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References

Daniels, L. R., Boehnlein, J. K., & McCallion, P. (2015). Life-review and PTSD community counseling with two groups of Vietnam War veterans. Traumatology,

21(3), 161–171. https://doi-org.library.capella.edu/10.1037/trm0000045

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Life-Review and PTSD Community Counseling With Two Groups of Vietnam War Veterans

By: Lori R. Daniels

Portland Vet Center, Readjustment Counseling Service (VA), Portland, Oregon;

James K. Boehnlein

Mental Illness Research, Education, & Clinical Center (MIRECC), VAMC, Portland, Oregon

Phillip McCallion

Center for Excellence in Aging Services, University of Albany

Acknowledgement: We acknowledge Portland Vet Center, Readjustment Counseling Service – Region 4B Department of VA; John A. Hartford

Foundation Geriatric Social Work Initiative; Gerontological Society of America; Research & Development Department, Portland VA Medical Center,

Portland, Oregon.

Over the past 30 years treatment for posttraumatic stress disorder gradually has become more formalized and evidence-based. Many of these

established PTSD protocol-driven interventions were originally developed to help Vietnam veterans while they were younger men and women. However,

even though 18% to 30% of these Vietnam veterans have met the diagnosis for PTSD sometime during their lives (Kulka et al., 1990), there are no

established therapy protocols for treating aging war veterans (Brooks & Fulton, 2010; Chatterjee et al., 2009; Cook & Niederehe, 2007; Hyer et al., 1995;

King et al., 2007; Lipton & Schaffer, 1986; Markowitz, 2007; Spiro, Schnurr, & Aldwin, 1994). Meanwhile, where the gerontology field has discussed

interventions that facilitate life reflection and reminiscing among older adults, it has supported the targeting of resolution of past problematic memories

that may impede the aging process (Blankenship, Molinari, & Kunik, 1996; Bohlmeijer et al., 2007; Coleman, 2005; Haight & Burnside, 1993; Hunt &

McHale, 2007; Maercker, 2002; Webster, 1998; Whitbourne, 1996; Wong & Watt, 1991). These interventions include structured reminiscing, also called

life review and narrative therapy, which has yet to be applied in group therapy protocols for older traumatized war veterans.

This feasibility study attempts to address the need for gerontologically informed interventions for aging war veterans by investigating the impact of adding

structured life-review to PTSD group therapy for older war veterans. This is likely the first study of its kind utilizing both PTSD group therapy and life

review interventions together with a community-based geriatric veteran population and feasibility questions must be addressed first before a more

structured test of the intervention.

Background and Theoretical Perspective

Much of the existing information about older war veterans with PTSD has focused on World War II and Korean War veterans, because of these war

veterans being in their 60s, 70s, and 80s at the time these studies were conducted (Cook, 2001; Hyer et al., 1995; Markowitz, 2007; Schnurr, 1991; Spiro,

Schnurr, & Aldwin, 1994). However, there are still gaps in understanding how the aging process may impact PTSD symptoms, and/or whether the

diagnosis of PTSD contributes to challenges during the normal aging process.

Erickson’s human developmental, psychosocial stages model (Erickson, 1982) states that positive resolution of the final psychosocial crisis should result

in ego integrity, implying a sense of positive self-concept (Schaie & Willis, 1996). Butler (1963) has added that reminiscing becomes a natural part of the

aging process in later stages of life and one’s type of reminiscence may contribute to successful or unsuccessful aging (Wong & Watt, 1991). If an older

adult uses sad, angry, or bitter reminiscence types (e.g., regrets), the theory suggests that an individual is unlikely to age successfully; if an individual

reminisces frequently about happier times of their life (e.g., positive contributions), their ability to age successfully is increased (Wong & Watt, 1991;

Webster, 1993, 1998).

The cyclical symptoms of untreated PTSD (i.e., reexperiencing, hyper-arousal, distorted cognitions, and avoidance; American Psychiatric Association,

2013), combined with normal old age reminiscing, can result in a burdened route toward successful aging. It is commonly understood within the mental

health community that war veterans often suffer for months or years from PTSD before seeking treatment, and by the time these veterans realize that

their personal efforts to control their symptoms do not have long-term success, the PTSD cycle may be well entrenched in emotional and behavioral

patterns. Therefore, natural reminiscing as part of the aging process may not occur among war trauma survivors because reflecting on one’s personal

past may include traumatic material and self-denigrating thoughts.

In the gerontology literature, the use of the term “successful (or optimal) aging” is loosely defined as one’s ability to function with behavioral flexibility

within a supportive environment, including maintaining social supports, developing new relationships, learning techniques for stress reduction, coping with

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change, and being selective in one’s efforts to implement alternative strategies in compensating for losses throughout the aging processes (Baltes &

Baltes, 1990). Successful aging is also bolstered by a positive self-concept and an ability to evaluate one’s performance in proper relation to one’s

physical and mental capacity (Schaie & Willis, 1996). If traumatic stress symptoms are added as a potential confounding variable to a survivor’s aging

process, increased anxiety, decreased self-regard, decreased confidence, and unresolved grief become possible barriers against “successful aging”

(Whitbourne, 1996).

Using concepts of reminiscence, life-review, and narrative story, geriatric and gerontological specialists have found that disclosing memories and personal

stories helps improve the self-identity of an aging adult (Bohlmeijer et al., 2007; Cappeliez et al., 2005; Coleman, 2005; Hunt & Mchale, 2007; Webster,

1998). There should be an emphasis on continuous life span identity rather than just war experiences when dealing with the life stories of war veterans

(Hunt & McHale, 2007).

There have been sporadic reports by PTSD researchers of the need to address aging and traumatic stress among survivors (Bonwick & Morris, 1996;

Brooks & Fulton, 2010; Chatterjee et al., 2009; Cook, 2001; Cook & Niederehe, 2007; Lipton & Schaffer, 1986; Schnurr, 1991; Markowitz, 2007). Brooks

and Fulton (2010), using data from the 2001 National Survey of Veterans, found that Korean War veterans 48 years after the end of combat showed

notably poorer mental health than those who served elsewhere during the same period of time. Schnurr (1991) discussed problems with mental health

readjustment and PTSD among older veterans and indicated that there was a clear lack of assessment and specific treatment of PTSD in older veterans.

Other authors suggest building a comprehensive life span model of long-term effects of military service, including the trajectories of symptoms over time

on physical and mental health (Chatterjee et al., 2009), and advocate for a developmental perspective in therapy in order to guide theory and practice

across the life span (Friedman, Resick, & Keane, 2007).

A few studies broach the relationship between war trauma, older veterans, and reminiscence/life review through case studies (Maercker, 2002; N = 3, all

females), with former POWs from WWII and the Korean War in a group setting (Boehnlein & Sparr, 1993), or coupled with cognitive–behavioral therapy

techniques (Hyer et al., 1995). Each of these studies has suggested that possible outcomes of allowing trauma survivors to share their stories and

address their past with therapeutic compassion are achievement of distance from trauma memories and the enhancement of meaning of past horrific

events (Hyer et al., 1995).

The only study conducted that combined a veteran cohort, group therapy, and reminiscing styles was conducted by Blankenship, Molinari, and Kunik

(1996), who hypothesized that the Bitterness Revival reminiscence type measured by the Reminiscence Function Scale (RFS, Webster, 1993; Wong &

Watt, 1991) could be modified toward a less problematic type of reminiscence through a life review group within an inpatient geropsychiatry unit. These

authors found no significant changes in the types of reminiscence at posttest from pretest measures, and concluded that the use of a psychiatric inpatient

sample may have contributed to their findings. Blankenship et al. (1996) suggested that a more functional and community-based sample may allow for

more Integrative Reminiscence to be accessed by older adults.

In spite of the encouraging prospects using reminiscence or life-review with trauma survivors, including veterans, the conclusions reached by previous

studies either were not statistically significant, were based on case studies, lacked comparison/control groups, had no follow-up data, did not use long-

term group psychotherapy, or were not focused on veterans diagnosed with PTSD. This current feasibility study attempts to fill this gap in treatment

interventions provided for older adult veterans with PTSD by investigating the interplay of PTSD and the aging process.

The two group interventions in the current study will be described to lend insight into the process of facilitating therapy sessions with a life span

perspective. In addition, results from this small feasibility study will be shared to demonstrate one program’s clinical outcomes using two group

interventions that address two central theoretical questions that emerged from the literature: (a) Do traumatic memories disrupt, prevent, or impact one’s

ability to consolidate one’s life story in a coherent fashion and in such a way that disrupts optimal aging? (b) Can a life-review intervention superimposed

on existing PTSD counseling help reduce a trauma survivor’s disrupted reflection of past memories, as well as reduce PTSD symptoms, increase

satisfaction with life, shift reminiscing style (to more productive reminiscence), and increase overall morale?

To explore these theoretical questions, three specific research questions were tested in this feasibility study:

Do scores on outcome measures of PTSD (current and late-onset), morale, or satisfaction with life significantly change after participation in a year-long

psychotherapy group that provides both Life-Review and Standard PTSD group formats?

Does the sequencing of group conditions (e.g., life-review structured group therapy prior to standard PTSD group therapy vs. standard PTSD group

therapy prior to life-review structured group therapy) impact outcome scores on measures of PTSD, morale, and satisfaction with life?

Does type of reminiscence (as scored on the RFS) change from a problematic reminiscing style to a more productive reminiscing style after participation

in a year-long psychotherapy group that provides both Life-Review and Standard PTSD group formats?

Method

This pilot study was conducted “in the field” at a Department of Veterans Affairs (VA) community-based, readjustment counseling center (Vet Center) in

an urban metropolitan area in the Pacific Northwest. Vet Centers provide services for veterans from war and military sexual trauma, bereavement

counseling for family members of recently deceased active duty military members, and use individual and group psychotherapy interventions toward

recovery. Counseling services offered for military trauma survivors within Vet Centers have never been methodically researched prior to this pilot study.

Research Design

The study was conducted using convenience sampling of subjects referred from within the Vet Center by their individual therapists. After approval by the

Portland VA Medical Center Research and Development Institutional Review Board, subjects were recruited and the informed consent process was

completed. Inclusionary criteria were Vietnam War veterans, at least 60 years old, who continued on their prescribed medications, and who previously

had not received group counseling at the Vet Center. In addition, study subjects were not already on the research clinician’s caseload. Exclusionary

criteria: actively psychotic, actively abusing nonprescribed medications, actively abusing alcohol, recent suicidal/homicidal ideation (within the past 3

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months). Twelve (12) Vietnam War veterans, all male, met criteria, consented to complete the protocol and agreed to participate in the newly formed

groups.

Subjects then completed their pregroup (Time 1) assessments and were randomly assigned to one of the two groups using an envelope pulled from a hat

to inform each subject which intervention group, Morning (AM) or Afternoon (PM), he was going to be participating in for the entire study. The research

design chosen was a repeated measures, partial cross-over study, which met the clinical needs of the VA Vet Center program, enabled data analysis of a

small feasibility study, facilitated testing of the core issue of what is the correct sequencing of components, and was consistent with measuring

psychotherapy outcomes for long-term interventions within a community-based setting. At the beginning of the study, one group was provided standard

care of PTSD group psychotherapy, whereas the other group was structured with facilitated reminiscence (Life-Review). After 6 months of treatment, the

group format for each cohort was “crossed-over” (at measurement Time 3) to the alternate structure for the following 6 months of meetings. Subjects in

both groups were measured at 3-month intervals throughout the group meetings (Time 2, 3, and 4). After 12 months of meetings (as the groups ended),

the subjects were assessed again (Time 5), and then finally 3 months after the group meetings had ended (Time 6) to determine any continuing effects of

the interventions. Group sessions were facilitated by one research clinician, who was blind to the dependent measure data-collection throughout the

study. The groups met weekly for two hours for a total of 48 sessions. Fidelity to, and separation of, the interventions was monitored in periodic review

sessions that included the research clinician and a member of the research team blind to measurement and to the participants.

The Interventions

During the very first meeting of each group, a brief presentation about PTSD symptoms and emotional avoidance was provided by the research clinician

to build rapport and set the foundation for future conversations. Also, throughout the entire year of meetings, each group meeting began with each subject

routinely prompted to “check-in” with a short-list of emotions in a round-robin format, which took up only the first few minutes of each meeting. The same

round-robin format to identify two to four feelings was also how the group would “check out” from each group session. Rationale for the round-robin part

of the group meetings was explained to the subjects as being part of overall PTSD healing and reconnecting with one’s emotional self (vs. emotional

avoidance that often accompanies PTSD; American Psychiatric Association, 2013).

Group structure: Life-Review “Autobiography” Intervention

Subjects who were randomly assigned to the Morning Group (AM Group) received guided life-review for the first 6 months, using the Life-Review and

Experiencing Form (LREF; Black & Haight, 1992) to structure delivery. The “autobiography” (life-review) component was split into three parts: Premilitary,

Military/War-zone, and Postmilitary. Each veteran shared his Premilitary history based on the questions on the LREF. After each veteran completed their

Premilitary sharing, each subject would then, in turn, share Military/War-zone history one-by-one, followed by each one sharing their Postmilitary history.

The LREF lacked questions regarding military or war history; therefore, the research clinician added additional questions regarding these military

experiences of a veteran’s life (see Appendix).

Group structure: Regular/Standard PTSD Intervention

Subjects randomly assigned to the Afternoon Group (PM Group) participated in client-centered, emotion-focused discussions on present-day issues and

the impact of PTSD symptoms on current functioning. This type of group structure is considered the “standard” of group psychotherapy meetings at the

study site Vet Center, as well as the other 300+ Vet Centers in the country. Standard Vet Center group therapy focuses on issues brought up by group

members during sessions, with a facilitator providing a structure for discussion and encouraging input, feedback, or related disclosures by other group

members. Subjects were invited to discuss any war-related issues during this group format as they pertained to here-and-now problem areas, although

discussion of war-zone situations was not formally structured as part of the group meetings.

Dependent Measures

Data were gathered by a third member of the research team who was blind to activity in the sessions and to the group assignment of participants. In

addition to demographic data from participants (i.e., age, marital status, branch of the military, ethnicity, number of years in Vietnam war-zone) from the

Vet Center initial intake paperwork, veteran subjects completed several different outcome measures every three months:

Reminiscence function scale (RFS)

The reminiscence function scale is a 43-item questionnaire used to assess different types of reminiscence over the course of one’s lifetime. Webster

(1993) originally created this scale to expand on Wong and Watt’s (1991) taxonomy originating from their study of older adults. The RFS provides a

measure of the functions of reminiscence that are categorized regarding when, and for what purpose, one recalls memories. Factor analysis suggest

seven functions: (a) boredom reduction, (b) death preparation, (c) identity/problem solving, (d) conversation, (e) intimacy maintenance, (f) bitterness

revival, and (g) teach/inform. Internal consistency of each factor suggests that the RFS is a reliable measure, with alpha levels ranging from .79 to .89. In

seeking to later replicate construct validity for the RFS with another sample, Webster (1997) identified an 8th factor, Identity (i.e., reminiscing to better

define oneself, to understand oneself better).

PTSD Checklist—Military version (PCL-M)

The PCL-M is one of the most utilized measures for military-related traumatic stress symptoms in the VA system (Weathers et al., 1993; Weathers &

Ford, 1996). The PCL-M assesses PTSD utilizing the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM–IV; American

Psychiatric Association, 1994) criteria for the disorder and is a 17-item self-report questionnaire that asks veterans to rate on a 5-point Likert scale the

severity of their symptoms within the past month. The PCL-M’s psychometric properties indicate a reliable measure (.96), test–retest reliability, and good

internal consistency (α = .97; Weathers and Ford, 1996).

Philadelphia Geriatric Center Morale Scale (PGCMS)

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The PGC morale scale, developed by a gerontologist (Lawton, 1975), has 17 items, and administered via interview or through a pen/pencil questionnaire

form. The PGCMS identifies changes experienced by an older adult. The PGCMS was found to have acceptable internal consistency (Cronbach’s alpha

= .92) and convergent validity correlations when using the Turkish SF-36 and social supports; and, divergent validity when correlated with a measure for

hopelessness (Pinar & Oz, 2011). For our study, the self-report questionnaire version of the PGCMS was used.

Satisfaction with life scale (SWLS)

The satisfaction with life scale is a measure of global life satisfaction. In five questions, the subject responds using a 7-point Likert scale ranging from

strongly disagree (1) to strongly agree (7). The items on the SWLS prompt the subject to reflect on their current and past life satisfaction. Diener et al.

(1985) found that the SWLS has favorable psychometric properties, including high internal consistency, and correlates well with other measures of

subjective well-being (Pavot et al., 1991).

Late onset stress symptomology scale (LOSS Scale; full version)

King and colleagues (2007) identified the phenomenon of “late onset stress symptomatology” (LOSS) which occurs when veterans who have previously

functioned well since military service begin to exhibit increased combat-related reminiscences and emotions later in life, consistent with age-related

stressors such as bereavement, physical decline, and retirement. The LOSS was then developed as a 44-item measure which asks true/false questions

regarding reminiscence of war experiences and possible delayed onset of memories related to one’s war-time exposure (King et al., 2007). The LOSS

scale demonstrated a high degree of internal consistency reliability (α = .97).

Results

Data analysis with SPSS Version 20 used repeated measures one-way ANOVA, and considered six data points: measurement at baseline and then after

every 12 sessions, plus 3-months after all group sessions had ended. Paired samples t test and independent samples t test were used for specific pretest

and posttest comparisons of outcome measures between the two groups. Given the small sample size and the pilot nature of the study, this level of

analysis was considered appropriate, with statistical significance probability set at .10. Correlation was also conducted between specific measures of

reminiscence styles (RFS, reminiscing subscale of the SWLS) and PTSD instruments (PCL-M, LOSS), as well as correlating subscales of the RFS

“productive reminiscing” (e.g., reminiscing style that focuses on Identity, reminiscing style that focuses on Problem Solving) with a measure of geriatric

morale (PGCMS). Data points for each outcome scale were also graphed. Although participant level outcomes are reported, the feasibility questions

answered that are related to the optimum sequencing of the intervention components focused on the groups.

Findings

Table 1 shows the combined demographic data of the veteran groups. Both groups started the interventions with six veterans in each cohort. However,

soon after the first month of group psychotherapy, one of the subjects dropped out of treatment. Two more subjects also did not complete the entire year

of group meetings; one suffered a stroke three months before the end of the meetings, and another who dropped out of treatment. Efforts to reengage all

three veterans back into the groups were unsuccessful. However, after the study groups were completed, the subject who suffered a stroke reconnected

with Vet Center treatment.

Demographic Information of Both Groups of Vietnam War Veterans Who Completed the Interventions

Our first research question addressed the overall effects of long-term group psychotherapy in both Life-Review and Standard PTSD group formats.

Findings from repeated measures ANOVA analyses on each of the six measurement time-periods for the PCL-M are found in Figure 1. There was a

gradual decline in the mean PTSD scores across the first 5 time periods (while in group therapy) for the nine subjects who completed the study. These

subjects originally started the groups in the range of clinically problematic PTSD symptoms, with their scores approaching a nonclinical level of PTSD

symptoms by the end of group meetings (PCL-M > 44 score indicates clinical PTSD; Blanchard et al., 1996). Mean scores of the subjects increased

slightly at the 3-month postgroup time period (6) with M = 46.5. The differences between these six time point means approached statistical significance,

F(5, 45) = 1.83, p = .13. An overall drop of more than 7 points on the PCL-M is encouraging, based on the National Center for PTSD’s criteria of a 10-

point reduction in PCL-M scores suggesting clinical significance.

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Figure 1. Repeated measures ANOVA of PTSD scores (as measured by the PCL-M): Mean scores across time-periods with subjects who completed the

study (N = 9). F(5, 45) = 1.83, p = .13; n = 9 who completed study groups. y axis: Mean scores of PCL-M. x axis: Time periods: Time 1 = Before groups

starting (Time 1) M = 53.66, SD = 10.9; Time 3 = Completion of 1st group cycle (Time 3) M = 52.44, SD = 11.05; Time 5 = Completion of 2nd group cycle

(Time 5) M = 46.33, SD = 12.02; Time 6 = Three months after groups end (Time 6) M = 46.55, SD = 12.5. Horizontal (red) line: 44 = cut-off score for

clinical PTSD (Blanchard et al., 1996).

The LOSS measure has both negative and positive subscales. An overall reduction was observed of LOSS “negative” (delayed onset war-related)

symptoms from pre-Group Time 1 = 75 to end of Group Time 5 = 70.8 for the 9 subjects who completed the entire study. The LOSS does not have a cut-

off level to indicate clinical changes. LOSS scores were also compared across all time periods using repeated measure ANOVA, with no statistically

significant findings.

Repeated measures ANOVA analysis with one of the “well-being” measures, SWLS, found no significant change for the 9 subjects who completed the

groups, with mean scores from Time 1 = 17.00 to Time 5 = 17.22. The subjects’ potential overall mean scores on the SWLS can range from lowest life

satisfaction = 5, to highest life satisfaction = 35; therefore, the subjects’ scores across the group meetings were between low satisfaction and neutral.

Independent samples t test comparing each time of assessment to the pregroup scores (Time 1) found that only at Time 5 (as group meetings had just

ended) was there a statistically significant difference among the subjects in their respective ratings of life satisfaction; t(7) = 1.92; p = .09.

Paired samples t test was used to observe the differences in Philadelphia Geriatric Center Morale Scale (PGCMS) mean scores (see Figure 2). For

subjects completing the study we found that overall morale increased from pregroup (M = 7.78; SD = 4.89) to the end of the group meetings a year later

(M = 9.44; SD = 5.64) at almost a statistically significant level; t(8) = −1.54, p = .16. However, combined group score means across the time of the study

never scored above the mean for the PGCMS (11.75). There was also a slight decrease of subjects’ reported morale at Time 6 (3 months after groups

ended); M = 8.11, SD = 5.69.

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Figure 2. Repeated measures ANOVA of Philadelphia Geriatric Center Morale Scale (PGCMS): Mean scores across time-periods with subjects who

completed the study (N = 9). Red horizontal dotted line: Mean for Phil Morale scale = 11.35 (Lawton, 1975). PhilMoraleATotals = Before groups starting

(Time 1); PhilMoraleCTotals = Completion of 1st group cycle (Time 3); PhilMoraleETotals = Completion of 2nd group cycle (Time 5); PhilMoraleFTotals =

Three months after groups end (Time 6).

The 2nd research question focused on sequencing of the two group interventions facilitated by a partial cross-over of group structures. Figures 3 and 4

show the distinctions between the AM and PM groups across the six time periods when the data from each cohort was analyzed and compared using

repeated measures ANOVA on outcomes for PCL-M, SWLS, and PGCMS. Figure 3 graphs the PCL-M scores with the two groups split into AM (Morning

group, the group that was structured with Life review for the initial 6 months and crossed-over to the Standard PTSD group) and PM (Afternoon group, the

group that was structured with Standard PTSD therapy for the initial 6 months and then crossed over to the Life review structure). For participants in the

AM group, Cohen’s d analysis suggested a large effect occurring by the end of the group meetings (Time 5, Cohen’s d = 1.35) and 3 months after the

group meetings ended (Time 6, Cohen’s d = 1.58).

Figure 3. Repeated measures ANOVA of PCL-M Scores for two groups: Mean scores of each group across time-periods with subjects who completed the

study (N = 9). y axis: Mean scores of PCL-M; x axis: Time periods: Time 1 = Before groups starting (Time 1); Time 3 = Completion of 1st group cycle

(Time 3); Time 5 = Completion of 2nd group cycle (Time 5); Time 6 = Three months after groups end (Time 6). Bottom/blue line: AM group; Upper/green

line: PM group. PCL-M: Total symptom severity score (range = 17–85); Horizontal red dotted line: cut-off of 44 recommended by Blanchard et al. (1996);

standard suggested by National Center for PTSD: 5–10 pt. change = reliable change (not due to chance); 10–20 pt. change = clinically significant

change; 10 pt. change considered a minimum threshold for determining whether the improvement is clinically meaningful.

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Figure 4. Repeated measures of PGCMS (left) and SWLS (right): Mean scores of each group across time-periods with subjects who completed the study

(N = 9). y axis: Mean scores of measure (PGCMS on left, SWLS on right). x axis: Time periods: Time 1 = Before groups starting (Time 1); Time 3 =

Completion of 1st group cycle (Time 3); Time 5 = Completion of 2nd group cycle (Time 5); Time 6 = Three months after groups end (Time 6). Upper/blue

line: AM group; Lower/green line: PM group.

As noted before, the cut-off for clinical PTSD is 44 (Blanchard et al., 1996). The split group analysis found both the Morning (AM) group and Afternoon

(PM) group at the same mean point before the groups starting at Time 1 (M = 54). The AM group reported reduced PTSD symptoms, with a 10- to 20-

point reduction of mean scores to M = 39 at Time 5, suggestive of clinically significant changes (NC-PTSD) across participation in the group meetings,

and the AM group maintained subclinical PTSD at Time 6 (3 months after groups ended, M = 38). The Afternoon (PM) group did not report either clinical

or statistically significant changes in PTSD symptoms throughout the study. However, while each group was participating in their respective Life Review

structured meetings (Times 1–3 for AM group; Times 3–5 for PM group), reported PTSD symptoms were reduced. Clinically significant changes were

observed with the AM group by the end of the study, and the differences between the two groups during the entire study approached statistical

significance; F(1, 7) = 3.20; p = .12.

Although less dramatic than with the PCL-M, similar results were observed with the LOSS negative subscale: the AM group had higher LOSS scores that

the PM group at Time 1 (AM M = 80.5; PM M = 69.6); but by Time 3 the AM group’s LOSS scores had reduced to a mean of 71.75 as they completed the

Life Review meetings. The PM group’s LOSS scores increased while participating in Life Review (Times 3–5). By the end of the year of group meetings,

the AM group’s LOSS negative subscores = 64.25, whereas the PM group’s subscores = 77.4. Post-Group Time 6 measurement found even more of a

difference between the two groups, with PM group’s LOSS score = 82 and AM group’s LOSS score = 61.25. Unlike the PCL-M, the LOSS scale does not

provide a clinical cut-off for late onset negative stress symptoms, but the lower the scores, the less stress symptoms reported (King et al., 2007).

For the “well-being” scales (see Figure 4), the PGMS and SWLS, means scores for each of the study groups started at different points at Time 1, and

then diverged during the year-long groups. With the PGMS, the AM group had higher morale at Time 1 (M = 8.40, SD = 3.9 than the PM group (M = 5.66,

SD = 3.6), and morale peaked at Time 5 (as groups were ending; M = 11.2). The PM group means generally trended downward throughout the study

periods, with the lowest morale mean reported at Time 6 three months after groups had ended (M = 4.00). Paired samples t test and paired samples

correlations found that three of the four AM group subjects had significant and strong positive correlations with reported morale across time (r = .77–.82;

p = .07).

Similar findings were seen with the SWLS, with the AM group reporting slightly higher life satisfaction at Time 1 (M = 17.67, SD = 6.27) than the PM

group (M = 13.83, SD = 8.61) in spite of the random assignment of subjects to groups. The line graph in Figure 4 (right graph) shows the repeated

measures ANOVA with some interesting trends but no statistically significant differences between the two groups across the six time periods. However,

independent samples t test analysis indicated that there were statistically significant differences between the two groups at Time 5 (the end of the year-

long meetings; t(7) = 1.93, p = .09), and with mean scores diverging at Time 2. Specifically, the AM group’s life satisfaction by the end of group meetings

increased to M = 23.5, SD = 8.26, placing this group into a “slightly agree” overall life satisfaction section of the SWLS.

The final research question focused on the original premise of using life review as an intervention for traumatically stressed veterans who are aging and

reminiscing about their past in a way that impedes their ability to emotionally heal. To answer this research question, only the data provided by those

subjects who completed the groups were accessed and all subjects—no matter their group assignment—were treated as one group. The Reminiscence

Function Scale (RFS) subscale of Bitterness Revival was correlated with the two PTSD scales (PCL-M and LOSS negative subscale), as were the RFS’s

more productive reminiscing styles of Identity and Problem-solving with the PCL-M and the LOSS positive subscale. No significant correlations were

found between the Bitterness Revival style of reminiscing means of the RFS and scores on the PCL-M, or the PGMS.

Using Pearson product–moment correlation, Table 2 shows a correlation matrix for only the data analyses that were found to be statistically significant,

and do not include all measures or subscales. The RFS subscale of Problem Solving reminiscing scores did inversely correlate with the PCL-M at Time 5

(end of group meetings) at a moderate level (r = −.64, p = .06) at Time 5 (end of group meetings), suggesting that PTSD scores decreased as Problem

Solving reminiscing increased. RFS Problem Solving style and LOSS positive subscale scores correlated at r = .52, p = .09 at Time 2 (midcycle of 1st

cycle of meetings), and at Time 4 (midcycle of 2nd cycle of meetings; r = .65, p = .03), but surprisingly not at the end of the group meetings. PTSD

symptoms reported through the PCL-M, and morale scores reported through the PGCMS were also significant at Time periods 1, 3, and 5, with strongest

inverse correlation at the end of group meetings (Time 5; r = −.75, p = .02) suggesting that as PTSD scores decreased across time periods, morale

scores increased.

Statistically Significant Pearson Product–Moment Correlations (R2) for Nine Veterans Who Completed Group Meetings (Not Including All Measures or

2

2

2

2

2

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Subscales)

Given the question being raised within our study, and the issue of reminiscence at the root of our hypotheses, Figure 5 illustrates the repeated measures

means for the RFS Bitterness Revival subscale, which shows graphically how subjects’ reminiscing style had changed over the course of the yearlong

therapy meetings—observing the time-periods when the groups were structured with life review. With the AM group (blue line), Bitterness Revival

reminiscing style increased between Times 1–3 (during their participation in the life review structured meetings) although it was not sustained; and with

the PM group, Bitterness Revival reminiscing decreased during Time 3–5 (during their 6 months of life review structured meetings) but increased again

once sessions ended. The fluctuation in scores throughout the year of group meetings make the differences in Bitterness Revival reminiscing for both

groups difficult to interpret.

Figure 5. Reminiscence Function Scale (RFS) Bitterness Revival subscale scores: Mean scores of each group across time-periods with subjects who

completed the study (N = 9). y axis: Mean scores of RFS Bitterness Revival subscale; x axis: Time periods: Time 1 = Before groups starting (Time 1);

Time 3 = Completion of 1st group cycle (Time 3); Time 5 = Completion of 2nd group cycle (Time 5); Time 6 = Three months after groups end (Time 6).

Darker/Upper/blue line: AM group; Lighter/Lower/green line: PM group.

Discussion

Our goals in this feasibility study were to identify whether reminiscence styles, PTSD symptoms, morale, and satisfaction with life would change as a

result of different sequences in participation in life review and standard PTSD group therapy. Although this feasibility study had a small number of

subjects, we found some statistically significant improvements in clinical status for several of the subjects apparently influenced both by the interventions

and their sequencing. Nonetheless, it would be premature to make wider conclusions given the limitations of N-size and relatively homogenous

demographics of our sample. Other limitations include the use of a cross-over design, and the decision to not deny other counseling options to veterans

agreeing to the study. However, the value of the crossover design appears to be demonstrated by its ability to identify that the experience of the initial 6

months of group meetings influences interactions in the following 6 months of meetings. Initial completion of a life review series appears to increase the

value of standard PTSD interventions in older male veterans. Further study of sequencing of interventions should rely on noncrossover comparison

groups or a Solomon Four Group-type design to also tease out the specific unique contributions of each intervention.

Yet, the study raises important questions that have clinical relevance and which can be explored in future research. For example the RFS, one of the few

reminiscence style assessments, may not have measured problematic memories in a way that intrusive traumatic stress memories actually are

experienced by aging war veterans. With our study, the predicted reduction of a bitterness revival reminiscing style was not observed across all time

periods. This may be because trauma survivors do not purposefully elicit intrusive traumatic memories, and the items within the RFS query respondents

about memories being generated by the respondent for a certain purpose. One could also rationalize that discussing war memories within group therapy

could increase bitterness revival reminiscing. Further research could focus on determining whether purposeful bitterness revival reminiscing is a different

process from the unintentional intrusive memories indicative of PTSD.

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With a small N size and a long-term group meeting format, our pilot findings suggest possible contributors to clinical outcomes rather than provide clear

conclusions. One contributor that was not measured in this study was the role of social support within the two groups, particularly because the veterans

had not previously shared their experiences with other war veterans prior to our study. This additional area for consideration is reinforced by anecdotal

reports that since the end of the split groups, both AM and PM groups have now merged into one group and their positive involvement in each other’s

lives subsequent to the study has become apparent in group therapy conversations.

Among community-based counseling programs, long-term, yearlong group therapies are common, especially within VA Vet Centers across the country,

and this study attempted to provide therapy consistent with the community-based model of treatment. One possible conclusion of this study is that

providing life review structured group therapy before standard PTSD group therapy may help veterans to more fully benefit from the less-structured

standard PTSD group interactions. Replication of this study is warranted among a more multicultural veteran group, with women veterans, and in different

communities (rural or larger urban areas) to see whether a similar outcome occurs. Replication could also “fine-tune” the sequencing of group structures

to see whether life review before standard PTSD group therapy truly has a role in ameliorating symptoms.

Enhanced understanding of the impact of life review and/or modification of standard PTSD group therapy among older war veterans could be beneficial in

influencing future treatment models that take into account the interface between aging and PTSD. Given the aging population growth now impacting

mental health practices in general, multidisciplinary approaches that maximally benefit older traumatized client groups are necessary and important. Our

small pilot study provides a starting-point for continued investigation and growth of knowledge that will improve clinical care.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual (5th ed.). Washington, DC: American Psychiatric Association.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Baltes, P. B., & Baltes, M. M. (1990). Selective optimization with compensation. In P. B.Baltes (Ed.), Successful aging: Perspectives from the behavioral

sciences (pp. 1–34). New York, NY: Cambridge University Press. 10.1017/CBO9780511665684.003

Black, G., & Haight, B. K. (1992). Integrality as a holistic framework for the life-review process. Holistic Nursing Practice, 7, 7–15.

10.1097/00004650-199210000-00005

Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric properties of the PTSD Checklist (PCL). Behaviour

Research and Therapy, 34, 669–673. 10.1016/0005-7967(96)00033-2

Blankenship, L. M., Molinari, V., & Kunik, M. (1996). The effect of a life review group on the reminiscence functions of geropsychiatric inpatients. Clinical

Gerontologist, 16, 3–18. 10.1300/J018v16n04_02

Boehnlein, J. K., & Sparr, L. F. (1993). Group therapy with WWII ex-POW’s: Long-term posttraumatic adjustment in a geriatric population. American

Journal of Psychotherapy, 47, 273–282.

Bohlmeijer, E., Roemer, M., Cuijpers, P., & Smit, F. (2007). The effects of reminiscence on psychological well-being in older adults: A meta-analysis.

Aging & Mental Health, 11, 291–300. 10.1080/13607860600963547

Bonwick, R. J., & Morris, P. L. P. (1996). Post-traumatic stress disorder in elderly war veterans. International Journal of Geriatric Psychiatry, 11,

1071–1076. 10.1002/(SICI)1099-1166(199612)11:12<1071::AID-GPS511>3.0.CO;2-B

Brooks, M. S., & Fulton, L. (2010). Evidence of poorer life-course mental health outcomes among veterans of the Korean War cohort. Aging & Mental

Health, 14, 177–183. 10.1080/13607860903046560

Butler, R. N. (1963). The life review: An interpretation of reminiscence in the aged. Psychiatry, 26, 65–76.

Cappeliez, P., O’Rourke, N., & Chaudhury, H. (2005). Functions of reminiscence and mental health in later life. Aging & Mental Health, 9, 295–301.

10.1080/13607860500131427

Chatterjee, S., Spiro, A., King, L., King, D., & Davison, E. (2009). Research on aging military veterans: Lifespan implications of military service. PTSD

Research Quarterly, 20, 1–3.

Coleman, P. G. (2005). Uses of reminiscence: Functions and benefits. Aging & Mental Health, 9, 291–294. 10.1080/13607860500169641

Cook, J. (2001). Post-traumatic stress disorder in older adults. PTSD Research Quarterly, 12, 1–3.

Cook, J. M., & Niederehe, G. (2007). Trauma in older adults. In M. K.Friedman (Ed.), Handbook of PTSD: Science and practice (pp. 252–276). New York,

NY: Guilford Press.

Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, S. (1985). The Satisfaction With Life Scale. Journal of Personality Assessment, 49, 71–75.

10.1207/s15327752jpa4901_13

Erickson, E. (1982). The life cycle completed: A review. New York, NY: Norton.

Friedman, M. J., Resick, P. A., & Keane, T. M. (2007). Key questions and an agenda for future research. In M. R.Friedman (Ed.), Handbook of PTSD:

Science and practice (pp. 540–561). New York, NY: Guilford Press.

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=9326...

9 of 11 2/16/2019, 3:33 PM

Haight, B. K., & Burnside, I. (1993). Reminiscence and life review: Explaining the differences. Archives of Psychiatric Nursing, 7, 91–98.

10.1016/S0883-9417(09)90007-3

Hunt, N., & McHale, S. (2007). Memory and meaning: Individual and social aspects of memory narratives. Journal of Loss and Trauma, 13, 42–58.

10.1080/15325020701296851

Hyer, L., Summers, M. N., Braswell, L., & Boyd, S. (1995). Posttraumatic stress disorder: Silent problem among older combat veterans. Psychotherapy:

Theory, Research, Practice, Training, 32, 348–364. 10.1037/0033-3204.32.2.348

King, L. A., King, D. W., Vickers, K., Davison, E. H., & Spiro, A., III (2007). Assessing late-onset stress symptomatology among aging male combat

veterans. Aging & Mental Health, 11, 175–191. 10.1080/13607860600844424

Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). Why is it that some developed PTSD

and others did not? In Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study (pp. 73–85).

New York, NY: Brunner/Mazel.

Lawton, M. P. (1975). The Philadelphia Geriatric Center Morale Scale: A revision. Journal of Gerontology, 30, 85–89. 10.1093/geronj/30.1.85

Lipton, M. I., & Schaffer, W. R. (1986). Post-traumatic stress disorder in the older veteran. Military Medicine, 151, 522–524.

Maercker, A. (2002). Life-Review technique in the treatment of PTSD in elderly patients: Rationale and three single case studies. Journal of Clinical

Geropsychiatry, 8, 239–249. 10.1023/A:1015952429199

Markowitz, J. D. (2007). Post-traumatic stress disorder in an elderly combat veteran: A case report. Military Medicine, 172, 659–662.

10.7205/MILMED.172.6.659

Pavot, W., Diener, E., Colvin, C. R., & Sandvik, E. (1991). Further validation of the Satisfaction with Life Scale: Evidence for the cross-method

convergence of well-being measures. Journal of Personality Assessment, 57, 149–161. 10.1207/s15327752jpa5701_17

Pinar, R., & Oz, H. (2011). Validity and reliability of the Philadelphia Geriatric Center Morale Scale among Turkish elderly people. Quality of Life Research:

An International Journal of Quality of Life Aspects of Treatment, Care & Rehabilitation, 20, 9–18. 10.1007/s11136-010-9723-4

Schaie, K. W., & Willis, S. L. (1996). Adult development and aging. New York, NY: Harper Collins Publishers.

Schnurr, P. P. (1991). PTSD and combat-related psychiatric symptoms in older veterans. PTSD Research Quarterly, 2, 1–6. Retrieved from

http://search.proquest.com.library.capella.edu/docview/42402679?accountid=28179

Spiro, A., III, Schnurr, P. P., & Aldwin, C. M. (1994). Combat-related posttraumatic stress disorder symptoms in older men. Psychology and Aging, 9,

17–26. 10.1037/0882-7974.9.1.17

Weathers, F. W., & Ford, J. (1996). Psychometric review of PTSD checklist (PCL-C, PCL-S, PCL-M, PCL-PR). In B. H.Stamm (Ed.), Measurement of

stress, trauma, and adaptation (pp. 250–251). Lutherville, MD: Sidran Press.

Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October). The PTSD checklist: Reliability, validity, & diagnostic utility.

Paper Presented at the Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.

Webster, J. D. (1993). Construction and validation of the Reminiscence Functions Scale. Journal of Gerontology, 48, P256–P262. 10.1093/geronj

/48.5.P256

Webster, J. D. (1997). The Reminiscence Functions Scale: A replication. The International Journal of Aging & Human Development, 44, 137–148.

10.2190/AD4D-813D-F5XN-W07G

Webster, J. (1998). Attachment styles, reminiscence functions and happiness in young and elderly adults. Journal of Aging Studies, 12, 315–330.

10.1016/S0890-4065(98)90006-8

Whitbourne, S. (1996). Psychological perspectives on the normal aging process. In L. E.Carstensen (Ed.), The practical handbook of clinical gerontology

(pp. 3–35). Thousand Oaks, CA: Sage.

Wong, P. T. P., & Watt, L. M. (1991). What types of reminiscence are associated with successful aging?Psychology and Aging, 6, 272–279.

10.1037/0882-7974.6.2.272

APPENDIX

APPENDIX A: Added Questions to Life Review Experience Form (LREF; Black & Haight, 1992) Focused on Military and War Experiences

When and how did you decide to go into the military? Were you drafted? Or did you enlist?

Where did you have your basic training? How was that experience for you?

Did you go to AIT (advanced infantry training)? If so, where was that? What were you trained to do after basic?

How soon did you know that you were going to be deployed to Vietnam?

How did you feel about arriving into Vietnam?

Where were you stationed in Vietnam? Did you actually do the job that you are trained to do prior to arriving into Vietnam? Or were you reassigned to do

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another job?

Tell us briefly about your first week in country.

When was the first traumatic event? How long had you been in country?

Was this the worst event that you recall experiencing during your tour in Vietnam? If not, would you be willing to share with us the worst part of your war

experience?

How long has it been since this worst traumatic event occurred? How often do you recall this or other traumatic events today?

When you remember these events from the war, how does it affect you?

Have you ever told anyone else about this traumatic memory?

What have you been saying about yourself all these years when you remember this event?

Has anything been helpful to you in coping with these memories? If so, what has been helpful?

How do you feel about sharing this memory with all of us today?

When did you finally leave Vietnam? And under what circumstances?

Did you serve a second tour?

Describe your return back to the United States from Vietnam? How did people close to you treat you upon your return?

How did you feel about being home? What did you do after you got back?

Overall, in what way did your experience in the Vietnam War change you? Are there any changes that you would keep? What changes would you not

want to keep?

Submitted: February 24, 2015 Revised: June 2, 2015 Accepted: June 2, 2015

This publication is protected by US and international copyright laws and its content may not be copied without the copyright holders express written

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individual user.

Source: Traumatology. Vol. 21. (3), Sep, 2015 pp. 161-171)

Accession Number: 2015-35172-001

Digital Object Identifier: 10.1037/trm0000045

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