The Theory and Practice of Group Psychotherapy (100 page)

Cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) were originally constructed, described, and empirically tested in individual therapy,
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but both now are used as brief group therapy interventions. Readers will no doubt find many concepts in these next pages familiar, although with different terminology attached.†

It is important not to be misled by labels. A recent review of the current literature on group therapy for women with breast cancer noted that many of the groups identified as CBT were in fact integrative models that synthesized contributions from multiple models.
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This important finding is by no means the exception: it is often the case that effective, well-conducted therapy of purportedly different ideological models shares more in common than good and bad therapy conducted within the same model. One of the major conclusions of the encounter group study reported in chapter sixteen was exactly that:
the behavior of the effective therapists resembled one another far more than they resembled the other (less effective) practitioners of their own ideological school.
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Cognitive-Behavioral Group Therapy

Group CBT (also referred to as CBT-G) arose from the search for greater clinical efficiency. Cognitive-behavioral therapists used the group venue to deliver individual CBT to a large number of clients simultaneously. Note this important and fundamental difference.
CBT therapists were using groups to increase the efficiency of delivering CBT to individual clients, not to tap the unique benefits inherent in the group arena I have emphasized throughout this text.
At first, cognitive-behavioral therapists had a narrow focus: they wanted to provide psychoeducation and cognitive and behavioral skill training. What about peer support, universality, imitative behavior, altruism destigmatization, social skills training, interpersonal learning? They were considered merely backdrop benefits. What about the presence of group process, cohesion, or phases of group development? They represented noise in the system, often interfering with the work of delivering CBT: in fact, some therapists raised concern that the group format diluted the power of CBT.
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We have passed now into a second generation of more sophisticated CBT group applications, in which the essential elements of group life are being acknowledged and productively utilized by CBT group therapists.
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Today the task of the group and the relationships of the members within the group are not considered antagonistic.

The CBT approach postulates that psychological distress is the result of impaired information-processing and disruption in patterns of social behavioral reinforcement.
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Although thoughts, feelings, and behaviors were known to be interrelated, the CBT approach considered one’s thoughts in particular to be central to the process. Often automatic and flying beneath the radar of one’s awareness, one’s thoughts initiate alterations in mood and behavior. CBT therapists attempt to access and illuminate these thoughts through probing, Socratic questioning, and the encouragement of self-examination and self-monitoring.

Once automatic thoughts that shape behavior, mood, and sense of self are identified, the therapist initiates an exploration of the client’s conditional beliefs—“if this happens, then that will follow.” These conditional beliefs are then translated into hypotheses that the client systematically tests by acquiring actual evidence that refutes or confirms the beliefs. This testing leads to further identification of the client’s core beliefs, those that reside at the center of the individual’s view of self.

What type of core beliefs are uncovered? Core beliefs fall into two main categories—relationships and competence. “Am I worth loving?” and “Can I achieve what I need to confirm my worth?” Interpersonally oriented therapists have noted that both core beliefs are strongly interpersonal at their center.
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Once these dysfunctional core beliefs (for example, “I am entirely unlovable”) are identified, the next objective of treatment is to restructure them into more adaptive and self-affirming beliefs.

Group CBT has been applied effectively to an array of clinical conditions: acute depression,
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chronic depression,
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chronic dysthymia,
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depression relapse prevention,
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post-traumatic stress disorder (PTSD),
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eating disorders,
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insomnia,
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somatization and hypochondriasis,
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spousal abuse,
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panic disorder,
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obsessive compulsive disorder,
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generalized anxiety disorder,
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social phobia,
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anger management,
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schizophrenia (both for negative symptoms such as apathy and withdrawal, and, positive symptoms such as hallucinations),
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and other conditions, including medical illnesses.

Substantial and durable benefits have been reported in all these applications. Group CBT has been found to be no less effective than individual CBT, and it does not have a higher rate of premature termination of therapy. Exposure-based group treatment for PTSD, however, does have a greater frequency of dropouts. Group members are often so overwhelmed by exposure to traumatic memories that a brief format is not feasible, and desensitization must be conducted over a considerable period of time.
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The application of CBT in groups varies according to the particular needs of the clients in each type of specialty group, but all share certain well-identified features.
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Group CBT is homogeneous, time limited, and relatively brief, generally with a course of eight to twelve meetings that last two to three hours.
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Group CBT emphasizes structure, focus, and acquisition of cognitive and behavioral skills. Therapists make it clear that group members are each accountable for advancing their therapy, and they assign homework between sessions. The type of homework is tailored to the concerns of the individual client. It might involve keeping a log of one’s automatic thoughts and how these thoughts relate to mood, or it might involve a behavioral task that challenges avoidance.

The review of the homework is a key component of each group meeting and represents a key difference between group CBT and interactional group therapy, in that it substitutes “cold processing” of the client’s athome functioning for the “hot processing” that typifies interactional group therapy.
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In other words, the group focuses on clients’ descriptions of their back-home functioning rather than on their real-time functioning in the here-and-now interaction.

Measurement of clients’ distress and progress through self-report questionnaires is ongoing, providing regular feedback that either supports the therapy or signals the need to realign therapy.

The group CBT therapist makes use of a set of strategies and techniques, in various combinations, that clients employ and then discuss together in the group.
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These interventions deconstruct the clients’ difficulties into workable segments and combat their tendency to generalize, magnify, and distort. For example, clients are asked to:

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Record automatic thoughts
. Make overt what is covert; link thoughts to mood and behavior. For example, “I will never be able to meet anyone who will find me attractive.”

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Challenge automatic thoughts.
Challenge negative beliefs; identify distortions in thinking; explore the deeper personal assumptions underlying the automatic thoughts. For example, “How can I actually meet people if I keep refusing invitations to go out for drinks after work?”

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Monitor mood.
Explore the relationship between mood and thoughts and behaviors; for example, “I think I started to feel lousy when no one invited me for lunch today.”

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Create an arousal hierarchy.
Rank anxiety-generating situations that are to be gradually confronted, building from easiest to hardest. For example, a client with agoraphobia would rank the venues that create anxiety from the easiest to the most challenging. Going to church on Sunday morning with a spouse might be at the low end of arousal. Going shopping alone at a new mall at night might be at the high end of arousal. Ultimately, gradual exposure desensitizes the client and extinguishes the anxious and avoidant response.

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Monitor activity.
Track how time and energy are spent. For example, monitoring how much time is actually lost to rumination about work competence and how that in turn interferes with completing required tasks.

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Problem-solve.
Find solutions to everyday problems. Therapists challenge clients’ belief in their incompetence by breaking a problem down into instrumental and workable components.

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Learn relaxation training.
Reduce emotional tension by progressive muscle relaxation, guided imagery, breathing exercises and meditation. Generally a meeting or two is devoted to training in these techniques.

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Perform a risk appraisal.
Identify the source of clients’ sense of threat and the resources they have to meet these threats. This might include, for example, examining the client’s belief that his panic attack is actually a heart attack and reminding him that he can use deep breathing to settle himself effectively.

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Acquire knowledge through psychoeducation.
This might include, for example, education about the physiology of anxiety.

The group CBT treatment of social phobia is representative.
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Each group consists of five to seven members and meets for twelve sessions of two and a half hours each. An individual pregroup or postgroup meeting may be used in some instances. Each meeting has a beginning agenda and check-in, a middle working phase, and an end-of-session review.

The first two sessions address the clients’ automatic thoughts regarding situations that evoke anxiety, such as “If I speak up, I will certainly make a fool of myself and be ridiculed.” Skills are taught to challenge these automatic thoughts and errors in logic. For example: “You assume the worst outcome possible and yet when you voice your concerns here, you have been repeatedly told by others in the group that you are clear and articulate.” Alternative ways of making sense of the situation are encouraged.

The middle sessions address each individual’s target goals, using homework, in-group role simulations, and behavioral exposure to the source of anxiety. The last few sessions consolidate gains and identify future situations that could trigger a relapse. Thus the entire sequence consists of identifying dysfunctional thinking, challenging these thoughts, restructuring thoughts, and modifying behavior.

Group Interpersonal Therapy

Individual interpersonal therapy (IPT), first described by Klerman and colleagues,
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has recently been adapted for group use. In the same way that CBT views psychological dysfunction as a problem of information processing and behavioral reinforcement, IPT views psychological dysfunction as a problem based in one’s interpersonal relationships. As the client’s social functioning and interpersonal competence improve, the client’s disorder—for example, depression or binge eating—also improves. This occurs with little specific attention to the actual disorder other than psychoeducation about its nature, course, and impact.†

Group IPT (sometimes referred to as IPT-G) emphasizes the acquisition of interpersonal skills and strategies for dealing with social and interpersonal problems.
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Group applications of IPT emerge not only from the drive toward greater efficiency but also from the recognition of the therapeutic opportunities group members can provide one another in addressing interpersonal dysfunction. The first group IPT application was developed for clients with binge eating disorder, but recent applications have addressed depression, social phobia, and trauma.
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It has been used effectively as a stand-alone treatment and conjointly with pharmacotherapy, either concurrently or sequentially.
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Its applicability has also been demonstrated in another culture (in Uganda), and it has the potential to be taught effectively to trainees who have little psychotherapeutic background.
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Group IPT closely follows the individual IPT model. A positive, supportive, transparent and collaborative client-therapist relationship is strongly encouraged. Each client’s interpersonal difficulties are ascertained beforehand in an intensive evaluation of relationship patterns and categorized into one or two of four main areas: grief, role disputes, role transitions, or interpersonal deficits. Self-report questionnaires may be used to refine the client’s focus and to measure progress. The most commonly used self-report measurements address the client’s chief areas of distress—mood, eating behaviors, or interpersonal patterns.† One to three goals are identified for each client to help focus the work and to jump-start the group therapy.