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Cognitive Behavioral Therapy in Groups: In-Depth Study

Introduction

Cognitive-behavioral therapy (CBT) is an approach to therapy that is especially focused on outcomes, problem-solving, and the use of evidence-based solutions. The present paper is dedicated to an in-depth study of CBT as applied to groups. Here, the key concepts of CBT, as well as its strengths and limitations, will be outlined. The evidence from ten peer-reviewed high-quality studies will also be summarized to make comments about the approach’s effectiveness. Furthermore, the most significant aspects of a CBT group will be considered, including the roles of the leader and members, the goals and tasks of CBT, CBT techniques and methods, and CBT group processes and evolution. The analysis will be used to demonstrate that CBT is among the evidence-based approaches that can be effective as a group therapy intervention if used appropriately; in turn, the appropriate use of CBT amounts to taking into account the specifics of a CBT group which will be discussed in this paper in detail.

Key Concepts

CBT is concerned predominantly with examining ineffective or unhelpful behavioral or thought patterns. In his studies of depression, Aaron Temkin Beck laid out the foundation for CBT in the form of behavior therapy when he discovered cognitive distortions in depressed people (Corey, 2016). His reasoning was that dysfunctional beliefs could be altered, thus alleviating the condition. This idea was eventually supported by evidence, and over the years, CBT has been evidenced to be effective with many other disorders as well (Hvenegaard et al., 2019; Yorke et al., 2017). Nowadays, CBT can be defined through its key features as a problem-focused and evidence-based therapy that uses a set of techniques, which focus on determining and correcting problem behaviors and cognitions, and measurably tracks an individual’s progress toward identifying and attaining individual goals (Corey, 2016; Sharf, 2016). These specific features do not just define CBT; they can be considered its primary strengths.

Strengths

As can be seen, from Corey’s (2016) analysis, the above-mentioned features of CBT can be viewed as strengths. Thus, it is apparent that a focus on evidence-based therapy is a major advantage; this approach increases the likelihood of CBT using effective techniques. Furthermore, the precision of CBT, which is reflected in its emphasis on planning, goals, and measurable outcomes, results in well-structured, specific interventions that can be directed at resolving a particular problem (Sharf, 2016). In addition, the evaluation supported by CBT extends beyond individual patients, groups, or programs; rather, CBT methods are continually assessed and improved through evidence-based solutions (Corey, 2016). Therefore, CBT is an approach that is going to be continually enhanced because of its emphasis on research and evaluation.

Corey (2016) also views the consideration of maladaptive, ineffective, and harmful cognitive, behavioral, and emotional patterns as a particularly positive feature of CBT that has originated specifically within this therapeutic approach. However, the author notes that CBT is fairly integrative; it has been adopting ideas, techniques, and principles from other approaches as well. An example, according to Corey (2016), is the humanistic features of CBT, which include, for instance, the setting of personalized goals by the group members for themselves. Conversely, CBT ideas, principles, and techniques can be employed by therapists who focus on other approaches to group therapy (Corey, 2016). This way, the structured and goal-driven strengths of CBT can be enjoyed in non-CBT groups, and CBT ones can practice the evidence-based techniques developed by other therapy methods.

Weaknesses

When discussing the weaknesses of CBT, Corey (2016) seems to mostly present its features that, when used to an unreasonable extent, may become detrimental. Thus, the CBT structure has been described as its strength, but Corey (2016) points out that excessive structure is more likely to be problematic. In other words, the structure may foster the focus on problems or techniques, but it can become inflexible and prevent group members from meeting their individual needs. Instead, Corey (2016) suggests, behaviors and their analysis should be at the core of CBT since their understanding is what guarantees their correction. Similarly, Corey (2016) emphasizes the importance of a group leader is familiar with CBT and its methods, pointing out the value of using CBT correctly. However, Corey (2016) does mention the potential challenge of balancing the attention to the internal and external factors of behavior, indicating that a CBT therapist should not focus on the internal causes for behavior only. Overall, this description of primary CBT weaknesses demonstrates that CBT needs to be employed with care by a leader who is familiar with its assets.

Another challenge that can be encountered during group CBT is multicultural sensitivity. As pointed out by Sharf (2016), cultural factors can technically become a reason for the development of ineffective beliefs or behavioral patterns, but when discussing these concerns, it is necessary to ensure an appropriate level of cultural sensitivity. It is essential to respect the experiences and opinions of group members while encouraging certain reflections on the latter (Corey, 2016; Sharf, 2016). As demonstrated by Hooper, Antoni, Okuyemi, Dietz, and Resnicow (2017), this challenge is not insurmountable, though, and culturally-sensitive CBT programs are evidenced to have positive effects.

Finally, there are limitations to the research dedicated to CBT. While CBT is markedly evidence-based, a number of issues remain unexplored or have only some limited data to inform their solutions (Pozza & Dèttore, 2017). Furthermore, there appears to have been a tendency toward the investigation of particular disorders and effective treatments for them, which left other fields of CBT application less well-researched (Sharf, 2016). For example, according to Sharf (2016), the above-described topic of multiculturalism is one of such under-investigated areas. Thus, CBT is not without limitations, as well as issues and challenges that a therapist needs to take into account when starting a CBT group.

Some Trends in Modern CBT Groups

It should be pointed out that CBT is also a still-developing approach to therapy, and some of its more recent versions are becoming more popular. Thus, while, as pointed out by Sharf (2016), CBT has been traditionally used for psychiatric issues, it is not limited to them. A common example of a CBT that does not directly target a health problem is social skills training, which aims to teach members to communicate effectively through the means of CBT (Corey, 2016). Similarly, CBT groups that exist for stress management training can be used by people with or without psychiatric difficulties (Corey, 2016; Sharf, 2016). As for a particularly recent but increasingly popular version of CBT, mindfulness and acceptance approaches can be mentioned. The general idea of such CBT groups consists of employing a more extensive understanding of psychological health that centers around self-awareness and acceptance of one’s problems, experiences, and other events (Sharf, 2016). In general, CBT is a growing and developing the method of group therapy, but the present paper will discuss its common techniques and processes without a particular focus on an individual approach.

Group CBT Evidence

Since CBT is explicitly focused on being evidence-based, which remains its major advantage, a review of relevant literature can justify its application. Here, ten peer-reviewed articles that were published within the past five years will be briefly considered. These articles contain the highest levels of evidence because they present the results of either randomized controlled trials or meta-analyses. In addition, they are dedicated specifically to group CBT, which is why they were chosen for this paper.

The review of the ten articles implies the following conclusions about the efficacy of CBT. First, CBT can apparently be used for people of different ages. Thus, Pityaratstian et al. (2015) demonstrated the effectiveness of a CBT program applied to children, but, for instance, Hooper et al. (2017) worked with adults. Furthermore, researchers involved people with different ethnic backgrounds and from different countries. For example, the study by Pityaratstian et al. (2015) took place in Thailand, and Hooper et al. (2017) focused on a culturally appropriate program for African Americans. Thus, CBT can be used in different contexts if it is adjusted to the needs of a specific population.

Secondly, CBT has been evidenced to be an effective solution to multiple different conditions. Thus, Bodryzlova, Audet, Bergeron, and O’Connor (2019) showed the effect of such interventions on hoarding disorder, Hooper et al. (2017) worked with substance abuse, and Hvenegaard et al. (2019) and Yorke et al. (2017) investigated anxiety and depressive disorders. Also, Pityaratstian et al. (2015) studied PTSD, and Pozza and Dèttore (2017) considered an obsessive-compulsive disorder.

The latter article is particularly interesting due to its focus on comparing group and individual CBT in combating the disorder. Being a meta-analysis, the study concluded that the evidence on the topic was not sufficiently extensive for definite statements, but at least, the existing data suggested that the two approaches are roughly comparable in their effectiveness. In a similar way, Hvenegaard et al. (2019) contrasted two different approaches to group CBT and indicated that they were alike in the long run, although one of them (a rumination-focused version) demonstrated superior initial results. These data show that the research on CBT is very active as new approaches are being tested in comparison with other treatments or no treatments and as new meta-analyses are providing more comprehensive assessments. Also, these articles establish the effectiveness of group CBT in treating various disorders, lending credibility to this approach to therapy.

Thirdly, CBT has been used to address issues that are not necessarily psychiatric disorders. An example of an unhelpful cognitive pattern being managed through CBT was presented by Handley, Egan, Kane, and Rees (2015) who focused on perfectionism. As pointed out by the authors, perfectionism could be associated with multiple disorders, and the study showed that CBT could help to resolve it. Similarly, Cape, Leibowitz, Whittington, Espie, and Pilling (2016) worked with people who had insomnia because of various health issues and showed that CBT had a positive effect on their condition. Overall, CBT appears to be capable of resolving multiple issues.

It should be noted that positive effects are not always shown by such studies. For instance, Berk et al. (2018) and Langdon et al. (2016) tested the effect of CBT on weight gain in people with obesity and diabetes and anxiety in people with Asperger syndrome respectively. Both studies failed to demonstrate any statistically significant outcomes in the measured variables, suggesting that the interventions from these articles were not effective.

The presented summary of the most recent peer-reviewed works can be used to make the following conclusions. First, as an approach that is very invested in the use of evidence-based methods, CBT is relatively well-studied, and this feature is also applicable to group CBT. However, the presence of literature on the topic does not imply that there are no blank spots in the field. Rather, as shown by Pozza and Dèttore (2017), when specific methods or populations are considered, more investigation may be required for conclusive statements. In addition, there are articles that report no noticeable improvements associated with CBT. It should be taken into account that they cover particular approaches and programs, which is why these data cannot be used to claim that CBT is ineffective. Instead, these articles are testimony to the intent of CBT researchers and practitioners to test their interventions and preserve only the ones that reliably show their effectiveness.

CBT in Groups

The Role of the Group Leader

As pointed out by Corey (2016), the role of a leader is central to CBT groups; after all, it is a rather structured approach, and the person who provides and maintains this structure is the leader. As a result, CBT leaders need to demonstrate the knowledge and skills related to the group process and CBT techniques (particularly coaching and cognitive restructuring), as well as correspond to any intervention-specific requirements (Corey, 2016; Sharf, 2016). Social skills are also a distinct asset, as well as the abilities related to planning and decision making because a leader is supposed to help members in performing the planned change (Corey, 2016). The significance of cultural competence has been mentioned as well (Hooper et al., 2017). Given that the primary weakness of CBT is CBT done incorrectly, these skills highlight the crucial role of a CBT leader.

In addition, as shown by Corey (2016), one of the specific features of CBT leaders is them being role models and coaches. Role modeling is needed since a part of CBT consists of observations of others’ behaviors and thinking patterns, and coaching presupposes reinforcing or discouraging particular behaviors as required. Since CBT is predominantly educational, these roles of a CBT group leader are also noteworthy and further emphasize the importance of this position for a group’s success.

Roles of Group Members

As was mentioned, CBT is commonly rather humanistic in its active engagement of participants, which should lead to their empowerment. As a result, the roles of group members in CBT are also noteworthy. Thus, group members are very actively involved in the establishment of the goals that they are supposed to achieve over the course of the therapy. A leader is definitely a part of the process and helps them to articulate effective, measurable, and achievable goals, but the input of members is crucial for planning in CBT. The activities that can help to achieve this outcome include problem articulation and analysis, as well as solution brainstorming; in the end, the member is expected to decide on their therapeutic plans (Corey, 2016). Therefore, members make the most important decisions in a CBT group.

In addition to that, an active engagement throughout the group process is required from the members; this prerequisite is necessary for learning. Some of the activities can be performed individually, for example, homework. In addition to that, self-reflection and self-management are considered important for CBT, especially for its effects to remain present after the end of the therapy (Corey, 2016; Sharf, 2016). While the group leader may help an individual to learn how to exercise self-control, the role of a member in ensuring it is crucial. Finally, just like a leader is typically viewed as a role model, individual group members can also become such models that other members can observe (Corey, 2016). In general, the cooperation and engagement of participants is a crucial aspect of a successful CBT group, and while it is to be ensured by the leader, the role of the members is still extremely significant.

Key Developmental Tasks and Therapeutic Goals

The developmental tasks and goals of CBT are connected to its specific features and focus. Thus, CBT consists of rectifying inappropriate, ineffective, and harmful ways of thinking and acting (Corey, 2016; Sharf, 2016). As a result, the working stage is typically concerned with the tasks of analyzing one’s thought and behavior patterns (through self-reflection) and setting goals that would enable their improvement. In addition, CBT is problem-focused, which is why the solution of particular issues (for instance, anger management) may become a goal (Corey, 2016). Finally, as demonstrated by the currently popular approaches to CBT, skills acquisition is also a common developmental task for a CBT member. Overall, the tasks and goals of CBT are determined by the specific features that are described above, including the focus on problem-solving, education, and the improvement of cognition and behaviors.

Techniques and Methods

As can be seen from the information presented above, the techniques and methods of a CBT group are very diverse and may range from those meant for skill acquisition to those related to mindfulness. However, there are certain general approaches used in group CBT that are worth mentioning. The most obvious one that is related to the name of this type of therapy is cognitive restructuring (Corey, 2016; Sharf, 2016). Simply put, it refers to the process of examining and rectifying unhelpful or harmful cognitive patterns (such as beliefs and ideas); an example would be perfectionism (Handley et al., 2015). Also, as it has been mentioned, CBT does address behaviors, and one of the ways of achieving this outcome is behavior rehearsal. These activities involve practicing a helpful behavior, which makes them especially well-suited for group settings where multiple participants can be engaged in the process (Corey, 2016). In addition to that, observation is another way in which group members are supposed to learn during CBT, and modeling is the technique that relies on this mechanism. Modeling, according to Corey (2016), consists of observing and repeating the behaviors that are deemed more productive than the ones that a participant already has.

As a learning-focused type of therapy, CBT also is associated with coaching, which is concerned with providing the help and scaffolding that are needed for acquiring new information, skills, or behaviors. Furthermore, homework is a CBT tool; it usually aims to put one’s CBT lessons to use (Corey, 2016). In addition, the role of the leader as a teacher presupposes providing feedback, reinforcing positive behaviors, and encouraging self-reflection. Finally, CBT is particularly well-suited for short-term, brief intervention, which is also a specific feature of its methods (Corey, 2016; Sharf, 2016). In summary, despite the complexity and diversity of group CBT, its key characteristic techniques can be determined.

Group Evolution

Here, the approach to the evolution of CBT groups that was described by Corey (2016) will be considered. The stages that are typical for CBT groups are similar to the general group process described by Corey (2016); basically, the groups are initiated during the initial stage, perform the necessary work during the working stage, and are finalized during the final stage. As highlighted by Corey (2016), the initial stage consists of forming the group and ensuring the orientation of its members, as well as their trust and the group’s cohesion. The leader’s role is central here since he or she needs to teach the members to be a cohesive and productive group. On the other hand, during the working stage, every member needs to contribute as the group establishes its plans and engages in the above-described techniques, as well as more specific activities, meant to achieve the desired goals. Therefore, both leaders and members have instrumental roles during the second stage.

Finally, as the group’s time runs out, the leader’s role becomes central once again because they should provide the necessary feedback, prepare the members to finish the therapy and encourage them to maintain the improved patterns that they have learned. The emphasis on self-management and self-control becomes prominent during the final stage. In addition, the leader is supposed to evaluate the work of the group and plan for follow-ups during it. Thus, the evolution of a CBT group is similar to other groups, although it can be considered especially structured and goal-driven.

Conclusions

The present paper aimed to provide an in-depth analysis of the application of CBT to groups with a focus on the group processes and roles, as well as techniques and specific features of CBT. Based on the findings, the following conclusions can be made. First, CBT is defined by its primary strengths, which include the focus on evidence-based and structured interventions. The fact that CBT is centered around evaluation can improve individual CBT programs and groups, as well as the various approaches that exist within CBT as they are tested more and more rigorously for effectiveness. Due to the interest in evidence-based studies, there is a lot of research on CBT, although certain of its aspects still require more investigation. However, CBT is shown to be effective with groups in resolving rather diverse problems, which is a major advantage.

The disadvantages and challenges of CBT can be connected to the lack of research on some topics, but mostly they are concerned with CBT being done incorrectly. As a result, it is important to consider CBT groups and their specifics. Thus, because of its structured nature, the CBT leader is an important part of a group who is supposed to provide the guidance and learning needed by the members. However, the members’ engagement is crucial as well; they are the ones to make the most important decisions about their therapy. Their goals are typically concerned with resolving specific problems, and the techniques of CBT are determined by these goals and CBT’s focus on learning and cognitive restructuring. The three stages of CBT groups further cement their structure and ensure that the members’ orientation, work, and follow-ups are scheduled as appropriate. To summarize, CBT is a well-established group therapy method, and the knowledge of its specifics is required for any therapist who is interested in applying it or its elements.

References

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Bodryzlova, Y., Audet, J., Bergeron, K., & O’Connor, K. (2019). Group cognitive‐behavioural therapy for hoarding disorder: Systematic review and meta‐analysis. Health & Social Care in the Community, 27(3), 517-530.

Cape, J., Leibowitz, J., Whittington, C., Espie, C., & Pilling, S. (2016). Group cognitive behavioural treatment for insomnia in primary care: A randomized controlled trial. Psychological Medicine, 46(5), 1015-1025.

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Handley, A., Egan, S., Kane, R., & Rees, C. (2015). A randomised controlled trial of group cognitive behavioural therapy for perfectionism. Behaviour Research and Therapy, 68, 37-47.

Hooper, M., Antoni, M., Okuyemi, K., Dietz, N., & Resnicow, K. (2017). Randomized controlled trial of group-based culturally specific cognitive behavioral therapy among African American smokers. Nicotine & Tobacco Research, 19(1), 333–341.

Hvenegaard, M., Moeller, S. B., Poulsen, S., Gondan, M., Grafton, B., Austin, S. F.,… Watkins, E. R. (2019). Group rumination-focused cognitive-behavioural therapy (CBT) v. group CBT for depression: Phase II trial. Psychological Medicine, 1-9.

Langdon, P. E., Murphy, G. H., Shepstone, L., Wilson, E. C., Fowler, D., Heavens, D.,… Mullineaux, L. (2016). The People with Asperger syndrome and anxiety disorders (PAsSA) trial: A pilot multicentre, single-blind randomised trial of group cognitive–behavioural therapy. Bjpsych Open, 2(2), 179-186.

Pityaratstian, N., Piyasil, V., Ketumarn, P., Sitdhiraksa, N., Ularntinon, S., & Pariwatcharakul, P. (2015). Randomized controlled trial of group cognitive behavioural therapy for post-traumatic stress disorder in children and adolescents exposed to tsunami in Thailand. Behavioural and Cognitive Psychotherapy, 43(5), 549-561.

Pozza, A., & Dèttore, D. (2017). Drop-out and efficacy of group versus individual cognitive behavioural therapy: What works best for Obsessive-Compulsive Disorder? A systematic review and meta-analysis of direct comparisons. Psychiatry Research, 258, 24-36.

Sharf, R. (2016). Theories of counseling and psychotherapy: Concepts and cases (6th ed.). New York, NY: Cengage Learning.

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OctoStudy. "Cognitive Behavioral Therapy in Groups: In-Depth Study." July 15, 2022. https://octostudy.com/cognitive-behavioral-therapy-in-groups-in-depth-study/.

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OctoStudy. 2022. "Cognitive Behavioral Therapy in Groups: In-Depth Study." July 15, 2022. https://octostudy.com/cognitive-behavioral-therapy-in-groups-in-depth-study/.

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OctoStudy. (2022) 'Cognitive Behavioral Therapy in Groups: In-Depth Study'. 15 July.

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