7 CBGT started out with highly homogeneous groups and those are still considered the easiest to run. However, research shows that groups including people with different diagnoses (transdiagnostic) can yield acceptable outcomes too—along with other practical benefits and efficiencies. Transdiagnostic group interventions are welcomed by many CBGT therapists and are gaining ground in community mental health settings, probably faster than the research literature can keep up. Clinicians’ main hesitancy toward transdiagnostic approaches may have more to do with this intervention not being part of the training of most senior CBT clinicians. As a result, when senior clinicians today talk about CBT groups, we are still usually talking about specific groups for specific disorders, such as depression, obsessive–compulsive (OCD), social anxiety (SAD), generalized anxiety (GAD), and panic disorder. The few existing guides on general group CBT (e.g., Bieling, McCabe, & Antony, 2006; Scott, 2011) reflect this categorical approach. A transdiagnostic option thus requires some effort to change one’s habitual approach to designing and running a CBT group. This chapter will first review the existing transdiagnostic approaches. It will take a transdiagnostic tour, beginning with the initial rationale for transdiagnostic groups, a content discussion, and finally a look at evidence of their efficacy. This research review will be followed by two clinical examples from the community program where I work. The first example is a group that combines social anxiety and panic disorder. The second brings together different types of posttraumatic stress disorder (PTSD), such as motor vehicle accident and sexual assault. The latter is an example of the challenge of combining different types of trauma—despite the same shared diagnosis of PTSD.1 I refer to this kind of mixed group as a heterogeneous group. The many terms for transdiagnostic can be confusing. Transdiagnostic is the most commonly used term, but others, such as unified, mixed, heterogeneous, and blended, are equivalent terms. A transdiagnostic group can include people with different diagnoses (e.g., some have panic disorder and some have GAD) and people who have more than one diagnosis (e.g., a group member may have both social anxiety and depression). Subsequent chapters will continue the transdiagnostic theme. Chapter 11 describes how older adults with depression and/or anxiety can be successfully treated in the same CBT group. Chapter 12 shows how children with different anxiety disorders can be accommodated in the same group. Chapter 13 describes how impulse control or OCD-related disorders, such as trichotillomania (hair pulling) and body dysmorphic disorder, can be mixed into an otherwise pure OCD group. Clinicians are aware that commonalities across emotional disorders often seem to outweigh the differences. They also know that similar CBT components are applied to different mental health issues. Putting people with different problems in the same CBT group—such as GAD and depression or social anxiety and panic disorder—thus seems like an attractive option for several reasons. Clinicians are, however, also concerned about how to practically implement such blended groups and how much mixing and matching is allowed. This concern stems from the strong CBT tradition of diagnostic-specific interventions. CBT clinicians take some pride in having developed different interventions for each and every diagnosable disorder, or defined problem. But the need for a transdiagnostic approach has been apparent to many clinicians for some time. One of the first published guides for transdiagnostic groups (without calling it transdiagnostic) was the Group Cognitive Therapy Program (Free, 2007), a 24-session generic group therapy manual emphasizing cognitive techniques. This program is suitable for people with depression, anxiety, and anger. Since Free’s group program, additional CBGT guides for transdiagnostic problems have been published and will be introduced in this chapter. Transdiagnostic treatment outcomes have until recently come from two main types of mixed groups: anxiety disorders with mood disorders (depression) and different anxiety disorders within the same group. Research has repeatedly demonstrated that anxiety and depression often go “hand in hand.” Early research showed that 50–80% of individuals report simultaneous symptoms of anxiety and depression (Kendall & Watson, 1989), and ongoing research continues to find high overlap—including in elderly people (Blazer, 2002; Hinrichsen & Emery, 2005). This has led to the development of CBGT interventions targeting both depression and anxiety. Thus, this kind of transdiagnostic group would include people who struggle with depression or anxiety or with both depression and anxiety. A second body of research that supports the move toward transdiagnostic groups focuses on conceptualizations of a core pathology primarily for anxiety disorders but also relevant for depression. Core pathology researchers posit that our diagnostic classification system, based on the DSM-IV (American Psychiatric Association [APA], 2000) with its 12 distinct anxiety disorders, all share the same vulnerability, namely, “a perceived inability to predict, control, or obtain desired results” (Barlow, 1988). Perceptions of uncontrollability and unpredictability are also a common underlying factor in depression and may indeed explain the high rates of comorbidity and similarity between mood and anxiety disorders (Clark, Steer, & Beck, 1994). The term negative affectivity is sometimes used to describe the common personality characteristics of people prone to anxiety and depression. It is defined as “a stable, heritable trait tendency to experience a broad range of negative feelings such as worry, anxiety, self-criticisms, and a negative self-view” (Keogh & Reidy, 2000). Our increased understanding of what is commonly shared by all types of anxiety disorders—while not losing sight of their unique distinguishing aspects—has led to successful implementation of transdiagnostic CBGT for anxiety. However, as we shall see, not all types mix equally well. A further argument supporting transdiagnostic treatment involves the concept of treatment generalizability. Experienced clinicians are familiar with how CBT can bring about improvements even in problems not specifically targeted. For example, clients in panic disorder groups are often surprised—but encouraged—to note that their depression also improved, even though it was not specifically addressed. In addition to the theoretically driven research, many pragmatic reasons compel clinicians to consider moving from homogeneous to transdiagnostic CBGT in community mental health settings. There are benefits to both clinicians and clients. For the clinicians, consolidating multiple diagnosis-specific protocols into fewer protocols simplifies efforts to teach and implement treatments. A transdiagnostic approach is more easily mastered by a generalist clinician who may not have received specialized, supervised CBT training during their education. This is usually the case for the majority of frontline mental health group therapists. They may have had supervised CBT training on individual cases, but rarely for CBT groups. Continuing education for staff in a transdiagnostic approach is thus more practical—and cheaper—than education in 12 diagnosis-specific treatments (Erickson, Janeck, & Tallman, 2009). However, juggling several different types of anxiety in the same group can be an enormous challenge for generalist clinicians, especially if they have not had much specific CBT experience. I say this to validate clinicians who often find that running transdiagnostic groups is not as easy as it may sound from some of the existing manuals. Clients benefit from the efficiency of only one course of therapy, which targets both their primary and secondary concerns (e.g., agoraphobia and GAD or panic disorder and depression), rather than undertaking sequential treatment for each disorder. Clients also get improved access to services when clinics do not have to wait to get enough people with SAD, as an example, to fill a group. A more transdiagnostic group approach can allow quicker access and reduce wait-list time. In many less populated areas, it is simply not feasible to run pure groups for sexual assault survivors since—fortunately—there are not enough demands for such a therapy service. Even though we still need more conclusive evidence from direct comparisons of transdiagnostic versus diagnosis-specific CBGT, the aforementioned practical advantages encourage clinicians to experiment with developing their own transdiagnostic groups informed by the available outcome research. Transdiagnostic CBGT includes basic CBT components, which at minimum include (a) psychoeducation, (b) self-monitoring, (c) awareness and replacement of dysfunctional thinking, and (d) graded exposure to internal or external triggers. These components run across all CBT for various problems but tend to take different forms depending on the disorder. Thus, the common components differ in content but not function, and their treatment rationale remains the same. For example, with GAD, exposures may include imaginary future and worst-case scenarios, such as worrying about one’s child not marrying within the same ethnic group. For panic disorder, the exposure is to concrete places such as buses, commuter trains, movie theaters, or concert halls. The rationale for both kinds of exposure is the same. It involves increased tolerance (desensitization) to repeatedly putting oneself in the feared situation (whether real or imagined) and realizing that one is not harmed or that the feared scenario is not as “horrible or devastating” as previously thought. A man with panic disorder realizes that feeling trapped in the middle of a row in a concert hall may be uncomfortable but not life-threatening and certainly not a sufficient cause for concern to forgo a favorite Beethoven symphony. A woman with GAD realizes that she can “survive” the possibility of her child marrying outside the family’s ethnic group. With successful exposure treatment, both clients will experience a decrease in symptoms. The man with panic disorder notices that his heart rate does not accelerate as quickly, his throat is less dry, and his legs are less wobbly. The woman with GAD notices that she is not consumed with “what if” worries about future scenarios she is unlikely to control and that her sleep is better and jaw and shoulders are less tense. In the following text, we will look at protocols for mixing anxiety disorders with depression and then different anxiety disorders in the same CBGT program. Some of the first attempts to mix people with anxiety and depression were done by Kush and Fleming (2000). They evaluated a 12-session CBGT program designed to conjointly treat individuals with comorbid depression and anxiety. Their program was primarily targeting cognitions, with less emphasis on behavioral interventions such as the exposures mentioned earlier. Their program followed a content specificity approach. This approach recognizes that people with depression or anxiety have different cognitive profiles. Anxious people tend to hold beliefs about excessive vulnerability and elevated perceptions of threat, especially future ones. Depressed people hold beliefs about inadequacy and personal failure, especially ruminations about past events. When dysfunctional thinking was addressed in the groups, members received different handouts and instruction for addressing their thinking depending on their primary diagnosis. For example, anxious group members were helped to identify and challenge beliefs about danger related to present or upcoming life events (e.g., “I’ll be so anxious that I cannot swallow my food during the business lunch meeting”), events nonanxious people would consider ordinary. Depressed group members were helped to identify and replace self-critical thinking (e.g., “Forgetting to bring my daughter to her friend’s birthday party shows what an incompetent parent I am”), events nondepressed people would consider ordinary. Results from a total of four groups showed significant improvement on measures of depression and anxiety and thus point to the clinical and practical utility for a combined CBGT approach. Similar to Kush and Fleming (2000), McEvoy and Nathan (2007) also reported good results from their 10-week 2-hour session CBGT for anxiety and depression. A total of 143 clients referred to a community mental health clinic received the same CBGT protocol, which was an integration of two individual CBT manuals: Beck’s Depression manual (1967/1972) and Barlow and Craske’s (1994) Mastery of Your Anxiety and Panic manual. Treatment components included psychoeducation about anxiety and depression, calming techniques, behavioral activation, exposures, and cognitive restructuring. Unlike in the Kush and Fleming groups, there were no diagnosis-specific, or content-specific, interventions. The achieved outcomes were compared to those from diagnosis-specific treatments reported in the literature and were found to be similar. As a result, the clinician researchers concluded that this transdiagnostic CBGT evaluation benchmarked the effectiveness of mixed depression and anxiety CBGT. Based on these and similar successful outcomes in combining depressed and anxious clients in the same group, we now have full transdiagnostic protocols (which include workbooks for clients and guides for therapists; Barlow et al., 2011). The Barlow transdiagnostic protocol, which Barlow and colleagues refer to as a unified approach, instructs clinicians on how to increase their clients’ awareness of their emotions and emotion-driven behaviors. Concepts from mindfulness training (reviewed in Chapter 5), such as nonjudgmental and present-focused emotion awareness, run throughout this therapist guide. There is less emphasis on exposures to different situations and triggers and on how to develop exposure hierarchies. Informed by the work of Barlow and colleagues, a number of innovative transdiagnostic CBGT programs have enjoyed successful dissemination and evaluation. One such example includes an inspiring version of the rapid access group discussed in Chapter 6. Hamilton and colleagues (2012) developed a two-part CBGT program for people with anxiety and depression, the CBT Basics I and CBT Basics II. As described in Chapter 6, CBT Basics I is considered a preindividual therapy group program primarily designed to reduce wait times for people on lists for more intense individual CBT. The additional program, CBT Basics II, was developed by the same group of clinicians and is a stand-alone CBT group adding an additional four weekly 2-hour sessions to the six sessions comprising CBT Basics I. In addition to the standard behavioral and cognitive interventions, a mindfulness component is included based on accepted knowledge of mindfulness practice reducing risk of relapse in individuals recovered from depression. Since its inception in 2005, over 160 clients have completed these programs in six different clinics located in a Canadian province. Several clients were severely depressed or anxious and also struggled with chronic medical illnesses such as diabetes. Fifty-eight mental health practitioners have been trained including psychiatrists, psychologists, nurses, and social workers. The reductions in symptoms of depression and anxiety suggest that such transdiagnostic groups may be an effective intervention in general mental health programs. Erickson et al. (2009) created a mixed anxiety group in a community outpatient service in a large metropolitan area. Their initial protocol involved transdiagnostic techniques such as psychoeducation about anxiety and general principles of graded exposure. Diagnosis-specific techniques were administered to the various subgroups within the larger group. These included (a) interoceptive exposure for panic disorder with or without agoraphobia, (b) assertiveness skills for SAD, and (c) worry-time and thought-stopping for GAD. Worry-time involves taking control of one’s worries by setting aside a certain block of uninterrupted time, for example, 30 minutes a day, to immerse oneself in worry. It tends to have the somewhat paradoxical effect of experiencing less worry outside of this dedicated worry-time. Thought-stopping involves the person imagining yelling “STOP–STOP!” the moment the worry-thought enters their mind; they may also snap an elastic band on their wrist upon noticing the arrival of a worry-thought.2 All group members engaged with all the treatment components, that is, they all did worry-time and role-plays regardless of diagnosis. A later protocol by the same clinician researchers reflected advances in the CBT anxiety disorders field and included more cognitive techniques, which were not developed at the time of the first protocol. The newer cognitive techniques replaced the older interventions of assertiveness and role-playing. These cognitive interventions—now standard in almost any anxiety protocol—include probability overestimation (“What are the odds of my dying next time I have a panic attack?”) and challenging catastrophic automatic thoughts (“What if people notice I’m anxious? That would be terrible”). Worry-time and imaginary exposure for GAD were still used as an example of a diagnosis-specific techniques. This revised protocol was applied to 152 clients in a total of 12 groups (social anxiety, GAD, OCD, and PTSD). Overall results revealed significant changes on outcome measures between the wait-listed group members and those who completed group treatment. These treatment benefits were maintained at 6 months follow-up. Conclusions from this evaluation state that transdiagnostic CBT groups could be effective, but that this particular protocol was not ready for dissemination. In particular, Erickson and colleagues caution that people with OCD and PTSD require a more intense and specific treatment focus compared to other anxiety presentations. For example, PTSD group members were more labile in their anxiety. Their reexperiencing of traumatic memories often occurred in the group sessions, distracting other clients from their exercises. The OCD clients struggled with motivation and were not as willing to let go of their compulsive behaviors as would be needed in order to engage in effective exposures. It is indeed our experience that clients with OCD need constant attention and encouragement to stay “on task” for their exposures. It is therefore not surprising to hear of their tendency to “hide” behind participation in apparent anxiety-reducing tasks such as relaxation training, when this has only minimal, if any, therapeutic value in reducing obsessions and compulsions. Similar to Erickson et al. (2009), Norton (2008) also obtained good results from 52 clients across the anxiety disorders. The strongest response to treatment was with the social anxiety and panic disorder clients, and the poorest was with GAD, OCD, and specific phobias (e.g., a fear of heights, dogs, or spiders). There were no PTSD clients in this trial. The 12-week 2-hour group session protocol emphasized three core ingredients of CBT: (1) psychoeducation and self-monitoring, (2) cognitive restructuring, and (3) exposure to feared stimuli. Similar to the Erikson study, Norton did not have sufficient OCD participants to conduct a specific treatment response analysis for this subgroup. Norton (2009) concludes that the initial developers of the transdiagnostic approach are hesitant to include clients with OCD and PTSD. Norton has since 2009 conducted a randomized controlled study on transdiagnostic versus diagnosis-specific CBGT and concluded that mixed groups of social anxiety, generalized anxiety, and panic disorder meet the same gold standard outcome as diagnosis-specific CBGT (Norton & Barrera, 2012). In his Group Cognitive-Behavioral Therapy of Anxiety: A Transdiagnostic Treatment Manual, Norton (2012) offers a 12-session transdiagnostic CBGT manual suitable for all anxiety disorders including OCD. There is an emphasis on exposure and many helpful examples of how to conduct those in the groups. The transdiagnostic literature on anxiety disorders encourages CBGT clinicians to consider combining the different disorders into the same group. However, despite some research supporting including OCD into a transdiagnostic group, the experience of many clinicians, including myself, is that OCD and PTSD do not mix well with other disorders and are best treated separately. The DSM-5 reinforces this with both of these disorders having their own category separate from the anxiety disorders category. I am familiar with successful transdiagnostic community programs offering groups with different combinations of anxiety disorders, usually panic disorder, separation anxiety, GAD, and social anxiety. But I have yet to hear positive outcomes from mixing PTSD and OCD with the rest of the anxiety disorders. These two disorders express themselves in highly varied ways even within their own diagnosis. Combining, for example, different traumas such as motor vehicle accident and assault in the same group often feels and looks like a transdiagnostic group. The same is true for an OCD group where someone will have obsessions involving molesting young boys and another group member will repeatedly check to ensure a hair straightener is turned off. We will return to the option of a heterogeneous trauma group at the end of this chapter. This discussion will be included because clinicians often wonder about combining different traumas, given that it can be hard to fill groups with the same trauma in a timely manner. First, though, I review a typical transdiagnostic approach involving combining people with social anxiety and panic disorder. Both types of mixed groups can make valuable additions to community CBGT settings. Community programs offering CBT for anxiety find that they can fill groups faster, and thus reduce wait lists, if they combine socially anxious and panic disorder clients into the same group. Other than quicker access to treatment, this combination works because those two disorders share many features. Further to practical benefits, however, clinical experience suggests that group members with social anxiety may derive improved treatment gains compared to a pure social anxiety group. A panic disorder and social anxiety CBGT program is admittedly a minor version of the transdiagnostic approach given that only two disorders are combined. SAD involves a persistent fear of one or more social and performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others. Individuals fear they will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Social anxiety can be specified as “performance only.”3 The “performance only” specification recognizes that people whose social fears are limited to performing in front of an audience seem to represent a distinct subset of SAD. Perhaps more than other anxiety disorders, people with social anxiety are at higher risk for substance abuse, an understandable coping mechanism or safety strategy. Chapter 17 presents a CBGT protocol for comorbid social anxiety and substance use.
Transdiagnostic and Other Heterogeneous Groups
Why Consider Transdiagnostic Groups?
What Do Transdiagnostic CBGT Protocols Include?
Mixing anxiety with depression in the same group
Mixing different anxiety disorders in the same group
CBGT for Social Anxiety and Panic Disorder
The diagnosis of social anxiety disorder
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