8 Just as it is becoming common to blend components within CBT to target multiple disorders—the transdiagnostic approach—there is increasing experimentation with blending CBT with another treatment tradition. This chapter introduces the idea of integrated treatment. Good reasons for integrated CBT approaches have increased over the past decade. Integrated CBT has proved helpful for “hard-to-treat” disorders where too many clients receiving only CBT do not reach desired levels of improvement within a reasonable time period. An integrated approach to CBT is also useful for client populations where symptom expressions clearly covary with interpersonal factors above and beyond what is the case for most mental health issues. In addition, integrated CBT is helpful for client populations where improvement in functioning is just as high a priority as better symptom control and where it is reasonable to expect that symptoms decrease as functioning improves (Chapter 16 on psychosis offers examples of a paramount focus on improving functioning). Many therapists already recognize that “pure” CBT can be tricky to deliver, especially in group settings, where supportive and interpersonal therapy approaches inevitably sneak in, even when not encouraged. It would, however, not be helpful, or appropriate, to add other forms of therapy to a CBGT protocol simply because we think “more is better” for our clients. When clinicians consider more integrated approaches, they must be mindful of the pragmatic, research-informed reasons for doing so. In this chapter, I will review how CBGT for generalized anxiety disorder (GAD) can benefit from formally integrating a mindfulness component. First, however, I describe a pure CBGT approach to GAD. This is followed by a discussion of how to integrate components of mindfulness training. The latter part of the chapter explores how CBGT for perinatal depression becomes enriched by including elements from interpersonal therapy (IPT). GAD involves excessive anxiety and worry for more days than not for a period of at least 6 months about a number of present or future events or activities. In order to be diagnosed, according to the DSM-5,1 people must find it hard to control their worry and experience at least three additional symptoms, such as (a) restlessness or feeling on edge, (b) being easily fatigued, (c) difficulty concentrating or mind going blank, (d) irritability, (e) muscle tension, or (f) sleep disturbance (difficulty falling or staying asleep or restless unsatisfying sleep). About 5% of people will be affected by GAD (lifetime prevalence rate). Similar to most anxiety disorders, the majority of people suffering from GAD say it started in childhood or adolescence. In the absence of treatment, GAD tends to be chronic with worsening during times of feeling stressed. A core feature of GAD is the person’s belief in their inability to control their worries, which then often get compounded by worrying about worrying. For example, a father in a job dependent on global financial markets may worry about losing his job (the content of his worry) and becoming unable to support his two daughters in university. He may then begin to worry about the impact his restless sleep and lack of concentration has on his physical health (the meaning or interpretation of his worry). This example is consistent with the metacognitive model of GAD developed by Wells (1997). Interestingly, and further to the metacognitive model, beliefs in the benefits about worrying can be a predisposing factor to GAD. Positive beliefs about worry can include seeing it as an attractive personality trait. For example, the above father may have assumptions along the lines of “Worrying about my children all the time shows how much I love them.” Positive beliefs can also take the form of protection from negative emotions: “If I worry a lot now, then it will not be so shocking when I do lose my job.” The latter is an example of how people hold beliefs about investing in a sort of “worry bank” hoping they will save themselves some grief when their fears become true. Another rationalization for worry has to do with fear of losing motivation and ability to function: “If I didn’t worry every day about the next task or deadline, I might become complacent and unproductive.” There are separate but related CBT interventions for treating GAD: the traditional, the metacognitive, and a new approach focused on tolerating uncertainty. The traditional CBT approach is outlined in Mastery of Your Anxiety and Worry therapist guide (Zinbarg, Craske, & Barlow, 2006) and client workbook (Craske & Barlow, 2006). Techniques include monitoring specific worries, relaxation training, challenging overestimation of the probability of a worry coming true, and exposure to worst-case scenario worries. Elements of this approach were used in the transdiagnostic CBT protocol used by Erickson, Janeck, and Tallman (2009) reviewed in Chapter 7. The metacognitive approach keeps a primary focus on negative—and positive—beliefs about worries and offers techniques for supporting clients in challenging those beliefs. The father who worried about being unable to support his daughters in university would learn to identify his different kinds of worries (positive, negative, and metacognitive) and how to rein them in to a more manageable level. A more novel CBT approach, targeting intolerance of uncertainty (CBT-IU), includes elements of the more traditional CBT and the metacognitive approach as well as new ones (Dugas & Robichaud, 2006; Dugas et al., 2003). This approach explicitly emphasizes that intolerance of uncertainty (IU) is the general vulnerability that drives different kinds of worries. This approach has also been specifically tested in a group format (Dugas et al., 2003) and works well in community CBGT programs. Key treatment components in group CBT-IU include (a) psychoeducation about GAD and worry (including metacognitive worries); (b) IU and behavioral exposure; (c) problem-solving training; (d) cognitive, or imaginal, exposure; and (e) relapse prevention. I will limit the discussion of these treatment components to uncertainty recognition, problem-solving training, and imaginal exposure, and illustrate how these various techniques work in a group setting. Further discussion of these three, plus the other treatment components, can be found in the helpful GAD manual by Dugas and Robichaud (2006), Cognitive-Behavioural Treatment for Generalized Anxiety Disorder: From Science to Practice. Few people are entirely comfortable with the idea that, no matter how much we try to plan, we cannot create certainty in our lives. It is hard to accept that we cannot be certain that our otherwise carefully thought-through decisions will have the desired consequences. People with GAD are especially intolerant of uncertainty, even compared to the other anxiety disorders. IU is the fuel that keeps the worry engine going. Thus, once individuals become more tolerant of uncertainty, they worry less in general. Targeting the underlying problem of uncertainty intolerance seems more productive than focusing on trying to control specific worries, which more traditional CBT for GAD does. CBT therapists working with GAD clients recognize that the content of a person’s worries changes constantly (yesterday, it was about my 12-year-old not wanting to play football; today, it is about my VISA card bill; and tomorrow, it will be about when I should retire). Instead, therapeutic gain is increased when the focus is directly on the underlying problem that is causing intolerance of uncertainty. Clients who manifest IU are constantly developing strategies for approaching worries and for avoiding worries. Their approach strategies include excessive information gathering, looking for reassurance, questioning a decision one has already made, and double-checking. Paradoxically, seemingly impulsive behavior often follows a long period of indecisiveness. For example, a woman new to the city in which her GAD group took place spent months researching a suitable restaurant for lunch with an old friend who was coming through town. She looked up restaurants in the local food magazines, searched the web, talked to people (including group members), and even visited a few places to look at their menu. She surprised the group when she announced having gone to the restaurant “just across the street” from the building where her group took place, a decent but not particularly special place. For a fuller discussion of the construct of IU, see Carleton, Sharpe, and Asmundson (2007). In addition to approach strategies, the worry-prone individual also uses avoidance as a way of coping. Avoidance can be cognitive or emotional. In cognitive avoidance, people may try to avoid watching the news, or reading newspapers, or active financial planning with an advisor. Interestingly, parents who worry a great deal tend not to engage their children; they just avoid connecting with them on certain topics. Children whose parents have GAD say they would never bring up certain issues with them, because they fear the parents could not control their worries. Sadly, the parents thus deprive themselves of becoming more effectively engaged with their children’s struggles, which only encourages the growth of their worried imaginations. In emotional avoidance, the worry may serve the function of actually distracting people from their feelings and detaching them from noticing sensations in their bodies. In this sense, worrying becomes a defense against getting more in touch with one’s emotional and inner life. GAD people are sometimes referred to as “emotion phobics.” In the shorter term, their avoidance strategies may offer some relief for distress, but they tend to maintain the worry in the longer term because a fuller emotional processing of their fears does not take place. Typical avoidance strategies in GAD include evading fully committing to certain tasks or people, finding “imaginary” reasons for not doing things, procrastinating, and asking others to make one’s decisions. When IU is targeted in treatment, it may involve asking clients to do some homework, such as not checking emails in their “sent” box, buying an item without researching it, and not calling a child’s or spouse’s cell phone multiple times in a day. People high on IU overestimate threat and underestimate their ability to cope. IU is also addressed in all other GAD treatment components, such as problem-solving training and using exposure to reverse cognitive and emotional avoidance and more recently also through mindfulness training. Protocols emphasizing problem solving lend themselves to a group because of the rich opportunities for group members to brainstorm and offer mutual support as members confront their worst fears. Problem-solving training involves five steps: (1) problem definition, (2) goal formulation, (3) generation of alternative solutions, (4) decision making, and (5) solution implementation. The book called Problem Solving Therapy: A Social Competence Approach to Clinical Interventions (D’Zurilla & Nezu, 1999) is an excellent resource for clinicians wishing to offer their clients better problem-solving tools, something that is not unique to GAD. Here is an illustration of what problem solving in a CBT group for GAD can look like. Therapist: Barry: Therapist: Cotherapist: Barry: Therapist: Barry: Cotherapist: Leslie: Nate: Barry: Jeannie: Barry: Thomas: Mohammed: Cotherapist: The group engages with Barry, who feels encouraged to implement a solution, knowing that it is not perfect but a pretty good one to at least try. Invariably, the person in question thanks the group for offering ideas they could not have come up with themselves. Exposing someone with GAD to their core fear follows the same rules as other CBT exposures. It involves gradually working up to the worst fear, writing it out as a coherent narrative or script with beginning, middle, and end, using information about all senses as much as possible, and reading the script out loud in the group in the present tense. This worry script looks a lot like the trauma exposure discussed in Chapter 7. With daily home practice of about 45 minutes, it generally takes about 2 weeks for habituation to occur. Most worries about hypothetical situations involve the same underlying fears. Imaginal exposures thus tend to be needed for only one or two scenarios. Clients in CBGT for GAD are asked to write several drafts of their chosen scenario while increasingly adding details about their sensory and body sensations. For example, a husband worrying about his wife dying in a car crash may in his first draft write: “I pick up the phone and it’s a call from the police. They tell me to sit down and I do.” In the final draft, he may write: “I pick up the phone and when I hear it’s the police, I shake all over and can barely hang onto the phone; my legs are so wobbly I cannot stand up; I am unable to speak because my throat is so dry and tight. I whisper, ‘Is she alive?’” In the GAD group, members take turns reading their drafts and offering comments and suggestions to each other, especially on the earlier versions of their scenarios. Peer support and modeling become crucial during these difficult exposure tasks. The group facilitators ensure that clients record and track their level of anxiety using the standard 0–100 scale—as they read their scenarios. They can also record their exposure scenarios on tapes and listen to them repeatedly. Similar to other exposures, the peak level of anxiety during a reading of a worry script is the most indicative of progress. Over time, group members will see that their peak anxiety is steadily decreasing as they confront and become more tolerant of their worst fears. Helpful downloadable forms for clinicians on “How to write a worry script” and “How to tolerate uncertainty” are available for free from www.anxietybc.com. Group facilitators of GAD often remark at how the group turns into a gathering of mutually supportive mini Buddhas! Transformative statements abound: “Life is too short to waste energy on things that are clearly beyond my control.” “I am so much more productive now that I try to enjoy each day and not always think about tomorrow.” “When I am calm and centered, I can actually really help others.” Or “I am more accepting of developments in my life.” Although GAD group members can get to this calmer place by relying on CBT techniques with support from the group, there are good reasons to explicitly include elements of Eastern philosophy-informed practices, such as mindfulness, to make CBGT for GAD even more effective. Another novel approach to GAD is mindfulness training. In what follows, I sketch what it looks like to integrate aforementioned Dugas and Robichaud CBGT approach with mindfulness. Despite the effectiveness of CBT and CBGT for GAD, some research clinicians convincingly argue that GAD remains the least successfully treated of all the anxiety disorders. On average, only slightly more than half of the GAD clients who have received CBT score in the “nonworried and anxious” range on GAD outcome measures after having completed treatment (Borkovec & Castello, 1993; Ladouceur et al., 2000). A theoretical rationale for including mindfulness approaches into CBT for GAD has been articulated by Orsillo, Roemer, and Barlow (2003). These clinician researchers agree with other GAD CBT researchers and clinicians on what characterizes people with GAD. First, people with GAD spend a great deal of effort avoiding distressing thoughts and feelings. Secondly, they use worry as a strategy to prepare for, or avoid, the occurrence of low-probability future negative events. Orsillo and colleagues remind us that mindfulness—and other similar new therapy approaches such as acceptance and commitment therapy (ACT) (Hayes et al., 1999)—helps people become fully observant and tolerant of external and internal sensations in the present moment (Segal, Williams, & Teasdale, 2013).2 The ability to notice an upsetting feeling, and just let it be without straining to figure out what it may mean and what one could do, is precisely what is extremely difficult for people with GAD. They find it difficult to just notice feelings, body tensions, and concerns without distracting themselves by staying busy with worries and action. For example, a parent with GAD may feel intense anxiety about a teenage child being 15 minutes past her curfew and have a strong urge to do something—such as call either her cell phone or the local hospital to check for new admissions. Not surprisingly, many people with GAD are high-functioning, highly productive people at work and at home—always busy with something important—but at the expense of being able to slow down into some leisure activity that may not be seen as productive by them. In their individual CBT treatment of four individuals with GAD, Orsillo and colleagues (2003) included progressive muscle relaxation (PMR), self-monitoring of worries, awareness of the present moment through the mindfulness exercise of physical sensation awareness (body scan), and increasing awareness of avoidant behavior. Therapists help clients overcome their avoidant behaviors by encourage them to commit to what is important in their life and to set goals to be accomplished in the service of a particular valued life direction (finding your values). For example, one client was chronically worried about his relationship with his partner but also pushed away thoughts of his relationship unhappiness. Through exploration of values, he became aware of yearning for a more intimate relationship than his partner was willing to provide. He then translated this into action by formulating a plan for achieving his goal of increased intimacy. Although the four cases in the Orsillo study all made improvements, the authors point out that more research is clearly needed in order to determine just how beneficial these new elements are to traditional CBT. Lastly, they point to group as a viable mode of treatment delivery, if at all feasible. Clinicians who have created their own integrated CBGT-mindfulness protocols for GAD report good results and a dropout rate of about 20%. More systematic outcome evaluations are needed in order to determine the added benefits of mindfulness. Here is an example of what a session agenda in the middle of a 12-week 2-hour CBT group protocol may look like based on integrating mindfulness (Marchand, 2012; Roemer & Orsillo, 2002) and CBT for GAD (Dugas & Robichaud, 2006): Although this integration is both attractive and doable, there are nevertheless challenges when designing and implementing such a group protocol. An integrated CBT-mindfulness protocol for groups would be strengthened by ensuring that any mindfulness skills be introduced early to allow for sufficient practice time and skills consolidation. CBT-mindfulness focus is inevitably on the individual—as each person quietly enters into their own mind and has potential for undermining the cultivation of a strong group climate. Facilitators can try to overcome that by encouraging postexercise discussions, where members can review what was helpful or challenging. This gives group members opportunities to support and learn from each other. Staying with silence can be almost impossible for some people with GAD, and they may experience distress in the form of relaxation-induced anxiety. Some clients with GAD reject any groups involving a requirement to meditate for at least 15 minutes. However, seeing that one is not alone is an advantage that individual CBT for GAD does not offer. Group members often talk about leaning on the group and feeling held and supported by it—even when there is no talking—as they work on becoming more comfortable with silence and stillness. It is easy to relate. (I for one cannot seem to develop a yoga practice at home, but am utterly dependent on my class to get me going.) As with any integrated protocol, there is a risk of offering a half-and-half approach, a watered-down version depriving clients of a fair dosage of a full treatment. When time is limited, as it is in CBGT, and especially in public settings, it is important that clients receive a whole course of a treatment with demonstrated efficacy. Thus, based on research to date, this protocol is best built around the basic CBT for GAD treatment protocol, which means that enough time will have to be devoted to practicing in-session CBT interventions including exposures. Full integration of exposure can indeed be a challenge. It can feel disruptive to the gentle, quiet flow of mindfulness practices. Mindfulness-trained clinicians often express some hesitation to engage in the more aggressive, full-on, worst-case scenario exposures right after a more contemplative exercise. Pairing facilitators—with one being primarily mindfulness trained and the other CBT—helps. It will be interesting to follow outcome evaluations on mindfulness-enhanced CBGT for GAD. One also anticipates other forms of silence-and-stillness interventions as a way of augmenting the CBT protocol. Compassion-focused therapy (CFT) is another candidate for an integrated approach, which is reviewed in Chapter 16. Mindfulness was the first spiritually informed practice to make its way into secular psychological treatment protocols, but many other wisdom or faith traditions—and secular, common sense approaches to slowing down and being more present with one task at a time—have similar potential. The positive psychology movement, with its emphasis on what makes individuals flourish as they try to overcome their worries (and other problems with anxiety), encourages clinicians to support their clients in engaging with absorbing and personally meaningful activities in a free-flowing, unrestrained, and nonjudgmental manner. These could be anything from meditative walking, listening to music, dancing, or quietly working with one’s hands, as with painting, knitting, woodwork, pottery, or cooking. About 10–15% of women experience a clinically significant major depressive episode in the perinatal period, the time from pregnancy to the first months after the child is born. Given that many pregnant women are reluctant to take medication, a psychological intervention is an attractive alternative. The symptoms are the same as in MDD or persistent depressive disorder (as listed in Chapter 4). Individual CBT has shown good results for depressed mothers. Given that social support is frequently cited as a risk factor for perinatal depression (Nielsen, Videbech, Hedegaard, Dalby, & Secher, 2000; O’Hara & Swain, 1996), it is no surprise that CBGT has emerged as helpful (Goodman & Santangelo, 2011). The group format not only breaks social isolation. It also offers opportunities to have feelings and worries normalized, as well as to receive tips and helpful advice from other mothers. New mothers who are not depressed also benefit from joining regular support group meetings. The Perinatal Depression Cognitive Behavioral Therapy Treatment Group Model (Fraser Health, 2009, September) is an example of a standard CBGT protocol for perinatal depression. This protocol is based on integrating material from a number of CBT depression protocol resources, including Mind over Mood (Greenberger & Padesky, 1995), Antidepressant Skills Workbook (Bilsker & Paterson, 2005), and Coping with Depression in Pregnancy and the Postpartum: A CBT-Based Self-Management Guide for Women (Haring, Smith, Bodnar, & Ryan, 2011). It can be downloaded from the web at www.fraserhealth.ca. The group session themes are as follows. The Perinatal Depression Cognitive Behavioral Therapy Treatment Group Model follows the general CBGT protocol for depression outlined in Chapters 4 and 5, including each session being 2 hours long and group size being ideally eight members. The goal-setting part is expanded to first focus on self-care skills such as nutrition and rest, which is then followed by goals that increase a sense of pleasure, mastery, and social connection. The cognitive restructuring work is also similar, with its focus on identifying negative automatic thoughts and replacing them with more adaptive and realistic thinking. It does not use the 7-column Thought Records reviewed in Chapter 5 but a shorter version of only three or a maximum of five columns. Therapists running these groups find that expectant and new mothers find shorter Thought Records more manageable. The manual does not provide any specific suggestions for how to work with the group climate. It does encourage the mothers to arrive 30 minutes in advance, to allow for socializing as well as to prepare the babies for childcare, which is provided by community volunteers. The screening and outcome measure is the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987). Some clinicians offering the Perinatal Depression Cognitive Behavioral Therapy Treatment Group have found it useful to augment the protocol by inviting partners and other loves ones to attend an education and information session. The group members do not attend this session for confidentiality reasons. The session is led by the two cotherapists and takes place around sessions 4–6. The format for this evening session is roughly the following: Clinicians implementing this partner-augmented CBGT protocol for perinatal depression find that the interpersonal component of inviting the partners to a separate session is well received, often so well that the women who are in the group ask for additional strategies for how to connect and communicate with their partners. IPT offers many strategies for improving connection and communication. IPT is a shorter-term form of therapy that directly addresses the nature and quality of people’s relationships. It is a rare couple that does not struggle to at least some degree with staying close and mutually supportive during the perinatal period. New mothers tend to feel they don’t get the kind of support they especially need, and new fathers tend to feel emotionally neglected, excluded from the intensely intimate mother–child connection. Fathers are often left trying to figure out how they can offer the right kind of help (e.g., one father was very pleased with himself for surprising his wife on a Friday evening—one month after the birth of their child—with having booked a table at an expensive restaurant, only to be taken aback by her bursting into tears because of “not having anything to wear”). It is not difficult to empathize with each partner in this couple nor to understand their communication challenges in recovering from this episode, keeping in mind that the woman is suffering from depression. It is common sense that an explicit interpersonal component becomes part of the CBGT protocol. Recent systematic reviews also encourage clinicians to experiment with IPT and CBT integration. A few words about IPT before we look at these reviews. IPT is derived from attachment theory (Ainsworth, 1969; Bowlby, 1977). IPT is based on the premise, which in some ways is obvious yet not always fully appreciated by lay persons and professionals alike, that interpersonal function is a critical component to psychological adjustment and well-being (Klerman, Weissman, Rounseville, & Chevron, 1984; Stuart & Robertson, 2003). Early attachment issues (secure vs. insecure) with caregivers are not directly addressed in IPT, but a sense of the client’s attachment style is helpful in understanding their relationships and communication problems. In attachment research, 65% of children are referred to as secure and the remainder 35% as insecure. Insecure attachments broadly take the form of having either an anxious/ambivalent or an anxious/avoidant attachment to the main caregiver (Ainsworth & Wittig, 1969). According to the attachment theory, children gradually construct increasingly complex internal models of themselves and others. Bowlby refers to this process as the construction of internal working models, a process essentially involving confidence or lack of confidence in the caregiver’s accessibility and responsiveness to the needs of the child, as well as the child experiencing itself as worthy or not worthy to be attended to. Once an attachment style is consolidated, these internal models provide the individual with certain cognitive patterns, or biases of information processing, about interpersonal cues. An assumption of attachment theory is that early attachment relationships continue to be important throughout life. People who were insecure as children tend to struggle more in their adult relationships (Bartholomew, 1993). Bowlby’s internal working model concept influenced Beck’s understanding of schemas as described in Chapter 5 where we reviewed how Beck came to understand a person’s schema about, for example, not being “lovable,” as influenced by childhood factors including the quality of the relationship to parents or other caregivers. IPT was originally developed in the 1970s for depression. It is most often used for this disorder, but attempts to apply it to eating and anxiety disorders are promising. Similar to CBT, IPT is a shorter-term (typically 16 sessions), evidence-based, therapist-directed, and manual-driven therapy. Although developed for individual therapy, it can also be offered in group format (Stuart & Robertson, 2003, 2012). Much like CBT, IPT does not claim to bring about fundamental changes in personality or attachment style. However, in contrast to CBT, the main focus is not on the depressed person’s thinking style or their daily activities, but on the relationships in their lives. The assumption is that the quality of our relationships is directly connected to changes in our moods and that otherwise insightful and mature people—when depressed—fail to recognize this connection. For example, when IPT therapists establish a time-and-interpersonal-event chronological line with their client, clients often express not having realized certain connections. They might say: “Now I see that the ongoing friction and lack of communication with my coworker led to my feeling more depressed” or “I realize that I started to become depressed when I retired even though I had looked forward to it.” IPT seeks to help clients improve their interpersonal relationships or change their expectations of them, as well as improve social support networks. IPT focuses on four main interpersonal areas, and suitable clients must acknowledge that at least one of those areas is troublesome for them. They are interpersonal disputes (conflict between the client and another person stemming from either poor communication or unrealistic expectations), role transition (change in social role and support during life-phase transitions such as leaving home, becoming a parent, or retiring), interpersonal sensitivity (difficulty forming satisfying relationships and feeling socially isolated), and grief (the death of a loved one, where grief has developed into complicated bereavement). Each area includes the opportunity for therapists to introduce various IPT techniques such as role-playing, problem solving, and communication analysis (Stuart & Robertson, 2003). In a second edition of the Stuart and Robertson IPT guide, the area of interpersonal sensitivity has been eliminated and incorporated into the remainder three areas (Stuart & Robertson, 2012). This makes sense to several IPT therapists, who find that the area of interpersonal sensitivity often gets the least attention in therapy because the other areas tend to cover it. Administration of IPT requires foundational skills in psychopathology and psychotherapy as well as at least 40 hours of didactic IPT training and ongoing supervision for a minimum of two cases. The training required to become a competent IPT group therapist follows a similar approach to that described for CBT in Chapter 10. The Interpersonal Psychotherapy Institute offers information about training and certification (www.iptinstitute.com). Adding one or two partner nights to the aforementioned CBGT protocol does not require full IPT training, but CBGT therapists interested in a fuller integration of CBT and IPT for their perinatal groups may consider becoming IPT trained. Recent systematic reviews have further consolidated the use of both IPT and CBT in treating perinatal depression. The evidence for a group format, however, is mixed but generally positive. Based on 27 studies of individual and group therapy, Sockol, Epperson, and Barber (2011) concluded that IPT and CBT in individual format—but not group—were equally helpful and superior to other forms of therapy, including group. The authors speculate on why the group format for IPT or CBT did not do as well. They noted that women were hesitant about the idea of groups. They worried about lack of confidentiality, not getting enough individual attention, and being uncomfortable at the thought of sharing with strangers. These pregroup fears are common but were perhaps not assuaged during the actual group experience. In contrast, Goodman and Santangelo (2011) found that many forms of group therapy were all effective for postpartum depression. They reviewed 11 studies (some but not all were randomized control studies). The group interventions included CBT, IPT, and psychodynamic. All but one study (a group described as unstructured social support) showed statistically significant improvement in depression scores immediately after the group ended and also at 6 months follow-up. No modality emerged as superior to others. The authors advise, however, against making generalized interpretations of their findings, given the considerable heterogeneity of the studies and the varying degrees of methodological quality. The researchers noted that for some groups the full benefit did not emerge until about 6 months after the end of the group. Goldvarg and Kissen (2011) have responded to this research suggesting that both CBT and IPT are effective for postpartum depression. They wonder if combining CBT and IPT may make a group format more attractive. Their group case study seems to be the first published evidence of an integrated IPT and CBT postpartum group. Goldvarg and Kissen (2011) report good outcomes in a case study involving a group of six mothers with postpartum depression. The group was offered in a community outpatient program serving primarily people of lower socioeconomic status. The IPT focused on each woman’s relationship with her baby, with her partner, and the transition back to work if relevant. The CBT part focused on education about the link between mood, thoughts, and behaviors, relaxation techniques, challenging negative beliefs, and identification and ranking of anxiety-provoking situations. There were no dropouts. Unfortunately, their case study does not include illustrations of the various CBT or IPT techniques, nor any outcome measures other than qualitative statement, such as “I never thought I would speak to my mother again. Being here helped me understand the importance of being a mother; it’s a special bond. It helped me reconnect with Mom” (Goldvarg & Kissen, 2011). In the following text, I describe an example of how a CBGT group for postpartum depression can be expanded to include an IPT component. This community outpatient program is similar to the one described by Goldvarg and Kissen. It follows the Perinatal Depression Cognitive Behavioral Therapy Treatment Group Model (Fraser Health, 2009) described earlier in this chapter. The CBT group was augmented by a specific integration of IPT communication analysis. This technique helps clients identify their communication patterns, recognize their contribution to communication problems, and motivate them to communicate more effectively. The technique is described in the widely used IPT manual by Stuart and Robertson (2003, 2012) and can easily be adapted to a group setting. Group therapists rely on several sources to get a sense of the group members’ style of communication: the client’s description of their communication, the quality of the client’s narrative to the therapists and the group, the client’s in-group communication, and reports from significant others such as partners who attend the partner evening. Here is an example of how the IPT communication analysis technique can be included in perinatal CBGT. Therapist:
Augmenting CBGT with Other Therapy Approaches
Integrating CBGT and Mindfulness: Generalized Anxiety Disorder (GAD)
The diagnosis of generalized anxiety disorder
CBGT for GAD
Intolerance of uncertainty
Problem solving
Imaginary exposure
GAD and mindfulness
Integrating mindfulness into CBGT
CBGT and Interpersonal Therapy: Perinatal Depression
Integrating interpersonal therapy (IPT) into CBGT
What exactly is IPT?
Research support for IPT and CBT in treating perinatal depression
Example of combined IPT and CBGT for perinatal depression
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Augmenting CBGT with Other Therapy Approaches
Barry, you’ve asked the group for some help with your mother.
Yes, I just can’t stand visiting her anymore because she keeps buying stuff from all the flea markets she goes to, and it’s getting close to impossible to even make a dinner in her cluttered kitchen not to mention clearing some space for plates on the dining table. She just laughs, and does not think she has any problems. She says she likes her stuff and that I’m an uptight neat-freak.
Sounds like you and your mother have a difference of opinion here.
Using our five-step problem solving framework, how would you define your present problem with your mother?
My present problem is that I don’t feel like visiting my mother, and the truth is that I have actually avoided her for four months now. I worry a lot about her, and I don’t know what to do. My goal would be to visit her once a week.
We can see how this sure adds to your worries, and why you would prefer to stay away from your mother and her apartment. Do you have some ideas for solutions that would help you meet your goal of getting back to a regular connection schedule?
No. I’m kind of stuck, other than just trying to force myself to go as I obviously feel terrible about myself for neglecting her. I lose so much sleep over this and have had to get a mouth guard because I grind my teeth at night.
[goes to board and writes brainstorming] OK group, let’s do some brainstorming! When we brainstorm we try not to think about how good or practical an idea is. That comes later.
How about having a frank conversation with your mother explaining why you are not coming as much.
A friend of mine has joined a support group for family members of hoarders. You may get a lot out of attending as you’re not alone with this problem.
I had no idea we had such support groups. Do you have a name or number I could call?
How about offering to pay to have a helper come in? There are services for helping people de-clutter their space.
Maybe I could get my children involved, as my daughter did say she would like to help grandma. My daughter is very organized and tidy.
How about just accepting your mom, if she really does not think she has a problem. Maybe this is more your problem than hers.
Yes, you could sort of make it a bit of a fun adventure. You could even bring a picnic basket and just spread out a cloth somewhere—and sort of camp out and bring the dirty dishes home with you.
All good suggestions, and we now have about five alternative solutions. Let’s talk about the pros and cons of each, keeping in mind questions like: How effectively will it solve the problem of “Barry wants to overcome his avoidance of his mother?” What is the time and effort involved for Barry? what might be some emotional consequences, or relationship consequences?
Let’s review how helpful the partner evening last week was.
