At the end of Session 6, participants responded to questions about their overall experience of the trauma exercises and the group in general. In response to the question “How do you feel now about having written and read your TN aloud?” five participants described positive experiences, involving catharsis, feeling proud of themselves, and appreciating knowing they are not alone. Two participants noted that they felt glad to have time to process the experience. Althoug one participant noted feeling embarrassed, while another commented that they did not write the entire narrative and felt that they did not write it well. Regarding whether they view their NICU experience any differently, three participants responded no, though one of them stated “No, but I was able to reflect more.” Two participants noted that the experience seems less daunting and scary than before. Two participants expressed feeling less alone: “I feel I am not alone in the experience” and “I feel like it’s a little easier knowing that I’m not alone. Although our babies might not face the same challenges, we are all in the same place.”

Distress Levels Throughout Trauma Narrative Exercises

Figure 1 illustrates mean distress ratings at each of the 12-time points. The highest increase in distress appears to have occurred while writing the TN. Seven of nine participants reported increased distress when writing their TN, while two participants reported that their distress level remained the same before and while writing their TN. Upon reading their TN aloud, seven of the nine participants reported an increase in distress, while two participants reported a decrease in distress. Seven participants reported that their distress levels decreased from the beginning of Session 6 to the end of Session 6 (the last session of the treatment), while one reported an increase and one reported that their distress level stayed the same.

Figure 1: Mean distress across sessions 4, 5, 6.

Paired sample t-tests of specific time-point changes were run in order to assess the three hypotheses about distress level changes: (1) that mothers would experience an increase in distress while writing their trauma narrative, (2) that mothers would experience an increase in distress while reading their trauma narrative out loud, (3) that mothers would experience a decrease in distress by the end of the last session (3). Paired sample t-tests found each of these hypothesized changes to be significant:

1. Increase (t(9) = -3.36, p = .01) from beginning of session four (mean = 4.11, SD = 2.26) to writing the TN (mean = 6.71, SD = 2.33).
2. Increase (t(9) = -2.68, p = .03) from beginning of session five (mean = 3.50, SD = 1.54) to reading the TN aloud (mean = 5.56, SD = 2.96).
3. Decrease (t(9) = 3.74, p = .01) from beginning of session six (mean = 5.2, SD = 2.37) to end of session six (mean = 3.21, SD = 1.41).

The individual distress rating trajectories of two subjects are depicted in Figure 2. The trajectories demonstrate similar relative increases in distress while writing and reading aloud the trauma narrative, and reduction in distress by end of Session 6. The contrast of these trajectories illustrates how subjects rate their own distress at different levels, given the subjective and individualized nature of observing and experiencing internal distress. However, both subjects report a relative increase in distress at similar time points, for example subject A reporting increase from 2 to 5 and subject B from 7 to 10 while writing the trauma narrative.

Figure 2: Individual distress changes over time for subjects A and B.

Discussion

As previously reported by Simon and colleagues [12], symptoms of PTSD in mothers of preterm infants participating in the 6-session group therapy intervention showed a significant decrease from baseline to six-month follow-up and from posttreatment to six-month follow-up. This is consistent with reviews of the efficacy of group cognitive therapy in individuals with other categories of trauma [14]. In the current study, we explored the hypotheses that although mothers would experience increased stress for both writing and recounting the TN, levels of distress would decrease following Session 6 and that mothers overall would perceive the experience of writing and reading their TN aloud as helpful. Extensive psychoeducation related to the NICU environment and trauma symptoms, cognitive restructuring, and relaxation training were provided in Sessions 1, 2 and 3 to prepare mothers before recounting their TN in the group setting.

Writing the Trauma Narrative

Mothers reported increased levels of distress while writing their TN. Mean levels of distress peaked in the middle of Session 4 while mothers wrote their TN but decreased towards the end of the session (Figure 1). However, when questioned about the subjective experience of writing the TN, mothers reported feeling safe, in control, and supported by other group members and the therapist and no mothers expressed wishing they had not participated in the exercise. This finding is consistent with the literature supporting the efficacy of group trauma-focused CBT for PTSD which incorporates writing an account of their traumatic experience as an opportunity for patients to rebuild a sense of safety and trust [15] and which is considered especially important for individuals with PTSD [16].

One commonly raised concern about the TN exercise is that participants often experience an increase in flashbacks because they are approaching instead of avoiding their traumatic memories for the first time [17]. It has been suggested that some patients might conclude that retelling and reliving the traumatic memory while recounting their TN is in itself traumatic and that without proper preparation, such interventions may worsen trauma symptoms. This may be one reason why CISD has in some studies been found unhelpful, or in some cases, to have worsened outcomes [8,9]. Our results demonstrated that some participants did in fact endorse feeling as if they were reliving the event while writing the narrative. However, all mothers responded neutrally or affirmatively when asked if it was helpful to write the TN, and no mothers endorsed wishing they had not written the TN. By contrast, participants’ responses suggest that it was possible for them to feel safe, in control, and supported in the group setting, even while experiencing flashbacks. Resick et al. [17], in the CPT manual, recommend that therapists explain that an increase in flashbacks may be normal and reflect a positive sign that patients are demonstrating engagement and decreased avoidance, and that flashbacks will likely decrease over time. 

Reading the Trauma Narrative

Data from the current study indicates that mothers felt supported, safe, and in control while reading their TN aloud in the group setting. Although mothers reported an increase in subjective distress in the course of reading their trauma narratives in Session 5, levels of distress decreased over the course of the session and most participants endorsed positive experiences of reading their TN aloud (Figure 1). Mothers also reported feeling supported by and more connected to the other group members after reading their TN. Some participants endorsed feeling like they were reliving their experiences, others endorsed feeling exposed, and one reported feeling embarrassed when reading narratives aloud. However, no participants endorsed wishing they had not shared details from their narrative or regretted sharing their TN with other mothers.

These impressions were supported by responses of mothers given at the end of the 6-session treatment. Participants reported feeling less alone, closer to other group members, and proud of themselves for writing and reading their narrative. Participants endorsed that the exercises helped them process their NICU experience. It is possible that the interpersonal nature of reading aloud and viewing the group as supportive may contribute to these positive reactions. The literature notes that trauma exposure in group CBT for PTSD allows patients to connect with others with shared experiences, which may reduce isolation and stigma [15]. It is possible that the process of hearing others’ narratives and experiencing others bearing witness to their own narrative assisted mothers in feeling more connected to one another. Reading the TN aloud in a group setting is hypothesized to encourage patients to work together therapeutically and to offer alternative perspectives following an imaginal exposure [15]. Patients may be more open to feedback from other group members than from clinicians, and such comments may have stronger effects when coming from someone with shared experiences [15].  It has also been observed that group members encourage each other to engage in exposure work [18]. Some participants endorsed feeling overwhelmed, exposed, and feeling as if they were reliving the experience when reading their narrative aloud.

Our findings suggest that despite experiencing some difficult emotions, participants viewed reading the narrative aloud as helpful.Most notably, all participants endorsed feeling less alone after sharing their narrative. This finding is consistent with Hobfoll & colleagues’ [19] identification of a sense of connectedness as one of the five major principles in effective peri-trauma preventative interventions. We also observed that in several groups, mothers exchanged contact information and communicated with each other between sessions. This phenomenon is consistent with studies on postpartum depression that have found that social support is associated with decreased risk of developing postpartum depression symptoms [20].

Length of Treatment

Some participants reported that they did not have enough time to process their TN, which suggests that more time may be needed for participants to write and read aloud their TN. This was a concern of the investigators during the design of the study given the choice to create a brief 6-session intervention which is significantly lower than the typical 12- to 15-session interventions that are typically used in trauma treatment. These observations were also noted in Simon and colleagues’ [12] findings that trauma symptoms improved more significantly in the four and a half months following treatment, rather than during the treatment itself, whereas in longer treatments, improvements are generally seen during the course of treatment. While this finding does raise the question of whether a longer treatment manual might be more effective, it is our impression that with a popluatoin whose length of hospital stay is unpredictable, this would lead to greater difficulty in both recruiting and retaining subjects. 

Limitations

The three primary limitations of this study are the small sample size, the sample composition, and the absence of a control group. With only nineteen participants in the previous analyses of PTSD symptoms [12] and nine participants in the current study’s TN analyses, caution should be exercised in interpreting our findings.

In addition, the entire sample was married or in an unmarried, committed relationship, so further research is needed to determine if the treatment would have different effects on single mothers. The sample did not include fathers of preterm infants, who may also experience PTSD and Acute Stress Disorder (ASD) after their infant’s premature birth [21]. Our sample was also highly educated. It is possible that this sample of participants may have been more amenable to the writing and reading aloud involved in the TN exercises. There was limited variability in race and ethnicity of participants. Future research should examine implicit bias in recruitment efforts and treatment delivery to support parents of preterm infants of all racial and ethnic backgrounds. 

Given that PTSD symptoms sometimes improve naturally over time after a traumatic event, the lack of a control condition limits our ability to conclude whether the intervention itself resulted in participants’ shifts in experiences of their trauma, or if such changes would naturally occur in the absence of intervention as well. It would be advantageous to create an RCT of group trauma-focused CBT compared to an active treatment group (such as psychoeducation and supportive group therapy) in order to determine whether symptom change and the reduction in isolation is due to the specific treatment components of traumafocused CBT. Participant responses to the intervention may be viewed as subjective evidence for its efficacy and the previously reported PTSD symptom reduction adds objective evidence that the intervention was helpful [12], however further studies using comparison groups are needed.

Clinical Implications

This study provides numerous insights for the group therapist facilitating trauma-focused CBT for mothers of preterm infants. Given the shared theme across responses about reduced feelings of isolation, the connections between group members appear to be crucial for treatment benefit. Thus, the group therapist should prioritize strengthening group cohesion over completing specific tasks in treatment. When introducing the TN exercises, the group therapist should educated mothers about the possibility of potential difficult reactions including flashbacks and increased distress. It may be helpful to explain that such symptoms tend to dissipate in the weeks following the TN exercises. If practicing in settings with more flexible time parameters, the group therapist may consider extending the treatment to eight to ten sessions. Spending two sessions on writing the narrative and two sessions on reading the narratives aloud may allow group members to process their emotional experiences more fully.

Conclusions

While a larger study is needed, the current research suggests that the use of TN in a group setting is a feasible and acceptable intervention with the ability to support mothers of preterm infants to feel less isolated. Rather than using a desensitization model with repeated exposure as in other trauma treatments, the TN in this format may serve to provide mothers with an opportunity to hear each other’s stories and bear witness to their experiences. That almost all participants responded to open-ended questions about their group experience with similar comments about feeling less isolated supports the hypothesis that the TN experience would reduce feelings of isolation.

These findings are especially important in the context of the research literature on isolation, PTSD, the NICU experience, and COVID-19 interventions, some of which heighten isolation in the face of healthcare stresses. Researchers have hypothesized that trauma survivors with poor social support might be at increased risk of PTSD [22] because they may not have the opportunity or may not be encouraged to speak about the event [23]. Feelings of isolation are common for mothers of preterm babies [6] and may be a risk factor for developing postpartum symptoms. The seeking of and connection with social support has been consistently found to be negatively associated with the development of PTSD [24]. Thus, if mothers feel less isolated and more connected through the group experience, this may reduce their risk of developing PTSD. In this study, participants were encouraged to read their narratives to their partner or loved ones outside of these NICU sessions. In that way, creating a coherent narrative of their experience offered benefits that extended beyond the timescale and walls of these sessions.

Acknowledgements

Stanford University 2019 Department of Psychiatry & Behavioral Sciences Innovator Grants. Robert L. Hess and his family, and their generous support of perinatal-neonatal research through endowment of the Rosemarie Hess Professorship and the Robert L. Hess Family Professorship in the Division of Neonatal and Developmental Medicine, Stanford University School of Medicine.

Conflicts of Interest

Richard Shaw receives publishing royalties from American Psychiatric Publishing. There are no other Conflicts of Interest to disclose.

Financial Support

Stanford University 2019 Department of Psychiatry & Behavioral Sciences Innovator Grants.

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