Evaluation of a spiritually focused intervention with older trauma survivors.
Abstract: This study evaluated the effectiveness of an 11-session, spiritually focused group intervention with older women survivors (age 55 years and older) of interpersonal trauma (child abuse, sexual assault, or domestic violence) in reducing trauma-related depressive symptoms, posttraumatic stress, and anxiety. Forty-three community-dwelling women survivors of interpersonal trauma were randomized into treatment (n = 21) or control (n = 22) groups. Participants in group psychotherapy discussed spiritual struggles related to abuse and developed spiritual coping resources. The treatment group had significantly lower depressive symptoms, anxiety, and physical symptoms at posttest compared with the control group. In a separate analysis, posttraumatic stress symptoms also dropped significantly in the treatment group. Gains were maintained at three-month follow-up. This study provides strong initial support for the effectiveness of spiritually focused group intervention for older survivors of interpersonal trauma from a Christian background.

KEY WORDS: interpersonal trauma; intervention; older women; spirituality; trauma symptoms
Article Type: Report
Subject: Psychic trauma (Care and treatment)
Aged women (Psychological aspects)
Spirituality
Authors: Bowland, Sharon
Edmond, Tonya
Fallot, Roger D.
Pub Date: 01/01/2012
Publication: Name: Social Work Publisher: Oxford University Press Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 2012 Oxford University Press ISSN: 0037-8046
Issue: Date: Jan, 2012 Source Volume: 57 Source Issue: 1
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 294900196
Full Text: Some women experience profound long-term mental and physical health consequences from experiences such as child physical and sexual abuse (Talbot, Duberstein, Cox, Denning, & Conwell, 2004). These symptoms are often exacerbated by repeated victimizations (sexual assault and domestic violence) over the life course (Coid et al., 2001), increasing long-term risks for health, mental health, and adult mortality (Felitti et al., 1998). The literature is replete with accounts of posttraumatic stress, depression, and anxiety as the long-term sequelae for survivors who experience these types of interpersonal trauma. Women are also two to three times more likely than men to report fear of being injured during violent episodes with their intimate partners (Morse, 1995), and seven to 14 times more likely to sustain a severe injury at the hands of an intimate partner (Tjaden & Thoennes, 2000). They are more likely to be murdered by an intimate partner than through all other types of crimes combined (Koss et al., 1994). These statistics indicate the great need for treatments addressing the needs of survivors of interpersonal trauma.

Some researchers have reported a delayed onset or reemergence of trauma symptoms as women age (Floyd, Rice, & Black, 2002; Graziano, 2003; Somer, 2000). Using data from a national survey (Tjaden & Thoennes, 2000), Wilke and Vinton (2005) found older women (age 45 years and older) experienced the same rates of violence as younger women, had more health and mental health problems, and were more likely to remain in abusive relationships. In response to a historical and ageist bias that older adults do not benefit from therapy to address their mental health needs (Jeste et al., 1999), and due to the lack of treatments for this underserved age group, we chose to test a spiritually focused intervention with older women trauma survivors.

SPIRITUALITY AND TRAUMA

Wink and Dillon's (2003) longitudinal life course survey offered evidence about the importance of spirituality to older women. These authors reported that women age 55 years and older valued their spirituality more than men or younger adults and that a spiritual focus was correlated with personal growth and involvement in creative activities. Women with a spiritual focus also exhibited greater well-being in late adulthood. Not surprisingly, some investigators (Crowther, Parker, Achenbaum, Larimore, & Koenig, 2002) have proposed incorporating positive spirituality into models of successful aging. However, life challenges may lead to spiritual struggles (Koenig, 1994; Pargament, 1997). Some people develop spiritual crises as a consequence of experiences of personal violation (Falsetti, Resick, & Davis, 2003). They report disruptions at the core of what felt unassailable: their spirituality, self-esteem, trust, and capacity for intimacy (Janoff-Bulman, 1992).

In this article, we use the term spirituality to include a broad scope of experience--from survivors' participation in a formal set of institutional rituals, doctrines, and practices to spirituality as a felt sense of connection to a sacred source that enables one to make meaning out of personal experiences (Pargament, 1997). Research has shown that for many older adults, the concepts of religion and spirituality are overlapping and cannot simply be separated (Marler & Hadaway, 2002). Participants in this study were encouraged to discuss both personal and communal practices. Only survivors who were open to talking about their spirituality in relation to their traumatic experiences joined this project.

We are aware that discussing spirituality in therapy is still a controversial topic. Religion has frequently been viewed as more of an impediment to health than as a resource to improve it. There are frequent definitional debates about the overlap or separation between religion and spirituality (Marler & Hadaway, 2002). Most of the studies showing a connection between spirituality or religion and health are cross-sectional (Thoresen & Harris, 2002). Some critics point out the lack of controlled studies (Sloan & Bagiella, 2002). Some practitioners also fear their personal beliefs may get in the way when approaching clients from diverse religious backgrounds. In many settings religion and spirituality are viewed as topics that are off limits. Yet, for at least some clients, religious and spiritual issues may be embedded in core struggles or strengths, suggesting that addressing them may be central to the change process (Pargament, 2007; Shafranske, 1996).

These debates point toward the need to conduct further research. Thus, we hypothesized that a group intervention supporting the discussion of spiritual struggles and strengths and the development of new spiritual resources would reduce trauma-related posttraumatic stress, depression, anxiety, and somatic symptoms for older survivors of interpersonal trauma who indicated interest in such a group.

Researchers postulating a connection between spirituality and mental health (Koenig, McCullough, & Larson, 2001) have drawn on stress and coping theory to construct a model to explain the relationship between spirituality and mental health. In adapting the model for the present study, we put forward an intervention designed to influence spiritual coping attitudes and behaviors, which in turn might be expected to affect trauma symptoms (posttraumatic stress, anxiety, depression). Evidence for the importance of addressing spiritual struggles in psychotherapy as part of recovery from interpersonal trauma can only be found in the work of a small number of researchers (Fallot, 1997; Murray-Swank & Pargament, 2005). Murray-Swank and Pargament used spiritual exercises (including breathing techniques and guided imagery) with five survivors of sexual abuse to test for a decrease in psychological distress and improvement in body image and sexual functioning. Four out of five participants experienced significant reductions in anxiety. Unfortunately, the sample was small, and the treatment results may have been confounded by participants' involvement in simultaneous treatments.

SPIRITUAL INTERVENTION

Practitioners and trauma survivors from an agency serving clients with co-occurring disorders developed a brief group intervention (1.5 hours per session) that was used in the present study. The intervention was chosen because it is a manualized psychoeducational, cognitive restructuring, and skill-building approach to addressing spiritual struggles in recovery (Fallot & The Spirituality Workgroup, 2001-2004). The model is an offshoot of the Trauma Recovery and Empowerment Model (TREM) (Harris & The Community Connections Trauma Work Group, 1998). There is evidence that TREM is effective in reducing trauma-related mental health symptoms (Morrissey et al., 2005), The first author, who conducted the intervention, was trained using the TREM model. In addition, she and her coleaders were versed in feminist theological approaches to interpersonal trauma. An extensive literature offers a critique of patriarchal Christianity and potentially harmful interpretations and practices (see Brock & Parker, 2001; Imbens & Jonker, 1992). The feminist perspective was used to raise questions, for instance, about endurance and sacrifice of self for others. Alternative viewpoints to patriarchal interpretations of scripture and religious life were sometimes introduced.

During session 1, participants discussed their spiritual histories in relation to their traumatic experiences. In session 2, spiritual gifts, such as discemment, forgiveness, and trust, were identified as qualities participants had or needed in their lives. In session 3, a spiritual recovery action plan was developed after participants discussed research literature about the value of positive spiritual coping for health. The harm of negative coping, such as viewing God as punishing or abandoning, or being unable to forgive oneself for abuse, was also discussed. Women named spiritual needs and places of struggle in their spiritual lives. Different psychological struggles often connected with trauma, including anger, fear and powerlessness, guilt and shame, despair, and loneliness, were explored in sessions 4 through 8 as challenges with potential spiritual solutions. Experiences within organized religious traditions were also discussed frequently. Sessions 9 through 11 focused on recovery strategies, such as prayer, music, poetry, visiting a new congregation when the old one was not meeting spiritual needs, reading a new translation of sacred text, and joining or creating a spiritual support group. In session 9, research on forgiveness/letting go and health was explored. During session 10, participants identified places of hope in their lives. In session 11, participants shared how they would continue their healing journey. They were encouraged to create a sacred space in their own homes. Throughout the intervention the leaders followed guidelines to foster a climate of respect for diverse beliefs and practices. Proselytizing was not allowed. The goal of the intervention was to create open dialogue and sharing of resources rather than to prescribe answers (Fallot & The Spirituality Workgroup, 2001-2004).

METHOD

Participants

Recruitment. Recruitment for this project ran from February 2006 to July 2007. The sample was composed of adult female community-dwelling survivors (age 55 years or older) who lived in St. Louis, Missouri. Ads were placed in a senior newspaper, and a poster and flyers were circulated at a university hospital. Most participants came from the hospital research volunteer list (n = 28).

The first author used a phone screening protocol with 129 women who expressed interest in the project. Fifty women were ineligible because they did not endorse trauma symptoms and spiritual struggles related to earlier abuse. Women who reported symptoms and struggles were asked whether they might benefit from "participating in a group discussing religious and spiritual issues in recovery?" An in-person clinical interview was held with women who passed the initial screening. Women were assessed for cognitive impairments and for suicidality. Ten women who completed the clinical interview did not meet the minimum requirements on trauma symptoms screening tests. Forty-four women were eligible and entered the study. One did not attend any groups and was unable to be reached after the randomization procedure.

Inclusion/Exclusion Criteria. During the initial phone screening, participants in the study indicated they had current trauma-related distress. None of the women, however, was in crisis due to current physical or sexual violence, Eligibility criteria for the study specified that participants have a history in the Christian tradition. This was used to increase the homogeneity of this small sample, because subgroup analysis was not possible. Participants were not in psychotherapy, did not have significant cognitive impairments, and were not actively suicidal or psychotic. Women who did not meet these criteria were referred to other community resources.

Sample Demographics. The average age of women in the sample was 61.3 years, with a range of 55 to 83 years. Thirty-six (84 percent) were Caucasian, six (14 percent) were African American, and one was Eastern Indian. Sixty-five percent had incomes of less than $50,000. The majority of the sample (n = 27) held an associate's or bachelor's degree. Twenty-three women were partnered and 20 were single at the time of the study. Religious affiliations varied and included Catholic (30 percent), Presbyterian (14 percent), Lutheran (9 percent), Episcopalian (5 percent), Baptist (9 percent), nondenominational Christian (14 percent), and other (19 percent). One question at screening assessed religiosity: "On a scale from 1 to 10, how religious/spiritual are you?" The scoring ranged from 1 = hardly at all to 10 = greatly. The mean for the total sample was 7.89 (SD=2.17), indicating a strong spiritual orientation.

History of Interpersonal Trauma. All of the participants reported more than one traumatic event (child sexual and/or physical abuse, domestic violence, sexual assault) and 42 of 43 women reported they had been exposed to multiple types of violence and abuse. Approximately 33 percent also disclosed chronic emotional abuse in their current primary relationship. Women reported domestic violence and sexual assault beginning in young adulthood. No one reported onset of abuse after the age of 55. Approximately 70 percent of women in the study had experienced sexual abuse, physical abuse, or neglect by a parent.

Design

This project was approved by the Human Research Protection Office at Washington University in St. Louis, Missouri. A power analysis revealed that a sample size of 48, assuming an effect size of 1.0, would provide power of approximately 80 percent to detect a relationship between the intervention and the mental health outcomes. A randomized controlled group design was used to evaluate the effectiveness of the intervention. Women were paired on scores from a spiritual distress scale (SDS) and then randomized into treatment or control groups using a random number table. A total of three experimental groups were held sequentially beginning in July 2006 and ending in January 2008. Three groups also completed the control condition during the same period. Posttests were completed for both the treatment and the control participants at 11 weeks. Subsequently the control participants were offered the opportunity to enter treatment. Fifteen out of 22 women completed the delayed treatment groups.

To assess leader fidelity to the group treatment model, an independent evaluator rated videotaped sessions randomly selected from each of the six groups. The mean adherence score for 18 sessions was 83.3 percent (SD = 19.40; range = 40 percent to 100 percent). Dumas, Lynch, Laughlin, Smith, and Prinz (2001) suggested that attaining an average fidelity statistic of 80 percent or above is ideal. This standard was met.

Measures

The outcome variables of posttraumatic stress, depression, anxiety, and somatic symptoms were measured using instruments with established validity and reliability. Symptom severity levels, question format, and Cronbach's alphas for the current study are displayed in Table 1. Women met eligibility criteria for at least a "mild" or "low" level on trauma-related depressive symptoms, anxiety, and/or posttraumatic stress. A primary outcome was not selected.

The Geriatric Depression Scale (GDS) is used extensively with older adults (Yesavage et al., 1982-1983). The Posttraumatic Stress Diagnostic Scale (PDS) measures different types of interpersonal trauma but has rarely been used with women over 65 years of age (Foa, 1995). The Beck Anxiety Inventory (BAI) demonstrated adequate validity with a population of older adult psychiatric outpatients (Beck, Epstein, Brown, & Steer, 1988; Kabacoff, Segal, Hersen, & Hasselt, 1997). The Patient Health Questionnaire Somatic Symptom Severity Scale (PHQ-15), derived from the Primary Care Evaluation of Mental Disorders (PRIME-MD), identifies somatic symptoms that may be associated with trauma or abuse (Kroenke, Spitzer, & Williams, 2002). The spiritual distress measure used to screen women for the study combined two subscales from the Spiritual Assessment Inventory (Hall & Edwards, 1996), three questions from a forgiveness scale created by Idler (1999), and the Interpersonal Religious Discontent (IRI)) subscale of the RCOPE (a measure of religious/spiritual coping; see Pargament, Koenig, & Perez, 2000). No previous validity or reliability information was available on the IRD subscale.

Testing. Testing at three time points (pre-, post-, and follow-up) was conducted by five PhD students with clinical experience with trauma

survivors. They were trained in the interview protocol. Tests were administered systematically prior to the beginning of the intervention, after 11 weeks at the end of the intervention, and three months later. All testing was held at the site of the intervention, and the researchers were not present. Nearly all participants completed paper and pencil tests at group testing sessions. Occasionally tests were completed in individual sessions with the testers or by phone. The testers were blind to the treatment conditions of the participants.

Data Analysis. The data were entered by a separate data entry person and were not analyzed until all treatment and control groups were completed. Multivariate analyses of variance (MANOVAs), t tests, and regression analyses were conducted with the individual outcome variables to calculate the program impact and effect size. A MANOVA was also completed for the three-month follow-up testing data to assess whether treatment gains were maintained.

RESULTS

Sample

All of the analyses conducted in this study, with the exception of the follow-up tests, were calculated with 43 women, 21 in the experimental group and 22 in the control group. Thirty-six women, including those from the delayed treatment groups, completed the follow-up tests.

Pretest means for the total sample indicated elevations on trauma-related symptoms. Depression scores ranged from 1 to 29 on a scale of 0 to 30, with a mean of 15.67 (SD=7.79). Scores on posttraumatic stress symptoms ranged from 2 to 41 on a scale of 0 to 51 with a mean of 17.72 (SD= 9.52), Anxiety scores approached moderate levels, with a mean of 17.42 (SD = 7.92) on a scale of 0 to 63. Scores on the BAI varied between 6 and 40. Physical health symptoms reported were at the moderate level (score of 10) with a mean of 10.49 (SD = 4.61). Scores on physical health symptoms ranged from 1 to 20 on a scale of 0 to 30. The sample mean on spiritual distress was 35.1 (SD = 9.67) on a scale of 17 to 68, 10 points above the minimum distress level needed to qualify for the study. The pretest scores on the SDS varied between 27 and 57.

Equivalency between Groups

A depiction of demographic and descriptive characteristics of the treatment and control groups can be found in Table 2. Chi-square tests and t tests were used to assess equivalency. No significant differences were found between the treatment and control groups at pretest.

A MANOVA with the pretest scores on the outcomes between the treatment and control groups [F(6, 36) = 1.20, p = .33] indicated there were no differences between the groups at pretest. Individual analyses of variance (ANOVAs) were also examined. Results are reported in Table 3. There was evidence the randomization procedure was successful

Analysis of the Variance

Cronbach's alphas on the measures ranged from .78 to .93, indicating they had acceptable reliability. Standard tests to determine the normality of the distributions were conducted. A regression procedure that accounted for clustering, heteroskedasticity, and intracluster correlation was also used. The PDS had high correlations with the GDS. It was excluded from the MANOVA.

The outcome model (GDS, BAI, PHQ-15) appeared parsimonious. The use of difference scores (the change between pre- and posttest scores) provided a statistical control for differences at pretest between groups. Thus no covariates were used in this analysis (Tabachnick & Fidell, 2001). Findings for the one-way MANOVA between groups design for four outcome variables indicated that the intervention had a significant effect on outcomes [F(4, 38)= 7.14, p = .0002]. Analyzing the post hoc tests for the individual ANOVAs to determine where the treatment had an effect showed the intervention was statistically significant for the three outcomes: BAI [F(1, 41) = 8.42, p = .0059], GDS [F(1, 41)= 23.66, p <.0001], and PHQ-15 [F(1, 41)=9.47, p = .0037]. There were no effects over time for the control group. Furthermore, using a paired sample t test, the variance around the mean of several dependent variables (GDS, PDS, BAI, PHQ-15) decreased significantly from pretest (SD= 8.60) to posttest (SD=6.94) for the experimental group (t = 3.295, p < .01).

Independent sample t tests were then conducted with the pre- to posttest outcome data using change scores and are reported in Table 4. Effect sizes delineating the strength of the relationship between the outcomes and the intervention were calculated using Hedges's g (Hedges & Olkin, 1985). Effect sizes ranged from medium to large.

In a separate analysis, an independent sample t test using change scores from the PDS indicated that women in the experimental group experienced a significant drop in their symptoms from pre- to posttest. Scores fell from a mean and standard deviation of 19.43 (9.65) to ones of 11.86 (6.77) [t(41) = -3.86, p < .001]. By the end of the treatment, on average, women in the experimental group had dropped from the high to the low end of the moderate symptom range for posttraumatic stress symptoms. Thus, there is support for hypothesis 1. The challenge of administering the PDS in this study has been discussed elsewhere (Bright & Bowland, 2008). The measure, as used here, is probably best thought of as capturing a set of traumatic stress events. The dmp in posttraumatic stress symptoms should be viewed as a secondary outcome of the intervention.

Hypothesis 2, that the intervention would lead to lower depressive symptom scores was supported. The intervention exhibited the largest effect on depressive symptoms. Mean scores on depressive symptoms dropped significantly from pre- to posttest for the experimental group when compared with the control group. By the end of the treatment, on average, women in the experimental group did not meet the criteria for clinically significant depressive symptoms.

Hypothesis 3, that anxiety levels would drop significantly in the intervention group, was also supported. Scores dropped an average of 0.8 standard deviations as a result of the intervention. The intervention appeared to have a large effect on anxiety symptoms.

The intervention led to lower physical health symptoms. Thus, hypothesis 4 was supported. On average, physical symptoms dropped by two points from 10.52 to 8.52, and this decline lowered the symptom level group mean from moderate to mild levels (< 10).

To assess whether the effects of the spiritual intervention were maintained at the three-month follow-up, change scores were calculated by subtracting the follow-up test scores from the posttest scores for both the treatment and the delayed treatment groups (n = 36). A one-way MANOVA was performed. Findings from posttest to follow-up indicated no significant multivariate changes [F (4, 32) = 0.60, p = .6138]. Analyzing the individual ANOVAs for changes over time, the probabilities were greater than .05: BAI [F(1, 35)= 0.02, p = .8970], GDS [F(1, 35) = 0.11, p < .7448], and PHQ-15 [F(1, 35)=0.39, p = .5388]. Thus, there is evidence that the treatment effects were maintained over time.

DISCUSSION

It is both shocking and dismaying that violence and abuse are so rampant in our society that a community-based sample of older women reports multiple debilitating experiences of interpersonal trauma. This study provides evidence for revictimization and long-term effects for some older survivors. Although 70 percent reported childhood abuse, many experienced abuse continuing through adulthood. Comparisons are needed between those living in chronically abusive adult relationships and those experiencing only early abuse. Are their trajectories similar or disparate? Higher rates of chronic depression in women compared with men (Kessler, 2003) may partially be explained by higher rates of early abuse, whose effects accumulate over time.

Trauma-informed services (Harris & Fallot, 2001) should be provided as part of the continuum of care in both community-based agencies and long-term care facilities. Research informs us of the return of these types of symptoms for older adults. At a minimum, agency policies should include routine assessment of trauma histories.

This research offers strong preliminary evidence for a causal link between a spiritual intervention and reductions in trauma symptoms. Survivors in the intervention group experienced both statistically and clinically meaningful reductions in their trauma-related mental health symptoms (depression, anxiety) when compared with the control group. We cautiously conclude that the intervention also significantly reduced posttraumatic stress symptoms.

These gains build a compelling argument for the value of practitioners attending to clients' spiritual issues and resources to help them cope more effectively with the impact of trauma. Although social workers are understandably slow to "intrude" on a client's personal religious or spiritual life, a more open stance in discussing religion and spirituality may be a key for some older survivors.

Our study also has implications for group work in an agency setting. At the present time it is unclear where group work of this type would be conducted. Could spiritually focused trauma groups be situated in assisted living centers, in long-term care facilities, or in a congregation? Recruitment may be an issue, as stigma is a barrier to mental health services for some older adults.

We should consider who is qualified to address spiritual issues and whether social workers will be willing to foster interdisciplinary collaboration with clergy to address the intersection of mental health and spiritual needs of survivors. Further research should determine the training needed for social workers and clergy to effectively work with spiritual struggles.

Limitations

Limitations in this study must be acknowledged. Recruitment, screening, and intervention were all completed by Sharon Bowland. Ideally, investigators would not deriver the intervention, to reduce the potential for social desirability bias. Limited funds for advertising, having only one person available to conduct recruitment, and extensive preliminary processes led to a slow qualification timeline. Most likely, a larger sample would have resulted in more accurate measurement of the treatment effects. The fidelity check on the intervention was performed by one evaluator, so interrater reliability was not assessed. Finally, social desirability was not measured and cannot be ruled out as a motivator for participants to improve.

Conclusion

Questions remain about the mechanisms that account for the positive effects of the intervention. First, how much of the treatment effect can be explained as social support? Future research should include a measure of social support. Second, all of the facilitators in this study had training in theology and pastoral care. Could a mental health professional trained in the treatment protocol competently run these intervention groups, or is specialized training in theology a prerequisite? Third, did a feminist theological perspective pose useful questions about church teachings that were helpful to some participants? These questions should be considered in designing future research in this area. Given the promising nature of the findings, this study should also be replicated in a larger clinical trial. The current sample was a Christian one. The intervention could be modified and tested with those from a diversity of religious or spiritual backgrounds.

Overall, this study expands our inadequate knowledge about older women's experiences of violence over the life span. The words of Bussert (1986) are germane to initiating a community discourse that ends the silence surrounding older survivors' experiences and brings to light the necessity of consciously examining spiritual beliefs to improve health and well-being: "We must help women survivors in articulating a faith that will provide them with resources for strength rather than resources for endurance" (p. 33).

COMMENTARY

Commentary offers writers an opportunity to present their critical observation on current professional issues, social problems, or policy matters. Submissions are expected to build on existing literature in the topic area. Send your manuscript (six double-spaced pages or fewer) as a Word document through the online portal at http://swj.msubmit.net (initial, one-time registration is required).

doi: 10.1093/sw/swr001

Original manuscript received February 17, 2010

Final revision received July 29, 2010

Accepted July 30, 2010

Advance Access Publication May 18, 2012

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Sharon Bowland, PhD, LCSW, is assistant professor, Kent School of Social Work, University of Louisville, Kentucky. Tonya Edmond, PhD, LCSW, is associate professor, Brown School of Social Work, Washington University, St. Louis, Missouri, Roger D. Fallot, PhD, is director of research and evaluation, Community Connections, Washington, DC. Address correspondence to Sharon Bowland, Kent School of Social Work, University of Louisville, Patterson Hall 300, Louisville, KY 40292; e-mail: sharon.bowland@louisville.edu.
Table 1: Outcome and Screening Measures

Measure              Symptom Level          Question Format and
                                            Cronbach's [alpha]

                                            Likert/type scales
                                            used to measure
                                            symptoms ranging
                                            from 0 = not at all
                                            to 3 = five or more
                                            times pc r week/
                                            almost always.

  Avoidance          [greater than or       Continuous: 17 items
                     equal to] 11  to
                     [less than or equal
                     to] 20  for moderate
                     symptoms

  Arousal            [greater than equal    Score range. 0-51.
                     to]21 to 535  for
                     moderate to severe
                     symptoms

Reexperiencing       236 for severe         Cronbaeh's
                     symptoms               [alpha]=.89

Depression (GDS)     Continuous: 30 items   Yes/No format.
                     [greater than or 11=   Score' range: 0-30
                     mild depression
                     [greater than or       Cronbach's [alpha]
                     equal to]  21 severe   =.91
                     depression

Anxiety (BAI)        Continuous: 21 items   Measured on a four-
                                            point scale ranging
                                            from 0 =not at all
                                            to 4 = severely, I
                                            could barely stand
                                            it. Score range: 0-
                                            63.

  Somatic            [greater than or       Cronbach's
                     equal to]  ll =mild    [alpha]=.81
                     anxiety

  Subjective         [greater than or
                     equal to]  19 =
                     moderate anxiety

Somatic symptoms     Continuous: 15 items   Measured on a three-
  (PHQ-15)                                  point scale ranging
                                            front 0= not
                                            bothered at all to 2
                                            = bothered a lot.

                     5 = low symptoms       Score range: 0-30.
                     10 =medium level       Cronbach's [alpha] =
                     15 =high level         .78

Spiritual distress   Continuous: 17 items   Measured on a four-
(SDS)                Elevations [greater    point Likert-type
                     than or equal to]      scale ranging from 1
                     25 on spiritual        = almost never to 4
                     distress               =almost always. A 3
                                            or 4 on three of the
                                            questions indicates
                                            spiritual distress.

  Instability
  Forgiveness
  Disappointment
  Interpersonal                             Score range: 17-68.
  religious                                 Cronbach's [alpha]=
  discontent                                .91

Note: Pus= Posttraumatic Stress Diagnostic Scale; GDS =Geriatric
Depression Scale; BAI=Beck Anxiety Inventory; PHQ-15 =Patient Health
Questionnaire Somatic Symptom Severity Style; SDS=Spiritual Distress
Style.

Table 2: Differences between Groups on Descriptive Variables at Pretest

Characteristic            Treatment Group    Control Group
                          n=21               n=22

Age, M (SD)               60.33 (4.6);       6.32;(7.7);
                          rage = 55-71       range = 55-83
Partnered (yes)           11 (50%)           11 (50%)
Education (college: yes)  13(48%)            14(52%)
Income < $50,000          11 (44%)           14(56%)

Religiosity: M (SD)       7.81 (1.9);        7.95 (2.4);
                          range= 2-10        range =1-10
Trauma exposure (yes)
Childhood abuse           14(66.7%)          16(72.7%)
Domestic violence         16(76.2%)          17(77.3%)
Sexual assault            10 (47.6%)         11 (50.0%)

Characteristic            Test                   P

Age, M (SD)               t (41) = -1.015        0.32

Partnered (yes)           Fisher's exact test    1.00
Education (college: yes)  Fisher's exact test    0.76
Income < $50,000          [chi square] =3.83,    0.80
                          df= 7
Religiosity: M (SD)       t(41)= -0.22           0.83

Trauma exposure (yes)
Childhood abuse           Fisher's exact test    0.75
Domestic violence         Fisher's exact test    1.00
Sexual assault            Fisher's exact test    1.00

Table 3: Equivalency on Pretest Outcome and Screenin Measures

            Treatment Group              Control Group
            (n=21)                       (n = 22)
Varlaisle   M (SD)         95% Cl                       95% CI

GDS         17.67 (5.92)   14.97-20.36   13:77 (8.96)   9.80-17.77
BAI         17.52 (6.58)   14.53-20.52   17.32 (9.19)   13.24-21.39
PDS         19.43 (9.65)   15.04-23.82   16.10 (9.32)   11.96-20.22
PHQ-15      10.52 (4-55)   8.45-12.59    10.45 (4.78)   8.33-12.57
SDS         34.57 (9.55)   30.57-38.92   35.64 (9.98)   31.21-40.06

Varlaisle   t(41)

GDS         1.67 (p = .10)
BAI         0.08 (P 93)
PDS         1.15 (p = .26)
PHQ-15      0.05 (p = .96)
SDS         -0.36 (p = .72)

Note CI = confidence interval; GDS=Getriatic Depression Scale; PHQ-
15= Physical Health Questionnaire  UAI= Beck Anxiety Inventory;
PDS=Posttraumatic Stress Diagnostic Scale;  Somatic Symptom Severity
Scale; SDS=Spiritual Distress Scale.

Table 4: Treatment Effects on Trauma-related Symptoms

                                                     95% CL
                      Pretest        Posttest        Lower   Upper
Depressive symptoms   M (SD)         M (SD)          Limit   Limit

  Treatment           17.67 (5.92)    8.86 (4.81)     6.67   11.05
  Control             13.77 (8_96)   14.50 (8.69)    10.64   18.36
Anxiety
  Treatment           17.52 (6.58)   11.24 (4.86)     9.03   13.45
  Control             17.31 (9.19)   18.91 (12,36)   13.43   24.39
Somatic symptoms
  Treatment           10.52 (4.55)    8.52 (4.42)     6.51   10.54
  Control             10.45 (4.78)   11.00 (5.19)     8.70   13.30

                      Change   Significance      Hedges's
Depressive symptoms   Score    t (41)               g

  Treatment           -8.81    -4.86 (p<.0001)     1.35
  Control              0.73
Anxiety
  Treatment           -6.28    -2.90 (p<.01)       0.83
  Control              1.60    --
Somatic symptoms
  Treatment           -2.00    -3.08 (p <.01)      0.53
  Control              0.55    --

Now CI =confidence interval.
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