Cognitive Behavioral Group Therapy

Challenges and Opportunities

Ingrid Sochting

• Publisher: Wiley-Blackwell
• Year: 2014
• Print ISBN: 9781118510346, 9781118510353
• eBook ISBN: 9781118510339
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

With coverage of the latest theory and research, this is a complete guide to implementing cognitive behavioral group therapy for practitioners and trainees in a range of mental health disciplines.

 

• Presents evidence-based protocols for depression, panic, social anxiety, generalized anxiety, posttraumatic stress, OCD, compulsive hoarding, psychosis, and addiction
• Provides innovative solutions for achieving efficient, effective therapy as mandated by emerging health care priorities, as well as trouble-shoots for common problems such as dropouts
• Details unique strategies for working with ethnic minorities and clients across the age spectrum, along with material on mindfulness augmentation and transdiagnostic approaches
• Includes clear, accessible instructions, complete with references to DSM-5 diagnostic changes, real-life clinical examples, and group session transcripts

Part 1
The Basics of Cognitive Behavioral Group Therapy

The first three chapters in Part 1 explain basic principles, research, and theory related to cognitive behavioral group therapy (CBGT). These opening chapters are sprinkled with clinical examples to illustrate how the principles of CBGT work in practice. Chapter 1 makes a case for extending individual cognitive behavioral therapy (CBT) to groups. Chapter 2 discusses why group CBT becomes more effective when clinicians are familiar with and actively engage with group process factors. Chapter 3 reviews research findings on CBGT for all the disorders covered in this book. This background information will provide a context for the last two more practical chapters of Part 1, which detail how to implement CBGT for depression.

1
Extending CBT to Groups

Cognitive behavioral group therapy (CBGT) can play an important role in making effective therapy for mental health problems more accessible and less costly—whether paid for by individual clients or governments. Within governmental mental health systems, CBGT offers significant cost savings and efficiencies without compromising effectiveness (Bennett-Levy, Richards, & Farrand, 2010). Groups run out of private offices or agencies are less expensive for clients because private group therapists do not charge the equivalent of an individual fee when they treat more than one person at the same time. This chapter provides an overview of how individual cognitive behavioral therapy (CBT) has gained momentum and why a group format is a logical extension of this success. Adapting an individual CBT protocol to a group setting is, however, not straightforward. A panic disorder group example illustrates some of these challenges. The chapter closes with a discussion of the unique therapeutic benefits offered by CBGT compared to individual CBT and how to be off to a good start with a CBT group.

Why CBT Is Increasingly Used for Common Mental Health Problems

The number of individuals who suffer from mental health problems is steadily increasing. Depression and anxiety disorders account for the majority of these mental health problems, with North American lifetime prevalence rates estimated at 16% for adult depression and 28% for anxiety disorders (Kessler, Chiu, Demler, & Walters, 2005). There are several reasons for this upward trend. Some likely reflect increased awareness of mental health problems and treatment options. However, even after taking better public education into consideration, rates of anxiety and depression are still on the rise. Larger socioeconomic trends may be operating, leading some health researchers to argue convincingly for a strong association between higher rates of mental illness and socioeconomic inequality. Rates for almost all mental health problems, but especially anxiety disorders, increase as socioeconomic status decreases, making poor mental health both a cause and consequence of poverty and inequality (White, 2010). Interestingly, inequality may also hurt the more affluent. In countries where the gap between rich and poor is large and widening, such as the United States (US), we see higher rates of depression and anxiety even among the financially comfortable members. Conversely, Japan has a relatively narrow income gap, and rates of mental illness across socioeconomic status are lower (Wilkinson & Pickett, 2010). Over and above socioeconomic factors, having a well-integrated family, friendship, and community network may be even more critical than previously thought for the psychological well-being of both men and women (Cable, Bartley, Chandola, & Sacker, 2013); conversely, any breakdown of family and community structure and support has been linked to increases in mental health problems (Alexander, 2010).

Medication can be helpful for many kinds of anxiety and depression and is usually the first treatment offered when a person talks to their family doctor about feeling anxious or depressed. For depression, the advent of the selective serotonin reuptake inhibitors (SSRIs) antidepressant medication in the 1980s was welcomed by family physicians because of their milder side effects compared to the “older” types of anti- depressants, the tricyclics, such as imipramine. SSRIs are also routinely prescribed for anxiety. Research suggests that CBT and medication may be roughly equally effective for treating the acute phase of depression (DeRubeis, Siegle, & Hollon, 2008) but that CBT is more likely to help people stay free of depression after discontinuing treatment, whereas ceasing medication has a higher likelihood of relapse (Hollon, Stewart, & Strunk, 2006). A combination of medication and CBT may be especially helpful for depression. A recent randomized controlled trial involving 469 United Kingdom (UK) patients treated for depression with medication by their family physicians showed that only when CBT was added to their usual care did patients begin to improve. At 6 months follow-up, 46% in the CBT group had responded well to treatment compared to only 22% in the care as usual. The treatment gains were maintained at 12 months follow-up (Wiles et al., 2013). It is our experience that people with more severe depression, who respond to antidepressant treatment, are in a better position to commit to regular group attendance. In particular, we notice that those group members benefit from better sleep regulation and increased levels of energy after starting medication and are therefore less likely to miss group sessions due to inertia and low motivation.

Still, regardless of effectiveness, many people prefer not to take medications for various reasons. For depressed people, antidepressants often include side effects such as weight gain and diminished sexual interest, which can lead to a further decrease in social and interpersonal confidence and well-being. For older people with depression, lower rates of metabolism create a necessity for lower dosages which may not even be therapeutic. Others simply prefer to learn sustainable self-help skills rather than relying on external agents such as medication, which can also be costly (Cooper et al., 2007; Dwight-Johnson, Sherbourne, Liao, & Wells, 2000). For people who prefer to take a more active role in their own health, CBT is an attractive option. Clinicians present CBT as a symptom- or problem-focused psychological treatment with an emphasis on personal change in behaviors and patterns of thinking about oneself, other people, and one’s day-to-day living environment. Clients are informed that CBT is a shorter-term treatment, typically 8–16 weeks, and that a commitment to practice new skills between sessions is necessary if treatment gains are to be sustained over time.

CBT is available in most Western countries and increasingly also in other parts of the world such as China. Indeed, clinical guidelines in Canada, outlined by the Canadian Network for Mood and Anxiety Treatments (CANMAT), recommend CBT as a first-line treatment for both depression (Ravindran et al., 2009) and anxiety (Swinson et al., 2006) due to the steadily growing body of evidence supporting the effectiveness of CBT. In the United Kingdom the National Institute for Health and Clinical Excellence (NICE, 2009) also recommends CBT for anxiety and depression, including for people who may not meet all diagnostic criteria, that is, minor or sub threshold depression. Not only is CBT helping individuals enjoy a better quality of life, but it is also cost-effective. Before highlighting the cost-effectiveness of CBT, I briefly summarize what CBT is.

Principles of CBT

CBT as we know it today has evolved from the original behavioral therapies developed in the 1960s as a result of the experiments by B.F. Skinner, Joseph Wolpe, Hans Eysenck, and I.P. Pavlov among several other physiologists and medical scientists. These early behaviorists conceptualized psychopathology as simple learning processes either involving classical or operant conditioning (Hawton, Salkovskis, Kirk, & Clark, 1989). They reacted to the notion in psychodynamic theory, as formulated by Sigmund Freud and his followers, of psychopathology being the result of unresolved intrapsychic conflict caused during the first 5 years of life. Instead of focusing on mind phenomena such as dreams, memories, and free associations, the early behavioral therapists focused exclusively on environmental determinants of behavior. They demonstrated that environmental factors lead to two basic forms of learning, classical conditioning and operant conditioning. We are all familiar with the classical conditioning of Pavlov’s dogs.

Initially, the dogs exhibited an unconditioned response of salivation to the smell of food (unconditioned stimulus). However, over time, the presentation of food was systematically paired with a bell. Simply hearing the sound of the bell therefore led the dogs to salivate even though no food was present. The bell (conditioned stimulus) had thus produced a conditioned response. We see other versions of classical conditioning in the modern CBT office. A woman may show a strong anxiety reaction to, and avoidance of, cats. She is puzzled because she is not afraid of cats per se. It becomes apparent that she had a first panic attack in a friend’s home where there were several cats around. Seeing a cat becomes a conditioned stimulus because of its association with the extreme unpleasantness of a panic attack. Avoiding cats as much as possible becomes the conditioned response. Treatment would in part involve exposure to cats and other places associated with panic attacks. Op...

Table of contents

• Cover
• Title page
• Copyright page
• Dedication
• About the Author
• Acknowledgments
• Introduction
• Part 1: The Basics of Cognitive Behavioral Group Therapy
• Part 2: Challenges of Cognitive Behavioral Group Therapy
• Part 3: Cognitive Behavioral Group Therapy Across Ages and Populations
• Appendix A
• Appendix B
• Appendix C
• Appendix D
• Appendix E
• Appendix F
• Appendix G
• Appendix H
• Appendix I
• Appendix J
• Author Index
• Subject Index
• End User License Agreement