In Chapter 2, we concentrated on how Yalom and Leszcz’s (2005) group process factors mapped onto an obsessive–compulsive disorder (OCD) group. In this section, I will touch on some other group process factors, such as group members’ readiness, their motivation, relations to the group therapists, and expectations. These factors all play an important role in group suitability and sustainability. But, first, we need to get people into the group!

Dedicated group therapists strongly recommend that mental health programs wanting to offer effective CBT groups not give clients a choice of individual treatment unless there are good reasons for not recommending a group, which of course is sometimes the case. Simply being uncomfortable with or fearful of CBGT is not a clinically sufficient reason for accommodating a client into individual therapy.

Policymakers are aware of the value of promoting group therapy when they point to evidence indicating that, after appropriate pregroup orientation, the outcome from group therapy for the majority of clients is as good as from individual treatment. However, since most people will prefer individual treatment, it is sometimes necessary to put some effort into “selling” group therapy (e.g., B.C.’s Mental Health Reform, 1999). In a recent study on treatment preferences, which included the mental health site where I work, 91% of men and 77% of women expressed a preference for individual therapy versus group (Sierra Hernandez, Oliffe, Joyce, Söchting, & Ogrodniczuk, 2014). Yet, group therapists also know that the vast majority of clients who make it to a group realize their fears were unfounded. They often express relief at having pushed themselves to attend.

To learn more about potential group members’ fears, we added a number of questions to a standard CBGT intake assessment. Eighty potential group members were asked, among other things, to indicate their fears (Söchting, Lau, & Ogrodniczuk, 2014). Somewhat surprisingly, when asked directly, most (93%) indicated they were not afraid and “looked forward to group therapy.” The fear themes of the more hesitant candidates for CBGT fell into three categories: (1) “I am afraid of being judged and people not liking me,” (2) “I’m afraid it will not help me,” and (3) “I’m afraid that other people in the group will be too unstable compared to me.” These categories likely capture a portion of the same fears expressed by the 38% of OCD patients who refuse CBGT, documented by O’Connor and colleagues (2005) and reviewed in Chapter 3. Not surprisingly, we see similar fears across different group programs.

Preparing Clients for CBGT

All interactions with clients prior to the group are crucial in terms of adequate preparation for CBGT. This first involves an assessment and confirmation of the most likely diagnoses or problems. In programs where CBGT specifically targets specific disorders related to depression, anxiety, obsessive–compulsive, and trauma, it is critical that people end up in the most appropriate group. The assessment is, ideally, done in a face-to-face intake meeting, but other forms of screening such as telephone or online can be reasonable substitutes so long as there is still an added group orientation. This assessment usually takes between an hour and an hour and a half. The time and effort spent up front is worth it, as it is time consuming when people end up in the “wrong” group and need to be redirected. In some outpatient programs, psychiatrists or psychologists initially perform a thorough diagnostic evaluation.

In the absence of a prior psychiatric evaluation, a full structured diagnostic interview following Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria is ideal. The Structured Clinical Interview for DSM-IV (SCID; First, Gibbon, Hilsenroth, & Segal, 2004) assists intake clinicians in making sure they do not miss any symptoms, but it can be lengthy to administer and therefore rarely feasible in outpatient community clinics. But developing a template for asking a couple of key screening questions for each disorder is doable and thus ensures that something was not missed. Appendix J offers such a screen, which can be used to guide a face-to-face assessment or support a telephone intake screening assessment. For example, if a client states she has worries about becoming physically ill, it is important to determine if this worry involves obsessions about contamination and excessive washing (OCD) or ongoing worries about health, the uncertainty of life, and difficulty deciding on a course of action (generalized anxiety disorder [GAD]). The intake clinician may also ask the client to complete a self-report measure in order to confirm the primary problem(s). Recommendations for various diagnostic self-report measures are given in The CORE-R outcome battery section of this chapter.

The majority of the staff where I work received training in the DSM structured diagnostic interview (SCID). Even though we do not perform full SCIDs, it is helpful to have the diagnostic criteria at our fingertips and understanding key differences between the various anxiety disorders. I thus highly recommend that the staff who do assessments for disorder-specific CBGT receive some basic training in the DSM, now DSM-5 (APA, 2013), even though they do not offer formal diagnoses themselves. Such training can be done in-house by any psychiatrist or psychologist who is required by their professional colleges or boards to be familiar with and use the DSM-5. Ongoing staff education and discussions about the differences and similarities among the various disorders are helpful in order to ensure groups run as effectively as possible and clients get the treatment they need in a timely manner.

In addition to inquiring about present symptoms, the general mental health intake assessment will involve detailed information about the expression of the symptoms or issues over the past to the present, how they interfere with daily functioning, and which coping skills have been tried, including previous mental health contacts. After the intake assessor and the client have established the main problems, the assessment focuses on the client’s goals or targets for treatment. The assessor collaborates with the client to ensure the goals are realistic for CBGT and that they include two to three shorter-term goals (during the active treatment phase) and one longer-term goal (where the client would like to be 5 years from now). Any CBT (not just groups) firmly flows from the stated intake goal(s), which must be reasonably specific such as the following: “Learn to control my symptoms better; do more things with friends such as join a book club, and find a physical activity that works for me” (short term) and “when I feel better, I want to review options for a new career” (long term). An ability to state these goals gives an indication of the client’s level of motivation, and any ambivalence about treatment can be discussed. So far, this pregroup assessment does not differ from the approach taken in individual CBT, but the last part, which is the introduction to the group format, does. This pregroup orientation is critical for maximizing clients’ group experience and ensuring they complete their CBT group. The pregroup orientations must include information about the treatment approach, expectations for homework and attendance, and also an opportunity to explore thoughts and feelings about being in a group. As will become apparent in the following text, some clients may have had an introduction to group CBT before their individual assessment if they have participated in a pregroup orientation session delivered in a group setting.

It is also important to discuss group start dates with the client. Often, there is no specific start date. Instead, therapists talk generally about, plans for simply a “fall” or “spring” group, as they need to assemble a sufficiently large group, usually eight members, before beginning. A downside to group therapy is that some members may have to wait for several weeks or even months before their group starts. We find that aiming for two more members than the ideal size is best. One or two people usually drop out just before the group starts, so if eight members is the preferred size, I recommend having 10 people on the list before starting. Clients tend to be accepting as they know wait times for any service in the public system are usually lengthy, up to 10–23 months between referral and start of therapy (Rezin & Garner, 2006). The intake assessors may decide to offer a few telephone check-ins with clients they deem could use support during the wait time. As we see in the following text, a rapid access group can also offer support— or actual treatment—while waiting.

Preventing Dropouts

Once people have committed to a group, the next challenge is to make them stay. Inconsistent attendance or dropping out has been identified as a particularly serious challenge to CBGT. Dropout rates in community outpatient settings tend to be around 20% for depression (Hans & Hiller, 2013a) and about 15% for anxiety (Hans & Hiller, 2013b) but at their extreme can be as high as 30–50% (Erickson, Janeck, & Tallman, 2009; MacNair & Corazzini, 1994). Dropouts are of course not unique to CBGT and also happen in individual CBT—and all forms of individual and group therapy—but are less problematic in individual therapy given the isolated impact. More than one dropout in a group can disrupt group solidarity and even precipitate a minor cascade of departures. Inconsistent attendance and departing people make remaining group members feel insecure, worried, and angry. As mentioned earlier, it is a good idea to take likely dropouts into account by going above the ideal group size when accepting members. I have experienced one grim scenario in which we started with a depression group of nine and ended with three members and four facilitators! Two psychiatry students participated in addition to the two senior therapists. This was an embarrassingly cost-ineffective group. Fortunately, such experiences are rare.

There is surprisingly little research on why people attend poorly or drop out altogether in CBGT—and other kinds of groups. Some reasons are legitimate and cannot be prevented, such as getting a job that conflicts with the group time, moving, losing childcare coverage, or getting seriously physically ill—or in some cases needing hospitalization for suicide attempts. As for more preventable reasons for dropouts, possible factors have been suggested. They include problems with alcohol (MacNair & Corazzini, 1994), physical health complaints (Bostwick, 1987), difficulty relating in general to others (Miller & Rice, 1993), and low expectations for and fear of group therapy (Yalom & Leszcz, 2005).

In the systematic review of 80 CBGT candidates mentioned earlier, we explored some of these possible reasons for dropping out, but did not find any correlation between health or interpersonal problems and low attendance or dropping out. There was a small correlation between prior alcohol use—but not present—and poor attendance. Overall, 11% of all the clients enrolling in CBGT dropped out. Poor attendance was the case for 7% (less than 50% of total number of sessions), 20% had medium attendance (between 50% and 75% of sessions), and 62% had good attendance (more than 75% of sessions). The dropout rate of 11% from this sample of 80 clients is lower than the rates reported in the literature. Perhaps this reflects clients being well prepared for CBGT, as well as efforts to create a strong group climate allowing for optimal learning of specific CBT interventions. We found a strong correlation between expectations and attendance.

Expectations for CBGT

People waiting for a group were asked, among other things, to rate their expectations on a 1–7-point scale (e.g., “I look forward to beginning group therapy” and “I expect I will stay with the group at least eight weeks”). In other words, looking forward to group therapy and having positive expectations for attendance bode well for completing. Conversely, feeling ambivalent does not. The role of expectations makes intuitive sense and is not a new idea. In his classic text, Persuasion and Healing, Frank (1961) argued that mobilization of hope and positive expectations for improvement within the patient seeking help is integral to effective therapy.

There are some studies showing that positive expectation in CBGT for anxiety is related to greater improvements (Dozois & Westra, 2005; Price, Anderson, & Henrich, 2008). In contrast, little is known about the relevance of members’ expectations in CBGT for depression. Given that, in our experience, dropouts from depression groups are more common compared to anxiety groups, we took a closer look at expectations in CBGT for depression (Tsai, Söchting, Mirmiran, & Ogrodniczuk, 2014). The Outcome Expectancy Scale (OES; Ogrodniczuk & Söchting, 2010) is a three-item self-report questionnaire asking clients to rate their degree of confidence in the helpfulness or expected benefits of therapy on a five-point Likert-type scale ranging from one (not at all) to five (completely). The questions are as follows: (a) How much do you expect to recover from your problems after therapy? (b) How successful do you think the therapy will be in helping you with your problems? and (c) How confident are you that this therapy will help you?

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