Topic 5: Cognitive & Behavioral Strategies in CBT Groups {by 10/8}
There are two readings due this week – Bieling et al. Chapters 3 & 4. Address the following two discussion points: (1) Beiling et al. discuss a variety of cognitive and behavioral techniques that can be used in groups. Identify and discuss a particular CBT technique/intervention that you think would be especially effective to implement in groups. (2) Is there a particular CBT technique/intervention that you think would be challenging for you to implement as a group therapist? Explain. Your original post should be posted by the beginning of class 10/8. Have your two replies no later than 10/10. *Please remember to click the “reply” button when posting a reply. This makes it easier for the reader to follow the blog postings.
Dr. Adam M Volungis 
Oct 06, 2014 @ 11:06:38
I particularly believe based on my clinical desires that exposure training holds the key to groups I am interested in. The use of In Vivo exposure to perceived or imagined threats with a hierarchy list of those threats appears to be a potent tool for PTSD individuals. The use of exposure experiences such as roadside debris not being a bomb as an example, driven by the clients own hierarchy list of which fears are more terrifying to him/her. This allows the client to work through issues pertaining to perceived or imagined threats based on a personal level of affect. This exposure culminates in a habituation to the perceived or imagined threats. Current veterans have many fears centering on driving due to the constant threat of roadside bombs while in combat theaters. A personal threat I perceived upon returning home was that of the wail of sirens at volunteer fire departments calling firemen to the station. This happened to be what we used during the Gulf War to signal a chemical or SCUD missile attack. The very first time I heard that same siren sound in the states, I went into instant panic searching for my gas mask. I was driving at the time. Through exposure (habituation) that fear subsided to the point that I am vigilant of the sound but no longer have any panic symptoms upon hearing it.
Exploring core beliefs seems to be especially difficult at the group level. Getting one to identify one’s extreme core beliefs in front of others has social acceptability issues of its own. Social desirability in a group setting would take time and trust to overcome. Once core beliefs are recognized, they then have to be rationalized and identified where they come from. This in some cases is another exploration that results in identifying that these behaviors are from individuals that they trusted. The chapter made it seem very clean and technique driven. I do not see it as simple as this. The process seems as though it could become very confusing quickly.
Oct 06, 2014 @ 22:07:41
Richard, I really like your discussion of how disclosing one’s core beliefs can be more challenging in a group setting than in individual therapy. This is not something I would have initially thought of, but after reading your opinion on the topic it makes total sense and that social acceptance plays a big role in disclosing these things too. Self disclosing one’s core beliefs can be more threatening than disclosing one particular scenario as those core beliefs are overarching in many areas.
Oct 08, 2014 @ 11:26:30
Great point about core beliefs. There is a level of vulnerability through exposing core beliefs that requires a great amount of trust and comfort. If the members had conflict in the group, it would make disclosing this delicate information very difficult. Even one comment that exacerbates the negative core belief can make evaluation of the beliefs or assumptions difficult to sway. There also seems to be a higher difficulty in identifying the core belief that may exceed the skill of the members
Oct 09, 2014 @ 10:29:07
I liked your example of using exposure techniques for treating anxiety related to PTSD. Exposures are often explained in the context of treating phobias, social anxiety, and certain OCD symptoms (fear of contamination, for example) but we don’t hear much about it being used with clients who suffer from PTSD or other populations. I was glad that Beiling et al. mentioned using exposure with eating disorders, because that is another population that exposure can be useful for but that usually goes unmentioned. Exposure therapy using a fear hierarchy is effective even with those who fear and avoid sex (though clearly this is not practiced in vivo during therapy! This relies heavily on the client to do his/her homework). Imaginal exposure seems to be more useful and practical for people who suffer PTSD from a trauma with stimuli that can’t be recreated- rape, natural disasters, witnessing or experiencing domestic violence, etc. Methods to treat trauma seem to rely heavily on imaginal exposure and in vivo or simulated exposure where possible. It seems to me that for exposure techniques to be most effective in a group setting, the group should be homogeneous so that they can be on the same page. A general group for PTSD with combat veterans and rape victims and victims of a natural disaster may use similar methods but have a hard time relating to one another and may use very different exposure techniques.
Oct 06, 2014 @ 13:16:58
A particular type of CBT technique that might be effective in group therapy would be social skills training. Within the group setting, there are many other individuals present in which group members can practice and role play in learning and identifying social skills. The ultimate goal is to improve the client’s performance in social situations. Some skills that may be targeted in social skills training are: nonverbal communication, conversation skills, presentation skills, conflict skills, etc. When practicing and role playing these skills, the group therapist may even video tape the skills in order for the group to review and provide feedback.
A technique that might be more difficult to implement in groups would be in vivo exposures. For some groups this might be possible, for example in treatment for eating disorders exposure to feared foods is easily feasible. For client’s who’s fears are of a more existential nature would be extremely difficult to perform in vivo exposures. Likewise, it may be difficult to take the group on a “field trip” for some fears. Though it may provide an incredible therapeutic moment, it could be difficult to move the group from it’s original location.
Oct 06, 2014 @ 22:25:48
Sarah, you make a really good point about how certain in vivo exposures are easier to do. Of course, it is also easier to work on exposure when all the group members are anxious or distressed by the same stimulus, such as the eating disorder example you gave. If the members had different stimuli causing anxiety, treating one member could potentially cause a phobia in another member.
Oct 08, 2014 @ 11:30:53
The environment of group therapy offers an environment for evaluating and changing social skills that is hard to replicate outside of group. The ability to receive direct feedback about social skills is considered appropriate in group, but taboo outside of group. This feedback is invaluable in helping someone improve socially. The group also provides a safe environment to try out budding social skills with less fear of alienation and more support. The acceptance and understanding of other members about social skills deficits can help the client feel more at ease
Oct 06, 2014 @ 20:02:32
The cognitive and behavioral techniques surrounding experiments appear to be especially effective to implement in groups. It allows clients to form their hypotheses of thoughts in a collaborative manner and test the accuracy of such hypotheses. A good experiment consists of two hypotheses that are credible and important and can be proven by facts to be either true or false. This process allows group members to offer useful suggestions for testing ideas and gives them the ability to learn from other members’ experiments. While this process occurs in individual therapy, a group setting provides not only more feedback, but much greater validation in a group where individuals are trying to work through similar types of problems.
The exploration of core beliefs in a group setting seems to be particularly challenging of group members and the therapist. Since many of these beliefs are socially undesirable, there are any number of reasons for group members to be hesitant in disclosing them when they have adequately explored them. It takes a cohesive group that has developed a fair amount of mutual trust to foster members’ willingness to disclose core beliefs they might perceive as being “silly”, “stupid”, or worse for all to hear. However, when group members start to overcome this hurdle and disclose their possibly socially undesirable beliefs, it makes it easier for the other members to do the same.
Oct 07, 2014 @ 09:49:52
Core beliefs might very well be difficult to examine while in a group setting. It is something that is so personal and unique to the individual. Unless individuals were prescreened to have similar core beliefs, it might be challenging to determine each individual’s core beliefs and how they are influenced. In this case individual therapy might be better suited to this technique. On the other hand, individuals witnessing other group members identify their own core beliefs and successfully cope might have a greater effect.
Oct 08, 2014 @ 15:01:26
Within those core beliefs can be prejudices that may be the result of learned behavior. While it can be difficult to experience this as group, it may have large group rewards. This is where I believe two counselors meeting before hand can be a great asset. In a diverse group makeup, getting to the center of core beliefs can help. But one has to balance that with, at what cost? Recognizing this diversity can definitely help one with social skills building.
Oct 06, 2014 @ 22:18:34
One intervention that would be especially effective in group therapy is what the authors call experiments. During this intervention a person’s automatic thoughts are challenged and alternative scenarios are considered. This would be especially helpful in groups because other members can come up with alternative scenarios that the individual may not think of. Other members are also able to see the situation from different perspectives and think of things that neither the therapist or the individual may have thought of. Also, hearing other group members deny one’s automatic thoughts and assumptions can be more powerful than just the therapist doing so. In addition, social skills training can be particularly effective in group as there is a built in opportunity to practice.
I feel exposure would be particularly challenging to monitor in a group setting. In particular, the pacing would be a challenge as not everyone would overcome their anxiety at the same pace; and going too fast or too slow can be anti-therapeutic. Another challenging intervention would be activity scheduling as not everyone enjoys the same activities or needs the same level of help and guidance in doing so.
Oct 07, 2014 @ 09:54:25
Addressing automatic thoughts through alternatives and challenges in a group setting could be quite effective. Getting the chance to hear different viewpoints about the scenario and alternative ways of going about it can show that you are not stuck in this situation. There are numerous ways of going about something and when we are too close to the situation, it may be extremely difficult to come up with new ways of thinking about it.
Oct 08, 2014 @ 11:05:27
The behavioral side of CBT seems to lend itself to groups with less issue and increased effectiveness. Exposures are ways to behaviorally test underlying negative assumptions and feared situations. First, groups allow individuals to brainstorm with others about the possible items on a fear hierarchy. Exposures can be very distressing so the added support from others can increase the possibility of adherence. Next, modeling is the first step in demonstrating that the exposure can be accomplished. The therapist first completes the exposure as a person in authority. Next, the other members with high similarity to the individual complete the exposure, thus covering the criteria of effective modeling. Conformity and peer pressure are powerful forms of motivation to engage in an action. In this respect these forces are used helpfully to nudge a client to complete the exposure. Competition and mutual motivation can be instrumental in helping an individual along his or her hierarchy.
The cognitive restructuring of CBT can be highly effective in groups, but come with more pitfalls and nuances. Depending on how open an individual is to receiving feedback or other perspectives, other group members’ words can be polarizing, causing the member to defend his or her negative beliefs. Often, an amount of validation is necessary before even a gentle challenge. Teaching members to offer the right amount of validation, before helping the member to adopt a more adaptive thought requires more attention and skill. The other member’s advice can be very effective because of the perceived similarity and genuine comments. Conversely, a member may feel attacked or reluctant to accept the correction of someone who is dealing with similar problems.
Oct 10, 2014 @ 21:04:52
I agree that cognitive restructuring, though effective, may be difficult in group due to individuals possibly feeling offended when challenged. However, these challenges may be helpful to discuss as a group and may provide an opportunity to practice social skills. These challenges may be brought up in social situations outside of group, and group is a perfect opportunity to work through these issues so individuals are prepared to address conflict.
Oct 11, 2014 @ 09:05:52
Challenging thoughts that have long been a part of a client’s thinking may be risky, especially if the client is in a less functional state. You are so right that as therapists, we will need to be sensitive to our client’s needs and where they are in level of motivation and capacity. Perhaps in a group setting this is an even more important point to remember. Even though the group is conducted with several members at once, it’s imperative that each member is treated as an individual.
I liked how Beiling offered the gentle narrative, asking members to consider if there might be alternatives. Because the thoughts that we will be targeting are dysfunctional, modification of those thoughts seems like an obvious task. Doing so, though, should be done with consideration, as some thoughts or core beliefs may be more delicately based than others. I’m so glad that you added the human element, Gil. As much as working toward goals is an integral part of therapy, doing so in a way that is sensitive to the needs of each client is regnant. Understanding that there are differences between members, and that advice may or may not always be recieved well is also important, and the therapist will been to stay on his or her toes to redirect if necessary. One thought to consider here, is possible exclusion criteria for a client who is so sensitive that they aren’t ready to explore such thoughts. It seems that the inability to participate in cognitive restructuring might be good exclusion criteria, if the client might be sensitive to many of the thoughts that will need to be targeted in group.
Oct 08, 2014 @ 11:26:14
A particular intervention that would be especially effective to implement within a group setting is the experiment. Experiments are utilized for clients to collaboratively gather information to challenge a negative automatic thought. This intervention would be useful within a group because alternative hypotheses are provided from other group members, rather than just from the therapist. The individual is able to gain a better perspective regarding the automatic thoughts and how to effectively challenge them.
I think that in vivo exposure is a technique that would be challenging to implement within a group. Although in vivo exposure is found to be the most effective exposure technique when an individual fears a specific situation, I feel this would be difficult to implement for a group of clients. The group members may have different feared objects or situations and have varying levels of anxiety to their fears, making it difficult to do exposure in a group. Depending on the fears being addressed, it also may be difficult to move the group setting to gain exposure.
Oct 11, 2014 @ 08:50:32
Using CBT as a framework for therapy, automatic thoughts and core beliefs are identified, examined, and at times, tested. In a group setting, the experiment provides the client an opportunity to not only question the thought, but to pursue other hypotheses about the beliefs, as well. Alternatives are encouraged and introduced, and a group setting may provide the benefit of modeling. The client observes others partaking in experiments, and finding that there are more functional ways to look at a given scenario and thought. Group cohesion will be a great tool here, as members open up, share their innermost thoughts, and are able to feel comfortable enough to not only share them, but to challenge them as well. Working together, members can also consider alternatives they may not have considered, and then see the support from the other members to choose to test and even implement these new alternatives.
Oct 08, 2014 @ 13:11:59
I think the social skills training is most effective to implement in a group compared to individual therapy. In individual therapy, the therapist only observes the client in one context, and based on the clients behaviors in this setting and based on what the client tells the therapist, the therapist might suggest social skills training. However this may not be well recieved by the client, who may take it as personal criticism or as a biased view of the therapist. As a group, everyone can work on social skills so it’s not personal and everyone can contribute to what they think of a person’s behaviors, so it’s not biased from one person. A group also provides more ways to practice social exposures (ie public speaking) and use of modeling compared to individual therapy.
The most difficult intervention to do in group I think would be imaginal exposure, as its a private experience better suited for individual therapy. However talking about imaginal exposure done as homework can be useful for the group to hear and learn from.
Oct 08, 2014 @ 14:53:19
I would tend to agree with you about imaginal exposure. Trying to individually focus the client on imagining one’s fears would be time and attention consuming. It is also not very clear how effective it is. It should be reserved during group time for only those whom can not face the actual fear in the beginning. It can however be useful as homework to experience physiological affects of one’s fear.
Oct 09, 2014 @ 13:37:30
I agree that social skills training may be easier to implement within a group setting since members will work on their skills in a collaborative manner. Within a group setting, the therapist can see first hand how individuals interact with one another and it can provide a healthy environment to practice these skills.
Oct 08, 2014 @ 16:12:54
Group therapy, as opposed to individual therapy, provides the additional component of peer interaction. Clients experience universality, learning that others share in their challenges and difficulties. Beginning from the start of group, members are encouraged and guided into an atmosphere of group collaboration, which provides a safe place for members to share, learn, experience, and open up. Perhaps these are the reasons why group therapy is an effective venue for social skills training. Members gain suggestions and feedback from other members, who are continually guided by the therapist. Other members may offer suggestions for issues that a member may need to work on. In individual therapy, the client may be less open to these kinds of suggestions. However, in the group format, these suggestions are brought up in the group, rather than specifically directed toward them, and may be more likely accepted. Role plays, and opportunities to practice the various social skills such as conversation skills, assertiveness skills, listening skills, and conflict skills are more readily available in a group setting, which can be a great help for a client wishing to address issues related to social skills.
Identification of core beliefs requires complete openness and revelation. As cohesive as a group can get, I can imagine that there would be times that doing so in a group setting may be challenging. As a therapist, and weighing the importance to move forward, while also remaining mindful to protect the client, it could be difficult to assess if the client is ready to move forward toward revelations that put them in an emotionally vulnerable position. If done in a way that permits the client to remain comfortable enough, a group setting to do so may have its advantages, providing peers who can offer support, question the belief, and help to provide alternate beliefs.
Oct 10, 2014 @ 20:53:58
I agree that social skill learning and practice is far more effective in a group setting. It reminds me of a topic we have discussed in class before, that critiques or advice about social interactions is far more powerful when heard from peers rather than a therapist. Social skills are most true to life when practiced with peers who are in the same boat. I also like how you mentioned suggestions brought up in group are less directed toward the individual and may be more accepted.
Oct 08, 2014 @ 16:47:31
The group environment allows for group social learning that is difficult to practice in individual therapy. Thus, I believe the most valuable aspects of group therapy are those that take advantage of the group participation and feedback such as experiments and exposure. Role playing may be the easiest for group members to act out and improve upon feared situations. Clients may have the skills and may be effective in portraying them in an individual setting, but a group setting allows for an experience that may be more true to life. If an individual is nervous about interacting with strangers and avoids all confrontation, it may be easier to practice in a group where he or she feels comfortable to practice social skills with a peer.
In regards to exposure, I think imaginal exposure may be the most difficult in a group setting. Not all group members will have the same exact fear, and it probably would not be effective to generalize in this situation. It seems that this would be more effective in an individual setting where the therapist and the client can have a more personalized approach. It may not be beneficial for the group as a whole to spend the time needed during group to focus on a specific situation or fear that is not applicable to the majority of the group members. Also, this seems like a big task to complete as homework, especially if this is a short run group and the members are not comfortable enough practicing the skills.
Oct 09, 2014 @ 13:25:03
Sarah, I agree that imaginal exposure would be challenging within a group especially since group members may have different fears to address. You make a valid point that individual therapy may be more effective for imaginal exposure since the therapist can tailor it to the individual’s specific fear. I wonder what types of fears would be suitable for use of imaginal exposure within a group setting.