Group Interventions A Manager’s Dream But A Clients….?

As the pandemic recedes and concerns about scarcity of individual therapy continues, there are likely to be increased calls for group interventions, whether psychoeducational or psychotherapeutic.  But the vexed question has to be asked, does the particular group intervention envisaged make a real world difference to client’s life? Is the group intervention more to do with appearing to have done something? 

There are protocols for depression and the anxiety disorders described in my book Simply Effective Group CBT (2011) London: Routledge.

The content for the group sessions I detailed in the book can be downloaded by clicking the link below:

https://www.dropbox.com/s/ys0ogfo3k93qmwb/Ptsd%20Group%20treatments%202018.pdf?dl=0

But I have a number of concerns about the utilisation of group interventions in the IAPT-ification of psychological therapy services. There is a danger of spin with regards to group CBT. This can happen easily by taking the abstracts of studies at face value, when many of the authors have developed the protocols that they are evaluating – allegiance bias. I doubt whether, despite the best efforts of any training institution, there will be a monitoring of fidelity to evidence-based protocols and a meaningful assessment of outcome. In practice clients may be short-changed by Group CBT and may then be put off further therapy. Whilst the group interventions may be intended as part of a stepped care package, clients are least likely to attend the appointment that marks the start of the new dawn [ Davis et al (2020)https://doi.org/10.1136/ebmental-2019-300133].  The following critique of group studies may be useful:

1. Group psychoeducation interventions have an appeal that belies evidence of their effectiveness. I can find no study in which there has been independent assessment of effectiveness using a standardised diagnostic interview. Thus it is not known what proportion of sufferers with a particular disorder would lose their diagnostic status as a result of treatment, much less how enduring recovery would be. ‘No longer suffering from a disorder’ is a metric that a member of the public can readily understand, but to be told that you no longer require treatment because you are now below ‘caseness’ on a psychometric test is likely to produce a puzzlement, that the client is too polite or disadvantaged to challenge.
2. It may be to the advantage of Managers  and Academic institutions to promote psychoeducational groups but to the pay-off for the client is what? The experience of group involvement may not be adverse, they may have even enjoyed the sense of belonging that has come from group attendance, but if at the end of the day it has not made a real world difference to the client’s life, was it worthwhile? The issue of group psychoeducation has to be approached from a bottom-up perspective not top-down.  Ost (2008) Outcome studies Quality Ost 2008  has published a 22 item measure of the reliability of psychotherapy outcome studies, each item is rated 0-2, so that a score of 44 is possible. Applying this measure to the most popularly delivered psychoeducation group Stress Control, I found yielded a score of 9, but the mean score in CBT outcome studies was 28 and Ost suggested that studies with scores of 19 or below could not be considered empirically supported treatments. Failings of the recent SC studies (the original White et al study fared slightly better because it specified a particular diagnosis, GAD) included amongst others the following domains: reliability of the diagnosis, specificity of outcome measure, blind evaluation, assessor training, design, assessment points, controlling for concomitant treatment, and assessment of clinical significance.

3. In a paper titled “Are individual and group treatments equally effective in the treatment of depression in adults? Cuijpers et al answered with a cautious ‘yes’. They drew upon my own study [ Scott and Stradling (1990)https://doi.org/10.1017/S014134730001795X ] comparing individual and group CBT with a waiting list, but did not mention that in order to get the group CBT to be a viable entity, we had to offer up to 3 individual sessions concurrently, though interestingly few took up all three.  Selling the group CBT was a challenge, however both modalities were equally effective and I think Cuijpers et al’s conclusion is appropriate. 

4. In 2018 carpenter et al published https://doi.org/10.1002/da.22728 a study of the efficacy of CBT for anxiety disorders. They considered only studies in which the comparison condition was a psychological placebo e.g supportive counselling i.e one in which there is a credible rationale, this controls for common factors such as the therapeutic alliance. Carpenter et al found only 7 studies comparing individual and group CBT with these provisos, and for only 2 disorders social anxiety disorder and PTSD was their sufficient data to reach conclusions and in both instances individual CBT was superior to group CBT.

But in 2020 Barkowski et al Group CBT for anxety dsorders 2020 published a meta analyses of group psychotherapy and claimed that group psychotherapy  for anxiety disorders  is more effective than active treatment controls.  They cite a Hedges g effect size of 0.29. But these authors fail to point that this effect size is small. A Hedges g of 0.2 would mean that the average person in the largely CBT groups would have done better than 58% of those in the control condition. Whether these differences are clinically significant is a matter of debate. Further only 3 anxiety disorders were considered GAD, panic disorder and social anxiety disorder, the results do not apply to OCD or PTSD (which historically was placed in the anxiety disorders but now no longer is). The authors proclaim that mixed-diagnoses groups are equally effective as diagnostic specific groups. But this is misleading, the most recently published group trans diagnostic study by Roberge et al (2020) Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clini had approx half of clients (52.8%) suffering from generalised anxiety disorder and approx a third (29.4%) suffering from social anxiety disorder, thus over 80% of the clients are suffering primarily from either one or the other of just 2 disorders, more accurately it should be termed limited transdiagnostic therapy.  Further clients were recruited via newspaper advertisements, 86% of the clients were women and 42% had a University Diploma, only half of clients were completers i.e attended 8 or more of the treatment sessions, and only half lost their principal diagnosis.  Making generalising from these studies problematic.

The danger is that group devotees look simply at the abstracts of the group studies, without realising that the authors were the developers of the protocols and their findings need taking with a great deal of caution. My worry is that IAPT in particular will seize on groups as a way forward in a numbers game and clients will be short changed.

Dr Mike Scott