Simply Effective Group Cognitive Behaviour Therapy

A Practitioner's Guide

Michael J. Scott

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136666957
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Group Cognitive Behaviour Therapy (GCBT) and guided self-help widen the availability of evidence-based treatment for common mental health disorders. This volume provides GCBT protocols for common disorders as well as session-by-session teaching materials and self-help survival manuals covering:

• Depression
• Panic Disorder and Agoraphobia
• Post-Traumatic Stress Disorder
• Social Phobia
• Obsessive Compulsive Disorder
• Generalised Anxiety Disorder

• 
  
  

The specifics of selecting and engaging clients in GCBT are first addressed and general group therapeutic skills are detailed. Transcripts of sessions show how group processes can be utilised to enhance outcome. Simply Effective Group Cognitive Behaviour Therapy adds to the armamentarium of tools for low intensity intervention and complements the high intensity individual approach of the companion volume Simply Effective Cognitive Behaviour Therapy. It will prove essential reading for all professionals using CBT with groups.

Chapter 1

Group Cognitive Behaviour Therapy

Cognitive behaviour therapy (CBT) is distinguishable from its psychotherapy forebears by its educational emphasis. However, for the most part CBT clients have undergone an individual rather a group intervention. The reasons for this are probably multifarious: a lack of training opportunities in group CBT (GCBT) interventions, the logistics of running a group, the unpopularity of group interventions amongst clients and a feeling of many therapists of being particularly exposed in a group.

Unfortunately therapists using individual CBT (ICBT) treat the tip of the iceberg of clients with psychological problems; in England only 10% of sufferers from depression or anxiety disorders receive a talking therapy (Adult Psychiatric Morbidity in England, 2007 2009). This has led to a demand to widen access by utilising innovative modes of service delivery such as GCBT, bibliotherapy and computer-assisted therapy (IAPT 2008). The educational nature of CBT makes it particularly suitable for dissemination in group format. There are four key features of CBT that lend themselves to an educational group format:

1. Therapy begins with an elaborated well-planned rationale. This feature encourages the client to believe that by changing their thoughts and behaviour they can affect how they feel. There is a cognitive model of each disorder; for example, in panic disorder catastrophic cognitions about unusual but not abnormal bodily sensations (e.g. ‘my heart racing means I am having a heart attack’) are held to play a pivotal role in the maintenance of the disorder. The model of a disorder can be presented just as well to a group as to an individual, with examples of the model (case formulation) used that are pertinent to all group members. Thus various examples of catastrophic cognitions would be offered, ‘I am going to faint and there will be nobody there for me’, ‘I am going to choke to death’, etc. Therapy is then described as challenging these beliefs both cognitively and by actions.
2. Therapy provides training in skills that the client can utilise to feel more effective in handling daily life. A group session is probably more easily construed as a training session than is an individual session and lessens the possibility of dependence. The focus is on giving clients strategies to try out before the next session that may make a difference. In individual sessions a client can easily feel a failure if they do not do the homework task perfectly. However, in a group it soon becomes apparent that mastery is an inappropriate standard and the group norm is one of gradually learning to cope better: ‘two steps forward and one back’; further difficulties are reframed as learning opportunities.
3. Therapy emphasises the independent use of skills by the client outside the therapy context. The knowledge that other group members are also being asked to engage in similar activities outside of a therapy session is likely to enhance compliance. It is not simply that group pressure is enhancing compliance but because the activity has been sold to other group members it has credibility. For example, if in a depression group members are asked to plan an activity to offset their anticipated low spot in the week, the endorsement of the rationale by others enhances motivation.
4. Therapy should encourage clients to attribute improvement in mood to their own skilfulness rather than to the therapist’s endeavours. In GCBT the therapist is more likely to be construed as a teacher rather than a therapist, more like a ‘driving instructor’, important initially, but with a knowledge that it is essentially independent practice that makes a difference.

In the understandable rush to give psychological help to all in need, there is an ever present danger of a sacrifice of quality on the altar of quantity. Fortunately, with regard to GCBT the evidence is that GCBT is as efficacious as individual CBT for depression and probably most anxiety disorders. Further, the goal of this volume is to assure the reader that there is a simplicity (and fun) in GCBT and that it can be conducted effectively in routine practice. This chapter begins with a review of the evidence supporting the efficacy of GCBT for depression and anxiety disorders and then looks at whether there is evidence that GCBT is effective in routine practice. It is suggested that ICBT and GCBT are not mutually exclusive and can be judiciously combined to address the needs of real world clients with more than one disorder. Finally, the strengths and limitations of heterogeneous groups are discussed.

Individual Versus Group CBT

One of the key axioms of Beck’s cognitive theory of psychological disorders (Alford and Beck 1997) is cognitive content specificity, i.e. that the different disorders have a different cognitive content necessitating a different approach with each. For example, the sufferer from depression might regard themselves as worthless, the future hopeless, whilst the sufferer from anxiety by contrast might see themselves as vulnerable and the future uncertain. As a consequence of cognitive content specificity, different protocols were developed and evaluated for different disorders. This development was made possible by Beck’s earlier work on improving the reliability of psychiatric diagnosis (Beck et al. 1962), so that in discussing, say, a person with depression there was clear agreement as to what this label meant. Beck et al. (1962) noted the poor reliability of routine unstructured psychiatric assessments (32–54%) in terms of diagnosis, making research impossible, and paved the way for structured interviews with much higher levels of reliability. For the most part it is disorder-specific CBT treatments that have been evaluated and the focus below is on studies of depression and the anxiety disorders.

Depression

A review of ten studies of the relative efficacy of ICBT and GCBT for depression by Tucker and Oei (2007) concluded that GCBT for depression is more cost-effective than ICBT. However, five of the studies showed the superiority of ICBT over GCBT and five showed the equivalence of the two modalities.

Social Phobia

In a comparison of GCBT for social phobia with a waiting list control condition, Hope et al. (1995) found that the former was superior, with treatment gains being largely maintained in the year afterwards (Salaberria and Echeburua 1998). More recently Stangier et al. (2003) compared GCBT and ICBT delivered over 15 weekly sessions and found the latter superior, with 50% of clients in individual CBT no longer meeting criteria for social phobia at the end of treatment compared with 13.6% in the group condition. However, only the first seven sessions of the Stangier et al. (2003) programme included training in shifting attentional focus to external cues, stopping safety behaviours, video feedback to correct distorted self-imagery, behavioural experiments and cognitive restructuring. The majority of the second half of treatment was devoted to cognitive work on schemas rather than behavioural experiments. It may be that had the latter half of the Stangier et al. (2003) programme been more behavioural, capitalising in the group modality on group norms about ‘daring’ to engage in social situations, the differences between ICBT and GCBT would have been less and both interventions more powerful. However, at present it is difficult to come to any firm conclusions about the relative effectiveness of GCBT and ICBT for social phobia. Marom et al. (2009) found that whilst the presence of coexisting depression did not affect the immediate outcome of GCBT for social phobia, those who had depression suffered an exacerbation of symptoms post-treatment, suggesting that people with depression and social phobia may need additional interventions to maintain gains.

Panic Disorder and Agoraphobia

Roberge and colleagues (2008) in a comparison of GCBT and standard CBT in the treatment of panic disorder and agoraphobia found that GCBT incurred lower treatment costs and had a superior cost-effectiveness ratio. (Whilst, as in most outcome studies for any disorder, clients with a severe comorbid disorder were excluded from the study, in the Roberge et al. (2008) study 30% of those treated met criteria for another anxiety disorder and 8% criteria for depression). If clients are given a free choice between ICBT and GCBT following initial assessment, the overwhelming majority (95% in Sharp et al.’s [2004] study of panic disorder clients) will opt for individual therapy.

Post-Traumatic Stress Disorder (PTSD)

GCBT can produce results comparable to ICBT. Beck et al. (2009) assigned individuals with PTSD following a serious motor vehicle accident to either GCBT or a minimum contact comparison group. Of treatment completers, 88.3% did not meet criteria for PTSD at the end of treatment compared to 31.3% of the minimal contact condition; further treatment gains were maintained at 3-month follow-up. However, earlier efforts by Taylor et al. (2001) to transport individual treatment into a group setting without modification were much less successful with only 38% of clients no longer meeting criteria for PTSD after treatment. In their translation of an individual programme into a group format Beck and Coffey (2005) addressed issues such as group cohesion and the possibility of a re-traumatisation of clients by hearing the stories of other group members about their accidents.

Engaging clients in GCBT is a particular challenge and Thompson et al. (2009) found that just over half of the people invited to consider attending a PTSD group chose not to do so. Further, there is evidence that the severity of PTSD symptoms varies by type of trauma – sexual assault, road traffic accidents, sudden death of a loved one – and the pattern of PTSD symptoms also varies (Kelley et al. 2009) suggesting that PTSD treatment groups should not be totally heterogeneous.

Generalised Anxiety Disorder (GAD)

In a comparison of GCBT for generalised anxiety disorder with a waiting list control condition, Dugas et al. (2003) found that the active condition was superior and the results similar to those in ICBT treatments reported in the literature. However, Dugas et al. (2003) add a cautionary note in that 5 of the 48 participants in GCBT dropped out compared to none out of 26 in an earlier study of ICBT for GAD. But Dugas et al. (2003) also pointed out that many participants reported that the group therapy format was particularly useful because it helped them to feel less isolated and better understood and it gave them the opportunity to learn from others in the group.

Obsessive Compulsive Disorder (OCD)

GCBT is an effective treatment for OCD but often, it seems, less so than ICBT. In a comparison of ICBT and GCBT for OCD conducted by Cabedo et al. (2010), though GCBT was effective in decreasing OCD severity, with 41% classified as recovered post-treatment, this was less than the 69% recovered in ICBT. At 12-month follow-up the figure for GCBT was 32% compared with 63% in ICBT. The results of Whittal et al. (2008) were slightly more promising for GCBT, in that recovery status or relapse rates were equivalent for ICBT and GCBT, but the psychometric test results for OCD and depression favoured ICBT. (Further, within the Whittal et al. [2008] study a comparison with exposure and response prevention was made and the cognitive therapy was better tolerated and resulted in less dropout. Interestingly in the GCBT programme, one session was held in the presence of a family member or friend. Overall about 50% of OCD sufferers recovered with cognitive therapy.) However, in a study by Jaurrieta et al. (2008), GCBT and ICBT appeared equally effective at 6-and 12-month follow-up and there was no difference in the dropout rate.

In a study of GCBT for obsessive compulsive disorder (O’Connor et al. 2005) 38% of clients refused treatment in a group format. Reasons for the refusal included anxiety about sharing problems with others, social anxiety, lack of personal attention and fears of acquiring new obsessions from others in the group.

Delivering Effective GCBT

Whilst the above review of GCBT interventions for depression and the anxiety disorders makes clear the potency of this intervention modality, it also indicates that it is not a simple matter to translate proven individual protocols into an appropriate group format or to engage clients in GCBT. It is suggested in this volume that group intervention needs supplementing with individual sessions, some of which would be concurrent with the group sessions but some sessions may precede the group if motivation for the group is an issue. Further, if the group programme is ineffective clients should be offered an individual programme. The motivational sessions can be used to address fears about attending a group. For example, a client with obsessive compulsive disorder who is besieged by repugnant thoughts/ images of a sexual or harmful nature may be very fearful about any possibility of disclosing such material in a group. Such concerns would be a focus in individual sessions and if the client’s fears were allayed, they may then opt into a GCBT programme. The particulars of how to address such concerns are detailed in Chapter 2. In routine practice clients should not be ‘assigned’ to GCBT but invited to engage when fears are assuaged; if they are not ready, individual treatment should continue. Attention to clients’ motivations with regard to GCBT could increase the uptake of the latter and reduce defaulting from a group programme.

The individual sessions can also be used to address other comorbid anxiety disorders/depression or associated marital problems. Individual sessions do not necessarily have to take place face to face and when conducted over the telephone typically take about 20 minutes (Clark et al. 2009); in the Clark et al. study (2009), about a quarter of sessions were face to face. Telephone consultations take place at a prearranged time and the therapist follows up the call if the client i...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• 1. Group cognitive behaviour therapy
• 2. Engagement
• 3. Content and process
• 4. Depression
• 5. Panic disorder and agoraphobia
• 6. Post-traumatic stress disorder
• 7. Social phobia
• 8. Obsessive compulsive disorder
• 9. Generalised anxiety disorder
• Appendix A: Cognitive Behaviour Therapy Pocketbook –Revised
• Appendix B: The 7 Minute Mental Health Screen/Audit –Revised
• Appendix C: The First Step Questionnaire – Revised
• Appendix D: General Group Therapeutic Skills Rating Scale
• Appendix E: Intake questionnaire
• Appendix F: Monitoring progress of group members
• Appendix G: Standardised Assessment of Personality –Abbreviated Scale
• Appendix H: Depression Survival Manual
• Appendix I: Panic Disorder and Agoraphobia Survival Manual
• Appendix J: Post-traumatic Stress Disorder Survival Manual
• Appendix K: Social Phobia Survival Manual
• Appendix L: Obsessive Compulsive Disorder Survival Manual
• Appendix M: Generalised Anxiety Disorder Survival Manual
• Appendix N: The Personal Significance Scale (PSS)
• References
• Index