Statistical modelling on the WHOQOL-BREF Psychological found:



For contemporary veterans, results on the WHOQOL-BREF Psychological at Mater Townsville
and Toowong were consistent with the expected results (see Appendix 8).
For contemporary veterans at Hollywood, there was a slightly greater improvement than
expected on the WHOQOL-BREF Psychological (see Appendix 8). This was due in part to a
continued improvement between discharge and nine months that contrasted with the expected
plateau.
On the WHOQOL-BREF Psychological scale the results at the comparison site, Heidelberg, were
broadly consistent with the expected results for contemporary veterans (see Appendix 8). The
pattern of results is slightly different to that of the other programs discussed in this section, with
Heidelberg’s observed results lower than the adjusted, but this is likely due to the lower scores
on entry.
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Results: HADS (Anxiety) for contemporary veterans
The anxiety scale of the HADS was examined for contemporary veterans. The pattern of results
remained broadly consistent with that discussed on other measures (see Appendix 9).
Results: DAR (Anger) for contemporary veterans
When site staff were asked about the differences in presentation for different age groups, anger was
frequently mentioned one of the symptoms that is more acute in contemporary veterans. Higher levels
of anger can also make working with this demographic more challenging for staff.
As see in Table 41, contemporary veterans had significantly higher DAR scores on entry – more than ten
points higher than veterans aged over 60. However, the reduction between entry and discharge is
comparable across age groups, indicating that the programs are no less effective for contemporary
veterans on this variable.
Table 41: Decrease in DAR scores between entry and discharge by age group
Age
No. at intake
DAR at intake
No. at
discharge
DAR at
discharge
Decrease in
raw score
20-49
(373)
36.8
(306)
32.8
4
50-59
(565)
31.7
(531)
26.5
5.2
60
(534)
26.2
(465)
21.2
5
However, because DAR (Anger) scores are higher on entry for contemporary veterans they are also
higher on exit.
Statistical modelling on the DAR (Anger) found:




On the DAR (Anger), results at Mater Townsville were consistent with the expected results (see
Appendix 12). In line with their broader trend, there was a continued improvement between
discharge and three months instead of a levelling-off.
Results for contemporary veterans at Toowong were broadly consistent with expected results
on the DAR (Anger) (see Appendix 12). There was a slightly sharper than expected reduction
between entry and discharge which, despite uneven maintenance, shows promise.
On the DAR (Anger), the results for contemporary veterans at Hollywood were broadly
consistent with expected results (see Appendix 12).
Results for contemporary veterans at the comparison site, Heidelberg, were broadly consistent
with expected results on the DAR (Anger) (see Appendix 12), although there was a slightly
sharper improvement than expected between three and nine month follow-up.
Section 7 Discussion of the effectiveness of group treatments for
contemporary veterans
On all measures in this section, the four programs performed within the expected range of raw scores,
indicating that they are functioning effectively for contemporary veterans. On both the PCL-M and the
DAR (Anger), it can be seen that contemporary veterans entered with worse symptoms than veterans
aged 50 and over but received a similar benefit from the programs. This indicates that the programs are
not functioning less effectively for contemporary veterans, however it does raise the question of what
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else might be required for this age group, who enter and thus leave the programs with worse
symptoms.
On the PCL-M, Townsville appears to make greater gains from discharge to three months (in line with
their general trend); Toowong’s results appear quite strong at discharge but regress slightly; Hollywood
appear to make greater gains from three months to nine months. The comparison site performs as
expected, and although observed scores remain above (worse than) the expected line at all points in
time this is likely to be due to worse severity on entry. In the featured sites the observed scores are
below (better than) the expected at several time points. The results are not statistically significant,
perhaps due to small sample sizes and high data attrition, but it seems to suggest that the changes
made to the featured programs may show promise for contemporary veterans with regards to PTSD
symptoms.
On the WHOQOL-BREF, there was almost no difference between sites on the Physical scale, including
the comparison site. On the Psychological scale, results for the three programs of interest were
stronger than that of the comparison site. Hollywood showed some additional promise because of the
continued improvement after discharge.
On the DAR (Anger), results seem much closer to the expected line. This appears to be consistent with
clinician reports that anger is the most difficult comorbidity to change in contemporary veterans. This
also seems to be the case for the comparison site.
These analyses indicate that the three programs that have made changes to better work with
contemporary veterans have been successful to some extent. They may require ongoing refinement
and change, and would benefit from further investigation. However, they each show promise. If larger
numbers of contemporary veterans begin to access other sites, it is important that changes to the
programs delivered in those sites are considered and this process could be informed by what has been
happening at Mater Townsville, Toowong and Hollywood.
Further information about the needs of participants according to age and changes made to programs
can be found in Section 8.
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Section 8: The needs of different participants with respect to age
Research question:
This section partly addresses the research question: “How can the needs of younger veterans be better
met by group treatments?”
Qualitative interviews with site staff found that the needs of contemporary veterans and veterans aged
50 and over can be quite different. These are detailed below but in summary, contemporary veterans
are more likely to have:






More acute symptoms
A slightly different symptom profile
Different/diverse deployment experiences
Different family needs
Different stage of life and associated demands
Potentially different experience of camaraderie
Veterans aged 50 and over are likely to have:



Long term symptoms and patterns of behaviour
Different stage of life
Issues to do with ageing
Triggers for seeking help, generational attitude and service status are also likely to be different between
the age groups.
Contemporary veterans: more acute symptoms
Site staff report that contemporary veterans have more acute symptoms that often need to be
stabilised before starting a group treatment program. This practice wisdom is borne out by statistical
analyses – contemporary veterans enter the programs with more severe PTSD as measured on the PCLM as reported earlier and in Table 42.
Table 42: Difference on PCL-M at intake and discharge by age group
Intake
Age at intake
Discharge
PCL score
N
PCL score
N
20-49 years
64.5
375
59.3
304
50-59 years
62.3
570
55.8
537
>=60 years
58.5
537
52.5
473
Higher acuity can mean that working with contemporary veterans can be more challenging for staff, and
it is important to ensure staff are adequately supported and supervised to undertake this work. The
acuity of the symptoms can have flow on effects to other areas of participants’ lives e.g. poly drug use,
trouble with the law, withdrawal from support networks. These can all impact program participation.
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Contemporary veterans: slightly different symptom profile
Site staff report that as well as more acute PTSD, contemporary veterans also tend to have higher levels
of anger, arousal and agitation. The trauma can also be more recent and more classically intrusive with
more active re-experiencing, although contemporary veterans may be less avoidant.
Staff report that this group tends to present for help during crisis e.g. suicide attempt, picked up by
police. This means it can be important to work with them immediately rather than delaying to the start
of a cohort, as the window of opportunity for intervention can close once the immediate crisis has
passed. Contemporary veterans are more likely to experience poly-drug use and instability in their life
such as relationship breakdown. It can be difficult to achieve symptom stability when other areas of the
participant’s life are unstable e.g. income, career, family, housing. It may be better to resolve some of
these issues prior to the program, but the program can also assist them to deal with these external
issues more effectively. Site staff cautioned that it is not always advisable to do trauma work when
there is a lot of external instability in the participant’s life.
Contemporary veterans: different deployment experiences
Veterans who deployed after the Vietnam war are more likely to have been on several deployments,
and to have experienced different rules of engagement during each. Site staff report that peacekeepers
and peacemakers can feel powerless and helpless, live in very different cultures, lack a clear role, have
trust issues with other nations with whom they are peacekeeping, and have a less clear definition of
who is their adversary. Increasingly it is likely that the contemporary veteran group will also include
people who have deployed on war-like operations.
Staff stated that working with contemporary veterans can be complicated by security matters – some
are unsure whether they are permitted to talk about their trauma, and some have expressed concern
about their actions being seen as war crimes.
Contemporary veterans: different family needs
Contemporary veterans are more likely to have younger children and staff report they may have more
marital instability. Staff stated that wives of Vietnam veterans “put up with a lot and stuck by their
husbands”, and that younger women may not. However, they also mentioned that many of the Vietnam
veterans are on their second or third marriage. Volatility at home means participants may receive less
support while doing a program, and lack of childcare options can be a barrier to the participation of both
men (who may be the primary carer while their wife is working) and women (who may not be able to
attend the partner sessions). However, having young children can often be a motivation for undertaking
the program – they are worried about the impact their PTSD will have on their children and their
partner.
Contemporary veterans: demands and stage of life are different
Site staff report that core issues around PTSD can be similar regardless of age but, but that stage of life
issues are different. Many contemporary veterans are working, have young children and may have less
capacity to commit to a program. It may be difficult to get time off from work and they may not want to
talk to their employer for fear of stigma or the impact it may have on their career. Contemporary
veterans can often be more mobile, and may have partners working in the ADF, which means treatment
may have to follow them. Some are in their early 20s, which means that the developmental issues of
late adolescence/early adulthood are being compounded by the trauma. Life instability can mean that
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contemporary veterans need more follow-up after the program, and they may benefit from boosters
e.g. anger management programs.
Contemporary veterans: focus is rehabilitation rather than retirement
Contemporary veterans are generally not considering retirement; instead, the program focus must be
on rehabilitation, including consideration of future employment goals and plans. Site staff expressed
concern about people going on a pension at a young age, and stated their belief that treatment with
contemporary veterans needs to include a focus on vocational rehabilitation, defined as working
towards a life of purpose and meaning if not necessarily employment, although some do go on to work
and study after the programs. Several contemporary veterans are employed, which can mean there is
pressure to get back to work, and their career may be under threat.
Contemporary veterans: potentially different experience of camaraderie
Mateship and camaraderie are of central importance to veterans, more so than perhaps other
populations. But contemporary veterans reportedly identify less strongly as veterans and they are not
joining ESOs in the same numbers as Vietnam veterans. This may mean they do not have access to the
same structures and encouragement to obtain care, and may have access to less information. Staff in
one site made the point that this may be a stage of life issue, saying that Vietnam veterans actively
connected with ESOs etc after they had worked and raised their families.
Veterans aged 50 and over: long-term symptoms and behaviour
Veterans aged 50 and over have usually been living with PTSD for an extended time and have patterns
of behaviour that have developed over that time. Staff report that even though the symptoms of older
veterans are generally less acute they can be very resistant to change.
Veterans aged 50 and over: stage of life
Staff report that the focus for veterans aged 50 and over can be different due to their stage of life –
more about living with PTSD, with a particular focus retirement, quality of life, relationships, addressing
avoidance and isolation, and finding peace. Grandchildren are a large positive influence and can provide
motivation for seeking help; in other situations wives may give them an ultimatum. In some cases
veterans or their partners are caring for their grandchildren, which can impact their ability to attend a
program. Veterans aged 50 and over are less likely to be working but many have scheduled holidays,
which may conflict with program dates. Staff from one site commented that Vietnam veterans tell the
same story, and in some ways have lived the same life, whereas the deployment and life experience of
veterans who deployed after Vietnam may be much more varied.
Veterans aged 50 and over: issues to do with ageing
Veterans aged 50 and over are more likely to experience physical issues due to ageing e.g. heart disease,
dementia, hip or knee replacements etc, which can have implications for how days and program
manuals are structured. One program found that older veterans “expect and actively participate in
psychodynamic and intensive trauma recovery work. While they were mellower and less fiery during
groups, they tire more easily and their intense emotions are more sustained, requiring supervision and
support in the evening.” Hospitalisations for physical conditions can also delay a veteran starting a
program, or may interrupt their participation.
Different triggers and level of commitment
The triggers for help-seeking may differ with age. In veterans aged 50 and over, seeking help may be
triggered by retirement or because of grief and loss; they can also be more certain about their
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commitment. Contemporary veterans often present in a crisis and are looking for short-term solutions,
and can be less certain about committing to a treatment course. There are generally delayed
presentations for all veterans, meaning that even in contemporary veterans clinicians are likely to be
working with people with chronic PTSD.
Different generational attitudes
Older and younger participants can behave differently in programs – older can be more compliant and
respectful, whereas younger can have clear ideas about how staff should do things. These attitudes may
require different approaches from clinicians.
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Section 9: Outcomes unique to group treatments
Research question:
This section addresses the research question: “Are there any outcomes unique to group treatments?”
The Phase 1 literature review found no studies that directly compared group with individual treatments
for PTSD – this is a gap in the knowledge base. It is also extremely difficult to assess based on the
current data available – what can a group treatment program be compared with particularly when
participants receive a variety of treatment both before and after the program from a variety of
treatment providers not associated with the program? Additionally, it is not currently possible to
directly compare outcomes from the PTSD group treatment programs with the outcomes of PTSD
treatments in the literature, as most of these studies use the CAPS, not the PCL, to measure outcomes.
If DVA is considering the future of the group treatment programs it may be important to consider how
this comparison may be validly made with an appropriate research protocol.
Data in this section of the report were obtained from interviews with staff from sites and VVCS and is
based on clinical expertise and experience.
Staff from sites and VVCS believe group treatments achieve some outcomes that cannot be achieved
from individual interventions alone, and this is in line with literature on the benefits of group treatments
for many other mental health disorders. There was widespread support for PTSD group treatments as
an option in the treatment continuum, with several outcomes listed as unique to group treatments.
These are detailed below, but the main reported benefits of group treatments for PTSD include:
•
•
•
•
•
•
•
•
•
Improved social skills, relationships and support: important because those with PTSD can be
socially isolated, and may have particularly avoided veterans and veteran gatherings.
Normalisation and validation: critically important.
Camaraderie: important within the military context, and one of the reasons group treatments
can work well with this population.
Help each other to process, understand and change: participants provide motivation, talk
together, share strategies, help each other through the “tough bits”.
Modelling and application: participants see the skills in action and practice what they’re
learning.
Enhanced trauma work: participants hear each others’ stories, are encouraged to disclose, and
experience a greater level of exposure and more triggers.
Contributes something the therapist can’t: including different ways of wording concepts and
peer perspectives. This is especially the case where the therapist doesn’t have military or
deployment experience.
Time efficiencies: especially around psycho-education (it is quicker to deliver to a group than
one-to-one), and the rate of change can be more rapid.
Staff are skilled in trauma work and work with veterans.
An additional benefit is that the group programs are delivered according to evidence-based guidelines
and regularly accredited; the same quality controls may not be in place on all individual treatments. The
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Phase 1 literature review demonstrated clear benefits for evidence-based treatment over other
treatments such as supportive counselling.
Improved social skills, relationships and support
PTSD as an illness can isolate and marginalise sufferers. A group setting counters this and helps people
begin to form connections. Often symptoms can be maintained by interpersonal difficulties and group
work can get to the heart of this by increasing tolerance, enhancing the person’s ability to be around
other people and reducing isolation. It also provides an opportunity to learn and practise social skills in
a supportive environment.
Veterans suffering from PTSD can find it difficult to connect with others, and may in particular avoid
other veterans and veteran gatherings. Group treatments help people to connect with others in similar
situations and develop a social network, and for some cohorts these relationships continue for many
years into the future. This may take the form of ongoing informal support, regular outings such as
football games, or annual gatherings. This can also be true for partners, who may maintain supportive
friendships after the PTSD program.
Normalisation and validation
One of the most powerful benefits of group treatments for veterans is the realisation that they are not
alone in their experience – they are not the only ones who experienced trauma, and they are not the
only ones struggling, which normalises their condition. In a military context, veterans who experienced
combat-related trauma may have had to bury their emotions and put on a “brave face”, yet in a group
of their peers they learn that others felt the same way. For some, this may be the first opportunity to
discuss it with their peers, which provides validation. Groups also provide hope that if others are
recovering, they will too.
Camaraderie
Group treatments may be particularly important in a military context because of the camaraderie that is
often an integral part of military service. The bond between cohort members can be the type of
camaraderie they may not have experienced since their ADF service, and many therapists draw on this
to strengthen the intervention. Group treatments can be well suited to this population because military
personnel are trained to work in groups, and feel that there is strength and safety in numbers.
Incentive to attend
For some participants, the group can provide an incentive to attend – they want to see the other
participants. The group members can provide an external motivation when the internal motivation is
not there. It can also provide a routine for people if they need to get out of the house for a certain
number of days per week, which can be particularly important for people who are not in the workforce.
Help each other to process, understand and change
As opposed to one-to-one treatment, the group provides an opportunity to learn from the experience of
others, to discuss and make meaning with peers, to share what is working and not working and to
problem-solve with each other, sharing suggestions and ideas. It can be beneficial to the therapists to
have input from group members – they may say things in a way that a therapist is not able to or would
not think of, leading to a deeper understanding. Participants may also be willing to try new things
because they are not doing it alone, and to share things with their peers that they might not tell anyone
else. There can also be a greater sense of hope and motivation – “if he can do it, so can I.” Hearing
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stories from others, and having their story heard, can be a powerful change agent. In some cases peer
pressure about appropriate ways of being can moderate aberrant behaviour.
Modelling and application
Groups provide an opportunity for therapists to model the skills being taught, and for group members to
begin to apply these with each other. It is easier for people to adopt skills they have seen in practice,
and to receive practical support while doing so. Group dynamics also provide an opportunity to deal
with a range different people and situations, which is not possible in individual treatment.
Enhances and assists trauma-focused work
Trauma-focused work in a group context can provide several benefits: it can make it easier for people to
disclose once they have watched someone else do so; there is a greater level of exposure than in oneto-one therapy because they are listening to others’ stories and experiencing more triggers; and a lot of
work is done to establish a trusting environment and a strong connection to the group, which allows the
therapist to move more quickly. Group members can also provide validation that each person’s trauma
was traumatic, and coming from peers this can carry more weight and be more powerful than from a
therapist who may not have experienced military service. There can also be validation that different
traumas are “worthy”, that it is not a competition.
Contributes something the therapist can’t
Because of their shared experience, group members can normalise symptoms and validate experiences
in a way that therapists cannot. Another veteran can say they did their best, that they could not have
done anything differently, and it has a more profound impact than if the same words had come from a
therapist who has not had operational experience. The group can also enable more use of humour and
fun, letting people drop their guard and laugh together. This is part of the restoration of affect: “Many
haven’t laughed for a long time.”
Groups create efficiencies of time
The group programs deliver a significant amount of content and psycho-education, and it would be less
efficient in terms of time to deliver this on a one-to-one basis. A group can also be more interactive and
discussion-based, which can increase understanding. Participants can also receive information from
each other, which means they are not relying on the facilitator to provide all of the information.
The group process can make some aspects of the therapeutic and change process move more quickly –
the development of rapport, the acceptance that the person has PTSD, the level of disclosure and
engagement. Shared background and experience and more minds in the room working together means
the groups can achieve outcomes in weeks that several psychiatrists noted would take two years to
achieve in one-to-one therapy.
Staff are skilled and experienced and receive regular supervision and support
Group programs often provide benefits for staff such as reduced burnout due to the multi-disciplinary
involvement, co-facilitation of sessions, and ongoing support and supervision. It means that participants
are working with staff who are highly experienced and who have specialist skills e.g. PTSD, military
context. It also brings an intense, multi-disciplinary focus on PTSD and the co-morbidities that is not
likely to be possible in one-to-one treatment.
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Section 9 Discussion of outcomes unique to group treatments
Staff from sites and VVCS have significant expertise in the conduct of group treatments for a range of
mental health disorders. It was very clear from the interviews with these staff that group treatments
achieve a range of outcomes that are not possible through one-to-one treatments.
Perhaps because of this, several staff made the point that it is not always a question of group or
individual – the two modes of treatment are complementary and can be more effective together than
alone. All of the group programs include a number of individual sessions, which allow participants to
reflect on the group experience with a therapist, undertake structured exposure and trauma work and
focus on other areas important to the individual, such as couple work. Staff at Toowong reported that
more than 90% of their cohort over ten years had received individual therapy prior to the group
treatment, yet they still achieved a significant effect from the program. Group treatment augments
individual treatment, and there was strong support for ensuring that group treatment remains an option
for those who wish to seek it or who would benefit from it.
Despite the clear benefits, it is important to say that groups are not appropriate or effective for
everyone. There is no exact science for selecting group members or judging readiness – individuals can
adapt to the group context better or worse than expected. Some individuals do not gain as much as
expected from the programs and can be a disruptive influence.
A final point is that the group treatment programs are evidence-based, monitored and accredited, which
may not always be the case for individual treatments.
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Section 10: After the programs
Research question:
This section partly answers the research question: “What happens once the veterans leave the
program?”
Discharge planning
During interviews with the PTSD program sites, staff members were asked what care or treatment is
provided to participants after they have finished the PTSD program, including treatment or care
provided by the site or by external sources.
Sites generally indicated that discharge planning was coordinated between the program and VVCS, DVA,
and local ESOs, and ACPMH where appropriate. Discharge planning includes relapse prevention
strategies which are formulated with the participant. This process is generally started before the
cessation of the program.
Discharge planning involves exploring post-group options (e.g., VVCS, engaging in other communitybased programs), and continuing with individual and/or relationship therapy. On completion of the
program, individuals are usually referred back to the original referral source. In cases where
participants did not have a supporting mental health professional, efforts were made to arrange one.
This was particularly important in instances where the participant required pharmacological
interventions.
Care arrangements are put into place for participants upon discharge from the PTSD program.
Participants are encouraged to review the goals that were set at the beginning of the program.
Subsequently, they are encouraged to prioritise what goals they will work on in the future. This includes
developing specific strategies for achieving those goals.
Care arrangements also include planning for the three month and nine month follow-up, at which point
participants are encouraged to review their goals. In many cases, participants will also review the
booklets they received during the program. During the scheduled follow-up visit, general reviews are
conducted with staff and participants, followed by staff providing refresher information on program
content in order to consolidate strategies which are being done well, and to assist with relapse
prevention. Any barriers participants have faced are discussed at this point.
Discharge letters are sent to appropriate external people, such as the participant’s psychiatrist or GP. At
this point, participants are also asked if they have scheduled their next appointment with the
psychiatrist.
The ACPMH website provides information on DVA-funded PTSD day hospital programs accredited by
ACPMH. These PTSD programs, as tertiary providers, are obliged to demonstrate a capacity to provide
clinical support to clinicians outside the program (including psychiatrists, general practitioners,
psychologists, VVCS counsellors, and contract counsellors), who are providing follow-up treatment to
discharged veterans. In these programs, the process of discharge is treated as vital in ensuring effective
continuity of care following the PTSD program. ACPMH recommends that copies of the discharge
summary should be made available to the veteran's general practitioner, their VVCS counsellor, and any
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other treating clinician. However, it is assumed that participants have a treating clinician or a
counsellor.
VVCS
Many sites indicated that participants received ongoing support from VVCS. VVCS was noted as having a
good range of programs that are considered suitable for participants after discharge and recommended
to individuals as they are needed. Programs include ‘Moving Forward’ and ‘Lifestyle’. The VVCS
program called ‘Moving Forward’ is offered to PTSD group participants (including their partners) to
continue with after the group program finishes. In this program they meet bi-weekly for a period of six
months.
A number of site staff indicated that they assisted group members to make contact with VVCS prior to
being discharged from the program. For example, Hollywood said that in their experience it was hard to
get the participants, particularly the contemporary veterans, to VVCS. So to assist them, the program
staff went with the veterans to VVCS to do a joint session with their counsellor. Similarly, Daw Park staff
went to VVCS with their group members to help participants familiarise themselves with the location of
the department, to meet the coordinator, ask questions, and to help participants learn what programs
are available for them to complete down the track, such as the Lifestyle program. Participants were also
provided information that partners and children could also access VVCS.
One program (Toowong) indicated that VVCS was not involved with participants after the PTSD program
was finished. This site indicated that VVCS attend the second last week of the PTSD program and speak
with the veterans at this stage only. Toowong do not actively stream veterans into VVCS, but they
acknowledge that they have links with VVCS. In particular, VVCS has a greater role in treating family
members of the PTSD participants. For example, at Toowong VVCS does a session with wives and offer
the ‘Heart Health’ and ‘Lifestyle’ programs.
VVCS is often involved with the partners of the participating veterans, generally in a supportive and
counselling capacity. VVCS also provide individual help for partners and children.
Site staff expressed that they liked the lifestyle programs offered by VVCS because they assisted in
reducing participants’ dependency on the unit in which the PTSD program was completed.
External involvement in activities/community
All participants, but particularly contemporary veterans, are encouraged to engage with the community.
For example, after being discharged from the program, participants are encouraged to continue with
education, such as going to university.
Heidelberg indicated that most participants disperse back into the community rather than staying at the
inpatient centre. Contemporary veterans often engage in individual work post completing the program.
Northside Cremorne said that their participants often sought activities, more so than treatment, after
the PTSD program finished. Such activities included cooking, TAFE courses, computer courses, and
woodworking.
Outpatient and inpatient care
In all sites, participants are encouraged to consult their referring psychiatrist and/or psychologist for
ongoing treatment, particularly during the nine month follow-up period.
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Does follow-up care have any impact on outcomes?
Sites were asked to comment on their experience with follow-up and the impact this has on treatment
outcomes for PTSD group participants.
Sites agreed that it is an essential part of treatment to have follow-up, particularly because PTSD is a
chronic condition. Programs are not viewed as a cure, but one piece of the treatment puzzle. It is an
opportunity to provide support to participants and it helps to prevent relapse.
For example, at three month follow-up some participants are struggling to implement new behaviours
successfully, and they may be tired and feeling frustrated that things are not working out as easily as
hoped. Further, participants may experience feelings of guilt and failure because they are trying new
strategies, but they are not always successful at first. Sometimes, families and social support systems
(which may have been strained and fractured prior to completing the program) have not caught up with
the changes being made by the participant. Therefore, the early follow-up sessions offer an opportunity
to provide encouragement and support.
The nine month follow-up sessions are seen as an opportunity to consolidate and shape the skills that
participants have acquired. It is an opportunity to provide encouragement to build ongoing confidence,
and to assist participants in their endeavour to reconnect with the community and in some cases, other
programs.
Anecdotally, sites generally thought that participants who attended the follow-up sessions, did followup with other programs/services, and whose wives/partners participated, tended to do better.
Differences between sites
Some sites differ considerably with the follow-up they offer to participants. For example, St John of God
conducts extensive follow-up whilst Geelong do not offer follow-up at all.
Sites, such as Northside Cremorne, thought that improvements could be made to follow-up care. They
suggested more extensive follow-up at three, six, and nine months that spanned a few days. Changes
and improvements to the follow-up structure at some sites were also endorsed in the qualitative data
obtained from participants who had completed the programs.
Section 10 Discussion regarding what happens after the programs
It seems clear from all interviews that follow-up is critical to the maintenance of program effect, and
there was also some support for this in the quantitative analyses.
There are several different options available for follow-up, including additional support or programs
through the site, individual or group treatment with VVCS, return to the referring practitioner, or some
other type of support.
CMVH do not have access to data on the follow-up treatments received by participants in the group
programs, and it would be worth examining or collecting this data in order to better understand what
impact follow-up treatment has on the maintenance of program outcomes.
There were no data available on the number of participants who go on – or return – to VVCS. From
interviews with staff from sites and VVCS, it appears this can vary with the quality of the relationship
between sites and VVCS. It appears that the great majority of sites encourage participants to take up
the option of individual support or group programs with VVCS, and many have supported referral
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procedures that involve taking veterans, and often their partners, to VVCS. This is an example of good
practice that is occurring in a small number of sites and which could be expanded to others.
Some VVCS staff mentioned they would like improved discharge information from sites, and this may be
an area that requires further discussion regarding what information would be useful and what
information is currently provided. It is important that clear discharge information is provided to any
treating professional working with participants after the program, and procedures could be reviewed in
cases where this is not happening.
From the Phase One literature review, it seems clear that ongoing support can be provided by
community-based practitioners, whether this is a GP, psychiatrist or psychologist or other treating
professional. However, it is vital that treating practitioners are experienced in evidence-based
treatment for PTSD. This may be less likely in smaller communities, such as rural or remote towns. In
these cases, it would be highly beneficial to explore options such as VVCS outreach counselling or video
counselling, or internet based therapies.
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Section 11: Economic analysis
Research question:
This section addresses the research question, “What are the outcomes of a cost-benefit analysis of the
group treatments?” and addresses the area specified in the tender regarding, “a cost-benefit analysis of
recommended treatment model(s)/ option (s).
Issues with the data
The financial data provided to CMVH listed amounts paid to sites for the PTSD group treatment
programs for the past five years. CMVH acknowledge that it was difficult for DVA to collate this data as
it involved working across multiple datasets. It was also complicated by various internal transitions such
as some hospitals moving from repatriation to private hospitals with different accounting systems.
Additionally, there are different contractual arrangements for each site.
The financial data received by CMVH was incomplete for many sites and inadequate for any type of
rigorous financial analysis. In particular:
 There are different payment and contractual arrangements for different sites and incomplete
data on these:
o Some sites were paid a lump sum per person per program.
o Other sites were paid per person per day of attendance.
o Some sites were paid for assessment and follow-up days and some did not appear to be.
Of sites that were, there were only payments for some participants and not all, and the
reasons for this were not known.
o Some sites have changed their payment arrangements during the past five years.
o It is not apparent whether costs for individual therapy sessions within the program are
included in the price or additional to it.
o It is not clear whether there are additional payments associated with family attendance,
pharmacological therapy, follow-up days etc.
 Incomplete data were received for most sites, and due to discrepancies between participant
numbers it was not possible to match the financial and outcome datasets:
o Example 1: Greenslopes. CMVH was provided with a lump sum figure for 05/06 but no
information on participant or cohort numbers. We were provided with the payment
per participant per day for 07/08, 08/09 and two cohorts in 09/10, and while the
participant numbers in cohorts largely matched the participant numbers in the program
outcome data, the days varied widely from four to 40 days attended. The duration of
the Greenslopes program is 22 days including follow-up. To our knowledge no one
repeated the program.
o Example 2: Hollywood. CMVH was provided with lump sum figures for 05/06 to 08/09,
as well as numbers of cohorts and participants for each year. These numbers were not
the same as those in the program outcome data, making it impossible to match the two
datasets. The data may have been complicated because there are two different DVAfunded programs at Hollywood, however even taking this into account participant and
cohort numbers still did not match. We were provided with the payment per
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participant per day for three cohorts in 09/10; participant numbers in one of the three
cohorts did not match participant numbers in the program outcome data.
o Example 3: Geelong. CMVH was provided with the payment per participant per
program for seven cohorts – in two of these cohorts the participant numbers in the
financial data did not match those in the program data.
o Example 4: Heidelberg. CMVH was provided with the payment per participant per
program for 30 cohorts. Site staff also provided information on participant numbers
per cohort. The participant numbers per cohort were different across the financial
data, program data and program outcome data, meaning the datasets could not be
matched.
 There are additional costs to the programs that are not included in the dollar amount paid to
sites:
o For example, participants in programs like Greenslopes may stay at a nearby hotel while
they attend a day program. This cost is reimbursed to participants, not paid directly to
the site, but is still part of the cost to DVA of the PTSD program at that particular site.
For other sites, the residential/inpatient component appears to be included in the cost
of the program and is paid directly to the site. This may lead to the conclusion that the
Greenslopes program costs comparatively less, which may not be the case.
o There may be other additional costs such as travel, medication etc that should be
accounted for in order to properly compare programs.
Analysis of the data
CMVH attempted to estimate an average cost/participant for each site based on the financial data
provided but rejected this as unreliable, as what was included or excluded from any program costs was
not apparent. Further, the accuracy of the data was questionable. Any conclusions drawn, comparisons
made or decisions taken on these data would be inaccurate and misleading.
Without clear understanding of contractual arrangements and what was or was not included in the
program, cost was indefinable. Accordingly, there were no data available that could be used to form the
basis of any valid comparisons or recommendations.
Future economic analysis
The question of program cost compared to program effectiveness is an important one. It cannot be
answered accurately or reliably on the provided financial data.
The tender specified a cost-benefit analysis of the preferred model. Technically, a cost-benefit analysis
involves assigning a numerical value to all costs and benefits experienced by all people impacted in
order to evaluate the desirability of an intervention. Professor Lapsley’s advice is that this type of
analysis is not suited to the purposes of the current review, nor possible with the data available.
A cost effectiveness analysis typically provides a cost per health outcome and is an analysis appropriate
to the purposes of the review. This analysis is not possible on the available data but would be possible
in the future with:


Accurate information on all costs associated with each program (including travel,
accommodation, accreditation, costs to participants, medication costs, assessments, follow-up,
individual therapies within the program etc).
An agreed definition of targeted effect.
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Section 12: Recommended treatment model/option
It should be apparent from the preceding discussion that there is no single model in either the literature
or at any of the sites that stands out as significantly better than the others. Perhaps this is because
variations in the treatments suit some people more than others and people gravitate towards
treatments that they are comfortable with. Indeed the clinical treatment guidelines list three treatments
as meeting the gold standard. The PTSD group treatment programs are in line with the Australian
Guidelines and are conducted by professional personnel keen to provide the best treatment possible for
their participants that is supported by evidence.
Nonetheless, as highlighted by this analysis there are areas that may be improved by relatively minor
changes. These have been discussed at length throughout the paper and specific recommendations can
be found in the Final Report.
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References
ACPMH, Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Posttraumatic
Stress Disorder, Australian Centre for Posttraumatic Mental Health.
http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/mh13.pdf, 2007.
Australian Bureau of Statistics (ABS) (2008). Australian National Survey of Mental Health and Wellbeing,
2007: Summary of results. http://www.abs.gov.au/AUSSTATS/abs@.nsf/mf/4326.0
Dunt, D. (2009). Independent study into suicide in the ex-service community.
WHOQOL Group (1994). Development of the WHOQOL: Rationale and current status. International
Journal of Mental Health, 1994, 23, pp.24-56.
Reports consulted for the review
ACPMH, Accreditation guidelines for PTSD programs purchased by DVA for veterans, Department of
Veterans Affairs, 2007.
Annual Report 2009/2010, PTSD Program Quality Assurance, Department of Veterans Affairs, 2011.
Annual Report 2008/2009, PTSD Program Quality Assurance, Department of Veterans Affairs, 2009.
Annual Report 2007/2008 PTSD Program Quality Assurance, Department of Veterans Affairs, 2008.
Annual Report 2006/2007, PTSD Program Quality Assurance, Department of Veterans Affairs, 2008.
Accreditation Report for the Northside Cremorne PTSD program, Department of Veterans Affairs, 2007.
Accreditation Report for the Mater Misericordae Hospital Townsville PTSD program, Department of
Veterans Affairs, 2007.
Accreditation Report for the Heidelberg Repatriation Hospital Older Veterans Psychiatry Program (OVPP)
PTSD program, Department of Veterans Affairs, 2007.
Accreditation Report for the Geelong Clinic PTSD program, Department of Veterans Affairs, 2007.
Accreditation report for the St John of God Hospital Richmond Closed PTSD program, Department of
Veterans Affairs, 2007.
Accreditation Review Calvary Private Hospital PTSD program, Department of Veterans Affairs, 2006.
Accreditation Review Austin Health PTSD program, Department of Veterans Affairs, 2005.
Accreditation Review the Hollywood Clinic PTSD program, Department of Veterans Affairs, 2005.
Accreditation Review Greenslopes Private Hospital PTSD program, Department of Veterans Affairs, 2005.
Accreditation Review Geelong Clinic PTSD program, 2005.
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Appendix 1: PCL-M results for each site
Figure 39.
PCL-M results for Northside Cremorne (n=141)
Figure 40.
PCL-M results for Mater Townsville (n=191)
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Figure 41.
PCL-M results for Hollywood (n=173)
Figure 42.
PCL-M results St John of God Richmond (n=68)
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Figure 43.
PCL-M results for Palm Beach Currumbin (n=30)
Figure 44.
PCL-M results Toowong (n=232)
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Figure 45.
PCL-M results for Geelong (n=60)
Figure 46.
PCL-M results for Heidelberg (n=251)
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Figure 47.
PCL-M results for Daw Park (n=132)
Figure 48.
PCL-M results for Greenslopes (n=162)
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Figure 49.
PCL-M results for Calvary (n=30)
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Appendix 2: WHOQOL-BREF (Psychological) results for each site
Figure 50.
WHOQOL-BREF Psychological results for Northside Cremorne (n=142)
Figure 51.
WH QoL-Bref Psychological results for Mater Townsville (n=192)
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Figure 52.
WHOQOL-BREF Psychological results for Hollywood
Figure 53.
WHOQOL-BREF Psychological results for St John of God Richmond (n=69)
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Figure 54.
WHOQOL-BREF Psychological results for Palm Beach Currumbin (n=31)
Figure 55.
WHOQOL-BREF Psychological results for Toowong (n=232)
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Figure 56.
WHOQOL-BREF Psychological results for Geelong (n=60)
Figure 57.
WHOQOL-BREF Psychological results for Heidelberg (n=252)
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Figure 58.
WHOQOL-BREF Psychological results for Daw Park (n=133)
Figure 59.
WHOQOL-BREF Psychological results for Greenslopes (n=162)
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Figure 60.
WHOQOL-BREF Psychological results for Calvary (n=30)
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Appendix 3: WHOQOL-BREF (Physical) results for each site
Figure 61.
WHOQOL-BREF Physical results for Northside Cremorne (n=142)
Figure 62.
WHOQOL-BREF Physical results for Mater Townsville (n=192)
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Figure 63.
WHOQOL-BREF Physical results for Hollywood (n=173)
Figure 64.
WHOQOL-BREF Physical results for St John of God Richmond (n=69)
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Figure 65.
WHOQOL-BREF Physical results for Palm Beach Currumbin (n=31)
Figure 66.
WHOQOL-BREF Physical results for Toowong (n=232)
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Figure 67.
WHOQOL-BREF Physical results for Geelong (n=60)
Figure 68.
WHOQOL-BREF Physical results for Heidelberg (n=252)
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Figure 69.
WHOQOL-BREF Physical results for Daw Park (n=133)
Figure 70.
WHOQOL-BREF Physical results for Greenslopes (n=162)
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Figure 71.
WHOQOL-BREF Physical results for Calvary (n=30)
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Appendix 4: DAR (Anger) results for each site
Figure 72.
DAR (Anger) results for Northside Cremorne (n=142)
Figure 73.
DAR (Anger) results for Mater Townsville (n=192)
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Figure 74.
DAR (Anger) results for Hollywood (n=174)
Figure 75.
DAR (Anger) results for St John of God Richmond (n=69)
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Figure 76.
DAR (Anger) results for Palm Beach Currumbin (n=31)
Figure 77.
DAR (Anger) results for Toowong (n=232)
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Figure 78.
DAR( Anger) results for Geelong (n=60)
Figure 79.
DAR (Anger) results for Heidelberg (n=250)
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Figure 80.
DAR (Anger) results for Daw Park (n=133)
Figure 81.
DAR (Anger) results for Greenslopes (n=161)
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Figure 82.
DAR (Anger) results for Calvary (n=30)
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Appendix 5: DAS (Family Function) results for each site
Figure 83.
DAS (Family Function) results for Northside Cremorne (n=117)
Figure 84.
DAS (Family Function) results for Mater Townsville (n=144)
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Figure 85.
DAS (Family Function) results for Hollywood (n=138)
Figure 86.
DAS (Family Function) results for St John of God Richmond (n=57)
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Figure 87.
DAS (Family Function) results for Palm Beach Currumbin (n=26)
Figure 88.
DAS (Family Function) results for Toowong (n=185)
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Figure 89.
DAS (Family Function) results for Geelong (n=49)
Figure 90.
DAS (Family Function) results for Heidelberg (n=200)
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Figure 91.
DAS (Family Function) results for Daw Park (n=101)
Figure 92.
DAS (Family Function) results for Greenslopes (n=145)
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Figure 93.
DAS (Family Function results for Calvary (n=26)
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Appendix 6: HADS (Anxiety) results for each site
Figure 94.
HADS (Anxiety) results for Northside Cremorne (n=140)
Figure 95.
HADS (Anxiety) results for Mater Townsville (n=192)
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Figure 96.
HADS (Anxiety) results for Hollywood (n=173)
Figure 97.
HADS (Anxiety) results for St John of God Richmond (n=68)
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Figure 98.
HADS (Anxiety) results for Palm Beach Currumbin (n=31)
Figure 99.
HADS (Anxiety) results for Toowong (n=232)
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Figure 100.
HADS (Anxiety) results for Geelong (n=60)
Figure 101.
HADS (Anxiety) results for Heidelberg (n=248)
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Figure 102.
HADS (Anxiety) results for Daw Park (n=131)
Figure 103.
HADS (Anxiety) results for Greenslopes (n=162)
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Figure 104.
HADS (Anxiety) results for Calvary (n=30)
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Appendix 7: WHOQOL-BREF Physical results for contemporary veterans
Figure 105.
WHOQOL-BREF Physical results for contemporary veterans at Mater Townsville (n=123)
Figure 106.
WHOQOL-BREF Physical results for contemporary veterans at Toowong (n=58)
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Figure 107.
WHOQOL-BREF Physical results for contemporary veterans at Hollywood (n=54)
Figure 108.
WHOQOL-BREF Physical results for contemporary veterans at Heidelberg (n=40)
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Appendix 8: WHOQOL-BREF Psychological results for contemporary
veterans
Figure 109.
(n=123)
WHOQOL-BREF Psychological results for contemporary veterans at Mater Townsville
Figure 110.
WHOQOL-BREF Psychological results for contemporary veterans at Toowong (n=58)
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Figure 111.
WHOQOL-BREF Psychological results for contemporary veterans at Hollywood (n=58)
Figure 112.
WHOQOL-BREF Psychological results for contemporary veterans at Heidelberg (n=40)
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Appendix 9: HADS (Anxiety) results for contemporary veterans
Figure 113.
HADS (Anxiety) results for contemporary veterans at Mater Townsville (n=123)
Figure 114.
HADS (Anxiety) results for contemporary veterans at Toowong (n=58)
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Figure 115.
HADS (Anxiety) results for contemporary veterans at Hollywood (n=54)
Figure 116.
HADS (Anxiety) results for contemporary veterans at Heidelberg (n=39)
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Appendix 10: Predictors for each scale
Table 43: Model used to predict expected levels of PCL-M based on the demographics of each program
Model term
Coefficient
(PCL-M)
95% CI
P- value
Constant
61.6
(57.7, 65.5)
Time point
Entry
Discharge
3 months
9 months
Baseline
-6.0
-7.1
-7.9
(-6.6, -5.4)
(-7.7, -6.5)
(-8.5, -7.2)
<0.0001
<0.0001
<0.0001
Age
20-49
50-59
60+
6.2
3.7
Baseline
(4.5, 8.0)
(2.4, 5.1)
<0.0001
<0.0001
Marital status
Single (never married)
Married or De facto
Separated, Divorced or Widowed
-3.3
0.7
Baseline
(-6.1, -0.5)
(-0.7, 2.2)
0.02
0.31
Education
High school or lower
Post high school
1.2
Baseline
(0.1, 2.3)
0.03
Employment
Working or looking for work
Retired
Unable to work
Other or unknown
-2.2
-3.7
-3.3
Baseline
(-5.6, 1.3)
(-7.2, -0.1)
(-6.7, 0)
0.22
0.04
0.05
Service
Army
Navy
-2.6
Baseline
(-3.9, -1.3)
0.0001
Service type
Regular
Conscripts
1.4
Baseline
(0.2, 2.6)
0.03
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Table 44: Model used to predict expected levels of WHOQOL Physical based on the demographics of
each program
Model term
Coefficient
(WHOQOL
Physical)
95% CI
P- value
Constant
34.3
(29.6, 38.9)
Time point
Entry
Discharge
3 months
9 months
Baseline
6.6
5.5
6.5
(5.9, 7.2)
(4.8, 6.2)
(5.8, 7.2)
<0.0001
<0.0001
<0.0001
Age
20-49
50-59
60+
-7.4
-4.1
Baseline
(-9.6, -5.2)
(-5.7, -2.4)
<0.0001
<0.0001
Marital status
Single (never married)
Married or De facto
Separated, Divorced or Widowed
8.1
0.8
Baseline
(4.6, 11.7)
(-1.0, 2.6)
<0.0001
0.38
Employment
Working or looking for work
Retired
Unable to work
Other or unknown
6.8
6.4
5.5
Baseline
(2.6, 11.0)
(2.1, 10.7)
(1.4, 9.5)
0.002
0.004
0.008
Service
Army
Navy
4.5
Baseline
(2.8, 6.1)
<0.0001
Service type
Regular
Conscripts
-2.5
Baseline
(-4.0, -1.0)
0.001
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Table 45: Model used to predict expected levels of WHOQOL Psychological based on the demographics
of each program
Model term
Coefficient
95% CI
(WHOQOL
Psychological)
P- value
Constant
34.6
(30.2, 39.0)
Time point
Entry
Discharge
3 months
9 months
Baseline
8.8
7.0
7.5
(8.1, 9.6)
(6.2, 7.7)
(6.7, 8.3)
<0.0001
<0.0001
<0.0001
Age
20-49
50-59
60+
-9.6
-3.7
Baseline
(-11.7, -7.6)
(-5.3, -2.1)
<0.0001
<0.0001
Education
High school or lower
Post high school
-1.5
Baseline
(-2.9, -0.2)
0.02
Employment
Working or looking for work
Retired
Unable to work
Other or unknown
4.2
8.5
4.9
Baseline
(0.2, 8.3)
(4.3, 12.6)
(1.0, 8.9)
0.04
<0.0001
0.01
Service
Army
Navy
3.1
Baseline
(1.5, 4.7)
0.0001
Service type
Regular
Conscripts
-1.5
Baseline
(-2.9, -0.04)
0.04
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Table 46: Model used to predict expected levels of WHOQOL Social Relationships based on the
demographics of each site
Model term
Coefficient
(WHOQOL
Social
relationship)
95% CI
Constant
31.1
(25.4, 36.8)
Time point
Entry
Discharge
3 months
9 months
Baseline
9.7
7.4
7.8
(8.7, 10.6)
(6.4, 8.4)
(6.7, 8.9)
<0.0001
<0.0001
<0.0001
Age
20-49
50-59
60+
-3.8
-3.9
Baseline
(-6.6, -1.1)
(-6.0, -1.8)
0.007
0.0003
Gender
Female
Male
10.2
Baseline
(2.5, 18.0)
0.01
6.7
7.2
Baseline
(2.3, 11.0)
(5.0, 9.5)
0.003
<0.0001
Employment
Working or looking for work
Retired
Unable to work
Other or unknown
5.5
8.3
5.4
Baseline
(0.3, 10.7)
(3.0, 13.7)
(0.4, 10.5)
0.04
0.002
0.04
Service type
Regular
Conscripts
-4.1
Baseline
(-6.0, -2.2)
<0.0001
Marital status
Single (never married)
Married or De facto
Separated, Divorced or
Widowed
P- value
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Table 47: Model used to predict expected levels of WHOQOL Environmental based on the demographics
of each program
Model term
Coefficient
95% CI
(WHOQOL
Environmental)
Constant
55.3
(51.1, 59.6)
Time point
Entry
Discharge
3 months
9 months
Baseline
4.0
2.7
3.6
(3.4, 4.6)
(2.1, 3.4)
(2.9, 4.3)
<0.0001
<0.0001
<0.0001
Age
20-49
50-59
60+
-9.7
-4.3
Baseline
(-11.7, -7.8)
(-5.8, -2.9)
<0.0001
<0.0001
2.9
2.4
Baseline
(-0.2, 6.0)
(0.8, 4.0)
0.06
0.003
Education
High school or lower
Post high school
-2.7
Baseline
(-3.9, -1.5)
<0.0001
Employment
Working or looking for work
Retired
Unable to work
Other or unknown
3.9
5.2
4.7
Baseline
(0.1, 7.7)
(1.2, 9.1)
(1.0, 8.4)
0.05
0.01
0.01
Service
Army
Navy
2.4
Baseline
(1.0, 3.9)
0.001
Service type
Regular
Conscripts
-2.0
Baseline
(-3.4, -0.7)
0.003
Marital status
Single (never married)
Married or De facto
Separated, Divorced or
Widowed
P- value
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Table 48: Model used to predict expected levels of DAR (Anger) based on the demographics of each
program
Model term
Coefficient
(DAR)
95% CI
Constant
26.8
(22.6, 31.1)
Time point
Entry
Discharge
3 months
9 months
Baseline
-4.9
-5.8
-6.4
(-5.5, -4.3)
(-6.4, -5.1)
(-7.1, -5.7)
<0.0001
<0.0001
<0.0001
Age
20-49
50-59
60+
9.6
5.2
Baseline
(7.6, 11.5)
(3.7, 6.7)
<0.0001
<0.0001
-0.1
2.6
Baseline
(-3.2, 3.0)
(1.1, 4.2)
0.96
0.001
Employment
Working or looking for work
Retired
Unable to work
Other or unknown
-0.8
-4.2
-3.8
Baseline
(-4.4, 2.9)
(-7.9, -0.4)
(-7.3, -0.3)
0.68
0.03
0.04
Service
Army
Navy
-1.7
Baseline
(-3.1, -0.2)
0.0227
Service type
Regular
Conscripts
2.7
Baseline
(1.4, 4.0)
<0.0001
Marital status
Single (never married)
Married or De facto
Separated, Divorced or
Widowed
P- value
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Table 49: Model used to predict expected levels of DAS (Family Function) based on the demographics of
each program
Model term
Coefficient
(DAS)
95% CI
Constant
16.9
(14.9, 18.9)
Time point
Entry
Discharge
3 months
9 months
Baseline
1.9
1.6
1.4
(1.6, 2.2)
(1.3, 1.9)
(1.0, 1.7)
<0.0001
<0.0001
<0.0001
Gender
Female
Male
5.6
Baseline
(2.4, 8.7)
0.001
Education
High school or lower
Post high school
-0.7
Baseline
(-1.3, -0.02)
0.04
1.1
2.7
1.8
Baseline
(-1.0, 3.2)
(0.6, 4.8)
(-0.2, 3.9)
0.30
0.01
0.08
Employment
Working or looking for work
Retired
Unable to work
P- value
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Table 50: Model used to predict expected levels of HADS (Anxiety) based on the demographics of each
site
Model term
Coefficient
(HADS anxiety)
95% CI
Constant
13.9
(12.7, 15.0)
Time point
Entry
Discharge
3 months
9 months
Baseline
-1.8
-2.0
-2.1
(-2.0, -1.6)
(-2.1, -1.8)
(-2.3, -1.9)
<0.0001
<0.0001
<0.0001
Age
20-49
50-59
60+
1.5
1.2
Baseline
(1.0, 2.1)
(0.8, 1.6)
<0.0001
<0.0001
-1.0
0.2
Baseline
(-1.8, -0.1)
(-0.3, 0.6)
0.02
0.47
Education
High school or lower
Post high school
0.4
Baseline
(0.03, 0.7)
0.03
Employment
Working or looking for work
Retired
Unable to work
Other or unknown
-0.4
-1.3
-0.9
Baseline
(-1.4, 0.6)
(-2.4, -0.3)
(-1.9, 0.1)
0.39
0.01
0.07
Service
Army
Navy
-0.8
Baseline
(-1.2, -0.4)
<0.0001
Service type
Regular
Conscripts
0.3
Baseline
(-0.02, 0.7)
0.06
Marital status
Single (never married)
Married or De facto
Separated, Divorced or
Widowed
P- value
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Table 51: Model used to predict expected levels of HADS (Depression) based on the demographics of
each program
Model term
Coefficient
(HADS
depression)
95% CI
P- value
Constant
11.8
(10.7 ,12.8)
Time point
Entry
Discharge
3 months
9 months
Baseline
-1.9
-1.6
-1.5
(-2.1, -1.7)
(-1.8, -1.4)
(-1.7, -1.3)
<0.0001
<0.0001
<0.0001
Age
20-49
50-59
60+
1.8
1.0
Baseline
(1.3, 2.3)
(0.6, 1.4)
<0.0001
<0.0001
Employment
Working or looking for work
Retired
Unable to work
Other or unknown
-0.6
-1.7
-1.0
Baseline
(-1.6, 0.4)
(-2.7, -0.6)
(-2.0, 0.01)
0.23
0.002
0.05
Service
Army
Navy
-0.8
Baseline
(-1.2, -0.4)
0.0003
Service type
Regular
Conscripts
0.5
Baseline
(0.1, 0.9)
0.007
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Appendix 11: PCL-M results for contemporary veterans
Figure 117.
PCL-M results for contemporary veterans at Mater Townsville (n=123)
Figure 118.
PCL-M results for contemporary veterans at Toowong (n=58)
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Figure 119.
PCL-M results for the Trauma Recovery program at Hollywood (n=51)
Figure 120.
PCL results for contemporary veterans at Heidelberg (n=40)
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Appendix 12: DAR (Anger) results for contemporary veterans
Figure 121.
DAR (Anger) results for contemporary veterans at Mater Townsville (n=123)
Figure 122.
DAR (Anger) results for contemporary veterans at Toowong (n=58)
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Figure 123.
DAR (Anger) results for contemporary veterans at Hollywood (n=54)
Figure 124.
DAR (Anger) results for contemporary veterans at Heidelberg (n=58)
159