Topic 7: CBT Groups for Depression & Anxiety Disorders {by 10/29}

There are two readings due this week – Bieling et al. Chapters 9 & 10.  Address the following two discussion points: (1) What are some potential advantages for treating depression in a group setting that may not be as effective (or an option) in individual therapy? (2) Treating most anxiety disorders tends to focus more heavily on behavioral/exposure techniques than other disorders (e.g., depression). What are some potential benefits to implementing exposure techniques in a group? What are some possible drawbacks? Your original post should be posted by the beginning of class 10/29.  Have your two replies no later than 10/31.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

19 Comments (+add yours?)

  1. Richard Hisman
    Oct 26, 2014 @ 18:27:34

    In dealing with depression, an individual will at some point need to start to change behaviors that reinforces the depression. The support found in a group setting can help facilitate that change. The fact that the client can sit with others whom share one’s symptoms increases efficacy in group over individual therapy. When the group has reached a measure of trust and familiarity with one another’s issues, the group can provide accurate feedback which may be more trusted than that of an individual therapist. Ideas can be exchanged while relating one’s automatic thought record from multiple viewpoints. This could include items the therapist had not thought about. The group can influence the individual to focus more on positive outcomes rather than negative ones. This group perspective can carry more weight than a single individual’s viewpoint.
    One very obvious one is that there are enough individuals to have ready-made social experiences. When it comes time to experiment with false believes groups can be formed in the session to test those beliefs. Another is the fact the individual is not alone in these beliefs. Efficacy can be increased session to session by the mutual support of other group members. Demonstrations become easier as those that understand the intent of the exercise can help those that do not. Role playing and external to the group exposures can be gaged by multiple viewpoints. This does not mean all is simple. Getting an SAD client to start exposure training is not necessarily an easy task. As a therapist, one is asking a client to participate in an activity to which will bring them immense anxiety or fear. Being able to establish a large enough pool of candidates may be an issue. Avoidance strategies is a main issue in individuals with GAD. Getting a client to show up knowing that exposure is part of the group therapy may trigger those strategies, thus missing sessions.


    • Gil
      Oct 28, 2014 @ 21:26:08

      I wonder how much shaping the therapist must do in order to guide the comments of the other group individuals. Those with depression often have a negatively skewed view of the world. It seems possible that the pessimism could affect others. Beiling addressed this fear, but the therapist had to play a role to shape the responses of the other members.


    • Sarah-Eve
      Oct 29, 2014 @ 08:55:35

      Obtaining enough individuals who are willing to participate in a SAD group might be difficult. The individuals who are most willing to participate may be the most motivated and the most likely to make gains from exposures. Taking part of a group, whether it’s directed at those with SAD or not, is still an exposure for these individuals. This could quickly deter individuals who could greatly benefit from the group.


  2. Sarah-Eve
    Oct 27, 2014 @ 19:56:57

    Within a group setting, depressed individuals may receive more positive reinforcement than in individual therapy alone. This might also mean more than just a therapist reinforcing behavior when it comes from a number of other individuals in similar situations. It might also be easier to identify automatic thoughts and core beliefs when in a group. Identifying with others thoughts and beliefs may make them feel less alone. Seeing others get better and providing help and feedback may be quite therapeutic for these individuals. Group activities could also be scheduled within behavioral activation techniques.

    Bieling finds that that many studies indicate performing behavioral/exposure techniques in a group setting to be just as effective as in an individual setting. In a group setting, members can contribute to one another’s exposures and help to simulate or practice for much larger exposures. For example, in social anxiety disorder, just being at the group is an exposure. Understanding that others also have these types of problems and seeing them overcome these issues through exposure can help other group members get through their feared situations. Beiling also states that you could leave the group to perform their own exposures, such as going to a nearby store and ordering some coffees. Some possible drawbacks to group exposures is that the group setting may simply be too much for some individuals. Inability to handle the group situation can prevent effective exposure techniques. It may also be difficult to implement such different exposures for all individual’s fears.


  3. Robert
    Oct 28, 2014 @ 20:31:24

    It gives clients an increased opportunity to utilize their self-efficacy in order to change their behaviors and their depression. They are with others who share their symptoms and group members can more readily provide feedback and specific examples than an individual therapist. Group members can help each other with activity scheduling and challenging automatic thoughts or core beliefs.
    A group setting involving exposure techniques allows for more brainstorming of experiments to test the validity of a belief. Group members can also role play anxiety-provoking situations and provide more credible feedback than a therapist. For some individuals with anxiety, especially SAD, just being in a group therapy setting is itself a form of exposure. A possible drawback to exposure techniques in a group may be achieving client participation since encountering a feared exposure within a group context is likely to be particularly anxiety provoking. This may be overwhelming for clients who may cope by avoiding sessions. Achieving a large enough client referral base for a group therapy program of this type may be a limiting factor.


    • Gil
      Oct 28, 2014 @ 21:30:31

      Client dropout during exposures is a real issue. Exposure is a very effective technique, but it is effective for those who perform the exposures to completion. The added pressure from others can be a concern if the therapist doesn’t take this into account. It would make sense to have the clients rate their hierarchy with an option of what their SUDs would be given that they will be performing the task infront of the group.


      • Richard Hisman
        Oct 31, 2014 @ 10:50:02

        Knowing the client becomes critical with respect to exposure drop outs. Being able to decide how fast each individual can proceed is paramount. Others exposure successes and sharing through discussion could mitigate this factor. Regardless the therapist must anticipate this issue and be prepared to try other less stressful exposure techniques if needed.


    • Paige Hartmann
      Oct 29, 2014 @ 12:52:50

      As Bieling mentioned, group members can contribute to one another’s exposures. However, this may be difficult to gain participation from group members because it may cause more anxiety for them, potentially causing group members to drop out. It is important for the group to be aware of each member’s fears and anxieties and slowly work toward exposure within the group setting to prevent possible drop outs.


  4. Gil
    Oct 28, 2014 @ 21:11:00

    During cognitive restructuring, individuals with depression attempt to take on different perspectives to view themselves and their situation. Some clients resist the direct approach taken by a therapist. The therapist may be seen as out of touch with the individual or the individual may resist adopting a new perspective because slow progress would further validate the extent of their problems. However, when these perspectives are offered by fellow group members, the individual can avoid these obstacles. The other members are seen as similar and the motives of the individuals can sometimes be more trustworthy than a therapist whose job is to be positive. Many of the problematic thoughts with depression are similar among individuals. Hearing one person’s negative thought and then the more rational thought would likely apply to multiple individuals. The indirect path can be more effective and avoid defenses of the clients. Finally, the group setting allows members to see other member’s improvement, therefore providing a sense of hope.

    Exposure can be a daunting task for individuals, but group exposure carries potential benefits for members. First, members can model other more successful members to see that the task is possible and provides benefits. Witnessing another person’s success lets the other members know that they can do it too. The group can also help with motivation to complete exposures. This motivation may come from actual verbal support from others or even though competition. The group provides an inherent exposure for some members and can help prepare them for more intimidating tasks to come. However, the group format may have drawbacks. Control is an important part of exposure. Even attending group may be an exposure for some individuals and without feeling in control, the member might decide to leave group. There is higher risk and reward associated with group exposure. The anxiety is likely increased during exposure because a member feels like they are being watched. If this does not deter the member, then the reward is greater.


    • Sarah-Eve
      Oct 29, 2014 @ 09:00:21

      Receiving feedback from individuals who are seen as similar may have a greater effect than feedback given from a therapist. To hear the experiences of individuals who have gone through similar situations and see them overcome the obstacles they faced may be more powerful than hearing what a therapist might have to say. Positivity by the therapist may go a long way, but the hope instilled by others who are percieved as similar to the group members may go further.


    • Paige Hartmann
      Oct 29, 2014 @ 12:44:29

      Exposure within a group setting can provoke more anxiety within individuals, especially if they feel like they are not in control. It is important for the group therapist and other group members to be aware of this as it can cause some individuals to drop out of the group. Support and motivation from other group members is essential to help avoid members from leaving the group.


  5. Paige Hartmann
    Oct 29, 2014 @ 12:32:25

    When treating depression within a group setting, Bieling discusses the importance of patients completing self-monitoring and behavioral activation techniques. Group members are able to discuss their self-monitoring homework and give each other positive feedback. Often times group members are able to identify the problems with other group members’ activities, and point out the stressors, frustrations, and suggest more rewarding activities to one another. Within individual therapy, depressed clients would only receive feedback from the therapist. However, within a group setting, group members are able to offer and receive feedback from individuals who are experiencing similar thoughts and beliefs which can be more therapeutic.

    For individuals with SAD, simply being part of a group setting is an exposure in itself. A benefit to implementing exposure techniques within a group setting is that group members can contribute to each other’s exposures. This can include simulated exposure role plays, or splitting group members into smaller groups for exposures involving one on one interactions. Having group members be active participants in exposure techniques allows them to see that they all have similar fears, and they can motivate one another to overcome these fears. Some potential drawbacks include the number of participants within a group setting. The larger the group, the more the group members may feel socially inhibited and less likely to feel comfortable participating in exposure with the group. It may be too overwhelming for some group members, which can prevent the effectiveness of the exposure techniques within the group.


    • Angela Vizzo
      Oct 29, 2014 @ 20:30:16

      Paige, I like your discussion of how group can help in giving feedback about activity scheduling and behavioral activation. I agree, getting feedback from other members is a big advantage to group and members may be more willing to accept that feedback from peers rather than from a therapist.


  6. Angela Vizzo
    Oct 29, 2014 @ 15:42:33

    There are numerous advantages to treating depression in groups that may not be as effective in individual therapy. A client may see the therapist as removed from their own problems and like they could not relate, but in group they would see other members as their peers and may be more likely to take suggestions from them. This can be very effective when determining alternate explainations for events or overcoming other negative thoughts, as individuals tend to attribute negative events as their own fault. Other group members can also help an individual recognize cognitive distortions or identify automatic thoughts that they may be having a hard time with on their own; alternatively if an individual is having trouble doing this on their own, hearing others do so may trigger that understanding that they were struggling with before. Finally, getting positive reinforcement from other group members can help increase self-esteem as well.

    There are both benefits and drawbacks to treating anxiety disorders in a group format. Some benefits include the in vivo exposure that happens naturally in group in the case of social anxiety, and the organic opportunities to implement and practice social skills that have been taught. Another benefit is that groups allow the opportunity for role-playing with other members, and some individuals may be more comfortable role-playing opposite a peer rather than the therapist. On the other hand, treating anxiety in group can have some challenges as well. One of these challenges is that each member may go at a different pace with exposure techniques and this has to be monitored carefully by the group leader to keep everyone at a comfortable pace in order for the treatment to remain beneficial. In addition, in the case of social anxiety disorder, just going to group can be challenging as it causes so much anxiety to be around others which can be challenging and may seem overwhelming to members. Finally, everyone’s triggers for anxiety and/or panic attacks may be different and members may have difficulty relating to others’ triggers.


  7. Sarah Gagne
    Oct 29, 2014 @ 17:48:41

    Individuals that are depressed often withdraw and isolate, and the group setting alone forces a depressed individual to socialize with peers rather than ruminating alone. Individuals are able to bounce ideas off one another, and cognitive distortions can be challenged by peers with similar experiences. The group process allows for both the leader and members to correct pessimism and hopelessness in others; skills that can applied to oneself in a real life situation. Sometimes individuals are more likely to try and adopt change if they see techniques work for someone else, especially if they are involved in the change process. As always, advice and suggestion may be more accepted from a peer as opposed to an authority figure.

    A potential drawback of treating social anxiety in a group setting is that an individual may not feel comfortable putting their full efforts into exposure techniques when surrounded by other people. Individuals must get over the initial fear of the group environment in order to get the best results. The structured nature of group therapy for social anxiety may be a drawback as well, as it can be difficult for a group member to make up missed meetings if he avoids group due to fear or misses for another reason. If individuals get over initial fears and decide they want to treat their social anxiety, there are many advantages to a group format. Members are able to meet others with similar experiences and can provide support to each other if they are placed in a fearful situation. If all of the individuals in the group can get similar results from the same exposure technique, it is cost effective and timely to treat in a group format. Social skill training is more effective in a group setting as the environment can mimic real life experiences providing more authenticity.


    • Angela Vizzo
      Oct 30, 2014 @ 10:04:27

      Sarah, that is a really good point you make about the exposure and how group members may not feel comfortable due to social judgement. I had not thought of that, but I could see that happening, that an individual may feel like they will be judged on their reaction to an exposure exercise an be less willing to participate.


  8. Jessica
    Oct 29, 2014 @ 17:49:28

    One benefit of treating depression in a group is that other members can help think of pleasurable activities, evidence for and against automatic thoughts, assumptions, and core beliefs, that the therapist may not think of. The group member may be more receptive to other group member’s ideas than just the therapist’s suggestions and questioning. Also as other members think of ideas to help another member, they begin to think how these ideas could apply to themselves. Another benefit of treating depression and any other disorder in a group is that other members can model desired behavior and serve as supports to each other.
    A benefit of using exposure techniques in a group is that the group itself can be used as part of the exposure technique, such as playing the role of “audience” to a member who has anxiety about public speaking, or role playing other scenarios with each other, Similarly, group members who are similar to each other can be more effective in modeling exposure for each other than is the therapist as a model or other less similar people. A drawback is that not all members of the group will do similar exposures (unless it is a very homogeneous group) so the group will likely need to be broken up. Even in smaller groups, one member may progress faster than the other. Also, if a group member has greatly more or less severity of anxiety, or problems co-morbid to his/her anxiety problems, this could distract from the focus of the group and make that group member feel like he/she doesn’t belong.


  9. Michelle
    Oct 29, 2014 @ 18:10:05

    Behavioral interventions can help clients to re-enter into activities that they had once found enjoyable or pleasurable, and which now, due to depression, they have lost interest in pursuing. Group members may be given homework to engage in activities, and report back to the group on what they did, and other relevant details. A group format provides a forum where members can gain feedback from their peers, rather than their counselor. Members might offer positive feedback, encouragement, and social support for successful attempts, and share with the member other ways that they might have chosen to engage, or even suggest other activities that might have provided a more positive experience. Although the therapist may show support and feedback, the same offered from several peers, experiencing similar issues, may provide an additional source of redirection and reinforcement than the client would receive if in individual therapy.
    Group members model to each other functional behavior, and group leaders can accentuate the successes of one member, to serve as a reinforce or encouragement for another. Again, although counselors can give examples in individual therapy, group therapy offers the advantage of a real-life peer who has successfully used an intervention. Because clients who have depression often times struggle with engaging in functional and positive activities, group treatment that offers social support from peers holds a unique advantage that individual counseling does not, in the same way, provide.
    Group treatment facilitates the use of exposure techniques by providing a group of people who the member can practice newly forming and emerging skills. The cohesion that a group affords may help to make the member better able to participate in difficult activities, and may give them practice opportunities within a controlled setting that offers support and safety. Members who witness other members successfully meeting challenges may be more willing to try an exposure intervention, and may gain ideas about how to deal with challenges that they may not have themselves considered. Seeing that others have similar challenges helps to promote normalization, and build group cohesion.
    Some members may become overly worried about participation in the exposure activities, and may end up leaving the group early, due to anxiety over the exposure rehearsal itself. There additionally lies the possibility that the exposure won’t go as well as hoped, in group. In a situation such as this, other members are also witnesses to the difficulties experienced by their peer. Overall, there are great potential benefits to including exposure techniques in a group setting, and many clients are left feeling glad that they participated in activities to move them toward their goals and higher functioning.


    • Richard Hisman
      Oct 31, 2014 @ 10:55:33

      I agree, the modeling of behavior by the other clients in the group is a very strong tool for eliciting the same behavior in other group members. This sharing of knowledge can accelerate the learning of the entire group. Is it one thing for therapist to direct what functional behavior is, but quite another when one with similar dysfunctions can demonstrate how it works.


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Adam M. Volungis, PhD, LMHC

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