individual cognitive behaviour therapy in the treatment of panic disorder and agoraphobia
Journal of Cognitive Psychotherapy: An International Quarterly Volume 24, Number 2 • 2010
132 © 2010 Springer Publishing Company
CBT Basics: A Group Approach to Teaching Fundamental
Sophie D. Macrodimitris, PhD Foothills Medical Centre, Alberta Health Services
Kate E. Hamilton, PhD Peter Lougheed Centre, Alberta Health Services
Barb J. Backs-Dermott, PhD Sheldon M. Chumir Health Centre, Alberta Health Services
Kerry J. Mothersill, PhD Sheldon M. Chumir Health Centre, Alberta Health Services
CBT Basics I is a psychoeducational group program originally developed as a pre-individual therapy introduction to cognitive-behavioral therapy (CBT) skills for clients presenting with depression and/or anxiety disorders. We describe the development and content of this six- session introductory CBT group and provide data from a 3-year pilot program. The results support the potential for symptom improvement and CBT skill acquisition, and provide pre- liminary evidence for the group’s potential to enhance accessibility to CBT. Future directions for the development of this group are discussed, including expanding to a 10-session group model incorporating mindfulness meditation.
Keywords: CBT; group; psychoeducation; depression; anxiety
Recent clinical practice guidelines (CPGs) for depression (National Institute for Clinical Excellence [NICE], 2007a; Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Depression, 2004) and anxiety (NICE, 2007b; Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Panic Disorder and Agoraphobia, 2003; Swinson et al., 2006) recommend cognitive behavioral therapy (CBT) as an equivalent, and in some cases (e.g., specific phobia, panic disorder), more effective treatment than medication. These guidelines recognize several years of randomized controlled trials consistently demonstrating the cost-effectiveness (e.g., Antonuccio, Thomas, & Danton, 1997) and efficacy (Chambless & Hollon, 1998; Chambless & Ollendick, 2001; Otto, Pollack, & Maki, 2000; Otto, Smits, & Reese, 2005; Vos, Corry, Haby, Carter, & Andrews, 2005) of CBT for depression and anxiety. Recent advances in CBT, such as the incorporation of mindfulness
Article 7 Macrodimitris.indd 132 4/16/2010 8:57:06 PM
CBT Basics Group Therapy Program 133
meditation techniques (Segal, Williams, & Teasdale, 2002), also demonstrate reduced relapse rates (Ree & Craigie, 2007).
A major limitation to CBT acknowledged in CPGs is accessibility (NICE, 2007a, 2007b). CBT is typically taught in specialized psychology graduate training programs, and it is difficult for other mental health care professionals to obtain adequate training (Hamilton & Dobson, 2001; Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Panic Disorder and Agoraphobia, 2003). Recent initiatives have targeted the accessi- bility issue through the creative provision of CBT (e.g., computerized CBT; see Wright et al., 2002).
The current article describes a psychoeducational group program, CBT Basics I (Hamilton & Macrodimitris, 2005; Macrodimitris & Hamilton, 2005) developed for individuals with de- pression and/or anxiety and implemented to enhance accessibility to CBT. This article describes the rationale for developing this non-syndrome-specific psychoeducational CBT group program. In addition, we review preliminary outcome data over 3 years of piloting this group program. Finally, we describe other current and future initiatives, including the expansion to a 10-session group format that incorporates mindfulness meditation techniques, and potential future applica- tions of the program beyond standard mental health clinics.
Rationale for Developing CBT Basics I
The group program described in this article was developed in order to address an increasingly long wait list for a CBT program. The CBT therapists in this program discussed the possibility of developing a psychoeducational group that (a) could provide more rapid access to service and (b) could enhance individual treatment by ensuring participants had the fundamental skills of CBT prior to entering more intensive individual treatment. Given that the primary presenting prob- lems treated through the CBT program are depression and anxiety disorders, it was proposed that we develop a psychoeducational “pre-individual therapy” group program that would address the core components of therapy that are similar across these two diagnostic groups.
Our CBT program is based on Beck’s cognitive theory of emotional disturbance, which proposes that an individual’s affective, physiological, and behavioral responses are mediated by cognitive interpretations (Beck, Rush, Shaw, & Emery, 1979). Although originally applied to depression, this theory and its associated treatment approach is established as an efficacious treat- ment for a variety of presenting problems, including anxiety, health concerns, marital problems, and criminal offending (Beck, 2005; Chambless & Ollendick, 2001).
Research is increasingly recognizing that mental health treatments must account for the fact that individuals often present with co-occurring conditions (Heldt et al., 2006; Kessler, Chiu, Demler, & Walters, 2005). For example, the comorbidity of depression and anxiety was well-es- tablished in a World Health Organization (WHO) study of close to 26,000 individuals presenting to primary care physician practices (Sartorius, Üstun, Lecrubier, & Wittchen, 1996). Diagnostic psychiatric assessments of participants revealed that one-quarter met criteria for a mental health disorder (as classified by the 10th edition of the International Classification of Diseases [ICD-10]; WHO, 1996), with depression and anxiety spectrum disorders being the most frequently diag- nosed conditions. When analyzing for comorbidity, it was determined that “nearly half of the cases of depression and anxiety appeared in the same patients at the same time” (p. 40). In addi- tion, depressive disorders were more likely to be comorbid with anxiety disorders than with any other ICD-10 diagnosis. These findings are consistent with Hirschfeld’s (2001) literature review demonstrating that comorbidity for depression and anxiety disorders in primary care settings is ~50%. Research on the comorbidity of depression and anxiety indicates that it is common for individuals to present with both types of symptoms and thus, provides a rationale for combining these individuals into a single treatment group. From a practical perspective, including clients
Article 7 Macrodimitris.indd 133 4/16/2010 8:57:06 PM
134 Macrodimitris et al.
with anxiety and/or depression into one group could facilitate the flow of referrals and decrease wait times for clients to enter individual therapy.
Core Components of CBT for Depression and Anxiety
The core components of CBT are similar across depression and anxiety (Barlow, 2001). In our therapy program, the initial CBT treatment phase typically involves teaching individuals to mon- itor affect, physical arousal, and cognition to gain greater self-awareness and identify targets for change (Beck, 1995). We emphasize behavioral techniques in this phase, given that problem behaviors are readily observable aspects of patient experience. In addition, research demonstrates the importance of behavioral techniques in affecting change (Jacobson et al., 1996). When de- pression is the primary presenting mood problem, CBT encourages monitoring activities and their relationship to mood shifts (“activity-mood monitoring”). Behavioral activation (“activity scheduling”) then promotes rewarding experiences (i.e., activities that encourage a sense of plea- sure and mastery/accomplishment), which leads to improved mood (Beck, 1995; Emery, 2000; Greenberger & Padesky, 1995; Lewinsohn, Steinmetz, Antonuccio, & Teri, 1985; Martell, 2003). Graded task assignment (Beck, 1995) is sometimes used as an adjunct to activity scheduling as a mechanism for breaking activities into smaller, more achievable steps.
When anxiety is the primary presenting problem, behavioral monitoring is also conducted in the initial stages of therapy to identify anxiety-provoking situations and stimuli. Individuals are then taught evidence-based Exposure Therapy techniques (Butler, Chapman, Forman, & Beck, 2006), which include building a graded hierarchy of anxiety-provoking situations toward the development of in vivo exposure exercises (Bourne, 2000; Craske & Barlow, 2000; Hazlett-Stevens & Craske, 2003a). Individuals then practice working up the hierarchy, with the goal of habituation to feared sensations and stimuli.
Another important component of early treatment in individuals with anxiety is diaphrag- matic breathing retraining for the management of physiological arousal. Interoceptive exposure is employed using hyperventilation as an example of the physiology of over-breathing (Hazlett- Stevens & Craske, 2003b). Breathing retraining may or may not be paired with the practice of specific relaxation techniques such as visualization and progressive muscle relaxation (Bourne, 2000). Increasingly, mindfulness meditation (Kabat-Zinn & Santorelli, 1993) is used for man- aging physiological reactions, as it also assists in managing negative cognitions (Kabat-Zinn et al., 1992).
Once behavioral techniques are well under way and self-awareness is enhanced, our CBT program builds in dysfunctional thought recording and cognitive restructuring to promote bal- anced thinking (Beck, 1995; Beck et al., 1979; Burns, 1980; Ellis, 2003; Greenberger & Padesky, 1995). These core cognitive techniques are similar across depression and anxiety, with the nature of the negative cognitions being specific to the disorder. For example, anxiety-based cognitions tend to be more future-oriented and based on overestimations of possible negative future out- comes (Burns, 1980). Throughout the course of therapy, behavioral techniques may be paired with cognitive techniques in order to reduce negative thinking. For example, behavioral experi- ments may be created to test the validity of negative cognitions or to support an alternate, more balanced thought or belief (Dobson & Hamilton, 2003). Problem solving using “action plans” (Greenberger & Padesky, 1995) also may be incorporated when it is determined that there is some validity to negative cognitions, thus requiring behavioral change.
Finally, in the later stages of therapy, our CBT program incorporates relapse-prevention tech- niques (Brunswig, Penix Sbraga, & Harris, 2003) to prevent engagement in problem behavior and thinking post-treatment. These techniques include identifying and recording key triggers for and strategies to overcome negative shifts in mood. Another important component of relapse- prevention is teaching individuals to maintain self-awareness through incorporating mindfulness
Article 7 Macrodimitris.indd 134 4/16/2010 8:57:06 PM
CBT Basics Group Therapy Program 135
meditation (Segal et al., 2002). The concepts of relapse prevention are introduced in the CBT Basics I group in order to inform participants of the strategies that will be used in their subse- quent individual therapy.
Group CBT to Enhance Accessibility
Group programs, implementing the above treatment techniques in a small group of 6–12 patients over several sessions, have been used to enhance accessibility to CBT and to reduce treatment costs (Guimon, 2004; Tucker & Oei, 2007). However, most group CBT research focuses on therapy provided for specific syndromes (e.g., obsessive-compulsive disorder, Anderson & Rees, 2007; panic disorder and agoraphobia, Sharp, Power, & Swanson, 2004). More recent CBT liter- ature supports the notion of combining diagnostically heterogeneous individuals into one CBT group (Barlow, Allen, & Choate, 2004; Hooke & Page, 2002), reflecting the increasing recogni- tion that (a) mental health problems like depression and anxiety often co-occur, and (b) core CBT techniques are similar across presenting problems. McEvoy and Nathan (2007) applied this rationale to the development of a 10-session CBT group program for a mixed diagnosis (de- pression and/or anxiety) sample. This group program resulted in symptom reduction that was comparable to diagnosis-specific individual and group CBT, providing evidence for the utility of combining individuals with depression and anxiety into one CBT treatment group. Intensive 2 week day program treatment for patients with mainly anxiety and mood disorders has also been shown to be effective (Hooke & Page, 2002; Manning, Hooke, Tannenbaum, Blythe, & Clarke, 1994). McEvoy, Nathan, and Norton (2009) and Erickson, Janeck, and Tallman (2007, 2009) identified additional promising results of outcome research on transdiagnostic treat- ment of anxiety disorders. However, as noted by Clark and Taylor (2009), more research is required to determine the effectiveness of transdiagnostic treatments, particularly for anxiety and depression.
The Current Pilot Study: Program Evaluation Questions and Hypotheses
A 6-session introductory CBT group program was developed to teach the fundamental concepts and techniques that apply to depression and anxiety disorders. Our initial research questions were as follows:
1. Is it feasible to combine individuals presenting with primary major depressive disorder into a group program with individuals presenting with primary anxiety disorders?
2. Can a six-session mixed-diagnosis group CBT intervention produce a reduction in symp- toms of depression, anxiety, and negative automatic thoughts?
3. Can a six-session mixed-diagnosis group intervention increase knowledge of CBT concepts and strategies?
From the fall of 2004 to winter of 2008, 72 participants, treated in 11 groups, attended the CBT Basics I program. Fifty-eight of these participants consented to participate in the present research. Of these 58, 44 attended 4 or more sessions of the group and completed the post-test measures.1 One participant’s data were excluded from the analyses because they contained outliers. Thus, the following represents 43 individuals (men = 19 or 44.2%; women = 24 or 55.8%) referred pri- marily for treatment of depression and/or an anxiety disorder. The mean age of the sample was 43 years (range = 18–65 years).
Article 7 Macrodimitris.indd 135 4/16/2010 8:57:06 PM
136 Macrodimitris et al.
Table 1 presents demographic and treatment characteristics of participants. Participants were married/living common-law (n = 19; 44.2%), single/never married (n = 17; 39.5%), or separated/divorced (n = 7; 16.3%). Participants were well-educated, with 48.9% completing at least some university. About half of the participants were employed either full-time or part- time (n = 19; 44.2%); the remaining participants were not employed outside of the home. The majority of participants (76.7%) were taking some form of psychotropic medication, with the most common being anti-depressants (n = 28; 65.1%). Only 20.9% (n = 9) had no previous
TABLE 1. DEMOGRAPHIC CHARACTERISTICS
Single 17 39.5
Married/Common-law 19 44.2
Separated/Divorced 7 16.3
High school or less 12 27.9
College/Trade school 10 23.3
University 21 48.9
Full-time 15 34.9
Part-time 4 9.3
Student 3 7.0
Disability 10 23.3
Other 11 25.6
Antidepressant 28 65.1
Anxiolytic 7 16.3
Mood stabilizer 4 9.3
Antipsychotic 8 18.6
CBT 9 20.9
Group 9 21.0
Supportive 22 51.1
Other 19 44.1
None 10 20.9
Primary reason for referral
Mood disorder 23 53.5
Anxiety disorder 10 23.3
Other Axis I 7 16.3
Missing 3 6.9
Article 7 Macrodimitris.indd 136 4/16/2010 8:57:07 PM
CBT Basics Group Therapy Program 137
therapy experience. The majority of participants (n = 23, 53.5%) had mood disorders (i.e., Major Depressive Disorder or Dysthymic Disorder) as their primary diagnoses. Other pri- mary diagnoses included anxiety disorders (i.e., Panic Disorder, Generalized Anxiety Disorder, Social Anxiety Disorder, Obsessive Compulsive Disorder, and Anxiety Disorder NOS; n = 10, 23.3%), and other Axis I disorders (e.g., Adjustment Disorder; n = 7, 16.3%). There was signif- icant comorbidity in this sample, with 44.2% of participants having comorbid Axis I disorders. Diagnoses were made by the referring physician or mental health therapist. All prospective par- ticipants’ referral information was reviewed for inclusion criteria (i.e., met criteria for depres- sion and/or an anxiety disorder) and exclusion criteria (current substance abuse or dependence; current acute suicidal ideation or crisis; Axis II personality disorder is the focus of clinical atten- tion) by one of the group leaders.
Beck Depression Inventory–II (BDI-II; Beck, Steer, & Brown, 1996). The BDI-II is a 21-item self-report measure of depressive symptoms presented in multiple choice format. Each item is answered on a 0–3 point intensity scale with total scores ranging from 0 to 63. The BDI-II has high internal consistency (α = .92 outpatient; α = .93 university sample). Content validity, factorial validity, and diagnostic discrimination have been established (Dozois, Dobson, & Ahnberg, 1998).
Beck Anxiety Inventory (BAI; Beck & Steer, 1990). The BAI is a 21-item scale that measures the severity of anxiety symptoms. The items are rated on a 4-point scale (0–3). Total scores range from 0 to 63. The BAI has shown excellent internal consistency (α = .94) and concurrent validity with other accepted measures of anxiety (SCL-90-R Anxiety subscale, r = .81).
Automatic Thoughts Questionnaire (ATQ; Hollon & Kendall, 1980). The ATQ is a 30-item self-report measure of automatic negative self-statements associated with depression. It assesses four aspects of dysfunctional automatic thinking that are associated with various forms of psy- chopathology: personal maladjustment and the desire for change; negative self-concepts and neg- ative expectations; low self-esteem; and helplessness. Items are scored on a Likert scale ranging from 1 (not at all) to 5 (all the time). The instrument has excellent internal consistency (α = .97), and concurrent validity (BDI and the MMPI-2 Depression scale). Scores are also highly correlated with measures of anxiety.
Cognitive Therapy Awareness Scale (CTAS; Wright et al., 2002). The CTAS was designed as a method of measuring the acquisition of basic knowledge of cognitive therapy concepts. The instrument also has been used as a standardized pre- versus post-measure for change in knowl- edge associated with participation in cognitive therapy courses. The CTAS is a 40-item self-re- port instrument that uses a true/false format. The items cover definitions of automatic thoughts, descriptions of thought records, activity schedules, and other commonly used cognitive tech- niques. The maximum score is 40. A score of 20 is the average score obtained by individuals who have no awareness of cognitive therapy. Terminology used in the original CTAS was modified for three items to coincide with the terminology used in CBT Basics I to describe the same concept or technique.
CBT Basics I: Structure. CBT Basics I is a short-term (6-session) psychoeducational group developed to prepare participants for further individual therapy. Rather than being a stand-alone treatment group, this program was designed to be integrated into the existing structure of our CBT program, which primarily provides individual therapy. The group is lead by two co-facilita- tors. One facilitator is required to have a Ph.D. in clinical psychology and extensive training and
Article 7 Macrodimitris.indd 137 4/16/2010 8:57:07 PM
138 Macrodimitris et al.
experience in CBT. The second therapist can be a trainee from another area (e.g., social work, nursing) but typically has some previous experience and training in CBT.
Potential participants were initially triaged through a central clinical coordinator at the Outpatient Mental Health Program, SMCHC, at Alberta Health Services, Canada. Potential CBT participants were added to a waiting list for service, with the primary diagnosis noted. Group referrals were obtained from this waiting list. Pre-group measures were completed at the outset of session 1, and post-group measures were completed at the end of session 6. Participants were offered an individual session with one of the group therapists halfway through treatment to enhance skills. At the end of the six sessions, a summary note was added to the participant’s chart and she or he was identified as ready for individual treatment. Individual CBT therapists then arranged an appointment with the participant and individual therapy commenced.
CBT Basics I: Content. CBT Basics I content is adapted from literature incorporating evi- dence-based CBT techniques, including Empirically Based Treatment Protocols (see Barlow, 2001; Bourne, 1998; Craske & Barlow 2000; Emery, 2000) and various therapist and patient resources (e.g., Beck et al., 1979; Beck, 1995; Bourne, 2000; Burns, 1980, 1989; Dobson, 2001; Greenberger & Padesky, 1995; Kabat-Zinn, & Santorelli, 1993). The overall structure and content of the group follows the typical stages of CBT skill integration used in our program, starting with behavioral techniques and moving toward cognitive techniques.
Session 1 educates participants about the CBT model, adapting the model as presented in Greenberger and Padesky (1995). This model highlights the interconnections among thoughts, behaviors, emotions, and physical reactions. It also acknowledges that these occur in the context of external factors (e.g., environment, financial, social, etc.). Session 1 also reinforces the concept of enhanced self-awareness as a cornerstone of change-ori- ented therapies. Homework is the activity-mood monitor.
Session 2 focuses on the behavior-mood connection. Skills taught are behavioral activa- tion for depression (Beck, 1995), including graded task assignment and exposure therapy for anxiety (Beck, 1995; Bourne, 2000; Craske & Barlow, 2000). Diaphragmatic breathing is also taught in this session. Homework involves scheduling rewarding activities to chal- lenge depression, and/or scheduling the first step of exposure therapy for anxiety, and regular practice of diaphragmatic breathing.
Session 3 focuses on the thought-mood connection. Participants are taught to monitor and identify negative automatic thoughts (Beck et al., 1979) and cognitive distortions (Burns, 1980).
Session 4 focuses on cognitive restructuring, using the “evidence for and against” method recommended by Greenberger and Padesky (1995) but integrating cognitive distortions (Burns, 1989) as part of the cognitive restructuring process.
Session 5 teaches participants how to use behavioral experiments and problem solving to challenge negative automatic thoughts that are partially supported by factual evidence (Dobson & Hamilton, 2003; Greenberger & Padesky, 1995).
Session 6 targets relapse prevention and helps prepare participants for individual therapy by having them summarize what they learned about themselves and the key tools they found helpful.
Each session builds upon the last, and participants are expected to continue to set behav- ioral goals in sessions where education focuses more on cognitive skills. In addition, participants are encouraged to apply breathing retraining (diaphragmatic breathing, taught in Session 2) by introducing them to different relaxation strategies: visualization in Session 3, progressive muscle relaxation in Session 4, and mindfulness meditation in Session 5.
Article 7 Macrodimitris.indd 138 4/16/2010 8:57:07 PM
CBT Basics Group Therapy Program 139
Statistical analyses were performed using SPSS Version 15.0. Two-tailed t tests were conducted to determine if there were significant differences between the pre- and post-group measures. Treatment effect sizes were calculated using Cohen’s d statistic (Cohen, 1988): d = Minitial – Mpost / SDpre. Effect size results are described according to Cohen’s categorization of small effect (d = .3), medium effect (d = .5), and large effect (d = .8).
In order to evaluate not only the statistical significance but also the clinical importance of changes in BDI-II and BAI scores, a Reliable Change Index (RCI; Jacobson & Truax, 1991) was calculated using the Reliable and Clinical Change Estimator (Devilly, 2005) for these two mea- sures.2 The RCI is a statistic used to evaluate whether clinically significant change has occurred by determining the magnitude of change necessary to be statistically reliable (i.e., to be larger than what is expected taking into account measurement error). The analysis involves establishing confidence intervals around the clinical and normal sample means using established test–retest reliability, standard error of measurement, and standard error of difference scores for the estab- lished reference group, and comparing individual change scores (from pre- to posttest) to these confidence intervals. Individual change scores can be considered to be reliably changed if the value of their change exceeds the chosen confidence interval. Each individual case is analyzed for reliable change and then a simple summation is conducted to determine the number (percent) of individual clients with reliably changed scores.
Separate analyses, using different cut-off points, are also conducted to determine the number (percent) of clients who reliably improved (cut-off = scale normal mean) and those who recov- ered (cut-off = intersection of normal and clinical distributions). The number of clients who reliably changed does not necessarily equate to the sum of those who are improved or recovered because these are separate analyses with different cut-off points used to determine each category (see Jacobson & Truax, 1991).
For all of these analyses, established normative data for normal and outpatient samples and test–retest reliability from the BDI-II manual (Beck et al., 1996, test–retest reliability = .93, 1 week interval; Non-clinical sample M = 12.56, SD = 9.93; Outpatient sample M = 22.45, SD = 12.75, respectively) and BAI manual (Beck & Steer, 1990, test–retest reliability = .75, 1 week interval; Outpatient Sample M = 22.35, SD = 12.36), and Dent and Salkovskis (1986; BAI Nonclinical sample M = 11.08, SD = 9.1) were used.
TABLE 2. PRE- AND POST-CBT BASICS I GROUP: MEANS, STANDARD DEVIATIONS, EFFECT SIZES, AND TESTS OF MEAN DIFFERENCES
Pregroup Postgroup Effect size Test of mean differences
n M SD M SD d t p
BDI-II 43 29.77 11.42 20.49 13.13 0.81 6.77 <.001
BAI 43 20.07 13.73 16.40 13.00 0.24 2.53 .015
ATQ 36 85.11 30.72 74.03 33.59 0.36 3.69 .001
CTAS 37 26.19 3.84 30.14 3.51 –1.02 –7.91 <.001
Note. BDI-II, Beck Depression Inventory; BAI, Beck Anxiety Inventory; ATQ, Automatic Thoughts Questionnaires; CTAS, Cognitive Therapy Awareness Scale. According to Cohen (1988), d = .3 small effect, d = .5 medium effect, d = .8 large effect. The negative value for the CTAS effect size reflects an increase in awareness of CBT skills and concepts.
Article 7 Macrodimitris.indd 139 4/16/2010 8:57:07 PM
140 Macrodimitris et al.
As indicated in Table 2, BDI-II scores reduced from pre- to postgroup. The change in BDI-II scores represented a large effect size. The reduction in pre- to postgroup scores on the BAI was also significant. Scores on the ATQ were lower following the group as compared with pregroup levels indicating a reduction in negative automatic thoughts. The change in ATQ scores repre- sented a small effect size. Group participants’ awareness of cognitive therapy concepts and skills, as measured by the CTAS, increased over the course of the group representing a large effect size.
Results of the RCI analysis of BDI-II change scores revealed that 51.2% of participants dem- onstrated a reliable change from pre- to posttesting. Of these, 25.6% could be considered “recov- ered” (i.e., reliably changed, and changed clinical status according to the intersection of the clinical and normal distributions), 23.3% could be considered “improved” (i.e., reliably changed in terms of reduced symptomatology but not changed clinical status), and 21 (48.8%) demonstrated no reliable change. RCI analysis of BAI change scores revealed that 97.67% of the participants could be considered to have no reliable change, with 2.3% considered improved, and 2.3% considered recovered. Thus, in our sample, the changes in BAI scores pre- to postgroup did not meet criteria for clinically significant change according to the RCI analysis.
Because the RCI analysis indicated that changes in BAI scores were not clinically significant, we explored pre-post changes in BAI scores. Interestingly, a sizable minority (n = 12, 28%) of the participants demonstrated increased BAI scores at posttest. To determine what might have contributed to increased BAI scores in these participants, we conducted an independent sam- ples t test comparing mean scores of other symptom measures (i.e., BDI-II, ATQ) and the CBT knowledge measure (i.e., CTAS) for those whose BAI scores increased (n = 12; “BAI increasers”) and those whose BAI scores either decreased or stayed the same (n = 31). Results indicated that “BAI increasers” scored significantly higher on both the pretest BDI-II, t(41) = 2.67, p = .011, and posttest BDI-II, t(41) = 3.21, p = .003, as well as the posttest ATQ, t(34) = 2.68, p = .011. The “BAI increasers” did not differ from the rest of the sample on any demographic (i.e., age, gender, education, employment) or clinical (i.e., primary diagnosis, medication, past therapy) variables. Consequently, it appears that “BAI increasers” may have been experiencing more de- pressive symptoms than the rest of the sample at both pre- and posttest.
Regarding drop-outs, 10 of the 58 participants who consented to research completed three or fewer sessions and/or did not complete postgroup questionnaires. An independent samples t test analysis comparing pregroup symptom scores for completers (total sample or n = 43; see Table 2 for means) and drop-outs demonstrated that drop-outs had lower pregroup BDI-II scores (M = 17.70; t(52) = –4.17, p < .001), BAI scores (M = 12.60; t(52) = –2.24, p = .035), and ATQ scores (M = 58.11; t(44) = –3.41, p = .003). Thus, these participants may not have been experiencing enough distress to warrant continuation in the group.
CBT Basics I is a psychoeducational group program for anxiety and/or depression that was developed as a precursor to individual CBT and as a way to enhance accessibility to CBT. This pilot study investigated whether this 6-session group program could provide symptom relief (in- cluding a reduction in negative cognitions) and enhance preparedness for individual CBT as in- dicated by increased knowledge of CBT concepts and skills. Results of our pilot study revealed significant symptom reduction on measures of anxiety and depression following completion of the group. The frequency and intensity of negative thinking, as measured by the ATQ, decreased significantly following group. Finally, CBT knowledge and skill acquisition were demonstrated with statistically higher CTAS scores following group.
Article 7 Macrodimitris.indd 140 4/16/2010 8:57:07 PM
CBT Basics Group Therapy Program 141
The CBT Basics I program recognizes high co-morbidity rates for depression and anxiety and applies common therapeutic principles across these diagnostic groups. This pilot study sup- ports findings derived from a diagnostically heterogeneous group therapy program (McEvoy & Nathan, 2007) that yielded results comparable with syndrome-specific (e.g., panic disorder and agoraphobia) individual and group CBT. Remarkably, the CBT Basics I program demonstrated symptom relief and skill acquisition after only 6 group sessions compared to 10 sessions in the noted study.
CBT Basics I has potential utility for programs already providing individual CBT. The pro- gram could be offered as a “pre-therapy” or “wait list” group for individuals presenting with depression and/or anxiety-related problems. CBT Basics I participants would putatively benefit in terms of reduced distress, enhanced coping skills, and shortened wait-time prior to more inten- sive individual therapy. Furthermore, the program’s proposed role in enhancing readiness for therapy may ultimately reduce overall time in individual therapy, thus reducing overall costs of CBT service provision. CBT Basics I may also help with identifying individuals who are not ready for further therapy, as evidenced by group drop-out, limited participation (measured by therapist assessment of homework completion), and poor responsiveness (measured by symptom change and skill acquisition measures). In addition, using a group format to teach CBT skills may further enhance homework adherence and vicarious learning, thus making participants better situated to actively engage in more intensive individual therapy. Finally, the CBT Basics I co-leadership model can assist with facilitating student and multidisciplinary training opportunities in CBT. Having more health care professionals well-trained in CBT skill provision would further enhance accessibility to CBT.
Although individual and group CBT are well-established as efficacious treatments for vari- ous anxiety- and depression-related problems (Chambless & Ollendick, 2001), the current study is limited by the lack of a control group and random assignment. Ideally, pre-post measures would have been administered to a waitlist control group for comparison with CBT Basics I completers. Thus, it is difficult to determine the extent to which the observed improvements are attributable to the group program as opposed to extraneous variables.
Another limitation of the study may have been the use of the BAI to assess for anxiety symp- toms. This measure focuses on symptoms associated with physiological arousal and panic, and thus may be less sensitive to changes in cognitive and affective symptoms that could be more prominent in other anxiety disorders (Cox, Cohen, Direnfeld, & Swinson, 1996). Scores on the BAI actually increased for 28% of participants in our group program. Although the results of our RCI analysis indicated that these increases were not clinically significant (i.e., the increases did not shift partici- pants from the “normal” to the “clinical” range of symptomatology), our post-hoc analyses revealed differences between “BAI increasers” and the rest of our sample. We determined that participants whose anxiety scores increased were more symptomatic in general, as reflected in higher pre- and post-group depression scores and higher post-group negative automatic thoughts scores.
These findings for the BAI raise a number of possibilities. First, it could be that participants’ whose BAI scores increased were simply experiencing an increase of symptoms due to factors ex- ternal to the group (i.e., difficulties in their work or personal lives, etc.). However, it could also be that the group itself was responsible for the increased scores. Specifically, the focus on exposure in the group may mean that participants were facing anxiety-provoking situations they typically had been avoiding, and so experienced increased anxiety symptoms. It also may be that clients learned that the physical symptoms they may have erroneously attributed to medical or other conditions actually reflect anxiety. Therefore, increased symptom scores may reflect a more accurate inter- pretation or attribution for physical symptoms. Certainly, our post-hoc analyses indicate that “BAI increasers” were generally experiencing more distress, including more severe symptoms of both depression and anxiety. However, it is difficult to know what exactly contributed to this in- creased distress. Steps will be taken to tease out the contributors to this trend in future research
Article 7 Macrodimitris.indd 141 4/16/2010 8:57:07 PM
142 Macrodimitris et al.
evaluating this psychoeducational group. The Depression Anxiety Stress Scale (DASS; Lovibond & Lovibond, 1995) has been incorporated into a current pilot project test battery as an alternate measure of anxiety.
Future directions for the CBT Basics I program include the development of a wait-list control trial. This trial will compare CBT Basics I with a wait-list control group to measure symptoms, negative thoughts, and CBT skill acquisition. In addition, the trial will aim to assess the program’s utility in: (1) decreasing CBT wait-time, (2) increasing preparedness or readiness for therapy, and (3) decreasing overall duration of therapy. We are interested in whether the CBT Basics I program does, in fact, increase accessibility to treatment, enhance participant readiness and commitment to change, and maximize cost-effectiveness of treatment as indicated by reduced overall time in therapy. Finally, the use of CBT I Basics’ co-leadership model will be evaluated as a CBT training tool for multidisciplinary mental health professionals.
Additional future directions for CBT Basics I include piloting an extended program (i.e., CBT Basics II) in outpatient programs that do not have a specialized CBT subgroup available to incor- porate the CBT Basics I program. In contrast to the CBT Basics I program’s role as a precursor to individual CBT, the expanded 10-session program, CBT Basics II, is designed as an intervention for depression and/or anxiety disorders in clinics where participants would not necessarily receive in- dividual CBT following group. Thus, CBT Basics II assumes a more flexible role to meet the needs of clinics offering diverse forms of outpatient therapy. For example, the group may function as a stand-alone intervention (McEvoy & Nathan, 2007), as an adjunct to concurrent treatments (e.g., pharmacotherapy, couples counseling), or as a relapse prevention strategy (Otto et al., 2000, 2005).
In summary, results of a pilot project suggest that the CBT Basics I program has utility in reducing mood and anxiety symptoms, shifting negative cognitions, and teaching fundamental CBT skills. The CBT Basics I program could be incorporated into mental health clinics already offering CBT to enhance treatment accessibility. It also could promote structured training in CBT, which could further enhance accessibility by making more CBT-trained health care profession- als available. Future research is required to determine the group’s potential for reducing therapy waiting lists and overall time in therapy (thus reducing costs of therapy) and enhancing readiness for therapy. The expanded CBT Basics II program’s efficacy as an adjunct treatment in outpatient clinics that offer limited individual CBT is currently under investigation.
1. CBT Basics I teaches new concepts in each group session. Thus, participants were required to attend
at least 4 of the 6 sessions to be identified as successful group completers. Group completers were also re-
quired to have post-group questionnaires submitted. Of the 58 who consented to participate in the study, 10
did not attend at least sessions and/or were missing post-group questionnaires. An additional 4 participants
were missing information about their attendance rates but completed post-group questionnaires. They were
also excluded from the analysis but not considered drop-outs because we did not have information about
the number of sessions they attended.
2. The Reliable Change Index (RCI) uses previously published normative data (i.e., test–retest reli-
ability, means and standard deviations for both normal and clinical samples) to derive standard error of
measurement, and standard error of difference scores in order to complete the RCI calculation. The scale
psychometric property publications for two of the measures included in this study (Automatic Thoughts
Questionnaire and Cognitive Therapy Awareness Scale) did not contain the information required to calcu-
Article 7 Macrodimitris.indd 142 4/16/2010 8:57:07 PM
CBT Basics Group Therapy Program 143
Anderson, R. A., & Rees, C. S. (2007). Group versus individual cognitive-behavioural treatment for obses-
sive-compulsive disorder: A controlled trial. Behaviour Research and Therapy, 45, 123–137.
Antonuccio, D. O., Thomas, M., & Danton, W. G. (1997). A cost-effectiveness analysis of cognitive behavior
therapy and fluoxetine (Prozac) in the treatment of depression. Behavior Therapy, 28, 187–210.
Barlow, D. H. (Ed.). (2001). Clinical handbook of psychological disorders. A step-by-step treatment manual (3rd
ed.). New York: Guilford.
Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Towards a unified treatment for emotional disorders.
Behavior Therapy, 35, 205–230.
Beck, A. T. (2005). The current state of cognitive therapy: A 40-year retrospective. Archives of General
Psychiatry, 62, 953–959.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York:
Beck, A. T., & Steer, R. A. (1990). Beck Anxiety Inventory manual. San Antonio, TX: Psychological
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory manual (2nd ed.). San Antonio,
TX: Psychological Corporation.
Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford.
Bourne, E. J. (1998). Overcoming specific phobia: A hierarchy and exposure-based protocol for the treatment of
all specific phobias. Oakland, CA: New Harbinger.
Bourne, E. J. (2000). The anxiety and phobia workbook. New York: New Harbinger.
Brunswig, K. A., Penix Sbraga, T., & Harris, C. D. (2003). Relapse prevention. In W. O’Donohue, J. E. Fisher,
& S. C. Hayes (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your prac-
tice (pp. 321–329). Hoboken, NJ: John Wiley.
Burns, D. D. (1980). Feeling good. New York: Signet.
Burns, D. D. (1989). The feeling good handbook. New York: William Morrow and Company.
Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behav-
ioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17–31.
Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and
Clinical Psychology, 66, 7–18.
Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies
and evidence. Annual Review of Psychology, 52, 685–716.
Clark, D. A., & Taylor, S. (2009). The transdiagnostic perspective on cognitive-behavioural therapy for anxi-
ety and depression: New wine for old wineskins? Journal of Cognitive Psychotherapy, 23, 60–66.
Cohen, J. (1988). Statistical power analysis for the behavioural sciences (2nd ed.). Hillsdale, NJ: Erlbaum.
Cox, B. J., Cohen, E., Direnfeld, D. M., & Swinson, R. P. (1996). Does the Beck Anxiety Inventory measure
anything beyond panic attack symptoms? Behaviour Research and Therapy, 34, 949–954.
Craske, M. G., & Barlow, D. H. (2000). Mastery of your anxiety and panic (MAP-3) (3rd ed.). San Antonio,
TX: Psychological Corporation.
Dent, H. R., & Salkovskis, P. M. (1986). Clinical measures of depression, anxiety and obsessionality in non-
clinical populations. Behaviour Research and Therapy, 24, 689–691.
Devilly, G. J. (2005). The Reliable & Clinical Change Generator for Windows (Prof. ed., Version 4.0)
[Computer software]. Melbourne, Australia: The Brain Sciences Institute, Swinburne University.
Dobson, K. S. (2001). Handbook of cognitive-behavioral therapies (2nd ed.). New York: Guilford.
Dobson, K. S., & Hamilton, K. E. (2003). Cognitive restructuring: Behavioral tests of negative cognitions. In
W. O’Donohue, J. E. Fisher, & S. C. Hayes (Eds.), Cognitive behavior therapy: Applying empirically sup-
ported techniques in your practice (pp. 84–88). Hoboken, NJ: John Wiley.
Dozois, D. A., Dobson, K. S., & Ahnberg, J. L. (1998). A psychometric evaluation of the Beck Depression
Inventory–II. Psychological Assessment, 10, 83–89.
Article 7 Macrodimitris.indd 143 4/16/2010 8:57:07 PM
144 Macrodimitris et al.
Ellis, A. (2003). Cognitive restructuring of the disputing of irrational beliefs. In W. O’Donohue, J. E. Fisher, &
S. C. Hayes (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice
(pp. 79–83). Hoboken, NJ: John Wiley.
Emery, G. (2000). Overcoming depression: A cognitive-behavior protocol for the treatment of depression.
Oakland, CA: New Harbinger.
Erickson, D. H., Janeck, A. S., & Tallman K. (2009). Transdiagnostic group CBT for anxiety: Clinical experi-
ence and practical advice. Journal of Cognitive Psychotherapy, 23, 34–43.
Erickson, D. H., Janeck, A. S., & Tallman, K. (2007). A cognitive-behavioural group for patients with various
anxiety disorders. Psychiatric Services, 58, 1205–1211.
Greenberger, D., & Padesky, C. A. (1995). Mind over mood. New York: Guilford.
Guimon, J. (2004). Evidence-based research studies on the results of group therapy: A critical review.
European Journal of Psychiatry, 18, 49–60.
Hamilton, K. E., & Dobson, K. S. (2001). Empirically supported treatments in psychology: Implications for
international dissemination. International Journal of Clinical and Health Psychology, 1, 35–51.
Hamilton, K., & Macrodimitris, S. (2005). CBT Basics I: Participant workbook. Calgary, AB: Calgary Health
Hazlett-Stevens, H., & Craske, M. G. (2003a). Live (in vivo) exposure. In W. O’Donohue, J. E. Fisher, & S. C.
Hayes (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice (pp.
223–228). Hoboken, NJ: John Wiley.
Hazlett-Stevens, H., & Craske, M. G. (2003b). Breathing retraining and diaphragmatic breathing techniques.
In W. O’Donohue, J. E. Fisher, & S. C. Hayes (Eds.), Cognitive behavior therapy: Applying empirically
supported techniques in your practice (pp. 59–64). Hoboken, NJ: John Wiley.
Heldt, E., Manfro, G. G., Kipper, L., Blaya, C., Isolan, L., & Otto, M. W. (2006). One-year follow-up of phar-
macotherapy-resistant patients with panic disorder treated with cognitive-behavior therapy: Outcome
and predictors of remission. Behaviour Research and Therapy, 44, 657–665.
Hirschfeld, R. M. S. (2001). The comorbidity of major depression and anxiety disorders: Recognition and
management in primary care. Primary Care Companion Journal of Clinical Psychiatry, 3, 244–254.
Hollon, S. D., & Kendall, P. C. (1980). Cognitive self-statements in depression: Development of an Automatic
Thoughts Questionnaire. Cognitive Therapy and Research, 4, 383–395.
Hooke, G. R., & Page, A. C. (2002). Predicting outcomes of group cognitive behavior therapy for patients
with affective and neurotic disorders. Behavior Modification, 26, 648–658.
Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., et al. (1996). A component
analysis of cognitive-behavioral treatment of depression. Journal of Consulting and Clinical Psychology,
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change
in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19.
Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert, L., et al. (1992). Effectiveness
of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal
of Psychiatry, 149, 936–943.
Kabat-Zinn, J., & Santorelli, S. (1993). Mindfulness-based stress reduction professional training resource
manual. Worcester, MA: University of Massachusetts Medical Center.
Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of
12-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of
General Psychiatry, 62, 617–627.
Lewinsohn, P. M., Steinmetz, J. L., Antonuccio, D., & Teri, L. (1985). Group therapy for depression: The
Coping with Depression course. International Journal of Mental Health, 13, 8–33.
Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression Anxiety Stress Scales (2nd. ed.). Sydney,
Australia: Psychology Foundation.
Macrodimitris, S., & Hamilton, K. (2005). CBT Basics I: Therapist manual. Calgary, AB: Calgary Health
Article 7 Macrodimitris.indd 144 4/16/2010 8:57:07 PM
CBT Basics Group Therapy Program 145
Manning, J. J., Hooke, G. R., Tannenbaum, D. A., Blythe, T. H., & Clarke, T. M. (1994). Intensive cognitive-
behavioural group therapy for diagnostically heterogeneous groups of patients with psychiatric disor-
der. Australian and New Zealand Journal of Psychiatry, 28, 667–674.
Martell, C. R. (2003). Behavioral activation treatment for depression. In W. O’Donohue, J. E. Fisher, & S. C.
Hayes (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice (pp.
28–32). Hoboken, NJ: John Wiley.
McEvoy, P. M., & Nathan, P. (2007). Effectiveness of cognitive behaviour therapy for diagnostically heteroge-
neous groups: A benchmarking study. Journal of Consulting and Clinical Psychology, 75, 344–350.
McEvoy, P. M., Nathan, P., & Norton, P. J. (2009). Efficacy of transdiagnostic treatments: A review of pub-
lished outcome studies and future directions. Journal of Cognitive Psychotherapy, 23, 20–33.
National Institute for Clinical Excellence. (2007a). Depression (amended): Management of depression in pri-
mary and secondary care. London: National Institute for Health and Clinical Excellence.
National Institute for Clinical Excellence. (2007b). Quick reference guide (amended): Anxiety: Management
of anxiety (panic disorder with or without agoraphobia and generalized anxiety disorder) in adults
in primary, secondary, and community care. London: National Institute for Health and Clinical
Otto, M. W., Pollack, M. H., & Maki, K. M. (2000). Empirically supported treatments for panic disorder:
Costs, benefits, and stepped care. Journal of Consulting and Clinical Psychology, 68, 556–563.
Otto, M. J., Smits, J. A., & Reese, H. E. (2005). Combined psychotherapy and pharmacotherapy for mood and
anxiety disorders: Review and analysis. Clinical Psychology: Science and Practice, 12, 72–86.
Ree, M. J., & Craigie, M. A. (2007). Outcomes following mindfulness-based cognitive therapy in a heteroge-
neous sample of adult outpatients. Behaviour Change, 24, 70–86.
Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Depression.
(2004). Australian and New Zealand clinical practice guidelines for the treatment of depression.
Australian and New Zealand Journal of Psychiatry, 38, 389–407.
Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Panic
Disorder and Agoraphobia. (2003). Australian and New Zealand clinical practice guidelines for the
treatment of panic disorder and agoraphobia. Australian and New Zealand Journal of Psychiatry, 37,
Sartorius, N., Üstun, T. B., Lecrubier, Y., & Wittchen, H. U. (1996). Depression comorbid with anxiety: Results
from the WHO study on psychological disorders in primary health care. British Journal of Psychiatry,
168(Suppl. 30), 38–43.
Segal., Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A
new approach to preventing relapse. New York: Guilford.
Sharp, D. M., Power, K. G., & Swanson, V. (2004). A comparison of the efficacy and acceptability of group
versus individual cognitive behaviour therapy in the treatment of panic disorder and agoraphobia in
primary care. Clinical Psychology and Psychotherapy, 11, 73–82.
Swinson, R. P., Antony, M. M., Bleau, P., Chokka, P., Craven, M., Fallu, A., et al. (2006). Clinical prac-
tice guidelines: Management of anxiety disorders. Canadian Journal of Psychiatry, 51(Suppl. 2),
Tucker, M., & Oei, T. P. S. (2007). Is group more cost effective than individual cognitive behaviour therapy?
The evidence is not solid yet. Behavioural and Cognitive Psychotherapy, 35, 77–91.
Vos, T., Corry, J., Haby, M. M., Carter, R., & Andrews, G. (2005). Cost-effectiveness of cognitive-behavioural
therapy and drug interventions for major depression. Australian and New Zealand Journal of Psychiatry,
World Health Organization. (1996). International classification of diseases (Vol. 10). Geneva, Switzerland:
Wright, J. H., Wright, A. S., Salmon, P., Beck, A. T., Kuykendall, J., Goldsmith, J., et al. (2002). Development
and initial testing of a multimedia program for computer-assisted cognitive therapy. American Journal
of Psychotherapy, 56, 76–86.
Article 7 Macrodimitris.indd 145 4/16/2010 8:57:08 PM
146 Macrodimitris et al.
Acknowledgment. The authors gratefully acknowledge the support provided by Maureen Leahey, PhD. and
the CBT therapists in the Outpatient Mental Health Program as well as Yuko Koshimori for her research
assistance. The research was partially funded by the OPMH and the Alberta Government STEP Program.
Correspondence regarding this article should be directed to Kerry J. Mothersill, PhD, Outpatient Mental
Health Program, Sheldon M. Chumir Health Centre, Alberta Health Services, 1213–4th Street SW, Calgary,
Alberta, T2R 0X7 Canada. E-mail: Kerry.email@example.com
Article 7 Macrodimitris.indd 146 4/16/2010 8:57:08 PM
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.