2 The previous chapter showed how CBGT, despite its advantages and promises, is challenging to implement. This chapter continues the discussion of how therapists can make their groups stronger by paying careful attention to both delivering content and the group process. Although the main message from research comparing group CBT to individual CBT is that the formats are equally effective (to be reviewed in detail in Chapter 3), the lingering notion of group therapy being inferior is out there, even among CBT clinicians. I understand this skeptical attitude. It is indeed a tall order to adhere to a highly structured didactic program where each session must deliver a preset amount of educational material within a strict time period and at the same time not have the group look and sound like a classroom. When I do interpersonal therapy (IPT) groups, I admit to often relaxing into my chair because I don’t have to worry about presenting anything in particular, but can rather work with what transpires and how it may further individual and group development. I am not minimizing the therapeutic skills required of more dynamically trained group therapists, but rather validating the experience of the conscientious and ambitious CBGT therapist: it is hard to combine two distinct therapeutic traditions, group therapy and CBT, into one seamless, elegantly flowing effective intervention! This chapter begins with a largely theoretical discussion of the distinction between the process and the content of a CBT group before offering concrete clinical examples illustrating how process factors support the delivery of the content in CBGT. A few words about the history of group therapy. Group psychotherapy was a movement that began in the 1950s. Many people with or without any particular mental health problems participated in these groups, often called T groups, with T standing for training (sensitivity training was the full name). These groups did not follow a certain format or structure but allowed members to freely interact and support one another. Today, these supportive groups are referred to as process groups. Process groups continue to be popular and available in public and academic mental health clinics. For many mental health professionals, especially more senior therapists, group therapy is still primarily equated with process groups. Professional group therapy organizations, such as those in the United States and Canada, also emphasize process groups, and it is rare to find them offering workshops on CBT groups. At the same time as process groups gained momentum, CBT arrived as the new kid on the therapy block, emphasizing a more structured, problem-focused, here and now therapy approach. CBT was originally developed as an individual form of therapy, and although CBT lends itself well to a group format, this adaptation is not straightforward. CBT groups are filled with content and structure as therapists educate group members about their problems and teach them coping skills. But the moment a group of people come together, a number of interpersonal dynamics take place, which can both undermine and enhance the way the group works. The two key trends in group therapy literature provide a helpful background for understanding the challenges facing the group CBT therapist (Burlingame, Strauss, & Joyce, 2013). The first looks at the process—the ways group members relate and experience the group, with the assumption that these dynamics and interactions primarily contribute to positive change. Group process has been defined by Burlingame and colleagues (2013) as the theoretical mechanisms of change within the group, including group development, therapeutic factors, degree and timing of group structure, and interpersonal feedback. Within this group process, overall treatment outcome is also influenced by therapist factors (e.g., leader characteristics such as warmth, ability to understand and work with the group as a vehicle for change in addition to didactic presentation, perceived credibility, and multicultural competence), patient factors (e.g., interpersonal skills, empathy, and more recently language fluency), and structural factors (e.g., length, frequency, quality of setting). This process approach is exemplified in the seminal work by Irvin Yalom in The Theory and Practice of Group Psychotherapy (Yalom, 1970, 1995; Yalom & Leszcz, 2005). In a process group, people presumably get better because of the work done BY the group, that is, the process by which group members relate and experience the group. In contrast, the content (also called structured) approach, which includes CBT focuses on adherence to specific treatment protocols in creating change. People are assumed to get better because of the work done IN the group, not by it. Clinicians and researchers have adapted individual CBT protocols to group settings for a number of disorders including depression, social and generalized anxiety, obsessive–compulsive, psychotic, and addiction-related disorders as classified in the DSM-IV (American Psychiatric Association [APA], 2000) and DSM-5 (APA, 2013). A few CBGT protocols have been published and provide step-by-step guidelines for treatment. Although research generally supports the efficacy of these adapted individual CBT protocols the clinical reality of running CBT groups in community settings is often less successful than described in the literature. CBGT therapists find themselves struggling with how to best deliver many treatment components in a tight time frame, how to give sufficient individual attention, and how to manage process-oriented interactional issues with little help from a given CBT protocol on how to do this. Although useful in understanding larger trends, the dichotomy between content and process is not so clear-cut. To say that CBGT is all content and Yalom-style interpersonal groups are all process is an oversimplification. Experienced group therapists of all stripes know it is impossible to not have both elements in both kinds of groups. Interpersonal group therapists find themselves giving mini psychoeducational lectures in their groups, and CBT therapists often bring out tremendous support between group members as they themselves step back and let the group take over. Burlingame and colleagues (2013) offer a helpful conceptualization of how clinicians can better understand the many factors contributing to therapeutic outcomes in any group. They emphasize the importance of understanding both the adherence to a formal theory of change, such as CBT, and the small group processes operating independently of what therapists formally present in their group sessions. In an ideal CBT group, therapeutic outcome would be a result of (a) the ability of the facilitators to deliver the formal content presentations and (b) the way the same facilitators capitalize on the group process factors. Bieling, McCabe, and Antony (2006) compiled a list of factors they considered to be involved in the process of CBT groups. One can put these factors into the following categories: (a) group member factors (e.g., the effects of group members’ symptoms and personality style on one another), (b) therapeutic relations (e.g., trust between the group and the therapists, between group members, between the cotherapists), (c) effects of individual variables (e.g., client expectations, client satisfaction, variables that may predict outcome or dropout), and (d) group mechanisms of change (e.g., the group processes of inspiration, inclusion, cohesiveness, and hope, among others). The primary focus in this chapter is the fourth category, group mechanisms of change. (The other factors are, however, also relevant and will be addressed throughout the book.) Yalom’s group process model is critical in any discussion of group mechanisms of change, an approach also taken by Bieling and colleagues (2006). The Yalom group therapeutic factors lens invigorates CBT groups. The positive benefits include, among many, increases in motivation for engaging with anxiety-provoking behavioral or cognitive challenges. It is, unfortunately, still a rare clinical psychology student in a doctoral CBT program who is familiar with the work of Yalom. Again, the opportunities for enriching existing therapeutic traditions with thoughtful integration are plenty. In their Theory and Practice of Group Psychotherapy, Fourth Edition (2005), Yalom and Leszcz list 11 group therapeutic factors all hypothesized to bring about relief from suffering. For people unfamiliar with Yalom and Leszcz’s therapy groups, it is important to know that they are typically for people who suffer from interpersonal problems or a sense of being stuck in their life. Group members may or may not suffer from a diagnosable mood or anxiety disorder, and the Yalom-style groups are not homogeneous in terms of being primarily for depression or anxiety. Thus, the idea of mapping these factors onto highly specific diagnostic CBT groups is perhaps a stretch but also a testament to the truly universal processes of human interactions identified by Yalom. Although 11 distinct factors have been identified and hypothesized to be present in all kinds of psychotherapy groups, readers will likely not be surprised to hear that there is a high correlation among the factors and they neither occur nor function separately (MacNair-Semands, Ogrodniczuk, & Joyce, 2010). The 11 factors are as follows: (1) instillation of hope, (2) universality, (3) imitative behavior, (4) imparting of information, (5) altruism, (6) group cohesiveness, (7) existential factors, (8) catharsis, (9) interpersonal learning, (10) development of socializing techniques, and (11) the corrective recapitulation of the primary family group. The remainder of this chapter illustrates—using sample dialogue—how some of these group process factors operate. I use an OCD group as an example. The choice of OCD is somewhat arbitrary, and one could pick any group for purposes of illustration of specific process factors. But we have found that process factors seem especially relevant in OCD groups, in part because it can be a challenge to engage group members with OCD in exposure exercises. Chapter 13 offers a detailed description of how to implement CBGT for adolescents with OCD. In what follows, each of the Yalom therapeutic factors is discussed in the context of what typically happens in a group for OCD. I have listed the factors in order of importance, according to the perspective of therapists routinely offering CBT groups for OCD. People with OCD are reluctant to go for group treatment. This is understandable given how they often feel guilty and ashamed. They worry about being judged as “crazy” or “disgusting.” Their obsessions may involve fears of molesting children or demanding one’s husband remove all of his clothes in the driveway upon returning home from work because he may “contaminate” the family home. It takes people with OCD an average of 10 years to seek help, which is much longer than for other anxiety problems. People with OCD often try to help themselves, and if family members are aware of their illness, they too try to help. Unfortunately, this help is often countertherapeutic and makes the symptoms worse. This happens because family members tend to comply with the request for compulsions or reassurance. It is, understandably, easier to agree to wash the same load of laundry a third time than put up with a temper tantrum. It is also fairly easy to quickly repeat to a loved one, even for the 15th time, as it literally takes only 2 seconds each time: “No, I don’t think you touched that girl inappropriately.” Thus, it is not surprising that when someone finally presents for treatment, hope is dwindling. Here is an example of how hope can be installed in the therapy group when members meet each other and realize they are not alone in wanting to face their fears. Therapist: Jim: Julia: Sun-ming: Therapists take steps to reinforce the sense of hope by concluding with words to the effect of: “We are glad you each found your way to this group, and the courage to give it a try. We know how hard it is for any person to confront something we would rather avoid. We can tell there is already tremendous support and this will make the hard work easier—and even fun at times. We really look forward to working with you all.” Almost invariably, the first OCD group ends with people chatting, even laughing, and exchanging “good to meet you” and “see you next week, man.” Learning—often for the first time—that one is not the only person doing “weird” things or having “bad” thoughts is tremendously encouraging for an OCD sufferer. As therapists, we go out of our way to highlight universality—even to the point of making people realize their obsessions are quite common. Here is an example of how to work with universality to strengthen the commitment to treatment. Gertrude:
Working with Process and Content
Process and Content in Group Therapy
Group Process in Theory
Group Process in Practice: Obsessive–Compulsive Disorder Illustration
Instillation of hope
Universality
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Working with Process and Content
So, we’re now nearing the end of our first session and we hope you all have a fairly good sense of how this group for OCD may help you. We know we have only spoken generally about the treatment components, and you probably have many unanswered questions about how this will work for you specifically, but it will all make more and more sense as we move on each week. Are there any further questions or comments before we let you go?
I just want to say I have never met another person with OCD and I can’t believe that Jenny also turns her car around and drives home on her way to work so that she can check she locked the front door. Her saying she is ready to face this fear makes me feel I can do it too.
Yes, I also feel ready to face my fears. Although it sounds scary to have to actually face what we fear and not give in to our compulsions, knowing that we’ll do it together and support each other makes me so glad I came to this group.
I really appreciate how you facilitators said that although it’s going to be difficult, really difficult at times, you promise that whatever you ask us to do will be safe and that we’re always in charge. I just feel so hopeful to have come to this group which I had no idea had been running in my city for so many years.
I know I’m the only person who hasn’t shared what my obsessions are and I appreciate the therapists telling me during my assessment that I didn’t have to. The treatment could still be effective as a big part of the group focuses on people’s individual fears.
