Change Mechanisms and Effectiveness of Small Group Treatments

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C HAPTER 16

CHANGE MECHANISMS AND EFFECTIVENESS OF SMALL GROUP TREATMENTS

GARY M. BURLINGAME,BERNHARD STRAUSS AND ANTHONY S. JOYCE

We had two aims in the revision of our cor- the group dynamic and process literature, built responding chapter from the last handbook these properties into their protocols, and often (Burlingame, MacKenzie, & Strauss, 2004): tested them as mechanisms of change that were (1) provide the best evidence-based recommen- independent of the theoretical model guiding dations for using specific group approaches to treatment. In contrast, most of the randomized treat specific patient populations; and (2) high- clinical trials (RCTs) summarized in this chapter light factors other than the treatment model appear to be conducted by investigators who are that may explain additional outcome variance. specialists in either a particular psychiatric or Today’s group treatments are guided by struc- medical disorder (e.g., depression) or theoretical tured protocols that have been submitted to orientation (cognitive-behavior therapy; CBT) rigorous empirical scrutiny. The typical research with the research being an extension of one or study identifies a particular disorder and then both of these identities. Stated differently, being articulates specific group interventions that are a group clinician or specialist in group dynamics proposed to lead to desired effects (e.g., reduction does not seem to be a core part of the iden- in depression). Indeed, in our previous review we tity of the investigators producing recent group criticized some areas of the group literature for treatment research. lack of clarity in the desired effects and the inter- The state of the current literature and our ventions intended to produce these effects (e.g., own appreciation of the group dynamic liter- groups for the elderly). Consequently, the bulk of ature led us to a choice point: criticize nearly the current chapter summarizes evidence about all RCTs for not explicitly incorporating group specific group interventions that lead to specific properties, or present a heuristic to assist future effects for specific patient populations. However, investigations. Our fundamental objective is it is clear that study authors continue to struggle to use empirical knowledge regarding group with outcome variance that is not explained by properties to increase the effectiveness of group specific group interventions based on a theoretical treatments. Hence, we provide a general model model. We believe insufficient attention is given of evidence-based group properties later in the to well-known and measurable group properties chapter and select a few properties to illustrate and processes, which account for some part of their relationship to patient outcomes. We urge this unexplained treatment variance. both researchers and clinicians to become famil- There is a distinct difference in the group iar with this part of the evidence-based group treatments reviewed in this chapter from those literature. We end with a discussion of a small but covered in past handbook chapters. Earlier group growing movement that uses sound measures of research was conducted by investigators who these properties to assist the clinician to maximize held group treatment as a major part of their outcome in group treatment: practice-based group professional identity. They were conversant with treatment. 640 Lambert c16.tex V1 - 10/08/2012 8:30pm Page 641

Conceptualizing Group Treatments • 641 CONCEPTUALIZING GROUP also include support, skills training, and psychoeducational groups. Information related to TREATMENTS theories of change is the most prevalent in the lit- In 20041 (Burlingame et al., 2004), we introduced erature and thus makes up the bulk of our review. a model that identified the main sources that The second source—principles of small group empirically explain patient improvement in group process —reflect group mechanisms of change treatment (Figure 16.1). This model subsequently that have been empirically linked to outcome and spawned new research and evidence-based sum- reflect the confluence of theory and research from maries; given its apparent heuristic value, we the clinical and nonclinical group literatures (e.g., reintroduce it with refinements as an organi- social psychology). In short, the therapeutic envi- zational framework. An abbreviated summary ronment of the group is a potent source of change follows and the interested reader is directed that is independent of formal change theory. We to our previous summary for more detail. The introduce a more detailed model of group process model begins with a general conclusion drawn later to guide research and practice. from the research literature —group treatment A third source is the patient. Typical patient facilitates client improvement—represented by factors considered by recent group RCTs are the therapeutic outcomes of group treatment element. those related to the disorder (e.g., pretreatment Below, we explore five sources of potential effects severity of depressive symptoms). However, our on these outcomes. model’s intent is to highlight group format char- The first source—formal change theory — acteristics that predict improvement or deterio- captures the mechanisms of change as tested by ration. For instance, interactions between patient efficacy or effectiveness studies. Group formal personality characteristics (e.g., attachment style, change theories overlap with the general psy- maturity of interpersonal relations) in conjunction chotherapy literature (e.g., psychodynamic, inter- with type of group approach have been recently personal, cognitive-behavioral, humanistic) but studied as predictors of benefit. The fourth source—group structural factors —takes into consideration logistical features of group such as dose (number and length of sessions), intensity of sessions (weekly, monthly, and bi-monthly), group Therapeutic size, setting, and cultural factors. Structural features can affect the size and durability of treatment Outcomes of effects, for example, studies of booster sessions GroupTreatment and varying dosage are emerging as important. The interconnection of all four sources is up to the group leader, who determines how these sources are integrated, whether the group is used as a vehicle of change or if individual therapy is Structural conducted in a group setting without regard for Patient Factors group dynamic factors. In 2004 we documented excellent examples of how to modify interven- Leader tions created for individual therapy to fit a group format (cf. Wilfley, Frank, Welch, Spurrell, & Rounsaville, 1998), noting that neglect of such Formal Small considerations can actually lower effectiveness. Change Group The complexity of group treatment emerges Theory Process when these five sources interact. Structural properties can interact with small group process (e.g., increased size can decrease member interaction FIGURE 16.1 Forces that govern the thera- and cohesion), formal change strategies may peutic outcomes of group psychology. compete with group process principles (e.g., in-depth individual exploration versus shared floor-time), and patient characteristics may inter- 1Summaries from our last handbook chapter are noted act with group processes (e.g., insecurely attached by the phrase “In 2004 we ....” clients respond differently to cohesion). In short, Lambert c16.tex V1 - 10/08/2012 8:30pm Page 642

642 • Chapter 16 / Change Mechanisms and Effectiveness of Small Group Treatments the group is comprised of multiple interactive producing thousands of abstracts. Each was parts and these multifaceted relationships change carefully read and accepted for inclusion using over time. the following criteria: published between January 2000 and June 2011; clinical populations; ran- CHAPTER ORGANIZATION domized clinical trials (RCTs) or effectiveness studies; and methodologically rigorous. Top- AND REVIEW APPROACH ics with sufficient research (> 5 studies) were This review includes studies from virtually every supplemented with meta-analytic findings when continent. It is encouraging that recent studies available. have begun to transfer group protocols developed in Europe, North America, or Australia to new VIDENCE FOR FFICACY AND cultures; likewise, new protocols being developed E E in Asia hold promise for Western application. The EFFECTIVENESS OF GROUP typical group continues to be time-limited (10 to TREATMENT 20 sessions) and of a diagnostically homogenous composition, but there is an increase in long-term Our primary interest in this section is to offer (1 to 2 years) psychodynamically oriented groups evidence-based recommendations to guide clin- with diagnostically heterogeneous membership. ical practice. In doing so, we summarized the We see the increase in published research on best efficacy and effectiveness studies that we these groups as a positive development because it could find in Tables 16.1 to 16.3. Efficacy studies examines actual clinical practice in many parts of are often fewer in number and provide an upper the world. limit of the improvement one might expect when The efficacy and effectiveness literature is using a particular group treatment. Effectiveness presented first and is organized by five sections: studies are included to provide an estimate of (1) disorders where group is the primary or sole pre–postimprovement one might see in daily treatment (mood, social phobia, panic, obsessive clinical practice. compulsive and eating disorders); (2) disorders The studies in Tables 16.1 to 16.3 are clas- where group is an adjunctive to other treatments sified across three domains; study and sample (substance and posttraumatic stress disorders); characteristics as well as the outcomes targeted (3) groups offered in hospital/medical settings for change. The study characteristics section (cancer, pain/somatoform, inpatient); (4) groups begins with the percentage of studies employing a for severe mental illness (schizophrenia and per- randomized clinical trial (%RCT) because experi- sonality disorders); and, (5) studies comparing the mental rigor rules out many confounds. Disorders differential efficacy of the group versus individual employing a higher percentage of RCTs (e.g., formats. We end this section with promising adult substance abuse) may claim greater rigor developments organized by the five sources and causal inference than those that primarily noted in Figure 16.1. The second major section employ pre-post effectiveness designs (e.g., bipo- describes a model to assist the reader in under- lar). We then note the percent of studies that standing group mechanisms of change based on use a conservative intent-to-treat (%ITT) versus the group dynamic literature. We then select completer analyses, which is especially important four mechanisms from this model to illustrate when there is either high or differential rates of how robust empirical evidence can guide group attrition; the range of percent of attrition (%Attr) practice and hopefully strengthen the effects follows immediately thereafter. Finally, an indi- described in the efficacy section. We end our cator of durability of outcomes is reflected by the chapter with a framework—practice-based group presence of and length of follow-up assessment. treatment (PBGT)—to illustrate how one might The increased number of RCTs allowed us to integrate the evidence-based protocols described identify several important sample characteristics in the efficacy section with measures of process to including sample size in active (A) and control (C) empirically guide group practice. conditions, which is important because smaller The studies reviewed in the efficacy section samples are more susceptible to confounds. We were located through a computer search of also list average age and gender ranges because PsycInfo, Medline, PubMed, ERIC, and Google both can moderate treatment effects. Finally, Scholar using the search terms group psy- we identify the primary and secondary effects or chotherapy, counseling, treatment, and therapy outcomes targeted by treatment, indicating the Lambert c16.tex V1 - 10/08/2012 8:30pm Page 643

Evidence for Efficacy and Effectiveness of Group Treatment • 643 number of studies studying each effect. This is posttreatment QoL change was explained by both critical since it affects how one would commu- pretreatment levels of depression and QoL (21%) nicate the expected benefits of treatment to a as well as by posttreatment change in depression prospective patient. (40%). Despite these high percentages, they concluded that QoL was not an epiphenomenon Group as Primary of depression and that QoL changes cannot be solely explained by reductions in depression. Mood Disorders Oei and colleagues (Furlong & Oei, 2002; In 2004, we concluded that group treatment Kwon & Oei, 2003; Oei, Bullbeck, & Campbell, produced reliable improvement over wait-list 2006) conducted a series of studies to better controls; that cognitive-behavioral group therapy understand changes in depression and cogni- (CBGT) had the most convincing randomized tion over the course of CBGT. The findings, clinical trial (RCT) support; that there was little in summary, called into question the cognitive support for differential efficacy based on the component as a primary change agent, leading the theoretical model guiding treatment; and that authors to explore alternative explanations (e.g., individual and group formats produced equiva- group as positive reinforcement). Kelly, Roberts, lent effects. These findings were replicated and and Ciesla (2005) noted sudden gains for more extended in 17 new studies listed in Table 16.1. than 40% of CBGT members, with early gains Two meta-analyses (McDermut, Miller, & (Sessions 1 to 5) being related to greater improve- Brown, 2001; Oei & Dingle, 2008, summarizing ment; sudden gains were unrelated to cognitive pre-2000 studies) yielded 28 unique RCTs, with change, suggesting another mechanism of action group therapy producing large effects (1.03 and (e.g., common factors). Unfortunately none of 1.10, respectively) relative to untreated controls. these studies could empirically link any aspect of With some variation, the aggregate results from group treatment to changes in depression. 14 studies showed equivalence between individual Seven studies focused on bipolar disorder and group formats (see below). The most recent (BD) with only two using RCT designs. Most literature clustered around two distinct diagnostic (5) tested psychoeducational groups (PEG) on groupings (Table 16.1). diverse effects including recurrence and length Ten studies focused on major depressive dis- of manic/depressive episodes (3), depression (5), order (MDD) with primary effects including mania (2), medication compliance (2), and gen- depression (the Beck Depression Inventory— eral functioning (2). PEG length varied widely, BDI—was employed in eight studies) and cog- from 4 sessions in an open inpatient group to 21 nitive measures [dysfunctional attitudes (6) and sessions in an outpatient setting. Patients ranged automatic thoughts (3)]; quality of life (QoL) was from mild or euthymic to acute and requiring the most studied secondary effect (3). Groups hospitalization. In short, there was little coher- were closed, lasted between 10 and 12 sessions, ence in the treatments offered, patients served, and had CBGT as the primary model (8) although and effects studied. The strongest effects came behavioral activation (Porter, Spates, & Smitham, from the RCTs. Colom and colleagues (2003) 2004) and Eastern philosophy models (Hsiao showed that PEG led to a reduced number of et al., 2007) were also tested. Five teams extended recurrences and hospitalizations, with gains main- CBGT models shown to be efficacious in past tained at 5 years (Colom et al., 2009); patients research to new populations (e.g., depressed with more than seven previous episodes, how- treatment-resistant medication patients; Enns, ever, did not show the same improvement (Colom Cox, & Pidlubny, 2002; Hsiao et al., 2007; Mat- et al., 2010). Simon and colleagues (2005) tested sunaga et al., 2010; Porter et al., 2004; Wong, a multicomponent systemic care management 2008). All studies reported statistically significant program (e.g., telephone monitoring, feedback superiority for the active compared to control to treatment team) that included a two-phase conditions on measures of depression and depres- PEG (disease management for five sessions fol- sive thinking. Enns et al. (2002) found that higher lowed by biweekly maintenance sessions) for levels of pretreatment self-criticism predicted less 212 patients versus 229 TAU controls. More BDI improvement. Three teams explored the than half completed both phases (59% and 52%, change process of CBGT groups. Swan and col- respectively) leading to fewer manic episodes, leagues (2009) explored change on a quality of life less intense symptoms, and more medication measured with 212 MDD patients, finding that management visits; gains were maintained Lambert c16.tex V1 - 10/08/2012 8:30pm Page 644 Criteria symptoms (6), depression (3) symptoms (20), depression (9), general anxiety (2), general psychopathology (2) recurrence/length (3), mania (2), medication compliance (2), general symptoms (2) cognitive (7), quality of life/well-being (4), general distress/functioning (3), anxiety (1) Effects Related to Different Outcome Age % Females Range Average Study Characteristics Sample Characteristics 83 16 0–43 3w.–5yrs 6–127 6–65 8–16 40–100 Social phobia 45 23 0–48 2–12m 17–219 17–84 21–39 33–60 Social phobia 22 22 15–41 6–60m 9–212 60–229 34–44 57–82 Depression (5), episode 20 20 8–26 3–12 m 12–176 13–159 36–45 44–100 Depressed mood (9), :Baerand : Enns et al., 2002; : Castle et al., 2007; Colom : Ashbaugh et al., 2007; 16.1 Group as Primary Efficacy and Effectiveness Research children and adolescents adults : : ABLE Garland, 2005; Gallagher etGarcia-Lopez al., et 2002; al., 2006;2000; Hayward Joormann et al., and UnnewehLiber 2002; et al., 2008 Borgeat et al., 2009;Fogler Delsignore, et 2008; al., 2007;Gruber Gaston et et al., al., 2001; 2006; Hofman, Herbert 2004; et al., Hofman 2005; andHofman Suvak, et 2005; al., 2006; KingsepMarom et et al., al., 2009; 2003; McEvoy,McEvoy et 2007; al., 2009;2009; McEvoy Mörtberg and et Perini, al.,Moscovitch 2005, 2006; et al., 2005;2007; Rapee Rosser et et al., al.,2003; 2004; Van Stangier Ingen et and al., Novicki, 2009 et al., 2003, 2009; deMichalak, Andres Yatham, et Wan, al., and 2006; Patelis-Siotis Lam, 2005; et al., 2001;2001; Pollack Simon et et al., al., 2005, 2006 Furlong and Oei, 2002;Kelly Hsiao et et al., al., 2005; 2007; KwonMatsunaga and et Oei, al., 2003; 2010;Porter Oei et et al., al., 2004; 2006; Wong., Swan et 2008 al., 2009; T CBGT SOCIAL PHOBIA CBGT Bipolar Disorder MOOD DISORDERS Major Depressive Disorder Study %RCT %ITT %Attr Follow-Up A C Lambert c16.tex V1 - 10/08/2012 8:30pm Page 645 (continues) anxiety (4), functioning (3), QOL (3) (9), depression (8), functioning (6), bodily sensation (2) functioning (2) anxiety (1) 0 20 6–28 3–49m 24–89 None 29–40 Not Reported Y-BOCS (5) depression (2), 86 43 14 1–24m 17–55 17–55 32–40 Not Reported Y-BOCS (7) depression (5) 38 23 0–42 0–24m 18–396 ?? 33–43 56–79 General anxiety (11), panic : : Braga et al., 2005; CordioliFenger et et al., al., 2007; 2002; HimleMeier et et al., al., 2001; 2006 Aigner et al., 2004; Anderson2007; Cordioli & Rees et al.,2005; 2003; Jaurrieta Fineberg et et al., al.,2001; 2008; Sousa McLean, et al., 2006 Clerkin et al., 2008;Erickson Erickson, et 2003; al., 2007;Norton, Galassi 2008; et Oei al., and 2007; Boschen,Otto et 2009; al., 2000;Rosenberg Roberge et and al., Hougaard, 2008, 2005;et Rufer al., 2010; Sharp et al., 2004 OCD Effectiveness Comparative studies PANIC Austin et al., 2008, Bohni et al., 2009; Q1 Lambert c16.tex V1 - 10/08/2012 8:30pm Page 646 Criteria Effects Related to Different Outcome frequency (2); eating-related cognitions (2). Comparative studies demonstrated equivalence of effects (see text) depression (9); BE frequency (7); abstinence (5); eating-related attitudes/concerns (4); self-esteem (3); mood regulation (3); emotional eating (3); weight (1) Age % Females Range Average Study Characteristics Sample Characteristics 44 67 3–42 3–54m 19–109 16–82 21–28 97–100 BN symptoms (4); B&P 76 90 0–41 1–12 m 11–253 9–51 21–58 76–100 BE symptoms (11); ) llings and ilian et al., BED ( ) BN ( (Continued) 16.1 ABLE et al., 2003; Jacobiet et al., al., 2000; 2002; Nevonen Leung Openshaw & Broberg, et al., 2006; 2004;2004; Peterson Shapiro et et al., al., 2010 Friederich et al., 2007;Paxton, Go 2006; Gorin etet al., al., 2003; 2002; Kenardy Munschet et al., al., 2000, 2007; Nauta 2001;Peterson Paxton et et al., al., 2001; 2007; 2001; Renj Safer et al., 2010;2009; Shapiro Schlup et et al., al.,Shelley-Ummenhofer 2007; and MacMillan, 2007; Tasca, Ritchie, etBalfour, al., et 2006, al., Tasca, 2007;2001; Telch Wilfley et al., et 2000, al., 2002 T Bailer et al., 2004; Bogh et al., 2005; Chen EATING DISORDERS Bulimia Nervosa Ashton et al., 2009; Duchesne et al., 2007; Binge Eating Disorder Study %RCT %ITT %Attr Follow-Up A C Lambert c16.tex V1 - 10/08/2012 8:30pm Page 647

Evidence for Efficacy and Effectiveness of Group Treatment • 647 at the 2-year follow-up (Simon, Ludman, Bauer, combination with other interventions (e.g., social Unutzer, & Operskalski, 2006) but no differences skills training or attention training), most (8) were on depression were noted between PEG and RCTs. Many of the studies that were located TAU. These results are promising given that defied easy classification other than being on medication compliance is likely linked to reduced social anxiety and involving group. Although all frequency and intensity of recurrences. The two studies are related to the CBGT manuals, the lit- RCTs underscore the relapse prevention poten- erature reveals a general lack of cohesion or focus tial of PEG, but additional rigorous research is on systematic programmatic research. One study needed before we can move our evaluation from (Stangier, Heidenreich, Peitz, Lauterbach, & promising to efficacious. Clark, 2003) found individual more effective than Social Phobia. In 2004 we detailed “com- group; however, the manual was not modified for pelling evidence” for the efficacy of a single the group setting, an omission shown to lower model—CBGT—developed by Heimberg and group effectiveness (Burlingame et al., 2004). Becker (2002). This model, along with two sim- In view of recent epidemiological studies ilar group approaches (Clark & Wells, 1995; showing that social phobia/anxiety is common Rapee & Heimberg, 1997), was the focus of 28 (lifetime prevalence 4% to 14%) and begins outcome studies published over the past decade early (11 to 13 years), it is not surprising that (Table 16.1). A recent meta-analysis (Powers, recent research included children and adoles- Sigmarsson, & Emmelkamp, 2008) summarizing cents. A Cochrane Review for anxiety disorders a portion of these studies estimated identical in children and adolescents (James, Soler, & effectiveness for group (d = .68) and individual Weatherall, 2005) showed a remission rate of treatments (d = .69). The typical group was 56% for CBT versus 28% for different control closed, and consisted of 5 to 10 patients who par- conditions, and observed that individual, family ticipated in weekly sessions of varying duration and group formats produced similar results (cf. (90 to 240 min.). Patients were between 30 and Garcia-Lopez et al., 2006; Silverman, Pina, & 40 years old with equal gender representation. Viswesvaran, 2008). Six recent studies tested Overall, the effects of CBGT have been con- CBGT for children and adolescents aged 8 to 16 firmed related to primary outcomes of social pho- years (Table 16.1). Most (5) were RCTs, although bia symptoms (commonly based on the Liebowitz sample sizes were relatively small. All six studies Social Anxiety Scale) as well as on depression and indicated positive effects of the active treatment several secondary outcomes (e.g., general anxiety, on primary (social anxiety) as well as secondary perfectionism, post-event processing; Ashbaugh outcomes (depression, n = 3). Social anxiety et al., 2007; McEvoy, Mahoney, Perini, & was usually assessed with the Social Phobia and Kingsep, 2009). A subset of studies looked at the Anxiety Inventory or the Anxiety Disorders effectiveness of successfully transferring manu- Interview Schedule for Children. There were alized CBGT from a research setting to private positive effects of CBGT on social anxiety in a practice or community clinics (e.g., Gaston, community-based setting (Baer & Garland, 2005) Abbot, Rapee, & Neary, 2006; Marom, Gilboa- and in non-English–speaking countries (Joor- Schechtman, Aderka, Weizman, & Hermesh, mann & Unnewehr, 2002). One study supported 2009; McEvoy, et al., 2007, 2009). Other studies the equivalence of the individual and the group summarized in Table 16.1 revealed CBGT to formats (Liber et al., 2008). be effective for specific populations (Kingsep, In summary, although there is increasing evi- Nathan, & Castle, 2003, Van Ingen & Novicki, dence supporting CBGT as an efficacious treat- 2009), other settings (e.g., intensive treatment, ment for social phobia, not all patients benefit. Mörtberg et al., 2005, 2006), combined with One study examined whether the active ingredi- adjuncts (e.g., antidepressants; Rosser, Erskine, & ents of CBT were responsible for improvement: Crino, 2004) or showed effects of CBGT depend- Rapee, Abbot, Baillie, and Gaton (2007) showed ing on other variables (e.g., prior treatment; that self-help groups were more effective in depression; Delsignore, 2008; Fogler, Tompson, reducing social phobia symptoms than wait lists Steketee, Hofmann, 2007; Marom et al., 2009). and that self-help groups augmented with min- We found nine other studies testing the differen- imal therapist assistance produced gains similar tial effects of CBGT with other treatments (e.g., to CBGT. This does not nullify the effects of exposure therapy, self-help groups with and with- the high-quality CBGT but encourages future out therapist assistance, individual CBT) or in research to explore mechanisms of change. Lambert c16.tex V1 - 10/08/2012 8:30pm Page 648

648 • Chapter 16 / Change Mechanisms and Effectiveness of Small Group Treatments The past decade of research has put group 2005; Rufer et al., 2010); all tended to have weak treatment of social phobia on an even stronger methodologies and pre- to posteffect sizes were foundation—particularly CBGT. It must be said smaller compared to previous RCTs (.12 – .69). that for many patients this has not proved to be Oei and Boschen’s (2009) large retrospective sufficient. Recent studies have attempted to refine study of routine clinical practice in Australia is and supplement this already effective treatment noteworthy for its sample size (n = 396); the study by augmenting it with other interventions (e.g., demonstrated variability of outcome by domain in acceptance and commitment therapy), by trans- pre–postcomparisons with general anxiety post- ferring it from laboratory to naturalistic settings ing higher gains (d = .64) than panic or depression and extending it to adolescents with both remedial (d = .32 – .55 and d = .12 – .69, respectively). and prevention goals. Moreover, there is some A second group of studies investigated how evidence for the additive value of several inter- change takes place in CBGT. In an RCT, Bohni, ventions (e.g., exposure, social skills training, self- Spindler, Arendt, Hougaard, and Rosenberg help groups, and relaxation training). Research (2009) tested for differential improvement when is still needed regarding alternative approaches a 12-session CBGT group was offered weekly for patients who do not benefit from CBGT. over 12 weeks or in a massed 3-week protocol Knijnik, Kapczinski, Chachamovich, Margis, and (4-hour daily sessions in Week 1, two 2-hour Eizirik (2004) have systematically tested a man- sessions in Week 2, one 2-hour session in Week ualized psychodynamic approach that may prove 3). Both posted equivalent results with moderate useful. The handful of studies with adolescents to large pre–posteffects (d = .67 – 1.47). Clerkin, is promising but more comparisons would clarify Teachman, and Smith-Janik (2008) studied sud- potential preventive and economic value. den gains in CBGT, noting that those occurring in Session 2 or after (20% of members) were asso- Panic Disorder ciated with better improvement by termination; In 2004, we noted CBGT as the dominant model this agrees with sudden gains in individual CBT for treating panic disorder and of the 13 new for panic disorder (Tang, DeRubeis, Hollon, studies included (Table 16.1), all used CBGT. Amsterdam, & Shelton, 2007). Approximately 40% were RCTs with the average patient being a female of 30 to 40 years of age Obsessive-Compulsive Disorder (OCD) whohadsufferedfor6to15yearswithpanic In 2004 we noted exposure and response pre- disorder and a comorbid anxiety or depressive vention (ERP) as the dominant treatment but disorder. The typical study had between 20 and expressed caution since it was supported by only 50 subjects; general anxiety and panic symptoms a single RCT (Fals-Stewart, Marks, & Schafer, were the primary outcomes, depression, and gen- 1993). The past decade produced six RCTs and eral functioning served as secondary effects. The four pre-post studies (Table 16.1); the Yale- Mobility Inventory for Agoraphobia and the Beck Brown Obsessive Compulsive Scale (YBOCS) Anxiety Inventory were the most frequently used continues to be the primary outcome scale, measures (5 and 4 studies, respectively) with the making direct effect size comparisons possible; dominant models being Barlow and colleagues’ secondary outcomes include depression, anxiety, panic control treatment and Clark’s cognitive general functioning and QoL. CBT protocols therapy (Barlow, Craske, Cerny & Klosko, 1989; that include ERP emerged and reflect the major- Clark, 1986). Most patients were on medication ity of protocols tested. The average patient was (SSRI and tricyclic), which, when combined with in his or her late 30s, suffering from chronic CBGT, has been shown to produce the greatest OCD (average duration 17 years) with high and most durable changes (Roy-Byrne, Craske, & co-morbidity (anxiety and depressive disorders), Stein, 2006). The primary focus across studies was treated in a group lasting an average of 12 sessions the clinical application and refinement of CBGT. (range = 7–20). The largest group of studies focused on With one exception (Himle et al., 2001), naturalistic open trials, testing the feasibility most pre-post studies involved small samples and effectiveness of transferring CBGT proto- (Table 16.1). Pre-posteffect sizes reflecting cols from RCTs into clinical practice (Austin, improvement on the YBOCS vary between 0.91 Sumbundu, Lykke & Oestrich, 2008; Galassi, (Fenger, Mortensen, Rasmussen & Lau, 2007) Quercioli, Charismas, Niccolai, & Barciulli 2007; and 1.74 (Cordioli et al., 2002); changes in anx- Oei & Boschen, 2009; Rosenberg & Hougaard, iety and depression measures were moderate. A Lambert c16.tex V1 - 10/08/2012 8:30pm Page 649

Evidence for Efficacy and Effectiveness of Group Treatment • 649 low withdrawal rate (6%, Cordioli et al., 2002) Finally, Sousa, Isolan, Oliveira, Manfro, and Cor- suggests high acceptance of CGBT. In the study dioli (2006) studied the differential gains for a 12- by Braga, Cordioli, Niederauer, and Manfro session CBGT and sertraline. Both CBGT and (2005), 35% of the sample relapsed at the 1- sertraline posted reliable pre–postimprovement year follow-up. The strongest predictors for not on YBOCS (ES = 1.6 and 1.2, respectively), relapsing were rapid improvement and full remis- anxiety, depression, general functioning and QoL sion (YBOCS < 9) by the end of treatment; onset measures. When complete remission was used as age, comorbidity, initial symptom severity, and the outcome criterion, CBGT was more effective intensity of obsessions were unrelated to relapse. and demonstrated greater gains in clinician-rated In a Danish study of CBGT effectiveness (Fenger general functioning. Q2 et al., 2007), a pregroup session to develop indi- The comparative RCT of Fineberg, Hughes, vidualized treatment goals was added. Smaller Gale, and Roberts (2005) tested if CBGT effects effect sizes were explained by higher levels of could be attributed to the active ingredients or comorbidity. In a German study (Meier, Fricke, the nonspecific effects of participating in a group. Moritz, Hand, & Rufer, 2006), it was noted that Following Fals-Stewart et al. (1993), they used comorbid dependent personality disorder was a relaxation therapy (RT) as a placebo attention a risk factor for worse outcome. The largest condition to compare the effects of treatment open trial (Himle et al., 2001) experimentally on OCD symptoms, depression, anxiety, adjust- contrasted the dose (7– versus 12-session) of ment and general functioning measures. CBGT an earlier group ERP model (Krone, Himle, & interventions were contrasted with progressive Nesse, 1991). No differences on the YBOCS or muscle relaxation, imagery, meditation, reflexol- depression measures were found, and they sur- ogy, aromatherapy, and breathing interventions mised that 12-week patients simply paced them- in the RT group. No differences were found selves slower than 7-week patients. on any outcome measure or in attitudes toward Thepastdecadealsosawanumberofcom- treatment although there was a higher dropout parative studies. Two teams (Anderson & Rees, rate for RT; patients with a more recent history 2007; Jaurrieta et al., 2008) tested the differential of OCD responded better to CBGT. efficacy of group (G) versus individual (I) formats, There is now ample evidence for the efficacy replicating the equivalence finding of Fals- of ERP and CBGT when compared to waitlist Stewart et al. (1993). CBGT was also compared control—a different conclusion from our last to wait-list control, ERP and medication. Cordioli review. Indeed, a recent meta-analysis of 13 et al. (2003) reported similar gains on the YBOCS studies (Jonsson & Hougaard, 2008) produced an as Anderson and Rees (2007) for a 12-session average effect size of 1.1 on the YBOCS for both CBGT (ES = 1.3). Modest improvement was treatments when compared to wait-list controls. found for quality of life but none found for anx- Interestingly, a few investigators have argued iety. McLean, Whittal, Thordarson, and Taylor for group ERP and individual CBT (McLean (2001) examined the differential efficacy of ERP et al., 2001; Whittal et al., 2008) although the against a contemporary CBGT protocol. Both collective evidence does not support a differential ERP and CBGT outperformed the wait-list con- preference. The findings of the single placebo trol on the YBOCS (ES = 1.6 versus 1.0, respec- attention group study, while intriguing, have been tively) and when differences in medication use criticized for a high differential dropout (Jons- were controlled, ERP proved superior to CBGT. son & Hougaard, 2008). Similarly, the paucity of Surprisingly, both active treatments posted equiv- comparisons with medications makes conclusions alent improvement on only one of three cognitive about differential effects impossible to draw at measures, suggesting ERP and CBGT produced this time. Nearly every study noted the power identical cognitive gains; a 2-year follow-up sup- of group dynamics in increasing attendance and ported these findings (Whittal, Robichaud, Thor- involvement relative to alternate treatments (but darson, & McLean, 2008). Aigner, Demal, Zitterl, without offering a specific estimate of this effect), Bach, and Lenz (2004), in a nonrandomized com- and they also highlighted the economic advantage parative study, examined the effectiveness of of group treatments. CBGT with and without medication (SSRI). Although both conditions caused improvement Eating Disorders (EDs) on the YBOCS, CBGT plus medication led Research on group therapy for EDs has bur- to more improvement than medication alone. geoned since our last review, especially regarding Lambert c16.tex V1 - 10/08/2012 8:30pm Page 650

650 • Chapter 16 / Change Mechanisms and Effectiveness of Small Group Treatments binge-eating disorder (BED) (Table 16.1). We reliable change of 28% to 45% on ED symptoms previously concluded that there was strong evi- and depression but lower rates of recovery from dence for the effectiveness of CBGT for bulimia BN and no effect for anxiety. The effectiveness nervosa (BN). Recent studies have reinforced this of integrated group treatments for BN appears conclusion, addressed mechanisms of change, promising; more controlled and comparative and expanded treatment to areas of patient trials are needed. functioning beyond ED. Despite a high rate Most research focused on BED with CBGT of dropout, CBGT had consistent effects on as the dominant model. These studies demon- BN symptoms and frequency of bingeing and strated strong rigor, with RCT designs, ITT purging (BAP) in intent-to-treat analyses. Three analyses, follow-up, and attention to power and pre-post studies examined refinements of CBGT clinical significance. Thirteen studies compared (Leung, Waller, & Thomas, 2000; Shapiro et al., CBGT against alternative approaches and with 2010); one included controls (Peterson et al., related conditions (e.g., subclinical BED, body 2004). Refinements included variations of session dissatisfaction and disordered eating). Dropout frequency or contracting for abstinence from rates varied considerably around an average of purging (Peterson et al. 2004; found no effects for 20% and did not differ between treatments. Alter- either), and the use of nightly text messaging as native modes of delivery such as video (Peterson a means of monitoring BAP (Shapiro et al. 2010, et al., 2001), CD-ROM (Shapiro et al., 2007), or report positive effects). These studies offered the Internet (Gollings & Paxton, 2006; Paxton, initial tests of key principles of CBT theory, McLean, Gollings, Faulkner, & Wertheim, 2007) that is, the association of core beliefs, attitudinal proved equivalent to CBGT with both outper- distortions, or behavioral monitoring to recovery forming controls, though Paxton et al. (2007) from BN. noted larger effects for group on ED-related Three comparative studies, all employing attitudes, depression, and self-esteem. Gorin, Le RCT designs, ITT analyses, and follow-up, tested Grange, and Stone (2003) found no additional for differential efficacy by comparing CBGT with benefit when spouses were involved in group guided self-help (Bailer et al., 2004), individual sessions. Three studies examined CBGT versus a therapy (Chen et al., 2003), or with fluoxe- behavioral weight control group (Munsch et al., tine or combined treatment (Jacobi, Dahme, & 2007; Nauta, Hospers, & Jansen, 2001; Nauta, Dittmann, 2002). Equivalence across conditions Hospers, Kok, & Jansen, 2000); consistently, the was the rule regardless of post-treatment out- latter was more effective for weight loss but the come measure. However, Bailer et al. (2004) observed higher remission rates for CBGT at 1- former had larger, more comprehensive effects year follow-up, Chen et al. (2003) recorded larger on ED symptoms and behaviors. Finally, four effects for group therapy on impulsivity and state studies compared CBGT against IPT (Wilfley anxiety by 3- and 6-month follow-up, and Jacobi et al., 2002), psychodynamic (Tasca, Ritchie, et al. (2002) found that CBGT alone resulted et al., 2006; Tasca, Balfour, Ritchie, & Bissada, in greater abstinence than combined treatment 2007), or nondirective groups (Kenardy, Mensch, at post-treatment and follow-up. These studies Bowen, Green & Walton, 2002). Equivalent provide evidence for maintenance of benefits effects on BE behaviors, BED-specific and gen- from CBGT for BN. eral symptoms, self-esteem and social functioning Three studies examined the effectiveness were common findings. Kenardy et al. (2002) of CBGT incorporating elements of psychody- reported greater effects for CBGT on BE at namic and psycho-educational models (Bogh, 3-month follow-up; patients in the “nonprescrip- Hagedorn, Rokkedal, & Valbak, 2005) or inter- tive” group had shown relapse. Tasca, Ritchie, personal therapy (IPT; Nevonen & Broberg, et al. (2006) reported mode-specific differential 2006; Openshaw, Waller, & Sperlinger, 2004). effects, with the dynamic-interpersonal group Dropout rates were low (∼12%), perhaps due to superior on depression and CBGT superior on a more relational focus in group sessions. Effects attitudes and susceptibility to hunger. were evident on ED and general symptoms, with Two studies reported positive effects for rates of remission/recovery ranging between 21% adaptations of CBGT (Ashton, Drerup, Win- and 58%. Bogh et al. (2005) noted that early dover, & Heinberg, 2009; Duchesne et al., reductions in BN behaviors were predictive of 2007). Three studies addressed protocol refine- better outcome. Openshaw et al. (2004) reported ments (Friederich et al., 2007; Schlup, Munsch, Lambert c16.tex V1 - 10/08/2012 8:30pm Page 651

Evidence for Efficacy and Effectiveness of Group Treatment • 651 Meyer, Margraf, & Wilhelm, 2009; Shelley- early advantages for CM, which also disappeared Ummenhofer & MacMillan, 2007), with clear at follow-up (Petry, Weinstock, Alessi, Lewis, & findings, that is, twice-weekly sessions were Dieckhaus, 2010). Although most protocols pro- less effective, booster sessions were associated duced positive results compared to no treatment, with continued improvement over follow-up. effect sizes were small to moderate when specific Further studies of modifications of CBGT for group programs were compared to other control BED are expected and necessary before clinical conditions (d = 0.3–0.7; e.g., Liddle, Rowe, recommendations become possible. Dakof, Henderson, & Greenbaum, 2009; Petry et al., 2010), supporting our previous conclusions. Group as Adjunct As with social phobia, group treatments for adolescent substance abuse emerged as a promising Substance-Related Disorders intervention (Waldron & Turner, 2008). The Burlingame et al. (2004) saw limited support typical adolescent study treated a high propor- for the effectiveness of group treatment with tion of males (75% to 80%) with an average substance related disorders since formal change age of 15 years. Most had multiple substance theories did not sufficiently explain variations abuse problems (illicit drugs, mainly marijuana), in outcome. We located six studies testing the and less commonly alcohol dependency, alco- comparative efficacy of group treatments, three hol/drug related problems, and/or behavioral studies that compared group and individual problems/delinquency. Groups were primarily formats, and seven studies concerning group closed, ranged between 8 and 20 sessions (usually treatments for adolescents (Table 16.2). Among weekly), and tested a wide array of interventions the comparative studies, groups varied from including feedback and motivational interview- very short (1 to 5 sessions, Tross et al., 2008) ing (Smith, Hall, Williams, An, & Gotman, to relatively long interventions (26 sessions, Litt 2006), psychoeducation (Burleson & Kaminer, Kadden, Cooney, & Kabela, 2003). Almost all 2005), social learning (Battjes et al., 2004) and groups were closed with a few studies treating CBGT components (Dennis et al., 2004; Liddle only males (Easton et al., 2007) or only females et al., 2004, 2009). Some multimodal approaches (Tross et al., 2008), but most had mixed gender embedded individual and/or family sessions with females in the minority (30% to 50%). into the program (Dennis et al., 2004; Smith The mean age of the participants varied between et al., 2006). 38 and 45 years. The primary outcome was Five studies compared family-based group substance-related (i.e., substance use and related interventions, with two showing advantages for problems, abstinence, and urinalysis); secondary a multidimensional family therapy compared effects included mood, violent behavior, and HIV to peer group treatment on primary outcomes risk behavior (Table 16.2). of substance abuse, substance use problems, One study contrasted CBGT with inter- and delinquency (Liddle et al., 2004, 2009) and actional groups (Litt et al., 2003), yielding three finding few significant differences between equivalence on abstinence rates and improved approaches (Battjes et al., 2004; French et al., coping skills, and raising the question of specific 2008; Smith et al., 2006). The only nonrandom- versus nonspecific effects explaining outcomes. ized study of a group based on social learning The other comparative studies tested specific theory reported positive effects on marijuana group programs for specific populations. Weiss et al. abuse, but not alcohol abuse and delinquency (2007, 2009) contrasted an integrated group (IG) (Battjes et al., 2004). therapy for patients with dual diagnosis (bipolar Collectively, groups for substance abuse (and disorder, substance abuse) with group counseling comorbid disorders) postmoderate positive effects and reported a moderate advantage for IG on for both adolescents and adults. There are minor substance-use outcomes. Easton et al. (2007) differences in effectiveness between specific for- conducted a RCT with CBGT designed for mal change theories and these often disappear domestic-violence offenders. CBGT was superior over time. Accordingly, several studies explored to a 12-step group control only on substance use factors that might explain additional variance. at the end of treatment but differences disap- A family history of alcohol abuse, specific com- peared at follow-up. Similarly, a study comparing binations of gender and ethnicity (e.g., female contingency management (CM) with a 12-step and non-Caucasian) and social anxiety appear to control in patients with HIV infection showed be hindering factors (Book, Thomas, Dempsey, Lambert c16.tex V1 - 10/08/2012 8:30pm Page 652 Criteria abuse (use, abstinence, urinalysis) (4), mood/coping (2), violent episodes (1), HIV risk behavior (1), unprotected sex occasion (1) abuse (5), delinquency (1), internalized stress (1), reducing risks in family, peers (1), self-efficacy (1) abuse (2), treatment completion and goal achievement (1) Effects Related to Different Outcome Age % Females Range Average Study Characteristics Sample Characteristics 86 14 8–29 6–12m 35–194 30–58 13–16 24–79 Criteria of substance 67 0 11–21 12m 143–2471 144–3919 41 28–31 Criteria of substance 100 50 9–38 3–18m 31–247 30–262 38–35 0–100 Criteria of substance : : group . : 16.2 Group as Adjunct Efficacy and Effectiveness Research ABLE et al., 2010; Tross etet al., al., 2007, 2008; Weiss 2009 treatment 2005; Dennis et al.,2008; 2004; Liddle French et et al., al., 2004,et al., 2009; 2006 Smith et al., 2009 T SUBSTANCE ABUSE Comparative studies with adultEaston patients et al., 2007; Litt et al., 2003; Petry Studies comparing individual vs Battjes et al., 2004; Burleson and Kaminer, Group treatments for adolescent substance abuse Panas et al., 2003; John et al., 2003; Sobell Study A C %RCT%ITT%AttrFollow-Up Lambert c16.tex V1 - 10/08/2012 8:30pm Page 653 (21), depression (16), general psychiatric symptoms (13), PTSD diagnosis (6), self-esteem (6), anger (5), anxiety (5), coping/avoidance (5), guilt (4), assertiveness (3), social function (3), alcohol/drug severity (2), HIV risk behavior (2), grief (2), GPA (2) 32 29 0–41 2–60m 12–181 11–177 12–55 0–100 Trauma symptoms 2002; llis, llingstad, PTSD / Westwood et al., 2010;2003 Zlotnick et al., 2003; Chard, 2005; ClassenCloitre et and al., Koenen, 2011; 2001;2002; Creamer Donovan et et al., al.,et 2001; al., Dorrepal 2010; Falsettiet et al., al., 2007; 2001; Ginzburg Gatz Richter, et al., and 2009; Snider, Gorey, 2001;Bergeron, Hébert 2007; and Kibler andKreidler, Lyons, 2005; 2008; Lau andLayne Kristensen, et 2007; al., 2001;Lundqvist Lundqvist and et Öjehagen, al., 2009; 2001;et Lundqvist al., 2006; MöllerMorrison and Steel, and Treliving, 2002; 2002;et Mueser al., 2007; RieckertRuzek and et Möller, al., 2000; 2001; RyanSaltzman et et al., al., 2005; 2001;Sharpe Schnurr et et al., al., 2001; 2003; 2007, Sikkema 2008; et Spiegel al., 2004, etet al., al., 2004; 2007; Toussaint Vaa et al., 2002; Wa Amaro et al., 2007; Bradley and Fo TRAUMA Lambert c16.tex V1 - 10/08/2012 8:30pm Page 654

654 • Chapter 16 / Change Mechanisms and Effectiveness of Small Group Treatments Randall, & Randall, 2009; LaBrie, Feres, Ken- team. Benefits on PTSD symptoms, social sup- ney, & Lac, 2009; McNeese-Smith et al., 2009), port, and daily functioning were seen at follow-up while higher motivation (Litt et al., 2003), social 1, 3, 6, and 12 months after intake (Stepakoff reinforcement (Lash, Burden, Monteleone, & et al., 2006). Lehmann, 2004), music therapy (Dingle, Glead- Psychodynamic groups wereoftenusedtotreat hill, & Baker, 2008), PTSD symptom reduction female survivors of child sexual abuse (CSA), and (Hien et al., 2010), and contingency management less often for male survivors (Morrison & Tre- (Ledgerwood, Alessi, Hanson, Godley, & Petry, living, 2002; Sharpe, Selley, Low, & Hall, 2001). 2008) enhance adherence and outcome. Three studies involved RCTs (Ginzburg et al., 2009; Lau & Kristensen, 2007; Spiegel et al., Trauma-Related Disorders 2004). Most groups were of moderate length Interest in group treatment of trauma has (24 to 36 sessions), but 1- (Lau & Kristensen, flourished since our last review. Studies usu- 2007) and 2-year models (Lundqvist et al., 2006; ally highlighted one of four approaches, that 2009; Lundqvist & Öjehagen, 2001) appeared. is, support/process-oriented, psychodynamic, Effects on general psychiatric and trauma-specific CBGT, or more recent integrated models (e.g., symptoms, social functioning, and assertiveness Gatz et al., 2007), and varied in methodological were reported. Follow-up evaluations occurred rigor. Three themes are evident in this literature. in 40% of studies; maintenance of post-therapy First, it is now accepted that trauma experience gains was not always evident (Sharpe et al., 2001). covaries with substance use and other activities, Cloitre and Koenen (2001) reported benefits which increase HIV risk, encouraging the incor- for a 12-week interpersonal-dynamic group but poration of a trauma focus into rehabilitation and noted that groups having even a single member prevention programs. Second, the importance diagnosed with borderline personality disorder of a clear group structure in trauma treatment had poorer outcomes. Kreidler (2005) evaluated has been acknowledged. Third, a distinction a 50-session dynamic group for survivors with or between “trauma-focused” and “present-focused” without chronic mental illness (CMI); all patients groups has been raised by psychodynamic showed improvement on trauma symptoms, dis- (Spiegel, Classen, Thurston, & Butler, 2004) and tress, and depression, but most CMI patients CBT practitioners (Schnurr et al., 2003) alike. remained in the dysfunctional range. Lau and “Trauma-focused” groups are concerned with Kristensen (2007) reported positive effects for the past trauma itself while “present-focused” survivors in either a 12-month analytic group or a groups are concerned with present circumstances 5-month systemic group (solution-focused, with and residual consequences. Apart from minor psychoeducation); effect sizes on global and social differential effects, the primary finding in com- functioning, distress, and quality of life were parative studies has been equivalence. It remains larger for the more structured, briefer group. unclear if this distinction is important, that is, Finally, no differential effects were observed whether different patients or trauma experiences when dynamically oriented “trauma-focused” necessarily imply the use of a “trauma-focused” and “present-focused” groups were compared or “present-focused” group approach. (Ginzburg et al., 2009; Spiegel et al., 2004), and Support/process groups were evaluated in three both outperformed wait-list controls. uncontrolled studies involving female patients, The majority of studies featured CBGT. but with minimal assessment of trauma symp- A trauma-focus was often paired with cognitive toms. These groups recorded few dropouts (< restructuring (e.g., Classen et al., 2011) but not 16%). Effects on depression and other symptoms, consistently (e.g., Ruzek et al., 2001); the latter guilt feelings, and self-esteem were observed, study reported no effects of treatment, suggesting but more consistent evaluations of outcome trauma-focused groups are insufficient without a are needed. Comorbidity with eating disorders cognitive component. Skills training was standard limited the effect of a problem-solving support in present-focused groups. Both approaches used group (Harper, Richter, & Gorey, 2009). A large 10 to 20 session formats and often incorporated uncontrolled study involved the Center for Vic- psychoeducation and attention to group pro- tims of Torture (CVT) of Minneapolis offering cess. Methodological rigor was high with some 10-week support/process groups to 4,000 Sierra studies being state-of-the-art (Classen et al., Leonean refugees in Guyanese camps. Leaders 2011; Schnurr et al., 2003). Target populations were native paraprofessionals trained by the CVT were heterogeneous (female CSA survivors, e.g., Lambert c16.tex V1 - 10/08/2012 8:30pm Page 655

Evidence for Efficacy and Effectiveness of Group Treatment • 655 Classen et al., 2011; male veterans with chronic a critical consideration. We noted smaller effects PTSD, e.g., Kibler & Lyons, 2008). Studies for educational interventions, mixed effects on provided strong evidence for effectiveness on survival and a link between therapist experi- trauma symptoms, depression and remission of ence and improvement. Twenty-three studies PTSD (e.g., Chard, 2005). Secondary outcomes were located testing breast cancer treatments for (anger, dissociation, anxiety, guilt) also improved. different phases of the illness (Table 16.3). CBGT lowered HIV-related risk behavior with Eight of nine studies employed a RCT design a “present-focused” (Classen et al., 2011) being using an inert control group to test the efficacy more effective than a trauma-focused (Sikkema of supportive expressive group therapy (SEGT) that et al., 2008) group approach. typically consisted of 6 to 10 women participat- Integrated treatments for co-occurring ing in 90-minute weekly sessions for at least 1 trauma and substance abuse (SA) melded CBT year. The format was slow open (e.g., members skills-training, psychoeducation, psychodynamic, added as space becomes available) with a support- and interpersonal-process group techniques, ive environment to confront problems, express often within residential or day treatment pro- emotions, strengthen relationships and find life grams. Research included multisite studies meaning. The inert control primarily (88%) (Women, Co-occurring Disorders and Vio- involved a self-directed educational intervention lence Study; Giard et al., 2005) and evaluations that included access to various media regarding of mental health systems-level effects (Morrissey relaxation and nutrition. SEGT attrition ranged et al., 2005). The Seeking Safety (Najavits, Weiss, from 8% to 38% and few studies (4) tested power Shaw, & Muenz, 1998) and Trauma Recovery a priori (range .89–.99). ITT analysis was used by and Empowerment (TREM; Harris, 1998) pro- half, with five primary effects: distress, quality of grams were evaluated for women with a history life, survival, coping, and pain. of trauma and SA (Amaro et al., 2007; Gatz et al., Psychological distress, assessed most fre- 2007; Toussaint, VanDeMark, Bornemann, & quently (4) by the Profile of Mood States Graeber, 2007; Zlotnick, Najavits, Rohsenow, & (POMS; McNair, Lorr & Droppleman, 1992), Johnson, 2003), while the Transcend program was improved in four studies (Bordelau et al., (Donovan, Padin-Rivera, & Kowaliw, 2001) was 2003; Goodwin et al., 2001; Kissane et al., 2007; evaluated for male veterans with co-occurring O’Brien, Harris, King & O’Brien, 2008). Classen PTSD and SA. All programs impacted positively et al. (2001) noted a marked increase in POMS on trauma symptoms or the PTSD diagnosis distress shortly before death, when these indi- (Toussaint et al., 2007). However, three studies viduals were excluded, SEGT showed more observed no incremental effects for SA severity improvement than controls. The sole primary relative to TAU (Amaro et al., 2007; Gatz et al., breast cancer study (Classen et al., 2008) used 2007; Toussaint et al., 2007), though Amaro an abbreviated SEGT protocol (12 weeks) and et al. (2007) reported greater abstinence at 6- and found no differences suggesting that it may be 12-month follow-up. Two studies also reported ineffective, too short, or that primary breast long-term effects for SA (Zlotnick et al., 2003; cancer women are insufficiently distressed for Donovan et al., 2001). Finally, two comparative treatment to have an effect. studies (Creamer, Forbes, Biddle, & Elliott, 2002; Mixed findings resulted on the same QoL Ryan, Nitsun, Gilbert, & Mason, 2005) and two measure (EORTC QoL C-30) with Kissane et al. effectiveness studies (Vaa, Enger, & Sexton, 2002; (2007) reporting an increased QoL for SEGT Westwood, McLean, Cave, Borgen, Slakov, 2010) and Bordelau et al. (2003) finding no effect. Two showed promising results when CBT and psycho- studies (Giese-Davis et al., 2002; Kissane et al., dynamic techniques were combined. Integrated 2007) supported SEGT’s effect on adjustment to models show definite promise for the treatment cancer on distinct measures, while Classen et al. of trauma and related conditions. (2008) failed to find an effect with primary breast Groups Within Medical Settings cancer patients. SEGT’s effect on QoL is unclear but there are three studies treating metastatic Breast Cancer patients supporting SEGT’s effect on adjustment In 2004, we concluded that a variety of group to the disease. Three new studies tested the sur- treatments had small to moderate effects for vival advantage of SEGT (Goodwin et al., 2001; cancer patients on anxiety, depression and psy- Kissane et al., 2007; Spiegel et al., 2007) and the chological distress, and that phase of disease was collective results from 514 women is that there is Lambert c16.tex V1 - 10/08/2012 8:30pm Page 656 Criteria survival (4), coping (5), pain (4) coping (2), physical (1) social support (1) physical (1) functioning (3) support (2) coping/adjustment (2), physical (1) Effects Related to Different Outcome Age % Females Range Average Study Characteristics Sample Characteristics 89 44 8–24 12–24m 56–178 41–179 48–54 100 Distress (6), quality of life (4), 75 5060 15–29 2–9m 20 17–102 3–32 37–10783 50–56 2–6m ?? 25–116 100 25–77 0–35 53–54 Distress (4), quality 3–12m of life (2), 15–154 100 19–149 46–51 Distress (4), quality of life (3), 100 Distress (5), family 16.3 Efficacy and Effectiveness Research for Groups With Medical, Hospital, and Seriously Mentally Ill Patients ABLE Classen et al., 2001,et 2008; al. Giese-Davis 2002; Goodwin etet al., al., 2001; 2007; Kissane O’Brienet et al., al., 2007 2008; Spiegel Dolbeault et al., 2009; Hunter et al., 2009 Helgeson et al., 2001;Sherman, Hosaka et et al., al., 2010 2001; Kissane et al., 2003;Manne Lane et and al., Viney 2005, 2005; 2007 T BREAST CANCER Supportive-expressive group therapy Bordeleau et al. 2003; Butler et al., 2009; Cognitive Behavior Therapy Antoni et al., 2006; Cohen and Fried, 2007; Psychoeducational groups Fukui et al., 2000; Heiney et al., 2003; Related studies Andersen et al., 2004; Bultz et al., 2000; Study A C %RCT%ITT%AttrFollow-Up Lambert c16.tex V1 - 10/08/2012 8:30pm Page 657 (continues) self-harm (6), general psychiatric symptoms (4), depression (4), negative affect/emotion regulation (4), global function (3), quality of life (2), hopelessness (2), admissions (2), drug use (2) self-harm (4), general psychiatric symptoms (3), depression (2), social function (2), hospital admissions (2), quality of life (2), medication usage (2) function (5), general psychiatric symptoms (4), clinical indicators (4) 0 20 47–58 6–72m 40–47 49 32–35 65–79 Social function (5), global 78 22 0–39 4–12m 10–90 10–90 22–37 51–100 Suicide ideation/attempts (6), 33 44 16–38 3–96m 22–1244 19–60 27–49 47–100 Suicide attempts (4), illan et al., 2005; Turner,et 2000; al., van 2002; den Verheul Bosch et al., 2003 2008; Bos et al., 2010,2009; 2011; Gratz Farrell and Gunderson, etHarned al., 2006; et al., 2008;Huband Harvey et et al., al., 2007; 2010; KliemKoons et et al., al., 2001; 2010; 2006; Linehan McMain et al., et 2002, al., 2009; McQu Davies and Campling, 2003;Thomas, Hulbert 2007; and Karterud etPetersen al., et 2003; al., 2008;Warren Reisch et et al., al., 2004 2001; et al., 2003, 2004, 2006 PERSONALITY DISORDERS Outpatient Ben-Porath et al., 2004; Blum et al., 2002, Day Treatment Bateman and Fonagy, 2001, 2003, 2008; Inpatient Chiesa and Fonagy, 2000, 2003; Chiesa Lambert c16.tex V1 - 10/08/2012 8:30pm Page 658 Criteria symptoms/patient functioning (6), self-esteem (3), social anxiety (2), service utilization (2), social/living skills (3), QoL (3), neuropsychological functioning (1), social cognition (1) symptoms/patient functioning (3), service utilization (2), family burden/functioning (1), QoL (1) burden/functioning (2), psychopathological symptoms/patient functioning (1) Effects Related to Different Outcome Age % Females Range Average Supportive Expressive Group Treatment = Psychoeducational Group, SEGT = Study Characteristics Sample Characteristics 80 40 3–51 0–12m 7–124 20–116 26–41 19–54 Psychopathological 50 25 8–53 0–84m 24–44 24–28 31–43 30–66 Psychopathological Multifamily Group, PEG 100 60 2–25 0–12m 32–55 31–51 32–38 22–41 Service utilization (3), family = ): CBGT ( ): MFG ( : Cognitive Behavioral Group Therapy, MFG 16.3 Efficacy and Effectiveness Research for Groups With Medical, Hospital, and Seriously Mentally Ill Patients = ABLE 2005, 2010; Borras etet al. al., 2009; 2006, Granholm 2007, 2008,et al., 2009; 2000; Halperin KingsepKlingberg et al., et 2003; al., 2010;McCay Knight et et al., al., 2006; 2006; Roberts Patterson et et al., al., 2010 2006; Chien & Wong 2007; Haller et al., 2009 Hazel et al., 2004; McDonell2006 et al., 2003, T SCHIZOPHRENIA Cognitive-behavioral group therapy Barrowclough et al., 2006; Bechdolf et al., Bäuml et al., 2007; Burlingame et al., 2007; Psychoeducation Multifamily groups Chien and Chan, 2004; Dyck et al., 2002; Study %RCT %ITT %Attr Follow-Up A C CBCBGT Lambert c16.tex V1 - 10/08/2012 8:30pm Page 659

Evidence for Efficacy and Effectiveness of Group Treatment • 659 no evidence for this effect. The research team that poorly trained leaders led to suboptimal effects. replicated Spiegel, Kraemer, Bloom, and Got- Fukui et al. (2000) found no effects for depression theil’s (1989) survival effect (Fawzy et al., 1993) and anxiety but reported improvement on two used a shorter intervention with a different cancer QoL measures, as did Heiney et al. (2003) and population, and survival benefits were not main- Sherman et al. (2010). The uniform findings on tained at 10-year follow-up (Fawzy, Canada, & psychological distress suggests PEG’s efficacy Fawzy, 2003). In short, SEGT does not improve on this variable. There is promising but less survival and there are alternative explanations for definitive support for improvement in QoL. past findings to explain the discrepancies (Coyne, Eight related studies extend the above find- Hanisch, & Palmer, 2007). ings. Andersen and colleagues (2004) conducted Awoman’scoping with her illness (measured a RCT for early breast cancer with a two-phase with the Impact of Event Scale; IES; or the 26-session group intervention. The 4-month POMS) is enhanced by SEGT (Classen et al., intensive phase includes 18 weekly sessions focus- 2001; Giese-Davis et al., 2002; Kissane et al., ing on psychosocial interventions (relaxation, 2007; O’Brien, et al., 2008). There was however coping, social support) and health strategies (diet, noeffectsontheIESwithprimarybreastcancer exercise, adherence); the maintenance phase patients (Classen et al., 2008). Three studies involved monthly sessions. The intensive phase addressed effects of SEGT on pain management. led to reduced distress, improved immune func- Although all patients in Goodwin et al.’s (2001) tioning, better coping and health behavior, and study reported pain worsening as cancer pro- reduced risk of disease recurrence and death gressed, SEGT patients reported less worsening (Andersen et al., 2007, 2008). Two explanations than controls. Butler and colleagues (2009) found for improvement were offered: (1) those with a similar effect (only when they eliminated assess- the greatest reduction in distress and physical ments proximal to death), no effect was found symptoms practiced relaxation more frequently, with primary breast cancer patients (Classen et al., highlighting the link between daily stress and 2008). SEGT’s small effect on pain requires one health, and (2) higher levels of group cohesion to think in terms of less worsening rather than were related to change on psychological, behav- absolute reductions. ioral and physical health measures. Kissane et al.’s Three rigorous studies tested CBGT with (2003) 20-session cognitive-existential group early stage (I–II) breast cancer women between for early stage breast cancer reduced anxiety 50 and 56 years of age, participating in a closed and improved family functioning; experienced group lasting 6 to 10 sessions. The unanimity of psychologists emerged as more effective leaders. findings across eight self- and rater-completed Lane and Viney’s (2005) eight-session personal measures supports CBGT’s efficacy in reducing construct group with a similar population resulted psychological distress. There were mixed effects in greater improvement on anxiety, death anxi- on QoL (Cohen & Fried, 2007; Dolbeault et al., ety, depression, and hope measures. Two teams 2009), but improved coping and reduced stress (Bultz, Speca, Brasher, Geggie & Page, 2003; (Antoni et al., 2006; Cohen & Fried, 2007). Manne et al., 2005) studied PEGS for partners of Five studies tested psychoeducational groups breast cancer patients and showed improvement (PEG) with four using a model originating with on psychological distress, depression, wellbeing F. Fawzy and Fawzy (1994) with several mod- and marital satisfaction. ifications (e.g., PEG provided via telephone The results from all 23 studies (Table 16.3) conference call, Heiney et al., 2003). All but two did not vary by analysis and compared to our (Hosaka et al., 2001, and Sherman, Heard, & last review, studies were more rigorous, better Cavanagh, 2010) used a RCT design, with attri- powered, and produced more conclusive findings. tion ranging from 8% to 32%. A closed format The most reliable effect for SEGT, CBT, and (six to eight sessions) was used for women, age PEG was improved emotional distress; what is 26 to 65, with early breast cancer. Primary less clear are the conditions when this effect is effects included distress, QoL, and social support. not realized, although it may be related to the Uniform results across studies were shown for patient’s initial level of distress. Both SEGT and psychological distress (Fukui et al., 2000; Heiney CBT produced reliable increases in coping with et al., 2003; Hosaka et al. 2001). Helgeson, the illness, which was not seen in PEG. SEGT Cohen, Shulz, and Yasko’s study (2001) is note- groups may have an edge in improving life adjust- worthy because peer support groups facilitated by ment, although it is more costly. Finally, there is Lambert c16.tex V1 - 10/08/2012 8:30pm Page 660

660 • Chapter 16 / Change Mechanisms and Effectiveness of Small Group Treatments virtually no support for the conclusion that these Inpatient Groups group treatments extend life. In European health care systems, group ther- Promising developments include the moder- apy has always been a primary treatment for ator analysis by Manne et al. (2005) who showed psychotherapy inpatients. Groups are usually greater benefit on depression for women with delivered to mixed populations comprising affec- greater impairment and unsupportive partners. tive, anxiety, eating and personality disorders. There was a single study (Antoni et al., 2006) that The only systematic summary available in our experimentally separated the effect of information last review was a meta-analysis by Burlingame, from group effects finding group produced more Fuhriman, and Mosier (2003), concluding that = improvement on psychological distress (d .33 outpatient group ( = 0.55) outperformed inpa- = ES to .74) and coping (d .55) than information tient group therapy (ES = 0.20) when both were dissemination alone. Kissane et al.’s (2003) link compared to waitlist controls. One limitation between experience and outcomes underscores of this conclusion was that it rested on only 6 our previous conclusion and the protocol mod- inpatient studies. ifications based on culture are a promising step In a more recent meta-analysis, Kösters, toward accommodating diversity (e.g., Dolbeault Burlingame, Nachtigall, and Strauss’s (2006) esti- et al., 2009; Fukui, et al., 2000; Hosaka et al., mated the effectiveness of inpatient group therapy 2001). Finally, several studies (e.g., Bulz et al., based on 24 controlled and 46 effectiveness stud- 2000; Heiney et al., 2003; Lane & Viney, 2005) ies published between 1980 and 2005. Beneficial noted group processes as an important compo- effects for inpatient group emerged in controlled nent, but the size of effect associated with these studies (d = 0.31) as well as effectiveness studies processes is unknown. (d = 0.59). Greater improvement was exhibited in patients with affective and anxiety disorders Pain and Somatoform compared to samples of mixed, psychosomatic, Disorders PTSD or schizophrenic disorders. We did not locate any RCTs that were not Systematic reviews summarizing behavioral treat- included in the Kösters et al. (2006) meta-analytic ment for chronic pain concluded that study review. Instead, effectiveness studies suggested methodology was poor (only 25% of stud- that greater attendance in inpatient group psy- ies reached a threshold for high quality, e.g., chotherapy can improve inpatient outcomes van Tulder et al., 2001). In contrast to indi- (Page & Hooke, 2009) and that CBGT might vidual psychotherapy (mostly CBT), research be related to a reduction in readmissions as well on group treatment in this area is limited but as improvement in patients’ personal and work shows potential. satisfaction (Veltro et al., 2008). Other stud- RCTs dealing with irritable bowel syndrome ies have focused on process-outcome questions all indicate that CBGT is effective in reducing (e.g., Dinger & Schauenburg, 2010), or on the pain and psychological symptoms, as well as influence of specific patient characteristics on increasing quality of life (Blanchard et al., 2006). outcome (e.g., attachment, Strauss et al., 2006; CBGT is provided to patients with heterogeneous alexithymia, Spitzer, Siebel-Jürges, Barnow, chronic pain symptoms (e.g., White, Beecham, & Grabe, & Freyberger, 2005). Kirkwood, 2008) or specific pain (e.g., myofascial, Bogart et al., 2007; low-back, Lamb et al., 2010) Groups for Severe Mental Illness with positive effects on pain intensity, functional impairment, depression and anxiety. CBGT in Schizophrenia primary care also appears to be cost-effective In 2004 we described a large number of stud- (Lamb et al., 2010). On the other hand, a recent ies testing the efficacy of one of four models meta-analysis on CBT techniques for distress and for group treatment of schizophrenia: social pain in cancer patients concluded that individual skills (SS), psychoeducation (PEG), cognitive- was more effective than group treatment, both for information processing and cognitive-behavioral pain (d = .61 versus d = .20) and distress (d = .48 therapy (CBGT), as well as multi-family groups versus d =−.06). As innovative manualized (MFG). Over the past decade, 27 new studies group treatments for pain emerge (e.g., Nickel, either tested modifications to the above mod- Ademmer, Egle, 2010), we expect an increase of els or introduced innovative approaches (e.g., studies in the future. Motivational Group Interventions, Beebe et al., Lambert c16.tex V1 - 10/08/2012 8:30pm Page 661

Evidence for Efficacy and Effectiveness of Group Treatment • 661 2010; Adventure- and Recreation-Based Group parameters of service utilization (reduced rehos- Intervention, e.g., Voruganti et al., 2006; Group pitalizations/total days in hospital) as primary Programs Teaching Metacognitive Strategies, outcomes in pre–poststudies or studies compar- Roncone et al., 2004). ing PEG with standard care. Chien and Wong Table 16.3 summarizes 24 studies testing dif- (2007) found that a PEG targeting family mem- ferential effects of CBT approaches with a wide bers reduced family burden and also improved array of specific interventions (e.g., social skills patient functioning and reduced rehospitalization training, cognitive therapy, functional adaptation rates. Bäuml, Pitschel-Walz, Volz, Engel, and skills-training and cognitive restructuring), along Kissling (2007) examined the 7-year follow-up with PEG and MFG studies. Groups are typically outcomes for the Munich Psychosis Information closed with the number of sessions (8 to 45) and Project Study and noted higher survival rates treatment duration (2 to 24 months) varying as well as lower rates of rehospitalization and widely. Samples are heterogeneous on age and hospital days for the PEG when compared to the gender and consist predominantly of outpatient control group. This study is noteworthy since populations; inpatient studies are primarily from recent evidence suggests a 25-year reduction European settings (e.g., Klingberg et al., 2010). in expected life span for this clinical popula- There was a sizeable increase in CBGT tion (Parks, Svendsen, Singer, & Foti, 2006). studies (Lawrence, Bradshaw, & Mairs, 2006). Similarly, Haller et al. (2009) found that PEGs In contrast to our previous review, where most decreased psychotic symptoms and improved studies used the UCLA-Social and Independent QoL. Finally, Burlingame et al. (2007) found that Living Skills program or integrated psycholog- intense training of nurses in running PEGs was ical therapy, recent CBGT studies were much unrelated to symptom improvement, failing to more heterogeneous with regard to treatment replicate earlier work (Burlingame, Fuhriman, components, target populations, and outcomes. Paul, & Ogles, 1989). The majority were RCTs comparing CBGT We previously concluded that multi-family with standard care or other active treatments groups (MFG) à la McFarlane, Link, Dushay, (e.g., psychoeducation, social-skills training). Marcial, and Crilly (1995) produced equivalent Psychopathological symptoms were assessed as improvement in symptoms, social and vocational primary or secondary outcomes in most (10) functioning as well as treatment compliance studies, but these did not always change following when compared to single family therapies. Con- CBGT (e.g., Barrowclaugh et al., 2006; Bechdolf, sequently, MFG may be a more cost-efficient Köhn, Knost, Pukrop, & Klosterkötter, 2005). treatment with respect to primary outcomes Other effects included self-esteem (Barrow- and relapse rates, a vexing challenge with this clough et al., 2006; Borras et al., 2009; Knight, population. Interestingly, the number of new Wykes, Hayward, 2006), social anxiety (Halperin, MFG studies over the past decade decreased, Nathan, Drummond & Castle 2000; Kingsep with only five new studies found. All were RCTs et al., 2003) and cognition and coping (McCay comparing MFG with standard care (4) or PEG et al., 2006; Roberts, Penn, Labate, Margolis, & (1); results were mixed. Two (Dyck, Hendryx, Sterne, 2010), functional adaptation and skills Short, Voss, & McFarlane 2002; McDonell, training (Granholm et al., 2007; Patterson et al., Short, Berry, & Dyck, 2003, report a decrease 2006), and quality of life (Bechdolf et al., 2010; in rehospitalizations with a third (McDonell, Kingsep et al., 2003; Klingberg et al., 2010). Short, Hazel, Berry, & Dyck, 2006) reporting Granholm et al. (2006, 2007, 2008, 2009) a parallel increase in outpatient service which describe a series of studies for older persons partially offset cost-efficiency. As per previous (> 50 years) with schizophrenia, showing pos- research, patients in MFG groups did not differ in itive results for social and living skills as well symptom reduction with one exception (Chien & as neuropsychological functioning. One study Chan, 2004). Thus, while MFG produced compa- (Klingberg et al., 2010) focused on relapse pre- rable symptom and functioning improvement, it vention and reduction of rehospitalizations using appears to have an advantage for stress reduction, a complex CBGT program. CBGT successfully improved family functioning and reduced rates of lengthened time-to-relapse compared to standard rehospitalization (Hazel et al., 2004; McDonell, care but did not reduce rehospitalizations. Short, Berry, & Dyck, 2003). The four studies testing PEGs commonly Group treatment for schizophrenia has good used patient symptoms and/or functioning and to excellent support. CBGT was dominant and Lambert c16.tex V1 - 10/08/2012 8:30pm Page 662

662 • Chapter 16 / Change Mechanisms and Effectiveness of Small Group Treatments shown to be effective across a wide range of emotional states were demonstrated. The Kliem outcomes. MFG and PE studies have decreased et al. (2010) meta-analysis highlighted effects in number; the disappearance of traditional on suicidal and self-harm behaviors but noted verbal therapies for schizophrenics continues these are reduced when the comparison treat- (Burlingame et al., 2004). ment is also BPD-specific. McMain et al. (2009) showed that DBT versus psychiatric management Personality Disorders conducted in line with practice guidelines (Amer- Group interventions for patients diagnosed with ican Psychological Association [APA], 2001) had personality disorders (PDs) was an active area of equivalent effects for a majority of clinical out- research since our last review. Studies consistently comes. Verheul et al. (2003) observed that DBT targeted Borderline PD (BPD) and central prob- was especially effective for patients with a history lems of the disorder: suicidality, parasuicidality, of more frequent self-harm. depression, hopelessness, and hospitalization. The efficacy of DBT for BPD with comorbid Studies at each level of care primarily tested the SA was shown in two of three RCTs (Harned effectiveness of “treatment packages” comprising et al., 2008; Linehan et al., 2002; van den Bosch, multiple interventions. The outpatient orienta- Verheul, Schippers, & van den Brink, 2002) tion is uniformly cognitive-behavioral (CBT); although a third of patients failed to complete day treatment/residential and inpatient programs DBT. Recent adaptations include DBT for ado- combined CBT and psychodynamic approaches. lescent (Fleischhaker et al., 2011), community Outpatient dialectical behavior therapy mental health center (Comtois, Elwood, Hold- (DBT) received more attention than any other craft, Smith, & Simpson, 2007), and inpatient approach; studies were frequently RCTs. DBT groups (Bohus et al., 2004; Kleindienst et al., uses a skills-training group (2.5 hours/week for 2008; Kröger et al., 2006). the usual year of treatment) that complements Systems Training for Emotional Predictability twice-weekly individual therapy and telephone and Problem-Solving (STEPPS) was introduced coaching to address emotion regulation, distress in a pre-post study of the 20-week group for 52 tolerance, and interpersonal behavior. A disman- BPD patients (Blum, Pfohl, St. John, Monahan, & tling study did not find the group component Black, 2002). STEPPS consists of CBGT empha- effective when added to ongoing, non-DBT sizing skills training for emotion and behavior individual therapy (Koerner & Linehan, 2000), management and a PEG for key members of the but a recent RCT found a DBT group alone patient’s support network. The study noted a more effective than a dynamic group on reten- decline in BPD symptoms. Four rigorous trials tion, psychiatric symptoms, lability, and anger (Blum et al., 2008; Bos, van Wel, Appelo, & (Soler et al., 2009). Further study is needed to Berbraak, 2010, 2011; Harvey, Black, & Blum, establish if skills training can be effective on its 2010) showed strong effects on BPD symptoms, own, and if the three DBT components function global functioning and QoL. Bos et al. (2011) synergistically. showed that STEPPS benefited patients with Two lines of evidence supported DBT’s either a “subsyndromal” or full BPD diagnosis; effectiveness with BPD. First, a RCT of DBT deterioration was noted for 20% of TAU but versus community treatment by experts (CTBE) only 4% of STEPPS patients. Later studies offered a highly credible control that accounted used STEPPS as a primary treatment, reflecting for multiple therapist, treatment, and contex- confidence in the model, but a higher dropout tual factors (Linehan et al., 2006). Both DBT rate (21% to 36%) than TAU (11% to 26%) is and CTBE had effects on depressive symptoms, an issue. but DBT also impacted suicide attempts, crisis Small-scale RCTs of other treatments for or inpatient service use, and drop out. Second, PDs tested schema-focused (Farrell, Shaw, & a meta-analysis (Kliem, Kröger, & Kosfelder, Webber, 2009), acceptance-based (Gratz & 2010), four RCTs (Koons et al., 2001; McMain Gunderson, 2006), and problem-solving group et al., 2009; Turner, 2000; Verheul et al., 2003), therapy (Huband, McMurran, Evans, & Dug- and two pre–poststudies (Ben-Porath, Peter- gan, 2007). These studies recruited samples with son, & Smee, 2004; McQuillan et al., 2005) a high proportion of male BPD patients and conducted by independent researchers also sup- reported positive effects on BPD symptoms. ported DBT’s efficacy. Consistent effects on Several day treatment models for PDs have suicidal ideation, self-harm, or problematic been tested. The 18-month Mentalization-Based Lambert c16.tex V1 - 10/08/2012 8:30pm Page 663

Evidence for Efficacy and Effectiveness of Group Treatment • 663 Day Treatment (MBDT; Bateman & Fonagy, Harrison-Hall, 2002). The outpatient group 1999) was compared to TAU for 38 severe BPD appeared to help patients make the transition to patients and proved superior on self-harm, sui- the community while the one-stage program had cide attempts, health services use, and medication regressive effects following discharge. use. Results were maintained at 18-month and Two studies (Leirvåg, Pedersen, & Karterud, 8-year follow up (Bateman & Fonagy, 2001, 2010; Wilberg et al., 2003) evaluated different 2008). MBDT was associated with reductions in outpatient groups following intensive DT. The emergency room visits and admissions relative step-down approach for severe PDs makes clinical to TAU, with the savings offsetting the costs of sense—it appears to be critical to the success of MBDT itself (Bateman & Fonagy, 2003). All MBDT—but there remain issues with patient MBDT patients attended a weekly maintenance compliance and retention and as yet no definitive group after discharge, but only a third of TAU picture regarding treatment effects. patients sought similar therapy. Four pre-post and two naturalistic clinical trials (Peterson et al., 2008; Warren, Evans, Group Versus Individual Dolan, & Norton, 2004) evaluated traditional The comparative effectiveness of the group versus day treatment (DT) programs. Samples involved individual format was extensively reviewed. We a range of PDs with BPD predominant. Karterud concluded that the collective evidence would et al. (2003) is notable for recruiting 8 DT “strongly support the no difference conclusion in programs and over 1,200 patients. Programs the aggregate but is weak with respect to format reflected a cognitive orientation (Reisch, Thom- by diagnosis interactions” (Burlingame et al., men, Tschacher, & Hirsbrunner, 2001) or, more 2004, p. 652). During the past 10 years, several commonly, a package of cognitive, dynamic, and meta-analyses have been published that dealt with process groups. These studies used a diverse array specific diagnoses. In addition, we found 23 single of outcome measures, but demonstrated sub- studies comparing the two formats related to a stantial effects on psychiatric symptoms, hospital wide variety of target problems. admissions, social functioning and QoL. The “no difference conclusion” is more Inpatient settings also featured applications or less confirmed for mood disorders (Baines, of group treatment. The Cassel Hospital study Joseph, & Jindal, 2004; Cuijpers, van Straten, targeted a mixed PD sample (predominantly Andersson, & van Oppen, 2008; Lockwood, BPD). Using a naturalistic trial design, a one- Page, & Conroy-Hiller, 2004a; Roselló, Bernal, & stage, 12-month analytically-informed inpatient Rivera-Medina, 2008), panic disorders (Sharp milieu, plus twice-weekly individual therapy, et al., 2004), personality disorders (Arnevik was contrasted with a two-stage “step-down” et al., 2009; Kelly, Nur, Tyrer, Casey, 2009), program involving 6 months of inpatient treat- schizophrenia (Lockwood, Page, & Conroy- ment followed by 12 to 18 months of outpatient Hiller, 2004b), and eating disorders (Chenet al., dynamic group therapy and 6 months of outreach 2003; Nevonen & Broberg, 2006). Exceptions nursing (Chiesa & Fonagy, 2000, 2003). Prema- occur including Nevonen and Broberg’s (2006) ture terminations were frequent in both inpatient finding at 1-year follow-up that effects on most groups (47%) but the rate of early dropout was measures were larger for individual. Renjilian higher for the one-stage program. Both pro- et al. (2001) reported that CBGT was more grams outperformed TAU (medication and case effective than individual CBT for weight loss in management in the community) on measures of BED patients, but the formats proved equiva- social functioning, global functioning, psychiatric lent regarding symptom improvement; patient symptoms, and clinical indicators. There was preference for either treatment had no impact. greater benefit in the two-stage program with Equivalence was also shown for substance related differences maintained at 24-month follow-up. disorders: One study (Panas, Caspi, Fournier, & Twice as many two-stage patients showed reliable McCarty, 2003) used archival data (n > 7,000 and clinically significant change at 24 (Chiesa, cases) and showed an increased likelihood of Fonagy, Holmes, & Drahorad, 2004) and 72- treatment completion and goal achievement for month follow-up (Chiesa, Fonagy, & Holmes, patients treated “heavily” in groups (i.e. > 2/3 of 2006). Costs were offset by reduced health and sessions in groups). Of course this finding was social service use in the year after treatment ter- not based on random assignment. John, Veltrup, mination (Chiesa, Fonagy, Holmes, Drahorad, & Driessen, Wetterling, & Dilling (2003) tested a Lambert c16.tex V1 - 10/08/2012 8:30pm Page 664

664 • Chapter 16 / Change Mechanisms and Effectiveness of Small Group Treatments motivational intervention provided as individual Bonne, 2004), but economic advantages for group counseling or as a 2-week group program and are constant. noted differences, but these disappeared at 12- Two teams went beyond the prosaic acknowl- month follow-up with equivalence on the primary edgement of the group’s cost-effectiveness by outcome of abstinence. The Sobell, Sobell, and employing distinct methods to estimate cost and Agrawal (2009) study randomly assigned alcohol effectiveness. Otto Pollack, and Maki (2000) and drug dependent patients to short-term indi- compared group, individual, and psychophar- vidual versus group treatment (4 sessions) with macology costs for patients treated for panic equivalent outcomes but an economic advantage disorder. Absolute costs ranked group lowest for group (41.4% less therapist time). ($523) followed by individual ($1,357) and medi- The picture is less clear with social phobia, cation ($2,305). Using clinician ratings, group was where reviewers come to contradictory conclu- found to be most cost effective ($246), followed sions noting advantages of individual therapy by medication and individual therapy ($447 and on effect sizes and attrition rates (Aderka, 2009; $565, respectively). Roberge, Marchand, Rein- Stangier et al., 2003) or equivalence (Powers harz, and Savard (2008) compared 14-session et al., 2008). Similarly, contradictory results were individual and group treatments with a brief found for trauma-related disorders (advantages 7-session individual CBT that did not include in of individual treatment for political prisoners vivo exposure for patients with panic disorder, on suffering from PTSD, Salo, Punamäi, Qouta, & a composite index made up of six panic, anxiety, Sarraj, 2008; equivalence or economic advantages and depression measures. Absolute costs ranked of group treatment for childhood sexual abuse the brief approach as lowest ($154) followed by survivors, Ryan et al., 2005; McCrone et al., group and standard individual therapy ($249 2005). and $376, respectively). However, when cost- Among the OCD studies, format equivalence effectiveness was included in the equation, group has been shown on YBOCS and depression mea- was more effective and somewhat less costly while sures (Anderson & Rees, 2007; Jaurrieta et al., the brief individual therapy was less costly and 2008; O’Leary, Barrett, & Fjermestad, 2009). slightly less effective. Interestingly, in one study superior outcomes for individual were reported in the completer General Conclusions Regarding analysis but equivalence in the ITT analyses, Effectiveness underscoring the importance of both types of We have summarized more than 250 studies analysis (Jaurrieta et al., 2008). A recent study that estimated the efficacy and/or effectiveness (Belloch et al., 2011) showed comparable effects of group therapy for 12 disorders/patient pop- on depression and tendencies to worry. Individual ulations (Tables 16.1 to 16.3). Taken together, treatment was more effective than group treat- the last decade of research demonstrated greater ment in decreasing dysfunctional beliefs and the rigor and continued to provide clear support for use of suppression as a thought control strategy. group treatment with good or excellent evidence Nevertheless, coupling these findings with Fals- for most disorders reviewed (panic, social phobia, Stewart et al. (1993), we find sufficient evidence to OCD, eating disorders, substance abuse, trauma- conclude format equivalence. O’Connor and col- related disorders, breast cancer, schizophrenia, leagues (2005) findings contradict this conclusion and personality disorders) and promising for but their results are based on nine group mem- others (mood, pain/somatoform, inpatient). bers, liberally analyzed (i.e., completer-analysis) Comparisons of different models often produced with a high refusal rate. Most studies calculated equivalent outcomes and, when differences were the economic advantage of group at a 3:1 to 5:1 shown, they were small; thus, the clinician has Q3 savings (cf. Jonsson & Hougaard, 2008). choice. Although there may be some disorders From the remaining studies, the majority where the individual format seems more promis- support the equivalence hypothesis (Bastien et al., ing (e.g., specific trauma-related disorders), for- 2004; Rose, O’Brien, & Rose, 2009; Shechtman, mat equivalence is convincingly supported, as are 2004; Turner-Stokes et al., 2003). One study the economic advantages. Indeed, there are now indicates an advantage for group (related to cop- empirically derived cost-effectiveness estimates ing with HIV infections; Heckman et al., 2011) supporting group over individual treatment. while another supports the individual format in a Several new trends emerged. There is an mixed clinical sample (Bachar, Canetti, Yonah, & increasing number of dismantling studies testing Lambert c16.tex V1 - 10/08/2012 8:30pm Page 665

Evidence for Efficacy and Effectiveness of Group Treatment • 665 whether theorized treatment mechanisms indeed Promising Developments explain change (e.g., mood, social phobia, and There have been several noteworthy devel- OCD). In some instances they did not, lead- opments over the past decade. Some advance ing investigators to explain change by common research noted in our last review while others effects, that is, group properties and processes. reflect new developments. We briefly summarize Once again, the bulk of research tested the this research by the five sources in Figure 16.1. efficacy of specific formal change theories, predominantly CBT, but also interpersonal (breast Formal Change Theories: Treatment cancer), psychodynamic (personality, eating dis- Integration orders), and integrated models. Protocols were An interesting trend is the integration of hereto- tested for their feasibility and transportability into fore “competing” approaches (e.g., CBGT + clinical practice (e.g., social phobia and panic), dynamic or IPT) for the treatment of certain providing the clinician with an empirical gauge disorders (e.g., trauma and ED). Clinicians treat- on their likely impact. We saw an increased focus ing these disorders are dealing with complex on groups for relapse prevention in populations conditions and integrating multiple treatments is that suffer from high relapse rates (e.g., bipolar an attempt to address several effects. In a related and schizophrenia), as well as models transferred manner, evidence-based treatment models shown to adolescent populations to attenuate or prevent efficacious for specific disorders are being applied an illness (e.g., social phobia and substance). to new disorders. For example, DBT, originally Several studies refined past efficacious protocols developed to treat BPD, is increasingly and to see if a more intense yet smaller dose led to successfully applied to BED (e.g., Safer, Robin- similar outcomes; results were mixed. Patient son, & Jo, 2010; Telch, Agras, & Linehan, 2000, change is now a topic of study with sudden gains 2001), shifting the theory behind treatment from showing different patterns by disorder (e.g., distorted beliefs/attitudes to emotion regulation. MDD, panic, social phobia). This has relevance for practitioners who track patient change using Structure: Mixed Group Composition sensitive outcome measures. A reality for many clinicians is the difficulty Despite these positive developments, im- composing diagnostically homogeneous groups. provements are needed. Greater consistency in Previously, we noted a single RCT that targeted the outcomes assessed would increase compa- a diagnostically heterogeneous group and praised rability across studies. We attempt to highlight it on clinical relevance. Several studies have this challenge in the effects column of the advanced this cause by examining the effects of tables because, fundamentally, clarity regarding mixed diagnosis (MD) groups for mood and anxiety expected effects is what the practitioner and client (Lorentzen, Ruud, Baldwin, & Hoglend, 2011; need. Fortunately, with some disorders (YBOCS McEvoy & Nathan, 2007; Rief, TrenKamp, in OCD, LSAS in social phobia), standard mea- Auer, & Fichter, 2000), anxiety and posttrau- sures of outcome have been established that matic stress (Dunn et al., 2007), mixed anxiety facilitate the aggregation of results. Methodolog- (social phobia, generalized, OCD and panic) ically, most studies are still using liberal completer and co-occurring disorders (trauma and sub- analyses. We read several studies where results stance use). Results were invariably positive; for were reversed when ITT analyses were applied. example, Norton and Hope (2005), and Norton As we noted last time, only a few teams addressed and Whittal (2004) showed that patients suf- within-group dependency effects and power, both fering from either social phobia (48%) or panic of which are essential to derive unambiguous con- disorder (42%) had equivalent improvement in clusions. Baldwin, Murray, and Shadish (2005; general anxiety (d = 1.06). Similar results were Baldwin, Stice, & Rohde, 2008) have empirically posted by Erickson, Janeck, and Tallman (2007), demonstrated that a small (.05) level of group Lumpkin, Silverman, Weems, Markham, and dependency and/or not analytically nesting mem- Kurtines (2002) and van Ingen et al. (2009). bers within groups leads to a predictable inflation Lorentzen and colleagues showed no differential of Type I error. This means our group studies may benefit between short- and long-term analytic be declaring significant effects when none exists. group treatment, although results were moder- Given that these effects were unaddressed in most ated by the presence of a personality disorder. studies, the above effectiveness conclusions are Studies of group interventions for mixed eating likely inflated; we just don’t know how much. disorder (MED) samples have also encompassed Lambert c16.tex V1 - 10/08/2012 8:30pm Page 666

666 • Chapter 16 / Change Mechanisms and Effectiveness of Small Group Treatments all levels of care (outpatient, day treatment, telephone call to increase module completion inpatient) and were weighted more toward eval- (Carlbring, et al., 2007). A large average effect uative than hypothesis-driven research (Newns, size on social phobia symptoms resulted when Bell, & Thomas, 2003; Rø, Martinsen, Hoffart, & compared to waitlist (ES = .95, range .39–1.3); Rosenvinge, 2003). Generally, studies integrated 93% completed all modules. Next, ICBT was CBGT with other approaches for mixed ED with tested with and without a five-session group promising results. However, only two provided exposure (Tillfors et al., 2008) with both condi- a control condition (Crafti, 2002; Kong, 2005), tions producing similar improvements (ES = 1); making causal inferences premature. definitive conclusions are difficult because nearly 40% failed to attend a single exposure session. Patient Characteristics: Focus on Finally, ICBT for panic disorder was contrasted Attachment Styles with traditional CBGT (Bergström et al., 2010) with equivalent outcomes and costs favouring As in other treatment formats, constructs from ICBT over traditional CBGT at a 1:4 ratio. attachment theory play an increasing role in was examined in the group literature (Markin & Marmarosh, Synchronous online treatment a naturalistic study (Golkaramnay, Bauer, Haug, 2010; Strauss, 2012). Existing studies provide Wolf, & Kordy, 2007) using real-time chat rooms evidence that attachment functions as a predictor composed of 8 to 10 members lasting 12 to 15 of outcome in group psychotherapy (e.g., Strauss weeks following inpatient care. Low dropout et al., 2006) and as a mediator/moderator of (9%) and high attendance rates (85%) with cohesion, group climate (e.g., Kirchmann et al., small gains on symptom distress and well-being 2009), interpersonal perceptions (Mallinckrodt & resulted ( = .27–.32). Subsequent research Chen, 2004), and self-disclosure (Shechtman & ES confirmed that treatment gains were maintained Rybko, 2004). There are an increasing number (Haug, Sedway, & Kordy, 2008; Haug, Strauss, of studies focusing on attachment to the therapy Gallas, & Kordy, 2008) and recent research using measures of group avoidance and group (Bauer, Wolf, Haug, & Kordy, 2011) found group dependency (e.g., Marmarosh et al., 2006). lower relapse rates compared to controls. Other Studies from social psychology addressing the studies focused on PTSD (Morland et al., 2010), relationship between attachment and processes in depression (Houston, Cooper, & Ford, 2002), nonclinical groups have been recently reviewed or body dissatisfaction and disordered eating (Mikulincer & Shaver, 2007). (Heinicke, Paxton, McLean, & Wertheim, 2007); all of these posted reliable improvements. Lieber- Leader: “Virtual Leaders” man, Wizlenberg, Golant, and Di Minno (2005) and Online Groups examined heterogeneous versus homogeneous Research is now evaluating the augmentation of internet support groups for patients suffering existing group treatments through technology, from Parkinson’s disease, showing homogenous that is, online modes of delivery. Group treat- groups were significantly more committed and ment has been combined and contrasted with posted better depression outcomes. A Dutch both asynchronous (e.g., email from therapist) study compared asynchronous and synchronous and synchronous contact (e.g., real time). The treatment (Blankers, Koeter, & Schippers, 2011) most thorough testing of asynchronous therapy using a three-arm RCT to test a self-guided ICBT was conducted by a Swedish team that developed approach that included motivational interviewing a nine-module web-delivered program (ICBT) (MI) for problematic alcohol drinkers. Using the for social phobia. The first RCT tested ICBT same manual, the self-guided ICBT was com- combined with two live exposure group sessions. pared to a synchronous seven-session 40-minute Large improvements in social phobia symp- chat group or waitlist control. All groups showed toms resulted, compared to a waitlist control a reduction in alcohol consumption and the two (ES = .87); however, nearly half failed to attend active treatments outperformed the waitlist but both exposure sessions (Andersson et al., 2006). at 6-month follow-up the synchronous condition ICBT was then tested without group exposure showed a greater reduction in consumption; and produced similar results (Carlbring, Furmark, effect sizes were modest. We see this study as an Steczko, Ekselius, & Andersson 2006), calling into exciting advancement for online treatment and question the value of group exposure. Next, ICBT encourage future research to explore differential was tested with and without a 10-minute weekly outcomes of online approaches. Lambert c16.tex V1 - 10/08/2012 8:30pm Page 667

Understanding Group-Level Mechanisms of Change • 667 Small Group Process: Attempts to demonstrated good criterion validity with well- Integrate Relationship Constructs known German relationship measures studies One of the more exciting developments over (Bormann, Burlingame & Strauss, 2011). Finally, the past decade is the conceptual clarity that has Thayer (2012) replicated Krogel’s factor analysis resulted from studies of the therapeutic relation- with 219 group members drawn from 65 groups ship in groups. Previously, we offered a set of conducted at four U.S. university counseling instruments “as a ‘beginning’ process assessment centers and demonstrated good criterion validity battery” (Burlingame et al., 2004, p. 679) to with the original measures used by Johnson et al. address the lack of conceptual and measurement (2005), to create the GQ. Most recently, the GQ clarity regarding the therapeutic relationship in subscales have been linked to leader interventions, groups. Our measurement proposal was tested providing clinicians with evidence-based action and refined in a series of studies from Europe steps to improve the therapeutic relationship in and North America. The first study (Johnson, groups (Burlingame et al., 2011). Burlingame, Davies, & Gleave, 2005) estimated the conceptual and empirical overlap of four com- UNDERSTANDING monly used cohesion, climate, working alliance and empathy measures by having 662 members GROUP-LEVEL MECHANISMS of 111 counseling center and personal growth OF CHANGE groups complete a copy of each. A 2-dimensional model resulted with the quality of relationship After reviewing group effectiveness across 12 dis- defined by three factors (positive bond , positive orders and populations we’ve offered conclusions work ,andnegative relationship)andthestruc- regarding specific outcomes being causally linked ture of relationship defined by two commonly to specific models. In other cases, outcomes accepted facets (member-to-member and member- were linked to unspecified group properties by to-leader). Bormann and Strauss (2007) replicated study authors. Defining these unspecified group and extended the Johnson et al. (2005) model properties has been a challenge for past review- by collecting identical data from members of 67 ers. To illustrate, we’ve noted that cohesion, inpatient psychodynamic groups drawn from 15 a ubiquitous group property, is assessed by no German and Swiss hospitals. The three factors of fewer than 23 measures (Burlingame et al., 2011). the quality dimension were replicated but a third This lack of clarity has led some to introduce structure factor emerged (member-to-group). new group properties and discard old ill-defined Next, a Norwegian team (Bakali, Baldwin, & ones (Hornsey, Dwyer, Oei, & Dingle, 2009). Lorentzen, 2009) replicated the Bormann and Our previous response (Burlingame et al., 2004) Strauss (2007) model with members from 1- and was to highlight research programs that carefully 2-year outpatient analytic groups, and found defined and tested these group properties. While that strong member-leader structure eclipsed useful, such research tends to be highly specific member-member and member-group structures and takes decades to develop. Conclusions are in the early sessions of the group. often too narrow for clinicians to apply broadly The robust factor structure from four distinct in their practice. In this section we provide an group populations (personal growth, counseling alternative. center, outpatient analytic and inpatient psycho- The organizational scheme shown in dynamic) and countries was sufficiently promising Figure 16.2 is an expansion of the small group pro- to develop a 40-item Group Questionnaire (GQ) cess and structure domains found in Figure 16.1. using two criteria: (1) empirical fit with the It identifies distinct group properties and aforementioned model and (2) content linked to processes that have been extensively studied specific group interventions to address relation- (Burlingame, Strauss, Bormann, & Johnson, ship problems (cf. Burlingame, McClendon, & 2008). Indeed, entire chapters have been devoted Alonso, 2011). Krogel (2009) replicated the to summarizing the research on single com- model using the GQ with 485 members drawn ponents such as cohesion (cf. Burlingame et al., from three group populations (personal growth, 2011). The model is based on Berne’s (1966) anal- counseling center, and state psychiatric hospital), ogy that knowledge of group dynamics for a group finding that 30 items were sufficient. A recent leader is as essential as knowledge of physiology study replicated Krogel’s (2009) work with 438 for a physician. Living organisms are composed inpatient psychodynamic group members and of anatomical form and physiological functions. Lambert c16.tex V1 - 10/08/2012 8:30pm Page 668

668 • Chapter 16 / Change Mechanisms and Effectiveness of Small Group Treatments

Group Structure—Anatomy Group as vehicle of change

Emergent Structure: Imposed Structure: - Group development - Pre-group preparation - Subgroups - Early formatting - Norms - Composition - Member selection

Formal Patient Change Group and Theory Properties Therapist Factors and Processes

Foundational Social Emergent Processes: Processes: - Reciprocal role functioning - Therapeutic factors - Conformity, power, and conflict - Interpersonal feedback - Performance - Self-disclosure - Decision making - Cohesion-climate - Leader style–characteristics - Leader interventions - Social identity theory

Group Processes—Physiology Interpersonal exchange as mechanism of change

FIGURE 16.2 Group structure—Anatomy.

Anatomical structure often sets limits on physi- Anatomy of a Group—Structure ological function. Likewise, our model identiﬁes In our model, anatomy refers to the form of the form (structure) and function (processes) of a group (Figure 16.2) and relates to leader small groups. We believe it is essential for group actions that create the group—imposed struc- leaders to be knowledgeable about group form ture. Similarly, member actions can also affect and function. Too many RCTs end with authors form—emergent structure. The components of speculating that unaccounted for outcome vari- imposed structure range from (a) how a leader ance might be explained by group properties. selects (b) and prepares group members before While we acknowledged the likelihood that many and in (c) early group sessions to (d) how they group investigators do not come from a group compose the group. Pregroup preparation and dynamic identity, we believe future progress must structure have sufﬁcient empirical depth to pro- include measures of well-known group proper- duce evidence-based guidelines; the interested ties to at least rule them in or out as potential reader is referred to past handbook chapters. mechanisms of change. Such research would also Expertise in group dynamics is not required positively impact clinical practice; see Burlingame to recognize that all groups develop a unique et al. (2008) for more detailed description. “personality.” Emergent structure describes how Lambert c16.tex V1 - 10/08/2012 8:30pm Page 669

Understanding Group-Level Mechanisms of Change • 669 this personality is formed with three constructs: abuse (Women’s Recovery Group) relative to a development, subgroups, and norms. Most the- mixed-gender treatment (Group Drug Coun- ories of group development describe it as an seling), but only among women having greater emergent property of closed groups that reflects symptom severity. temporal patterns of work and climate. Norms are More complex composition effects based on formal and informal rules that develop in the first the proportional representation of certain patient sessions while subgroups form more gradually variables were also studied. Wade and Gold- over time. We highlight a single component of man (2006) examined the gender composition each type of structure. of 2-week, 6-hour groups aimed at promoting forgiveness of actions by others that members Imposed Structure— Composition felt were harmful (e.g., relationship break-up, The impact of group composition has been a abuse). As the proportion of men in the group presence in the clinical literature for decades. increased, women showed greater declines in The accepted principle that “the therapist strives the desire for revenge while men became less for maximum heterogeneity in the clients’ conflict empathic towards their offender. We highlighted areas and pattern of coping, and at the same time Piper and colleagues’ work on composition in strives for homogeneity of the clients’ degree our last chapter because they had identified an of vulnerability and capacity to tolerate anxiety” interaction between an aptitude (quality of object (Yalom & Leszcz, 2005, pp. 272–273) is counter- relations—QOR) reflecting interpersonal matu- balanced by limited empirical findings over the rity and type of treatment (interpretive versus past decade. Two meta-analyses (Ang & Hughes, supportive groups; Piper, McCallum, Joyce, 2001; Burlingame, Fuhriman, & Mosier, 2003) Rosie, & Ogrodniczuk, 2001). More recently, identified heterogeneous group composition, Piper, Ogrodniczuk, Joyce, Weideman, and Rosie based on problem focus or gender, respectively, (2007) composed groups using the QOR variable; as more effective. The former summarized 18 homogeneous groups were predicted to out- studies of social-skills groups for antisocial youth perform heterogeneous groups but this was not and found mixed groups (combined anti- and supported. Instead, the proportion of high-QOR prosocial youth) produced more improvement at patients predicted better outcomes for all mem- posttreatment (d = .70 versus .55) and follow-up bers, regardless of a member’s QOR or the treat- (d = .46 versus .30). Similarly, Burlingame et al. ment approach. These studies raise the intriguing (2003) concluded that mixed-gender groups were question of the optimal proportion (men, high- more effective than single-gender groups, relative QOR patients) needed to maximize outcomes. to wait-list controls (d = .66 versus .40). Shecht- The diversity of findings regarding com- man, Goldberg, and Cariani (2008) varied the position suggests that there is no simple rule to ethnic composition of counselor trainee groups follow, requiring group leaders to be conversant in Israel and found that Arab students in ethni- with relevant research findings. Gender provides cally heterogeneous groups demonstrated greater a good example: For certain topics (e.g., shared engagement, more disclosure, and less regret traumatic experience, gender-specific issues), after disclosure than their Arab counterparts in homogeneity can be a boon, but for others (e.g., homogeneous groups. relational problems with the opposite gender) In counterpoint, three studies demonstrated heterogeneity would be preferred. Patients’ needs greater effectiveness for homogeneous groups. and deficits and the group’s purpose and focus The Burlingame et al. (2003) meta-analysis iden- are important elements of the context, and there tified groups homogeneous for problem focus as are likely additional parameters that require more effective than heterogeneous groups, rela- consideration in order to facilitate composition tive to wait-list controls (d = .56 versus .25) and in effects. terms of pre-post change (d = .82 versus .42). In Lieberman et al.’s (2005) aforementioned study Emergent Structure—Group of online support groups for Parkinson’s disorder Development patients, homogeneous groups demonstrated Group development posits that closed groups greater improvement than heterogeneous groups pass through recognizable temporal stages that on depression and symptom severity. Greenfield affect work and emotional climate. Recent reviews et al. (2008) demonstrated greater effectiveness (Johnson, Burlingame, Strauss, & Bormann, 2008; for a women-only group treatment for substance McClendon & Burlingame, 2011b) argue that our Lambert c16.tex V1 - 10/08/2012 8:30pm Page 670

670 • Chapter 16 / Change Mechanisms and Effectiveness of Small Group Treatments empirical knowledge rests upon use of MacKen- Physiology of a Group— Emergent zie’s Group Climate Questionniare (GCQ; and Foundational Processes MacKenzie, 1983) and this trend continued over Physiology reflects function and we’ve argued that the past decade. Two studies tested MacKenzie’s group function is best articulated by considering (1994) stage model of group development with the member interaction as a primary mechanism of GCQ in CBGT versus IPT groups for inpatients change (Burlingame et al., 2008). The five com- with eating disorders (Tasca, Balfour, et al., 2006) ponents in emergent processes describe empirically or social phobia (Bonsaksen, Borge, Sexton, et al., tested member/leader interactions (interpersonal 2011). The Engagement subscale captures affec- feedback, self-disclosure, leader interventions) tive group bonds and is commonly regarded as an or byproducts (cohesion and therapeutic fac- indicator of cohesion. Both studies documented a tors) that have been linked to outcome. The linear increase in CBGT but a fluctuating (Tasca, six foundational social processes reflect social and Balfour, et al., 2006) or linear decline (Bonsake- organizational psychology principles that have sen et al., 2011) in the interpersonal-dynamic relevance to group treatment. We highlight a few group. Tasca et al. (2006) suggest the fluctuations relevant findings to raise reader awareness. captured an alliance rupture-repair cycle while Bonsakesen et al. (2011) ascribed the decline to Emergent Processes—Cohesion a focal shift from intra- to extra-group relation- As noted earlier, greater clarity has been achieved ships. The high-low-high pattern described by in measuring the group therapeutic relationship, MacKenzie (1994) was not supported. The Con- but what about the relationship between cohesion flict subscale reflects the level of distrust, anger, and outcome? Heretofore, two challenges with and friction in the group with a low-high-low the construct of cohesion have created active sequence expected. Tasca et al. (2006) reported debate on what we can conclude: (1) some studies a linear decrease in both groups; Bonsakesen empirically link cohesion with outcome while et al. (2011) found support for the phasic pattern others do not, and (2) the sheer number of mea- in both groups but only after the removal of sures makes it impossible to know what is meant extreme outlier scores (7.5% of the sample). The when a writer uses the construct. We believe the Avoidance subscale reflects members’ efforts to findings of a recent meta-analysis address both conform to perceived expectations. Tasca, Bal- challenges (Burlingame et al., 2011). four, et al. (2006) reported stability throughout A weighted and significant aggregate cor- the IPT and a linear decrease in CBGT; Bonsake- relation between cohesion and outcome of r = sen et al. (2011) found no temporal changes in .25 (95% confidence range of .17–.32; a medium either group. Finally, both studies found that lin- effect) was estimated from 40 studies published ear growth in Engagement, a group-level effect, between 1969 and 2009. A high level of hetero- was associated with individual-level treatment geneity was present, necessitating a moderator outcome (see also Ogrodniczuk & Piper, 2003; analysis; 5 moderators were detected. Interper- Ryum, Hagen, Nordahl, Vogul, & Stiles, 2009). sonal groups posted the highest relationship (r = These studies, while limited in number, .58) followed by psychodynamic (r = .25) and agree with past research (cf. Johnson et al., 2008; CBT (r = .18); but all coefficients were signifi- McClendon & Burlingame, 2011) and suggest cant. Groups with five to nine members posted that characteristics of the patient (diagnosis), a stronger relationship (r = .35) than smaller or treatment approach (focus on skills-training larger groups (r = .16), groups of more than 12 versus interpersonal process), setting (outpa- sessions posted a stronger relationship (r = .36) tient, inpatient), and possibly culture (North than those of 12 or fewer sessions (r = .18), and American versus Scandinavian) may influence groups emphasizing member interaction, irre- patterns of group development in complex ways. spective of orientation, posted a higher cohesion- In turn, there is evidence that group climate can outcome relationship than those with a problem- mediate the impact of therapist intentions and specific focus (r = .38 and r = .21, respectively). interventions on eventual outcome (Kivlighan & Finally, groups composed of younger members Tarrant, 2001). Attention to moderators of the had a higher cohesion-outcome relationship (r = group developmental sequence and the impact −.63). Interestingly, the cohesion-outcome rela- on outcome are worthy aims for further research tionship varied by measure (.04–.58) but most and critical for practitioners to be aware of to defined cohesion by the positive bond between effectively harness group-level mechanisms. the member and group. The overall conclusion Lambert c16.tex V1 - 10/08/2012 8:30pm Page 671

Understanding Group-Level Mechanisms of Change • 671 is that cohesion predicts outcome across the most conceptual and empirical understanding of clini- common theoretical orientations and that the size cal groups in the theories and empirical literature of this relationship varies by measure; further, of social and organizational psychology. moderators may exist that suggest specific leader actions (e.g., group size and member interaction). Becoming an Evidence-Based Group Foundational Social Psychological Practitioner Processes We end by sharing our view of an evidence-based group leader. Our context is important; we oper- The last component attends to the impressive ate in an era of accountability with evidence-based array of studies conducted by social and organiza- practice (EBP) being a fundamental component tional psychologists. The components delineated of contemporary mental health care worldwide represent a subset of the available basic science (McClendon & Burlingame, 2011a). This context and field research studies that focus upon small can generate substantial clinician resistance since group functioning. We encourage group clini- it can be experienced as interfering with profes- cians to become acquainted with the foundational sional autonomy. As Kobos and Lescsz (2012) theories and findings by consulting excellent pointed out, three vectors of evidence-based textbooks (e.g., Forsyth, 2010). In these texts, con- practice have been articulated: structs such as entitativity (Yzerbyt, Corneille, & Judd, 2004) capture member perception of 1. The use of empirically supported therapies “groupness,” a potential barometer for when a (ESTs; APA, 2006). therapist should increase the importance given to 2. Practice-based evidence and the acquisition of group properties in their treatment groups. ongoing data regarding patients in treatment Emergent social psychological processes via standardized measures. such as conformity, power, and the management 3. The use of clinical practice guidelines. of conflict are relevant to clinical groups. For example, ample direction is available in models Several sections of this chapter report on RCTs related to conflict development, escalation and that test group ESTs for specific disorders, reveal- resolution (e.g., Lewicki, Saunders, & Barry, ing a solid foundation of support. Two major 2006). All groups, including treatment groups, initiatives of the American Group Psychother- have specific goals and there is an impressive apy Association (AGPA) during the past decade literature on group performance and decision specifically addressed the latter two vectors; making that has not been translated to the field of namely the revision of the AGPA CORE Battery psychotherapy. For example, some social psychol- (Burlingame et al., 2006; Strauss, Burlingame, & ogy studies give guidance on increasing member Bormann, 2008) and the publication of clinical involvement to reduce social loafing (DeMatteo, practice guidelines (CPGs) that synthesize the Eby, & Sundstrom, 1998). The organizational best available research evidence, coupled with psychology literature provides a wide range of clinical expert consensus (Bernard et al., 2008). theories and research on leader style such as sit- Each is briefly described. uational leadership theory (Hersey, Blanchard, & In the early 1980s, the AGPA sponsored Johnson, 2001). This theory assumes that an the development and dissemination of a CORE effective leader must display at least four different Battery consisting of outcome instruments com- leadership styles as groups move though different monly used in group research and shown to be phases, that is, directing, coaching, supporting, sensitive to change. The aim of the CORE was or delegating. The theory fits well with models to assist practitioner-members in evaluating the of process-related leadership in groups. Finally, effectiveness of their groups and to augment clin- how and to what extent members identify with ical perception (MacKenzie & Dies, 1982). A task their group (social identity theory) is a critical force to expand and revise the CORE was created consideration regarding emergent structure and in 2003 and produced a revised CORE Battery group process. It is still an incompletely answered consisting of three types of measures: (1) group question about which factors (e.g., categorization, selection and principles for starting a group, identification) transform group membership into (2) group-level processes, and (3) outcomes. The a social (group-related) identity. As we have stated measures were selected by an international task elsewhere (Fuhriman & Burlingame, 1994), there force based on their psychometric soundness and is an enormous potential for improving our ability to assist group leaders at all stages of their Lambert c16.tex V1 - 10/08/2012 8:30pm Page 672

672 • Chapter 16 / Change Mechanisms and Effectiveness of Small Group Treatments TABLE 16.4 Summary of Measures and Handouts in CORE-R (Strauss et al., 2008) Section Material/Method Group selection and Pregroup Handouts for group leaders and members preparation Presenting group therapy to clients How to get the most out of group therapy Information regarding group therapy Group conﬁdentiality agreement Methods for group selection Group Therapy Questionnaire (GTQ) Group Selection Questionnaire (GSQ) Process measures Primary assessment tools: Group Questionnaire* Working Alliance Inventory (WAI) Other assessment tools: Empathy Scale (ES) The Group Climate Questionnaire-Short Form (GCQ-S) Therapeutic Factors Inventory Cohesiveness Scale (TFI) Cohesion to the Therapist Scale (CTS) Critical Incidents Questionnaire (CI) Outcome measures Primary assessment tools: Outcome Questionnaire-45 (OQ-45) Youth Outcome Questionnaire (Y-OQ) Other assessment tools: Inventory of Interpersonal Problems (IIP-32) Group Evaluation Scale (GES) Rosenberg Self-Esteem Scale (SES) Target Complaints Scale (TCS) * Not included in the CORE-R manual but derived from recommended measures (see promising development section on group process).

TABLE 16.5 Key Domains of Practice Guidelines for Group Psychotherapy (Kobos & Leszcz, 2008) 1. Creating Successful Therapy Groups (client referrals, administrative collaboration) 2. Therapeutic Factors and Therapeutic Mechanisms (change mechanisms, group cohesion) 3. Selection of Clients (inclusion/exclusion, composition of groups, instruments) 4. Preparation and Pregroup Training (objectives, methods, procedures, impact and beneﬁts) 5. Group Development (models, developmental stages) 6. Group Process (social system, group as a whole, subgroups and splits, roles) 7. Therapist Interventions (different functions, transparency) 8. Reducing Adverse Outcomes and the Ethical Practice of Group Psychotherapy 9. Concurrent Therapies 10. Termination of Group Psychotherapy

group work. Table 16.4 provides an overview AGPA also impaneled a Science to Service of the recommended material and methods for task force composed of notable group practi- each section. A very recent application of these tioners, educators, and researchers to develop recommendations in clinical practice is provided evidence-based Clinical Practice Guidelines by Jensen and colleagues (2012). (CPG; Klein, 2008; Leszcz & Kobos, 2008). A Lambert c16.tex V1 - 10/08/2012 8:30pm Page 673

References • 673

FIGURE 16.3 Resources support evidence-based group treatment.

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Queries in Chapter 16 Q1. Please specify which Jaurrieta et al. 2008 is being cited Q2. AU: Please specify which Jaurrieta et al. 2008 is being cited Q3. AU: Please specify which Jaurrieta et al. 2008 is being cited Q4. AU: Please add Kaminer 2005 to text