Copyright © 1998 Elsevier Science Ltd. All rights reserved.
6.15 Group Therapy: A Cognitivebehavioral Interactive Approach SHELDON D. ROSE University of Wisconsin±Madison, WI, USA 6.15.1 INTRODUCTION
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6.15.2 THE IMPLICATION OF THE GROUP IN CBIGT
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6.15.3 THERAPIST ACTIVITIES IN CBIGT
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6.15.3.1 6.15.3.2 6.15.3.3 6.15.3.4 6.15.3.5
Pregroup Planning Orientation to Group Therapy Assessment Intervention Generalization
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6.15.4 INTERVENTION STRATEGIES USED IN CBIGT
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6.15.4.1 Systematic Problem-solving 6.15.4.2 The Modeling Sequence 6.15.4.3 Cognitive Change Methods 6.15.4.3.1 Cognitive restructuring 6.15.4.3.2 Self-instructional training 6.15.4.4 Relaxation Methods 6.15.4.5 Reinforcement and Stimulus Control 6.15.4.6 Small-group Procedures 6.15.4.6.1 Role-playing 6.15.4.6.2 Subgrouping 6.15.4.6.3 Buddy system 6.15.4.6.4 Group exercises 6.15.4.6.5 Group feedback 6.15.4.7 Identifying and Resolving Group Problems 6.15.4.8 Phases of Group Development 6.15.4.9 Integrating Diverse Intervention Strategies in CBIGT
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6.15.5 SUMMARY AND CONCLUSION
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6.15.6 REFERENCES
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6.15.1 INTRODUCTION
are many types of group therapy, one of which makes use primarily, though not exclusively, of cognitive and behavioral procedures. The purpose of this chapter is to describe the rationale for, review research concerning, and present one general approach and the techniques commonly applied in this form of group therapy primarily for adults. Unfortunately, in the existing literature, the role of the group is
Group therapy is widely used as the context of treatment for patients with a variety of problems and concerns. In a recent survey of mental health providers in a middle-sized American city, it was noted that 72% of the providers made the option of group therapy available to their patients (Rose, 1998a). There 319
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rarely explicated (see Rose, Tolman, & Tallant, 1985, for a review of the cognitive-behavioral group therapy literature until 1984). Because of this neglect the potential use of the group as a set of interventions in itself in administrating cognitive and behavioral procedures is described in this chapter. Because the approach lends itself to evaluation and specific description of its primary intervention, assessment, and generalization strategies, cognitivebehavioral group therapy appears to be growing in popularity among practitioners and patients. Its relevance in particular for women has been described by Wolfe (1987) and for minorities in studies by La Framboise and Rowe (1983) and Comas-Diaz and Duncan (1985). Cognitive-behavioral group therapy (CBGT) refers to an approach that occurs in groups and makes use of behavioral (e.g., modeling and reinforcement), cognitive (e.g., cognitive restructuring, self-instructional training, problemsolving), relational change methods, and group procedures to enhance the coping skills of the participants and to resolve or ameliorate relational problems they may be experiencing. Coping skills refer to that set of behaviors and cognitions which facilitate adaptation to stressful or problematic day-to-day situations. Some coping skills which participants learn in CBGT are systematic problem-solving, relaxation, meditation, imagery, techniques for ªdecatastrophizing events,º correcting other cognitive distortions, being appropriately assertive, distancing or objectifying one's pain or strong emotions, communication skills in dealing with others, negotiation, and making more effective use of social networks and increasing socialrecreational skills. Many of these skills are both target behaviors and a means of intervention for learning more specific target behaviors. Group treatment approaches in general when compared with individual approaches seem to fare favorably. A meta-analysis (Toseland & Siporin, 1986) reviewing all group vs. individual therapy comparisons (many of which were cognitive and behavioral) showed evidence that groups are at least as effective and sometimes more effective than individual treatment and more efficient in that more patients can be dealt with effectively for the same cost. This finding was confirmed by Tilliski (1990) who used only those studies from the Toseland and Siporin review that contrasted group, individual, and a control group. In all cases, regardless of theory or problem focus, there was no difference between treatments and significant differences between treatment and the control group. Since that time several studies involving CBGT have appeared which also support the equivalency of individual and group therapy and their greater
effectiveness than control groups in the treatment of a variety of presenting problems. For example, Spence (1991) demonstrated that CBGT was equivalent to individual cognitivebehavioral therapy and both were more effective than a wait-list control in the treatment of chronic occupational pain. Oneytt and Turpin (1988) found that a six-week cognitivebehavioral group treatment was more effective than a control group but equivalent to individual general practitioner appointments in the reduction of benzodiazepine use and anxiety. All changes were maintained at 15week follow-up. The results are confounded somewhat by the fact that the general practitioner may not have used cognitive-behavioral methods. Teri and Lewinsohn (1986) also found that both individual and group behavioral treatment were equivalent and both were more effective than a wait-list control in the treatment of patients with moderate depression. Support for the effectiveness of CBGT has also been demonstrated in studies in which CBGT was compared to wait-listed and other approaches. When Wolf and Cowther (1992) compared CBGT with behavioral treatment for 41 bulimic women, both were more effective than an extreme weight control method in terms of reduced bulimic tendencies. CBGT was also more effective than the behavioral treatment measures in the treatment reduction of severity of psychopathological symptoms and preoccupation with dieting. Lee and Rush (1986) had similar results with 30 bulimic patients. Those receiving five weeks of CBGT reduced their binging and purging behavior significantly more than those in a wait-list control group. However, only four of the CBGT patients showed a full remission of the binging and purging behavior. When Bottomley, Hunton, Roberts, and Jones (1996) compared nine patients in CBGT to a eight patients in social support group and to 14 ªdeclinersº for newly diagnosed and psychologically stressed cancer patients, they found that the CBGT patients significantly improved their coping styles in comparison with the other two conditions. At three-months follow-up, the differences washed out possibly because two CBGT patients had died. Ehlers, Stangier, and Gieler (1995) compared cognitive and behavioral methods carried out in groups with intensive or standard dermatological treatment. They found that the behavioral treatments for atopical dermatitis resulted in significant improvement in skin condition and in topical steroids used when compared to dermatological condition alone, at one-year follow-up. Once again, the group factor and the behavioral methods were confounded in the experimental condition.
The Implication of the Group in CBIGT Fals-Stewart, Marks, and Schafer (1993) compared a behavioral group therapy condition (n=30) consisting of group exposure and response prevention with an individual therapy condition (n=31) using the same methods and a relaxation control condition (n=32). The subjects were randomly assigned to the conditions. Patients in all three conditions showed stress reduction at the end of treatment, but only in the behavioral conditions were the gains significantly maintained at the six-month follow-up. Lutgendorf, Antoni, Ironson, and Klimas (1997) tested the effects of a 10-week cognitivebehavioral group stress management program on mood and immunologic parameters in HIVseropositive gay men whose disease had progressed to a symptomatic stage. The patients were randomly assigned to the CBGT (n=14) or a wait-list control group (n=12). At the end of the 10 weeks patients in the CBGT condition significantly decreased self-rated dysphoria, anxiety, and total distress. The intervention also decreased Herpes simplex virus-type 2 (Hsv-2) immunoglobulin G antibody titers. No such changes were found in the control group. There was no follow-up measurement. Subramanian (1991) found that 39 chronic pain patients in eight weekly sessions of CBGT improved significantly more than a wait-list control (n = 20) in the areas of physical and psychosocial dysfunction, but showed no difference in the experiencing of pain. Group strategies as well as cognitive-behavioral strategies were described in this study. However, in a follow-up study, Subramanian (1994) found that the gains of a subsample that could be located were not maintained. However, no specific steps in and after the therapy program had been taken to achieve maintenance. Patients in CBGT in a number of before and after multiple cases without control groups have consistently shown significant change over time and for the most part these changes were maintained 2±3 months following treatment. These studies include coping with generalized anxiety (Lindsay, Gamsu, McLaughlin, Hood, & Espie, 1987; Power, Simpson, Swanson, & Wallace, 1990), adaptation problems of recently divorced women (Graff, Whitehead, & LeCompte, 1986), managing one's depression (Abraham, Neundorfer, & Currie, 1992), social phobia (Enright, 1991), obsessive-compulsive disorders (Krone, Himle, & Nesse, 1991; Van Hoppen, Rassmussen, & Eisen, 1991), insomnia (Kupych-Woloshyn, MacFarlane, & Shapiro, 1993), and a heterogeneous population of 531 patients suffering from various psychiatric problems in intensive CBGT at a private psychiatric clinic (Manning, Hooke, Tannenbaum, & Blythe,1994).
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Although each of the above researchers treat the given problem area in groups using cognitive-behavioral and/or behavioral intervention strategies, most use different combinations of these techniques and, as already mentioned, a few describe specific uses of groups in the treatment process such as member modeling and building cohesion of the group. In summary, modest support for CBGT can be identified. Usually in the control group and databased case studies, the group factor and the cognitive-behavioral techniques are confounded, thus making interpretation of the findings unclear as to whether group or the cognitive-behavioral strategies are the major causes of change. Because of the variations mentioned above, different kinds of cognitive-behavioral approaches to CBGT exist. Some primarily rely on cognitive, relaxation, relational, and didactic procedures, while others integrate with the cognitive procedures extensive behavioral methods such as modeling and reinforcement into the treatment program. Only a few make specific uses of the group. Because of our clinical and research experience with a model of CBGT that incorporates group techniques into treatment, the purpose of this chapter is to present a cognitive-behavioral model that indeed makes use of the group. In this chapter the specific model that includes the extensive use of group methods and a focus on group variables that impinge on outcome along with the use of cognitive-behavioral procedures is referred to as cognitive-behavioral interactive group therapy (CBIGT), while CBGT refers to all group models using cognitive-behavioral methods, whether explicit use of the group has been determined or not. 6.15.2 THE IMPLICATION OF THE GROUP IN CBIGT Originally the group was used in therapy because of its convenience and efficiency in treating more than one or two people at the same time. As many scholars of group therapy have noted, it has a number of other advantages (e.g., Yalom, 1985, p. 3). Improved opportunities for assessment is a major contribution of therapy in groups. The group therapist has the opportunity to observe live interactions as opposed solely to second-hand accounts of interactions and make solid conclusions as to social skill strengths and deficiencies. He or she can hear the cognitive distortions typical of many patients being played out in the group. This is possible only insofar as there is broad participation among the patients which is the focus of many interventions in CBIGT.
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The group provides the patient with a source of feedback about those behaviors which are irritating or acceptable to others and about those cognitions which can be viewed as distorted or dysfunctional. In CBIGT, participants are trained to help each other be concrete in the formulation of problem situations and the cognitive, emotional, and behavioral responses of the patient to those situations and to identify specific goals towards which intervention is aimed. Another advantage of using the group in CBIGT is the frequent and varied opportunity for mutual reinforcement which for patients is often far more powerful than reinforcement by the therapist only. Each patient is given the chance to learn or to improve his or her ability to mediate rewards for others in social interactive situations (with acquaintances, friends, family members, acquaintances in other groups, fellow therapists, or employer). The group therapist in CBIGT creates situations in which each patient has frequent opportunities, instructions, and rewards for reinforcing others in the group. In CBIGT, special exercises have been designed to train patients specifically in mutual reinforcement, and often extragroup tasks (homework) are used to encourage them to practice reinforcement skills in the real world. High levels of reinforcement, among other techniques, contribute to the cohesion of the group. As Yalom (1985, p. 49) argues, group cohesion is the equivalent in groups to relationships in individual treatment. At least in the early phase of therapy, cohesion must be high if other methods are to be maximally effective. If cohesion is high, the group creates the opportunity for the group therapist to mobilize the members to use of a wide variety of coping skill training procedures that are either unavailable or less efficient in the therapeutic dyad. For example, the most effective way of systematic problem-solving is in the group. In the ªbrainstormingº phase of problem-solving, the multiplicity of patients and patients' experiences results in numerous ideas and suggestions. The group also provides a large number of models, role-players for behavioral rehearsal, manpower for monitoring, and partners for use in a ªbuddy system.º In CBIGT, as well as most other CBGT models, members are expected to carry out homework or extragroup tasks which are cognitive, behavioral, or both, to practice what they have learned in the group. Much of the program in CBIGT is designed to prepare the members for completing those tasks. If appropriate norms are established, the group serves to enhance the design through group feedback and mutual supervision in subgroups, and to
reinforce the completion of extragroup task completion if the members report publicly at the beginning of the following session what they did for their task during the week. Negotiating rather than assigning homework tasks in CBIGT and the use of extensive feedback from members and brainstorming increases the power of the members and reduces the excessive didactic quality of many other models of CBGT. Specific questions on weekly postsession questionnaires (see Table 1) keeps the therapist in touch with the group's evaluation of their own participation and power in the group. Finally, Yalom (1985, p. 14) points out the importance of helping others (altruism) in facilitating therapy in groups. Although he refers to insight-oriented group therapy, the same appears to be true for CBIGT provided that the therapist creates conditions which permit patients to help each other. In this way the participant is not only a patient, he or she is also a co-therapist±teacher within the given structure. This appears to increase the participant's sense of self-efficacy or the belief that he or she can perform in such a way as to achieve a desired outcome (Bandura, 1977). Yalom (1985, p. 8) also reminds the reader of the principle of universality. Patients experience that they are not the only person with the given problem, as serious as it may be. Of course, groups are not without disadvantages. The time allotted to each individual is drastically reduced in most groups compared to individual treatment. Thus, individualization of patients may suffer. If the group process is utilized in treatment, the amount of material covered is less than when the group process is ignored. In addition, it is difficult to assure the patients of the confidentiality of their comments, even though the therapist emphatically points out its importance. For this reason, some individuals in group therapy are less likely to self-disclose relevant material than they would in individual therapy. However, many others are encouraged by the modeling of other members to self-disclose more readily. Usually as the group progresses, interpersonal trust increases, and the patients become more comfortable with selfdisclosing significant concerns. Another danger of CBGT is its tendency to become excessively didactic because of the amount of material to be disseminated. This didactic quality may reduce the cohesion of the group and reduce the benefits which might otherwise ensue. Also, the opportunity for altruistic activities is diminished. For this reason, in CBIGT group therapists are encouraged as early as possible to create conditions that maximize patient participation and self-determination. The use of small group
The Implication of the Group in CBIGT Table 1
Example of a postsession questionnaire.
code name±±±±group name±±±±date±±±± 1. How useful was this session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 2. How actively involved were the members in today's session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 3. How helpful were members to each other during this session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 4. How much did the members reveal about themselves (their real thoughts, feelings, motivations, and or concerns) during this session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 5. How bored or tired looking were the members during this session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 6. How close did the members feel to each other during this session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 7. How upset or angry were the members during this session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 8. How task oriented were the members during this session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 9. How important were the problems the group worked on in this session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 10. How much did the members control the content and direction of this session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 11. How much conflict was there during this session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 12. To what degree were the goals of the session acheived? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 13. How anxious were you during this session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 14. How prepared were you for this session? 1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9 not at all very little somewhat quite a bit extremely 15. What specifically did you find useful in todays session? 16. What specifically did you find unhelpful in todays session?
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exercises especially in subgroups (see Rose, 1997, for a description of most of these) also enhances broad participation. 6.15.3 THERAPIST ACTIVITIES IN CBIGT One cannot merely assume that if a problem and the appropriate coping skills are identified, one can then intervene at any time in the therapeutic process with the best techniques available and help the patient to solve it. In CBIGT just as in other group therapies, one can identify a number of sets of activities each of which is linked to unique and overlapping therapist functions. They are somewhat overlapping in time and in content. Differentiating these sets is useful insofaras each set of activities provides a guide for the group therapist as to when emphasis should be shifted. These include a pregroup planning, an orientation, an assessment, an intervention, a generalization and termination, and a postgroup set of activities. 6.15.3.1 Pregroup Planning In planning for therapy, the CBIGT therapist must establish the group's purposes, assess potential membership, recruit members, decide on the group social environment or structure, and create the group's physical environment. In determining the group's purposes, the group therapist can draw on several sources. Based on experience with patients in the agency or community, the agency may have identified a need for a certain type of program. Patients may have been requesting help for certain types of problems for which help is not generally or readily available. To the degree that these needs can be translated into behavioral or cognitive responses to identifiable problematic situations, the CBIGT approach can be considered. Decisions must be made as to the theme of the group, group size, number of therapists, frequency and length of sessions, a sufficient number of candidates for the group, and group composition. In citing the literature above, it appears that most cognitive-behavioral groups have a theme, that is, all patients in the group have similar problems. A few practitioner±researchers (e.g., Flowers & Schwartz, 1985; Manning et al., 1994) also use CBIGT to deal with more heterogeneous groups (i.e., groups consisting of persons with diverse presenting problems) with positive results. Many of the homogeneous groups, although comprising members who have similar presenting problems, are diverse in terms of race, gender, and ethnic background, although in most of the reports from the
literature the groups are predominantly White middle class. Some groups are homogeneous in terms of gender and race. Some single case research and descriptions of clinical experience point to the efficacy of CBGT (although not necessarily CBIGT) approach with Hispanics (see Comas-Diaz & Duncan, 1985), Native Americans (La Framboise & Rowe, 1983; Schinke & Singer, 1994), and economically disadvantaged depressed women (Azocar, Miranda, & Dwyer, 1991). Wolfe (1987) makes use of all-women groups because consciousness raising is a component of the CBGT model she employs. Wolfe (1987) asserts that CBGT and in particular, rational emotive therapy in groups, seem to come the closest to meeting the criteria for feminist therapy. Sometimes allwomen groups exist by default rather than by plan as in the case of many parents groups or groups of depressed persons where only women sign up. All-men groups in CBGT can be found for male abusers, anger management groups in prisons, and men who are HIV positive. At least two kinds of basic organization for therapy groups can be identified. The first is open-ended groups in which new group participants come at any time in the history of the group and leave at any time. These are usually found in institutions although some community groups are organized in this way as well. It is a more common model with support groups than CBGT groups. The model duration of most open-ended groups is approximately a year, although some groups may go on for much longer. However, participants may stay for any length of time, and they often come and go sporadically. The session length varies from one to two hours. The second type of organization is closed groups which have a fixed beginning and fixed end-date for all participants. Most of the available research is on this type of group and most cognitive-behavioral community groups are closed. Although there are many exceptions, most closed groups last from 6±16 sessions once a week for one and a half to two hours. The modal number is eight. Experience indicates that 12±16 sessions are required to achieve complex or multiple goals. There is usually only one group therapist except in training situations. The size of the groups varies from as few as four to as many as 20 participants. However, with adults the modal number is eight, which permits participation by everyone at any given session and provides a wide variety of ideas and experiences. Most CBGT groups are sponsored by social agencies, clinics providing mental health services, schools and colleges, social welfare agencies, and private practitioners.
Therapist Activities in CBIGT 6.15.3.2 Orientation to Group Therapy As part of recruitment and later during the first group sessions, members are oriented to the purposes of the group, the methods to be used, the potential goals that can be achieved, and the importance of keeping what goes on in the group confidential. An overview of the group activities and expectations are presented and discussed. As part of orientation, group contracts are often developed; these contracts establish what the patients can expect from the group therapist and the agency and what the members can be expected to do. These contracts are often in writing. Patients are also oriented to the basic assumptions underlying each of the treatment techniques used. In this way not only do patients know what is happening to them, expectations of positive outcomes can be stimulated. In orientation, the therapist in CBIGT also introduces the patients to the use of the group as a vehicle of treatment. The use of subgroup exercises (Rose, 1997) are also initiated. The therapist draws on patient experience to orient members to the assumptions of the approach. Broad group discussion is encouraged by means of assigned tasks in subgroups and/or in exercises, which is the first step taken to enhance group cohesion. Other means of building group cohesion are by using introductory exercises in which members interview each other, keeping the tone and interaction of the group positive, encouraging others to provide frequent mutual reinforcement, noting similarities as well as differences among members in terms of background and presenting concerns, keeping the group small, providing occasions for the patients to help each other, permitting and encouraging physical movement during the session, using humor, using role-playing, providing variation in program and program media, and providing or having the members provide refreshments (see Rose, 1989, pp. 250±251, for additional detail.). One can also develop cohesion by enhancing the motivation of the members. Groups can serve to develop motivation primarily if the group therapist takes specific actions (see Miller & Rollnick, 1991, for a discussion of these principles in more detail as they apply to the individual therapy of people who abuse drugs and alcohol). In the first place the therapist should accept and encourage the patients to treat ambivalence or reluctance to participate as normal phenomena. No pressure is placed on the participants initially to change or to get out of ªdenialº either by the therapist or the other group members. The members are encouraged
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to review the advantages of the problem state as well as the disadvantages and to weigh the relative merits of changing or not changing. The patients are taught to identify motivational statements made by one another and to reinforce each other as they occur. Throughout the process the therapist makes ample use of empathic statements which are often emulated by the members with each other. The level of motivation is an ever changing process and requires constant attention by both therapist and group members. 6.15.3.3 Assessment Assessment is a concept central to all empirical approaches. The purpose of assessment is to determine the specific targets of interventions and the specific coping skills to be learned, in such a way as to make them amenable to intervention, the situations in which these coping skills and other target behaviors should be applied, the social and material resources of each patient that might impinge on treatment, and the potential barriers to effective treatment. It has the additional purpose of determining whether the given group or another type of therapy might be the most appropriate setting for each potential patient. Finally, it forms the basis for establishing treatment goals. The goals of CBIGT may be changes in the level of intensity of specific behaviors or an increase of more general adaptive coping behaviors. Among those specific target behaviors that patients have worked on in CBIGT and on which research exists have been mentioned earlier. These include reducing the extent or intensity of agoraphobia, social phobia, mood swings, obsessive-compulsive behaviors, smoking, alcohol and drug abuse, binging and purging, stress reduction, anger responses, and pain responses. Positive targets involve sleeping regularly, specific ways of making and keeping friends, increasing social activities, making more effective use of the patient's social network, improving relationships and communication skills. Another set of target phenomena are the development of coping skills which mediate resolution of the target behavior. Two kinds of coping skills can be identified, cognitive and behavioral. Cognitions refer to thoughts, images, thinking patterns, self-statements, expectations, or other private or covert events which may be inferred from verbal or other overt behavior. Cognitive coping skills are those cognitions which facilitate coping with internal and social phenomena. Examples are skill in analyzing
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one's own cognitions, in labeling appropriately one's self-defeating self-statements, in observing and rehearsing new, more appropriate selfstatements, and in reinforcing oneself covertly. Though important skills in their own right, some cognitive coping skills also mediate the attainment of the more observable social skills and other behaviors mentioned above or other coping behaviors. Thus, the goal of increasing cognitive coping skills is important as a means of reducing the frequency of anxiety-inducing and behavior-inhibiting cognitions, in diminishing the intensity of anxiety, and in improving social behavior (Beck & Emery, 1985; Meichenbaum, 1977). Self-statements, such as ªeveryone thinks I'm strange,º not only may produce anxiety, but promote inaction or selfdefeating action. Changing such self-statements to something like ªSure, I'm different than others in many ways, some things I like and some I'll changeº may reflect a more accurate appraisal, may suggest avenues of change, is more self-respecting, may reduce anxiety, and ultimately should improve social behavior. In order to teach these coping skills, assessment involves having the patients examine each others cognitions in the situational analysis of stressful or anger-inducing situations. Checklists (e.g., see Piacentini, 1993, for a description of most of these) are also used: keeping track of one's cognitions with such procedures as Beck's (1976) three-column technique in which the patient records in the first column an anxiety- or anger-producing situation; in the second, his or her automatic thoughts or thinking errors; and in the third, types of errors found in these thoughts. These are then shared with other members of the group. Another set of cognitive coping skills is the problem-solving sequence described earlier (D'Zurilla, 1986). In assessment, the therapist determines the patterns of problem-solving of each of the patients by means of the social problem-solving inventory (D'Zurilla & Nezu, 1988). Simulated problems can also be presented to the group for the members' solutions. The therapist can observe the process. Those who are either impulsive or chaotic problemsolvers would profit from being able to approach problem situations in a careful, step-by-step, analytic, and planful way. Self-management refers to those cognitive coping skills by which patients control their own environment as a means of controlling their own behavior. Procedures such as the use of environmental cues, self-monitoring, selfinstruction, self-modeling, self-evaluation, and self-reinforcement fall under this rubric. These are used in changing patterns of smoking, drug and alcohol abuse, studying, and other pro-
blems of self-control, which are targets of change or the themes of many groups in CBGT. As part of assessment the therapist ascertains the degree to which these self-management skills are present and the target behaviors in which the self-management skills can be directed primarily by means of patient self-report and situational analysis. These self-management skills, if learned, represent a set of strategies that the patient can utilize even when only limited external support is available. Among the most common behavioral coping skills are social skills, a set of learned performance behaviors that relate an individual to others. These include such behaviors as responding to criticism, techniques of dealing with other people (family, friends, colleagues, strangers) in stressful situations, asking for help when needed, disagreeing constructively. They may even be more specific such as giving appropriate eye contact in conversations or smiling occasionally. These social behaviors are often essential for effective social fuctioning and can be readily taught in the group. Social skill inventories (e.g., Gambrill & Richey, 1973) and role-play tests (Magen & Rose, 1998) are commonly used to assess patient skills in this area. Recreational and leisure time skills may also be regarded as behavioral coping skills. The extent of these interests are explored in assessment to determine whether they should be amplified or modified. Although some are social in nature, they may be regarded as a separate category for coping with general life stress. Information about these skills and interests are obtained in a group exercise in which the members interview each other in pairs about their interests and leisure time activities and then each reports his or her partner's interests and skills to the group. Because therapy does not go on forever, patients will have to learn to make use of their social network more adequately. A number of social network surveys have been developed which the patients fill in and ascertain the relative helpfulness and limitations of the various social units of which they are a part (see e.g., Rose, 1998b, p. 329, for an example). In the group they share the results of the survey with other members. Numerous other noninteractive coping skills can be explored as part of assessment such as the patients's ability to manage his or her time, or to relax or mediate during stressful situations. Skills in relaxation can be readily observed as they are taught and tried out in the group. Relaxation is frequently used as part of most cognitive-behavioral programs. In most cases, coping skills and specific behavioral targets are intertwined.
Therapist Activities in CBIGT One cannot learn coping skills in a vacuum. One must identify the specific situations with which the individual must learn to cope. To this end the group members are taught to identify and define their unique problematic situations. The therapist first provides models of such situations, which the members discuss in terms of the criteria for formulating troublesome situations they have thus far had trouble dealing with. For example, in a group of men working on reducing the frequency of drinking behavior, an example of a situation in which a coping response was required was as follows: A friend of yours stops you after work. He urges you to have drink with him. He notes that several other old friends will be there. You have refused and then he says, ªwhat kind of friend are you, if you can't have a drink with your old buddies.º
A group of patients who have problems managing their stress are presented with the following example of a situation that might increase stress and which they will analyze as a group: Your car has just been ticketed. You are only eight minutes late for your meter. You really rushed to be back on time. You tell yourself it isn't fair. You know people who are hours late and don't get parking tickets. You feel the tension rising in your stomach.
An example used for a group of men who batter is the following: You get home right on time. You've had a couple of drinks, nothing much, you feel, and your wife says she smells alcohol on your breath, you feel anger rising, your head hurts, you say to yourself she can't talk to me that way. If she loves you, you think, she won't nag me. It's my life, I'll drink what I want.
The criteria for a situation that readily lends itself to examination are that the situation is important to the patient and likely to occur again, that it is specific as to time and place and the people involved, and that it represents a situation the patient might have difficulty in dealing with. After discussion of the application of these principles to the model situations, as an extragroup task it is suggested that each person develop one or more such situations which would be presented at the following session in the group in terms of how well each situation meets the criteria. After working with a group for a while, the therapist can put together a roleplay test consisting of a wide variety of such situations (see e.g., Magen & Rose, 1998) to ascertain the social skills needed to deal with social situations the patients with a common
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problem area encounter. The group therapist develops a set of predetermined or ªcannedº situations for those members who cannot develop one for themselves. An exercise is used to train the members in defining relevant and useful situations. In this exercise a number of models of situations are presented and the members analyze whether the criteria for ªusefulº situations are met. As part of assessment and to determine the progress of treatment, data on patient behavior and the resolution of problems are usually systematically collected before, throughout, and following therapy, and several weeks or months after therapy. In order to understand patients' reponse session by session to the program as a whole, a postsession questionnaire is filled out by all the patients and the therapist at the end of each session (see Table 1). In summary, some of the methods of collecting data mentioned above include diaries, personality inventories and checklists, role-play tests, sociometric tests, self-observation, direct observations of the group or of individuals when not in the group, postsession questionnaires, and interviews. (Each of these are discussed in more detail in Rose, 1989, pp. 109±136 for adults, and Rose, 1998, pp. 130±151 for adolescents.) The more structured methods permit evaluation of outcome, one of the purposes of assessment. Based on the initial data collected in the first part of assessment, goals are eventually established together with the patient. These goals are usually in terms of the specific target behaviors and cognitions that the patients need to achieve by the end of treatment and the coping behaviors required to deal with the problem situations. Knowing each other well because of their intense interaction, the group members provide each other with ideas as to goals each might pursue and feedback as to the formulation of the goals, the importance of the goals, and the degree to which these goals are realistic. Goals may be either behavioral, affective, and/ or cognitive change. Some examples of common treatment goals that people have worked towards in these groups are: 1. (For the depressed patient) By the end of treatment, I will participate in at least two social activities every week with friends or family members. I will also identify any self-defeating thoughts I make and will change each into a coping thought. On my self-monitoring card, I will score an average of 5 or lower on the 10 point depression scale. 2. (For the angry and abusive male) By the end of treatment when I begin to feel angry, I will take a deep breath and let it out slowly and remind myself that I can destroy my marriage if I give way to it. When I experience the first signs of anger with my
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wife, I will excuse myself from the situation and walk away. I will also increase the number of compliments I make to my wife to a minimum of once a day.
The criteria for effective goal formulation are that the goal is important to the individual, that a time frame be provided (e.g., by the end of treatment or by next month), that the goal be sufficiently specific that the patient knows when he or she has achieved it, and that the goal is realistic. If necessary, subgoals may also be formulated which are even more concrete. The patients are trained in goal formulation by means of an exercise in which the model goals such as those above are provided, the above criteria for effective goals listed, simulated goals are presented and these are corrected in group discussion. Then the members formulate their own goals which are evaluated by the group in terms of how well the goals meet the above criteria. Once goals are formulated, an additional means of measurement, goal attainment scaling, can be used to ascertain progress towards goals (see Cardillo, 1994). The goal attainment scales are developed in the group with the members helping each other. Following the formulation of goals, group programs and interventions can be planned which facilitate the achievement of these goals. 6.15.3.4 Intervention Based on the goals, intervention activities change or maintenance or decisionmaking strategies are selected. The patients are oriented to these procedures, and with their concurrence, the strategies are applied. Specific strategies are selected which have empirical support as well as a relationship to the goals. In order to develop these and specific behavioral and coping skills, usually no one intervention technique is sufficient. A number of methods of teaching patients necessary specific skills include problem-solving, modeling (overt and covert), rehearsal, coaching, cognitive-restructuring, rational-emotive techniques, self-instructional training, reinforcement and stimulus control, sociorecreational, relaxation training, and small-group techniques. In CBIGT most of these methods with special emphasis on the group are combined into one integrated approach. A method is selected for inclusion preferably if it has some independent empirical foundation and some relationship to the above mentioned targets. In the following sections, most of these methods will be reviewed in terms of their contribution to the total approach.
6.15.3.5 Generalization Generalization, a concern of all therapies, refers to the process of transferring what the patient has learned in the group to the outside world and maintaining what he or she has learned beyond the end of therapy. The most fundamental principle of generalization is that it rarely occurs without taking steps to see that it occurs (Stokes & Baer, 1977). One of the major strategies in CBIGT for transferring learning from the group to other situations involves the use of extragroup tasks, described above, which are used in almost every session. The patients are prepared by modeling and rehearsal on how to deal with persons unsympathetic to their changes. Former patients are sometimes brought in to discuss the possibilities of setbacks and how they might be handled. Possible self-referral sources are discussed, such as a counselor or a local clinic or health service. Finally, as part of this phase, a follow-up or ªboosterº session would be held two or three months following therapy. The members are taught the general principles of what they practice specifically. For example, they learn the general steps for problem-solving. They learn the principles of how anxiety and stress is in part a function of how we evaluate situations. They learn the principle that if one practices a given behavior it is more likely that they can learn that behavior. In CBIGT one goes from the specific exercise and experience to learning the general principles behind them. Members are finally prepared for termination by getting them to develop a plan for how they intend to apply what they have learned in the group when the group ends, and by designing activities appropriate to practicing their newly learned skills. These plans often contain such actions as joining a nontherapeutic group, reading a self-help book, practicing relaxation on a regular basis, meeting with a group member to talk about the principles learned in the group, and meeting again for a booster session. In order to diminish the intensity of the relationships of the members with each other and with the group therapist as the group approaches termination, the therapist encourages members to establish relationships outside of the group and to become involved in extragroup activities such as family activities, bowling leagues, bridge clubs, dancing lessons, and social organizations. Furthermore, relationships with nongroup members are encouraged. These new activities and social relationship become the focus of the later sessions in CBIGT. Extragroup tasks become less structured but more extensive. Preparation
Intervention Strategies used in CBIGT is largely in the hands of the patient. Monitoring is less strict. Social, recreational, and other cohesion-building activities are kept to a minimum in the group. Many of the leadership functions are performed by group members (see Table 2).
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procedures are used to prepare the group members to impliment the solutions they have agreed to. Each of these have their own empirical foundation. One of the most important is the modeling sequence. 6.15.4.2 The Modeling Sequence
6.15.4 INTERVENTION STRATEGIES USED IN CBIGT The most commn intervention strategies used in CBIGT are systematic problem-solving, the modeling sequence, cognitive change procedures, relaxation, reinforcement and stimulus control, and small group procedures. 6.15.4.1 Systematic Problem-solving Systematic problem-solving is a central method to CBIGT insofaras patients bring problematic situations of concern to the group and the group under the guidance of the therapist attempts to help them find solutions to those problems. It is systematic insofaras the members follow (or deviate by plan from) specified steps. The steps characteristic of the problem-solving process include orienting the members to the basic assumptions of problem-solving, defining the problem, generating alternative solutions, selecting the best set of solutions, planning and preparing for implementation, implementing the solution, and evaluating the outcome (except for ªpreparation for implementationº which has been added, these steps are taken from D'Zurilla, 1986). Many of the steps of problem-solving can be classified other than as intervention. For example, orientation to problem-solving is an orientation activity, defining the problem is clearly a part of assessment, implementation through extragroup tasks is part of the generalization of change, and the other steps are intervention activities. Problem-solving is not only a general paradigm. It can be identified as a set of coping skills to be learned in their own right to replace impetuous or uninformed problem-solving. In using the problem-solving method to find more effective ways of copying with the many problems of concern to group members, patients learn the skills involved in carrying out the general problem-solving paradigm. Such a set of procedures can be effectively taught in groups since the general paradigm is repeated frequently in the course of therapy not only dealing with individual problems but also in dealing with group problems should they arise. Moreover, once learned, it can be used by patients to deal with problems long after the group has ended. Within the framework of problem-solving, a number of other cognitive and behavioral
This sequence is designed to teach specific interactive behaviors for coping with various problems situations, and includes such techniques as overt modeling, behavior rehearsal, coaching, and group feedback. Modeling refers to learning that occurs through the observation of a model who might be the group therapist, another member of the group, someone in the patient's environment, or an admired person on stage, on screen, in novels, or in public life. Modeling may be role-played in the group or it may be observed directly in real life. Modeling is specifically used to demonstrate how a situation problematic to one or more patients in the group may be handled effectively. Behavioral rehearsal is a role-play technique in which a patient with a given problem situation practices new, more effective ways of handling that situation. Coaching refers to instructions, verbal or physical cues given to the patient when she or he is modeling or rehearsing a set of behaviors in a given situation. Group feedback is the verbal evaluation from others as to how effectively the patient roleplayed or modeled. Following the modeling sequence, the patient prepares for and carries out extragroup tasks to practice the newly learned coping skill in the real world. Following the situational analysis of the situation calling for a refusal of drink when offered (see example above), the therapist asks the group members for possible responses to the one of agreeing with the friend and going with him which is what the patient, Pete, had done in the original event. Based on the suggestions of his fellow patients, Pete decided that he would like to refuse clearly and in a matter-of-fact tone of voice, reminding his friend that he (Pete) was on the wagon and was working hard to stay there and he would appreciate whatever help his friend could give him. Pete would repeat the statement if pressured further. The therapist set the scene outside a bar, and then modeled the situation with one of the other group members acting as the friend. Then Pete, who felt that one demonstration was enough, played himself and his friend was played by the same person as in the first role play. When it was finished the therapist asked the other patients to tell Pete what he did well and then what he might consider doing differently. The members responded that Pete made an impressive statement and didn't argue. They suggested that he might consider giving better eye contact and speaking in
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Group Therapy: A Cognitive-behavioral Interactive Approach Table 2 Group development in a structured group.
Group phase
Therapist behavior
Group processes
Orientation phase
Orients members to theory and approach Ascertains levels of motivation Encourages broad participation Orients members to each other Introduces rules Promotes protherapeutic norms
Factual communication, limited self-disclosure High mutual anxiety Feedback is limited and polite Norms loosely established Leadership functions primarily controlled by therapist
Preliminary work phase
Stimulates moderate self-disclosure Examines problem situations Extragroup tasks introduced Trains in effective feedback Teaches basic concepts Initiates brief role-plays
Weak subgroups begin to form Increase somewhat in cohesion Members focus attention on therapist Feedback is descriptive and positive Distribution of participation broadens
Deterioration or conflict phase
Examines nonproductive activities Group processes becomes more flexible and empathic Begins to look at consequences of present behavior Initiates discussion of group problems Introduces concept of cognitive distortions Introduces group problem-solving
Homework completion rate drops Feedback is more negative Anger and withdrawal begin to intensify Cohesion begins to weaken Roles and norms are challenged by some members
Resolution phase
Assists members to assume responsibility for therapy Encourages leadership from members Deals with complex situations
Feedback to each other more constructive Cohesiveness decreases slightly Group engages in systematic problemsolving Distribution of participation increases broadly Interaction more task oriented New protherapeutic norms Higher levels of cohesion
Secondary work
Therapist reduces own activity Reduces frequency of reinforcement Encourages members to work on complex problems Interaction highly task oriented Rate of homework completion high
Members assume major phase leadership functions Significant self-disclosure to each other Cohesion decreases slightly Rate of homework completion high
Termination phase
Points to principles of generalization Prepares for termination Increases own activity slightly Summarizes progress Helps individuals to plan post-therapy activity
Group is more spontaneous Cohesion diminishes, focuses on extragroup social units Group focuses on future actions
a more matter-of-fact tone of voice. Pete rehearsed one more time, trying to incorporate the suggestions with the ªfriendº in the role play being much more insistent.
The therapist is the director of the role-play. He or she coaches significant others and the target person when necessary. He or she stops the roleplay before it goes on too long or if the person
cannot handle the situation. He or she instructs the observers as to what they should observe. He or she makes sure the tempo is reasonable. He or she makes sure that the role-play remains task oriented. Modeling is an excellent group procedure because of the presence of many potential models and rich source of feedback, and the opportunity for client leadership if these characteristics are taken advantage of.
Intervention Strategies used in CBIGT 6.15.4.3 Cognitive Change Methods Cognitive change methods refer to the steps taken to train the patient in more effective ways of thinking about or evaluating him or herself as the patient responds in specific problematic situations. In groups many different cognitive procedures are used, often in combination with each other and with other types of procedures such as the modeling sequence. It is assumed that in a given set of circumstances cognitions in part mediate overt behavioral and affective responses. These cognitions include how one values oneself and one's action and how one specifically thinks in or evaluates a given situation. In CBIGT the most commonly used cognitive procedures are cognitive restructuring (Beck, 1976), which includes rational emotive techniques (Ellis, 1973), and self-instructional training (Meichenbaum, 1977). 6.15.4.3.1 Cognitive restructuring Cognitive restructuring is characterized by two sets of procedures. First, one set of procedures is to identify the distorted patterns of thinking and/or dysfunctional schemata (Beck, 1976) which interfere with social functioning or create intensive emotions. Second, a set of methods are used to replace such distorted or dysfunctional thinking with self-statements that facilitate effective coping with day-to-day life events and reduce anxiety and stress. In the first set of procedures the patients are trained to identify cognitive distortions in case examples or group exercises and to label them into such categories as absolutizing, catastrophizing, mind reading, selective perception, or prophesizing (Beck, 1976). In one exercise the group members are given a list of self-statements which represent both cognitive distortions and coping statements. They are asked to identify independently to which category each statement belongs, and if a distortion, to identify the nature of that distortion and how it might interfere with social functioning and the eliciting of strong emotions. In the group the members exchange their ideas until each person has a clear picture of what a cognitive distortion is and why a given statement is a cognitive distortion. Later using the theoretical framework they have learned, they are better able to identify their own unique patterns of cognitive distortions, dysfunctional thinking, or illogical expectations and those of their peers. Continuing with the above exercise the clients are asked to identify one statement they are likely to make which they might be identified as a cognitive distortion. To help each other in the process of
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identification of each person's distorted thinking, the other group members are taught to ªrub inº the errors in each person's thinking through logical disputation and analysis. Supportive evidence is also sought through interviewing by the other group members either to invalidate or validate the assumptions of each client. In addition, as members relate ongoing problem situations to the group, they are asked to note their thinking in these situations and to identify and ask the peers to identify any cognitive distortions. Once the distorted thinking is identified and labeled, each patient, assisted by the other group members, is asked to replace the distortions with coping statements. Group exercises are used to facilitate this replacement in which the patients first correct the list of ªcannedº statements of distorted or dysfunctional statements. To facilitate this process, a list of coping statements is presented as points-of-departure. For example, ªif I take one step at time I can handle this,º or ªI should remind myself to take a deep breath and relax,º or ªif I make a mistake it's not so terrible; nobody is perfect.º Once the members become skilled in replacing cognitive distortions with coping statements on simulated examples, they can begin with the help of the group to replace distorted thoughts of their own with coping statements. If they have difficulty the group can provide each other with corrective information or they can ªbrainstormº alternate ways of thinking about a given situation which might help them to cope with the situation. Finally, the members assign each other tasks to perform outside of the group to try out and self-monitor their use of coping self-statements to replace cognitive distortions. At a subsequent session each patient reports back his or her observations to the group. 6.15.4.3.2 Self-instructional training In self-instructional training, the members are taught first in the face of a problematic or stress-inducing series of situations to utilize functional self-statements at each step of the series. This process consists of step-by-step verbalizations concerning the problem definition (ªWhat's wrong with the way I'm thinking about this?º), problem focus (ªWhat can I do about it?º), focusing of attention (ªI should think about how that will get me in trouble.º), coping statements (ªIf I keep relaxing I won't blow it!º), and self-reinforcement (ªWow! I did it! See, I can do it!º). In groups, the members are trained in the method first by providing the members with a model. Examples of situations in which self-instructional training would be
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appropriate are the following: (i) a situation in which a person is unfairly critizing the patient and escalates the criticism over time; (ii) a situation in which the patient is being persistently hassled to do something she does not want to do; and (iii) a situation in which a person must make a presentation to colleagues and others of which he has little experience. If a given member identifies such a situation, the members brainstorm coping self-statements the given patient might make in the several steps involved in learning to cope with the situation. A group member models the statements (cognitive modeling) for the given patient who then practices the same statement (cognitive rehearsal). The given patient is assigned the task of self-monitoring how he or she handles the given situation should it occur, and reports his or her experience back to the group. Often this method is combined with social skill training. Other methods with cognitive as well as behavioral elements used in groups are thought stopping in the face of persistent recurring thoughts, systematic desensitization or exposure methods in the case of phobias, and guided imagery. Gradual exposure methods have been used in the treatment of agoraphobia (Hand, Lamontagne, & Marks, 1974) and obsessivecompulsive disorder (Fals-Stewart et al., 1993) with positive results. In the treatment of agoraphobia the group members accompanied each other to face the feared setting together. The group served as support and encouragement for each other. Later the members accompany one person at a distance and eventually each patient faces the feared situation alone. In the group treatment of obsessive-compulsive disorder (OCD), Fals-Stewart et al. (1993) used both exposure to the feared object (e.g., dirty materials, garbage cans, etc.) and response prevention (e.g., by preventing the individual from washing their hands for at least an hour after exposure to a contaminant). Where in vivo exposure was not feasible, imaginal flooding was used. This combination seemed to be effective in alleviating OCD symptoms of patients in groups as well as in individual therapy. The groups are used effectively because of the multiple modeling effect. Also members can help plan each other's hierarchy of anxietyprovoking activities with which they would expect to be confronted in the near future. 6.15.4.4 Relaxation Methods These are strategies for helping patients to cope with strong emotional responses such as anger, stress, or depression. Thus, relaxation training is an intervention and the skill in
relaxation is a coping target in its own right. The training involves teaching patients a modified version of the alternate tension and relaxation technique (developed by Jacobsen, 1978, and adapted by Bernstein & Borkovec, 1973) and then later fading the tension phases. Various alternatives uniquely suited to various populations are also taught. Modest research support for the use of relaxation procedures in reducing anxiety and stress is to be found in studies by Stovya (1977) and Lyles, Burish, Korzely, and Oldham (1982). However, Heide and Borkovec (1983) warn that for a few persons relaxation may increase anxiety. In groups the members are taught the procedures by the therapist modeling the procedure then by having them practice the procedures a few muscle groups at a time. Once the therapist has relaxed the entire group together, in order to make use of the group, the members then go through the same procedures with each other in pairs. The therapist prompts the ªteachersº and monitors the process and is available if someone gets stuck. This affords each member the opportunity to be both teacher as well as learner. The members are given tapes and encouraged to practice the relaxation out of the group, if possible with a ªbuddyº so that they can monitor each other's practice. In addition, meditation (Carington, 1978) and diaphragmatic breathing in some groups are taught as alternatives to deep muscle relaxation. 6.15.4.5 Reinforcement and Stimulus Control These are not central methods in most applications of CBIGT except in parent training groups where the parents are taught to modify antecedent conditions and consequences with their children. Reinforcement is derived from operant theory and involves the target person performing a target behavior followed by a reinforcing event (positive reinforcement) or the withdrawal of an aversive stimulus (negative reinforcement). Both forms of reinforcement increase the probability that the target behavior will increase under similar conditions in the future. Stimulus control involves procedures in which the immediate conditions which lead to or are parallel with a given behavior are changed to create conditions more amenable to the performance of a desired behavior. Creating conditions in the group through subgrouping as a means of getting broad participation is an example of modifying the stimulus conditions. In groups patients receive many kinds of reinforcement for the performance of prosocial group behavior and the completion of extragroup tasks. With adults, this reinforcement
Intervention Strategies used in CBIGT takes the form of praise by the group therapist or other group members. Occasionally it takes the form of smiles, applause, approving nods, and delighted laughter. Also reinforcement is an effective communication skill in its own right if carried out appropriately. Finally, high levels of mutual reinforcement have been shown to to increase the cohesion of therapy groups (Goldstein, Heller, & Sechrest, 1966). For these reasons every effort is made to include as much reinforcement as possible in the early sessions. Reinforcers can also be withheld in response to undesirable behaviors. This is referred to as extinction and is an occasional response in groups when someone is frequently off-task or complains a great deal. Extinction is difficult to perform in groups since it requires the cooperation and prior agreement of all group members along with the therapist. 6.15.4.6 Small-group Procedures Because CBIGT is also a small-group approach, it is possible to take advantage of the multiple interaction to enhance the effectiveness of the intervention and assessment procedures described earlier and to provide entirely new ones. Since most group therapies make use of some of these techniques, only a few are illustrated in terms of their unique application in CBIGT. These include role-playing, the buddy system, subgrouping, leadership delegation, and group exercises. (These and other group procedures commonly used in CBIGT are described in detail by Rose, 1989, as they apply to adults and Rose, 1998a, as they apply to children and adolescents.) 6.15.4.6.1 Role-playing Role-playing is a set of procedures that has several purposes in CBIGT. First it is used to demonstrate or model behaviors targeted in problem-solving and for the patient to practice (behaviorally rehearse) them before trying them out in the real world as part of the modeling sequence discussed earlier. It is highly focused and followed by highly specific feedback. Roleplaying may also used for assessment by having a patient role-play a problem situation as much as possible as it originally occurred. A set of situations may also be presented to the patients who role-play their responses. It is also used to teach specific therapy skills such as providing constructive feedback and receiving critical feedback, and in generalization training to practice preparing for an unsympathetic environment or the eventuality of setbacks. When using role-playing, practitioners have found it
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useful to encourage physical movement (knocking at and opening imagined doors, sitting and standing when appropriate), separate the players clearly from the observers, give the observers a clear observational task, and to keep the role-plays brief at least in the beginning. Where patients are reluctant to participate, the therapist will model role-playing with colleagues, write out scripts, and let members express their thoughts with ªI would say . . . º before having them actually act it out. Usually in groups there are some members who are willing to try it out first and who consequently serve as models for the others. 6.15.4.6.2 Subgrouping Subgrouping is a simple procedure of working in pairs, triads, or other sized subgroups as a means of increasing interaction among the members and providing them an opportunity to work without the constant oversight of the therapist. Many of the group exercises are performed in subgroups. Subgrouping also creates an opportunity to practice leadership skills. Care is taken to assign subgroups with various compositions in order to avoid ªcliqueº formation which might work against the pursuit of treatment goals. In working with subgroups, the therapist must give them clear assignments, the results of which they report back to the larger groups. He or she must also carefully monitor the activities of the subgroups to make sure they are working on the given tasks. 6.15.4.6.3 Buddy system The buddy system is a special subgrouping procedure for patients to work together outside of the group (see O'Donnell, Lydgate, & Fo, 1979, for a review of the research with children). In CBIGT the buddy system is especially useful in facilitating completion of the group tasks. Buddies check with each other on their respective progress and reinforce each other for small successes. In addition to the advantages mentioned above, it contributes to the transfer of learning within the group to situations outside of the group. 6.15.4.6.4 Group exercises Group exercises refer to the use of structured interactive activities as ways of teaching patients the skills which mediate the achievement of therapeutic goals. For example, an introduction exercise is used in which patients interview at least two patients in the group and introduce them to the others. Another exercise is one in which the patients study a case and
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discuss how each of them is different from the person in that case. In stress groups an exercise is used in which members identify their own unique stress response (see Rose, 1998, for a list and description of commonly used exercises, most of which can be used with adults as well as children). Often the exercises are performed in part in subgroups of varying sizes. Each exercise has a rationale, a stated purpose, and a set of instructions for individuals and for the group as whole. In one particular application of CBIGT, exercises are used in every session. The exercises serve to provide variation in program, enhance interest and cohesion, and create opportunities for broad participation. 6.15.4.6.5 Group feedback Group feedback is another group technique that plays an important role in group therapy. Members are constantly giving each other feedback as to what they do well and what they might consider doing differently. In CBIGT the patients are trained in how to give feedback in such a way as to maximize its positive reception. The criteria which the participants are trained (in exercises) to use are to give positive feedback first, describe what was done in specific terms, and use an I statement. In giving critical feedback the members are asked to affix the word, ªwhat I might do differently is . . .º or ªone thing you might consider doing differently is . . .º In order to protect the recipient of feedback, he or she can stop feedback any time he or she chooses. Even with these protections the therapist must be careful to monitor feedback to make sure that no one is being devastated by what he or she hears. Usually the norms of giving helpful feedback are quickly established and the group members correct inappropriate feedback whenever it should occur. The group members in contrast with the individual therapist provide a wide range of diverse observations and feedback. The danger of multiple comments being too destructive or aversive can be limited by training the members receiving and giving feedback and by careful monitoring by the group therapist. 6.15.4.7 Identifying and Resolving Group Problems In all groups one can observe a number of group problems. These can be defined as an intragroup interactive event (or series of events) or a product of interactive events which interfere with effective member task performance or goal
attainment. The responsibility for achieving a change in group process cannot usually be linked to a change in behavior of any one member or the group therapist, but to interactive changes among all or most of the members and the therapist. Several problems in particular stand out such as when group cohesion is too low, when the communication pattern primarily directly from members to the therapist and not to each other, when self-disclosure is too low, when some members dominate the interaction while others are virtually excluded, when antitherapeutic norms exist such as a pattern of lateness, and where members are frequently off-task. In general, most of these group problems are avoided by careful treatment programming. Occasionally when a group problem persists, it is necessary to use systematic problem-solving. The therapist points out the problem as he or she experiences it and checks with the group if they perceive it. Often the therapist can back up his or her perception by the results on the postsession questionnaire or other ongoing measurement procedure. If in discussing the problem, blame is laid at the feet of the therapist, one member, or one subgroup, the therapist points out that the problem cannot exist without the shared contribution of all members and the therapist. It requires a change in behavior or attitude of everyone. If the group agrees, the members are asked to brainstorm what the group can do, what each member him- or herself can do, and what the therapist can do to ameliorate the problem. Then the group uses the ideas to negotiate a group plan and a therapist plan and each person commits him- or herself to an individual plan all of which are found in the following example. In a hospital group of patients with borderline personality disorders, the therapist noted that everyone seemed to be addressing all their questions to her and not to each other, in spite of the fact that many of them knew the answers better than the therapist. The co-therapist had been noting the direction of all interaction at the past session and provided the group this information. The group members agreed, stating that it was easier, somehow, to do that, and besides she had the most power. The therapist pointed out that eventually they would have to depend on their own resources and those of their peers, and this was a good opportunity to practice solving a problem. Since the group members agreed with her assessment, she suggested that everyone write down one idea as to what the group could do differently, what the therapist could do differently, and what each of them could do differently. An extensive list for each category was generated, and after an evaluation, the group selected for the group that whenever a question is asked, everyone would write down what
Intervention Strategies used in CBIGT they each thought was the answer. Then the person asking the question would ask the others what they had written. They agreed that the therapist would throw back to the group any question directed to her and remind them of the agreement. The individual plans included relaxing before the session and before answering a question, looking at other members instead of the therapists, and listening more carefully to each question asked by writing down the question.
6.15.4.8 Phases of Group Development Many of these group problems are a function of the phase of group development in which the group finds itself. Group development refers to the ways in which norms, roles, cohesion, communication patterns, subgroups, and leadership shift over time. In that sense group development is a kind of metaprocess. Common elements seem to run through most paradigms of group development (see e.g., Corey & Corey, 1997; Forsyth, 1990; Garvin, 1987, pp. 110±111; Sarri & Galinsky, 1985; Tuckman, 1965), which suggest that some phenomena are at least in part a function of time. It is useful for group therapists to be aware of group process insofaras the phase of therapy is one of many conditions which may contribute to the appearance of certain behaviors viewed as obstructionist or constructive such as one might experience in the conflict phase. In Table 2 these often overlapping phases are differentiated into the phase of development, the therapist activity, and the observable group phenomena. 6.15.4.9 Integrating Diverse Intervention Strategies in CBIGT In the following example the way in which various intervention strategies are developed into an integrated treatment package in CBIGT are examined. In the fourth session of a stress management group the therapist reviewed the postsession data from the previous week. He noted that satisfaction and a feeling of self-control of the activities of the group had showed a lot of improvement over the previous session and the members agreed that that was a good sign. Then the therapist asked each member to review what he or she had done on the extragroup tasks during the week. Applause and cheers greeted those who completely or partially succeeded. A group exercise was used to train all the members in correcting the cognitive distortions that they had identified the previous week in the first part of the exercise. In this exercise each person eventually identified one distortion that each usually made. Following the exercise, each member brought in a stressful situation he or she
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had encountered the previous week and had recorded in their diaries. For example, Laura told about a commonly occurring situation in which she felt upset by the half joking way in which her boss implies criticism of her in front of others but never states it. She always felt anxious at work and constantly afraid he would criticize her at any time. The other members by asking questions helped to spell out the details of the situation and to relate it to other situations in which she is also often quite anxious. They also examined her thoughts in these situations. In each situation, the group suggested how her self-defeating statements, ªI can't stand being criticised,º ªIf I'm criticized, I must be an awful personº seem to keep her in a state of constant anxiety and she agreed that something must be done about these cognitions and some action with respect to her boss was called for. Based on suggestions generated through ªbrainstormingº from the group, she decided to do two things differently. First, she would let her boss know that she was dissatisfied (while reminding herself that she was a highly regarded employee and she was willing to risk any potential fall-out) with his public suggestion of criticism; if he had any criticism she would like to hear it explicitly stated in private. Whenever she began to feel negative about herself, she would take a deep breathe and relax. In order to prepare Laura to carry out the solution, several members of the group demonstrated in a role play how she might act with her boss, and then she rehearsed what she would actually say first to herself and then aloud to her boss. Then several members demonstrated how, when confronted with implied criticism, what she might think to herself and say aloud to her boss. Laura also rehearsed her thoughts and her actions until she indicated she was comfortable with the way she handled them. Most of the other members handled a similar stress inducing situation with emphasis on the cognitions that prevented them from dealing with them. Towards the close of the session, all the members designed with a partner their new extragroup task and announced it to the group. For example, Laura reported that she would make an appointment with her boss and then carry out the plan developed earlier in the session. She would also monitor her self put-downs and her self-praise statements throughout the following week (which she has been working on for several weeks) and practice relaxation at least four times for 15 minutes each time. After the others also reported a plan for their extragroup task, they practiced relaxation (all had problems with handling strong emotions) in pairs. The session was closed by filling in the postsession questionnaire.
Although sessions vary considerably, the above session is typical insofaras previous extragroup tasks are monitored, the results of the postsession questionnaire are reviewed and evaluated, a group exercise is carried out, problematic situations are presented by most of the members of the group, alternative responses to those
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Group Therapy: A Cognitive-behavioral Interactive Approach
situations are generated, cognitive and overt modeling of the alternative responses takes place, the members practice cognitive and behavioral alternatives for which they receive group feedback, cognitive distortions the client may have had in relation to the situation are considered, relaxation is practiced, and extragroup tasks are planned. The group was used in many ways: the use of role-playing, subgroups, the generation of ideas, group exercise, group feedback, and the structuring of broad participation. All were integrated into a coherent and fast-moving session. 6.15.5 SUMMARY AND CONCLUSION Some of the research supporting the use of CBGT with various populations has been reviewed. It appears that group therapy is as effective as individual therapy and more efficient. It is also more effective than doing nothing and several other alternative therapies. Follow-up information is either limited or reveals little maintenance. Most of the research on CBGT does not report on any use of the group beyond it being the context of treatment. In this chapter the reader has been presented with one type of cognitive-behavioral group therapy in which use is explicitly made of the group. The various assessment, intervention, and generalization strategies employed in CBGT have been presented specifically as they could be uniquely applied in a group and which take advantage of the group context. Specific group interventions are identified. The cornerstone of using the group is maximum involvement of the members in the treatment process both as patient and as cotherapist. Because of the focus on interaction, this particular approach to CBGT has been referred to throughout as cognitive-behavioral interactive group therapy or CBIGT. It is clear that intense involvement of members in the therapeutic process is costly in time. Much less can be covered in a given number of sessions. According to our clinical observations, failure to become involved often results in a highly didactic quality of therapy, high drop-out rates, and lower levels of learning. More research on these very issues is required before one can be firmly committed to this conclusion. 6.15.6 REFERENCES Abraham, I. L., Neundorfer, M. M., & Currie, L. J. (1992). Effects of group interventions on cognition and depression in nursing home residents. Nursing Research, 41(4), 196±202. Azocar, F., Miranda, J., & Dwyer, E. V. (1991). Treatment
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