Delivering Group CBT
Dr Michael J Scott
Consultant Psychologist
SAKT Workshop,
Sinatur Hotel Frederiksdal,
Copenhagen, Denmark
June 21-22nd, 2013
Learning Objectives
1.
2.
3.
4.
5.
6.
7.
8.
How to assess clients for GCBT
How to market GCBT
How to engage clients in GCBT
How to deliver evidence-based GCBT protocols
for depression and the anxiety disorders
How to manage group processes
How to assess group skills
How to deal with complex cases
How to troubleshoot difficulties
Resources
•
Scott, M. J (2011) Simply Effective Group Cognitive Behaviour Therapy: A
Practitioners guide. London: Routledge. Free self-help manuals for
depression and the anxiety disorders are available at
www.routledgementalhealth.com/simply-effective-group-cognitivebehaviour-therapy-978041557342 and are the basis for the group
programmes (they can also be used for individual therapy).
•
Wenzel, A., Liese, B.S., Beck, A.T and Friedman-Wheeler (2012) Group
Cognitive Therapy for Addictions. New York: Guilford Press.
•
Bieling, P.J, McCabe, R.E and Anthony, M.M (2009) Cognitive –Behavioral
Therapy in Groups. New York: Guilford Press.
Who is interested in
doubling the staff of their
Department, at no extra
cost?
Group CBT Cuts the Cost of
Providing Therapy by 40-50%
Compared to Individual Therapy
• Scott and Stradling (1990) Group Cognitive
Therapy for Depression Produces clinically
Significant Reliable Change in Community-based
Settings. Behavioural Psychotherapy, 1, 1-19
• Sobell, Sobell and Agrawal (2009) Randomized
controlled trial of a cognitive-behavioral
maturational intervention in a group versus
individual format for substance use disorders.
Psychol Addict Behavior, 23, 672-683
Group and Individual CBT Appear Equally Effective for
Depression and the Anxiety Disorders
• Depression Tucker and Oei (2007) five studies showed the
superiority of ICBT over GCBT and five showed the
equivalence of the two modalities
• Social phobia ‘ it is difficult to come to any firm conclusions
about the relative effectiveness of ICBT and GCBT’ P3 Scott
(2011)
• Panic disorder Sharp, Power and Swanson (2004) showed ICBT
and GCBT to be equally effective
• PTSD both modalities can be equally effective Beck et al
(2009)
• GAD both modalities can be equally effective Dugas et al
(2009)
• OCD ‘GCBT is an effective treatment for OCD but often, it
seems, less so than ICBT’p5 Scott (2011)
Group and Individual CBT Also Appear
Equally Effective for Bulimia
• Katzman et al (2010) concluded ‘outcome
differences between individual and group CBT
were minor, suggesting that group treatment
prefaced by a short individual intervention
may be a cost-effective alternative to purely
individual treatment’ Psychosomatic Medicine
72: 656-663.
Group based behavioural and cognitive-behavioral parenting interventions
are effective for reducing child conduct problems in 3-12 year olds
• See Furlong et al (2012) meta analyses of 13
trials. Cochrane Database Syst Rev
2:CD008225
• Parent training programmes were also found
to improve parental mental health
• Scott, M. J and Stradling, S. G (1987)
Behavioural Psychotherapy, 15: 224-39 The
evaluation of a group parent training
programme
If CBT is primarily about teaching
skills, it is an anachronism that
groups are the exception
We need to go beyond treating the tip
of the iceberg
Given that GCBT results in a
greater throughput of clients, it
is perhaps surprising that clients
predominantly undergo
individual CBT
Why then is GCBT such a rarity?
GCBT Has Not Been Encouraged In
Supervision
• In Simply Effective CBT Supervision Scott
(2013) London: Routledge, suggests that the
primary purpose of supervision is to act as a
conduit for evidence-supported treatments
• Until Supervisors take GCBT on board it is not
going to happen
• The same process skills that are used in GCBT
can be applied to group supervision
Is this the horror video that puts
therapists off running a group?
Perhaps we need to replace it by a reality
video, grounded in everyday experience?
Group CBT mirrors the everyday, but is
in addition educational
Assessing Clients for GCBT
Why bother?
Evidence-based GCBT
• Predominantly diagnosis specific
• Most compelling evidence for depression and
the anxiety disorders
• Very limited evidence that it is possible to
focus on more than one disorder within a
group
• Some evidence that can combine individual
and GCBT
Problems of Engagement
• If clients are given a free choice between GCBT
and ICBT the overwhelming majority 95%in Sharp
et al’s (2004) study of panic disorder clients will
opt for individual therapy
• Thompson et al (2009) found that factor half of
the people invited to consider attending a PTSD
group chose not to do so
• In a study of GCBT for OCD [O’Connor et al
(2005) ]38% of clients refused treatment in group
format
Making GCBT Tempting
‘You are not alone’ – classes and individual
tuition for your nerves in just three steps
Complete the
‘What’s up?
Questionnaire
Choose a Survival
Manual, have a
read to see how
someone just like
you has moved on
Join a class to go
into the Manual in
detail
Engagement
• Direct client access, phone call returned within on
average 8 hours, use of 7-Minute Interview to screen
for all common disorders, detailing of problems,
appointment for detailed inquiry with same therapist if
possible
• Face to face interview, detailed inquiry about positive
screens, personality problems
• Normalising distress ‘others with same problem we
teach special ways of handling this’
• Motivational ruler
• The ‘carrot’ of individual sessions
• Addressing comorbidity
The 7-Minute Interview Revised - Extract
1. Depression
Yes
No
Don’t know
During the past month have you
often been bothered by feeling
depressed or hopeless?
During the past month have you
often been bothered by
little interest or pleasure in doing
things?
Is this something with which you
would like help?
A positive response to at least one symptom question and the help question
suggests that detailed enquiry be made
The 7-Minute Interview Revised –
Further Extract
8. Substance abuse/dependence
Yes
No
Have you felt you should cut down on your
alcohol/drug?
Have people got annoyed with you about your
drinking/drug taking?
Have you felt guilty about your drinking/drug use?
Do you drink/use drugs before midday?
Is this something with which you would like help?
A positive response to at least two of the symptom questions and the help
question suggests that detailed enquiry be made.
Don't
know
Making a Diagnosis
1. The CBT Pocketbook, from Simply Effective Group CBT, is
used after first screening clients for possible disorders
2. For each disorder there are questions which directly
access each symptom in the DSM-IV-TR criteria
3. For a symptom to be regarded as present it must produce
clinically significant distress or impairment
4. When there is a need to reassess the client, the same
questions can be asked again to check progress
Screening for Personality Disorder
Only circle Y (yes) or N (no), in the case of question 3, if the client thinks that the
description applies most of the time and in most situations.
1. In general, do you have difficulty making and keeping friends? . . . Y/N
(yes = 1, no = 0)
2. Would you normally describe yourself as a loner? . . . . . . . . . . . . . . Y/N
(yes = 1, no = 0)
3. In general, do you trust other people?. . . . . . . . . . . . . . . . . . . . . . . . . Y/N
(yes = 0, no = 1)
4. Do you normally lose your temper easily? . . . . . . . . . . . . . . . . . . . . . Y/N
(yes = 1, no = 0)
5. Are you normally an impulsive sort of person? . . . . . . . . . . . . . . . . . Y/N
(yes = 1, no = 0)
6. Are you normally a worrier?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y/N
(yes = 1, no = 0)
7. In general, do you depend on others a lot? . . . . . . . . . . . . . . . . . . . . Y/N
(yes = 1, no = 0)
8. In general, are you a perfectionist? . . . . . . . . . . . . . . . . . . . . . . . . . . . Y/N
(yes = 1, no = 0)
In Simply Effective Group CBT suggested a score of 5 or more should be used to
exclude from GCBT
Assessing Motivation – Readiness for a Group
Please circle a number, on the ruler below, to indicate how ready you feel to
join a group of others with your difficulties, to learn new ways of handling
your problems.
No
1
2
Maybe
3 4
5
6
Yes
7 8
9
If you indicated a `No' or `Maybe' number above, what is it that puts you off
joining a group?
..............................................................
...............................................................
...............................................................
10
A Credible Rationale – Disorder Specific Survival Manual (freely
available at www.routledgementalhealth.com/simply-effective-groupcognitive-behaviour-therapy-978041557342)
• Clarifies the content of sessions – ‘we will be
working through the Manual’
• Normalises the client’s problems
• Individualises the client’s problems – ‘read
through see what resonates’
• Enhances self-efficacy by suggesting manageable
first steps
• Address
the
whole
range
of
client
concerns/diagnoses by the provision of a Manual
for each disorder
Extract of a Survival Manual - PTSD
3. Better ways of handling the traumatic memory
You have probably tried to blank the memory, distracting yourself by doing something
or talking to someone. Trouble is that that works only briefly. Here is why: supposing if
I said
`Do not think about the orangutan‘
Continuation of Extract from PTSD Survival Manual
As you continue to read you are still thinking of
orangutans (perhaps you think he looks like
somebody you know!). The more you try to
deliberately not think of something the more you
think about it.
Structure of a Group Session
1. Welcome over coffee/tea/fruit juice
2. Review of homework
3. Introduction of new material
4. Setting of individualised homework
incorporating new learning
General Group Therapeutic Skills
Rating Scale
1.
2.
3.
4.
5.
6.
7.
8.
9.
Review of homework/agenda
Relevance
Adaptation
Inclusion
Additional disorders
Magnifying support and minimising criticism
Utilising group members as role models
Therapist presentation skills
Addressing group issues
The Determinants of Effective GCBT
Depression Programme Extract
Mood Chart
Monitor
Mood –
how I am
feeling
now
Observe
thinking –
what I am
saying to
myself to feel
the way I feel
Objective
Decide what
thinking –a to do and do
better way of it – don’t
thinking
stew, get on
about it is
and do
Information Processing Biases
1. Dichotomous (black and white) thinking, e.g. `I'm either a total success or a
failure'.
2. Mental filter, focusing on the negative to the exclusion of the positive, e.g.
`how can you say it was a lovely meal, how long did we have to wait for the
dessert to be served?‘
3. Personalisation, assuming just because something has gone wrong it must
be your fault, e.g. `John did not let on to me coming into work this morning,
must have been something I said'.
4. Emotional reasoning, assuming guilt simply because of the presence of
guilt feelings, e.g. `I can't provide for the kids the way I did, I've let them
down, what sort of parent am I?'
5. Jumping to conclusions, e.g. assuming that being asked to have a word with
your line manager means that you are in trouble.
Contd.
Information Processing Biases contd.
6. Overgeneralisation, making negative predictions on the basis of one bad
experience, e.g. `I've had it with men after Charlie, you cannot trust any of
them'.
7. Magnifcation and minimisation, magnifying faults or difficulties, minimising
strengths or positives, e.g. `I am terrible at report writing and I am lucky to
have got good
appraisals for the last couple of years'.
8. Disqualifying the positives, e.g. brushing aside compliments and dwelling
on criticism.
9. `Should' statements, overuse of moral imperatives, e.g. `I must do . . . I
should . . . I
have to . . .'.
10. Labelling and mislabelling, e.g. `if I make a mistake I am a failure as a
person'.
Dissemination
• See one
• Assist with one
• Do one
The Advantages of Having A Co-leader
• It is possible to run a group with a sole therapist but it
is easier with a co-leader
• With two therapists one of you is likely to be able to
take over if the other becomes stuck
• If one group member is having particular difficulty e.g
becomes too distressed to focus on the content of the
session, the co-leader can take him/her to one side
• It is easier to individualise homework assignments with
two therapists
• It is easier to address co-morbidity outside the session
• Having a co-leader is an aid to dissemination
Working Synergistically
with a Co-leader
• Both therapists need to agree in advance who is
doing what
• Therapists can give each other feedback on their
performance
• Both can troubleshoot how to resolve difficulties
in the group
• It is useful for the two therapists to sit opposite
each other
• It can be useful to have a therapist sit next to a
particularly troublesome group member
Addressing Comorbidity
Most clients have more than one disorder,
additional disorders can be addressed by
telephone/email/texts between sessions using
the pertinent Survival Manual or other self-help
materials
Diversity in Group Approaches
• Group interventions have focussed exclusively on closed i.e timelimited groups, the only exception to this is the Sobell, Sobell and
Agrawal (2009) open group for addicts. The rationale Sobell and
colleagues give for this is that addiction is a chronic condition,
rather like diabetes and there will always be a need to revisit the
problem and that this is different to acute conditions like
depression, OCD.
• Scott and Stradling (1990) offered up to three individual sessions
running alongside the depression group
• Katzman et al (2010) offered four individual sessions before the
eight session group programme for bulimia. Further they
broadened the diagnostic criteria for bulimia to include clients who
met diagnostic criteria for Eating Disorder Not Otherwise Specified.
‘Mixed Groups?’
• A single focus on what is common in the group helps group
cohesion
• Groups are easier if they are homogenous – if too many disorders
are the focus there is a danger of not addressing any one disorder
in sufficient depth. Arch et al (2013) [BRAT 51, 185-196] ran a CBT
group admitting all clients who were troubled most by any anxiety
disorder, only half (57%) completed treatment and only half (53%)
showed a reliable and clinically significant change by the end of
treatment.
• But there is some evidence that a limited transdiagnostic approach
e.g panic disorder/social phobia Norton (2007) can work
How Important is Group Process?
• GCBT studies have been conducted without an
explicit focus on group process, but this does not
mean that therapists were not mindful of them,
for example would not go out of their way to
include a group member who seemed to take up
little ‘air-time’
• GCBT may work for reasons other than the same
material delivered in individual format
• We do not know the relative importance content
and process, intuitively they seem both important
Improving Access to GCBT
•
•
•
•
•
Where are we now?
Where do we want to get to?
How do we nudge GCBT onto the agenda?
What would be the first step?
What obstacles are there in the way of
completing the first step?
• How might we step around the first obstacles?
• How will we ensure that we keep moving
forward?
Danish Group CBT for Bulimia Study
• Jones and Clausen (2013) Int J Eating Diord
• 8 session GCBT
• Significant reductions in eating disorder
pathology were found on all measures of
bulimia related behavioral symptoms, as well
as on all measures of bulimia related distress
On the 200th Anniversary of the birth of
Soren Kierkegaard, Danish Philosopher, some of his quotes –
I think he got there before CBT!
• ‘To dare is to lose one’s footing momentarily. Not
to dare is to lose oneself’
• ‘Our life always expresses the result of our
dominant thoughts’
• ‘Don’t forget to love yourself’
• ‘A man who as a physical being is always turned
toward the outside, thinking that his happiness
lies outside him, finally turns inward and
discovers that the source is within him’