Introduction: The Depth and Breadth of Cognitive Behavior Group Therapy

As a graduate student in the 1980s in a psychology department known for its focus on individual psychodynamic therapy, I did not imagine eventually writing a book in which I shared my enthusiasm for cognitive behavioral group therapy (CBGT).

While Im grateful for my psychodynamic training, I have come to appreciate the many benefits of cognitive behavioral therapy (CBT) including its shorter term duration making it more affordable, if individuals are paying themselves. Individual CBT and group CBT (CBGT) both offer specific interventions for specific problems, especially problems with mood and anxiety. Clinicians typically present CBT as a symptom or problem-focused psychological treatment with an emphasis on personal change in behaviors and patterns of thinking about oneself, other people, and ones day to day living environment. CBT clinicians focus more on what maintains problems or disorders than on what causes them, and they help clients understand and problem solve barriers to living their lives more fully. CBT always conveys deep respect and empathy for clients goals, needs, and unique personal histories. Indeed, CBT is credited with coining terms such as client-centred and client collaboration.

CBGT at its finest has much to offer. Not only are clients offered effective help for their fear of, lets say, becoming contaminated and seriously ill by taking public transit. They also get to experience that they are not alone in their fears and, perhaps most importantly, that they are perceived by others as a wholesome human being and not just as an OCD patient. To witness clients undergo this transformation is one of the many benefits of CBGT for clients and therapists alike. Unlike individual CBT, CBGT gives clients an opportunity to connect meaningfully with society, however small the slice. It is an undisputed psychological fact
that human beings benefitthey feel and do betterwhen connected to a larger community. With increased levels of social isolation in many Western societies, in-person group CBT may indeed offer individuals far more than symptom relief.

Across mental health training in the Western world, we are seeing a renewed interest in promoting individuals well-being, resilience, and sense of purpose and meaningthe so-called positive psychology approach. Positive psychology proponents led by psychologist Martin Seligman and psychiatrist George Vailliant, among others, argue that psychology and psychiatry have for too long been too confined to working with all the negatives that come with pejorative diagnostic labels and debilitating symptoms, instead of taking a more holistic, strength-based view of our clients. I argue throughout this book that CBGT offers both effective symptom relief and promotion of positive individual resources, which are harder to bring about in individual therapy. CBGT also moves therapy from a concern with the individual to the societal and even global arena. CBGT embodies a democratic and communitarian feel given its vast opportunities for people struggling with mental health problems to break the isolation and stigma as they interact with and feel supported by peers in addition to mental health professionals.

In the earlier text, I deliberately used the phrase group CBT at its finest to imply that those moments are not the norm. The rewarding times are of course what keep us going as group therapists, but they also challenge us to ask why we do not experience them more often. As with any craft, some solid basic skills are imperative for the CBGT therapist, but equally important is openness to revisions and trying new ways without losing ones foothold in and fidelity to CBT theory and principles. A helpful analogy may be a musical one where practicing scales is tedious but necessary for later improvising and playing with
others in the same keyand in tune, including with ones group cofacilitator!

I have written this book to help CBGT facilitators become more confident in leading their groups and more appreciative of the many ways groups can be strengthened and become even more effective. My own journey as a CBT group therapist has come a long way since conducting a first panic disorder group as an intern in 1994. Thinking back on this group, I feel embarrassed when remembering how we did the homework review go-round in the traditional CBT fashion dealing with one person at the time: Thanks, next! Its sad to think of how much was lost by not tapping into the collective experience of the group on the difficulty of completing home practice and ways to overcome this common problem. I believe this introduction to group therapy installed some inflated self-confidence because, for some baffling reason, we did not have any dropouts. (I hasten to say that panic disorder may be a problem that requires the least process attention, thus it is a good starter group for CBGT novice therapists.) Our success made it seem so obvious that trapping eight people with anxiety in the same room for 2 hours during 8 weeks was the way to go in terms of human and financial efficiency. I was converted and have co-conducted four to six CBT groups weekly since.

This guide is meant as a conversation with both beginner and experienced CBGT therapists. I find it helpful to think of myself as a conduit. I aim to share much of what we already know about CBGT based on academic and clinical research in addition to my experience over the past 20 years with developing, running, training, and evaluating CBT groupsand always talking to and learning from other group therapists. Unlike individual therapy, there is usually at least one other professional being a witnessand criticto our work, something that took me a little while to get used to given how intensely private the individual therapy room feels. But CB
GT presents a wonderful opportunity for peer feedback and consultation, something many individual therapists often miss after their training is completed. The term we thus refers to my colleagues and trainees, primarily psychology and psychiatry students, but also students from occupational therapy, counseling, social work, and nursing. This book is similar to other books on this topic in that it covers most of the disorders for which CBGT has been shown to be especially helpful, namely the so-called common mental health problems of mood and anxiety disorders. It is different in that it also offers more discussion on how to troubleshoot problems in implementing and running CBT groups. In addition, it shows how to apply CBGT to problems and populations where the clinical research is limited but promising.

Readers will notice my bias for emphasizing the B in CBT when it comes to CBGT. In individual therapy, I tend to be more balanced in including both cognitive and behavioral interventions. My experience has unequivocally been that the more doing, in form of exposures and group activities, the better the cohesion in CBT groups becomes, which in turn positively influences motivation and outcomes for everyone. In addition to underlining behavioral interventions, three other themes recur throughout this book.

The first theme I emphasize is that CBGT offers a unique opportunity to promote the common good by offering access to high-quality, cost-attractive mental health care for the most prevalent mental ailments. Second, CBGT must take group process variables more seriously in order to become even more effective. Third, while it does not necessarily require several university degrees to be a CBGT leader, it does necessitate a thoughtful approach to training, to the nature of cofacilitation, and to ongoing professional development in order to achieve and maintain basic and advanced skills.

The book is organized into three parts. >Part 1 offers an introduction to basic principles, research, and theory related to CBGT. This part ends with two highly practical chapters on how to implement CBGT for depression, the most common mental health problem. In reading Part 1 experienced clinicians may enjoy having their CBGT skills validated and getting a new perspective or idea for consideration in their practice.

Part 2 tackles practical, or how-to, questions facing clinicians and mental health program managers interested in developing and conducting viable CBGT programs. We will look at questions such as How much training is necessary in order to take the lead in a CBT group? How homogeneous do groups need to be in order to be effective? How to prepare people for CBGT? How to prevent dropouts? And How to develop individual exposure hierarchies in a group? Part 2 discusses several challenges for successful implementation of CBGT as well as suggestions for solutions. In addition to drawing on my own experience, I refer to the literature when relevant. This is especially the case for Chapter 7 where I present a literature review of transdiagnostic approaches to CBGT before offering practical examples.

Part 3 explores opportunities for CBGT in populations that have received less attention in the group therapy literature. These populations are included because they are likely to be new health care priorities, certainly within the public system. CBT, whether individual or in group, has traditionally been limited to a fairly narrow age range and presenting problems,...