Cognitive behavioral group therapy for anxiety: recent developments

Abstract

Anxiety disorders occur frequently, and can have a negative impact on the quality of people's lives. They often begin at an early age and can have some serious consequences. This article is an overview of the recent studies concerning group cognitive-behavioral interventions for anxiety disorders. In the last few years, anxiety disorder prevention for children and adolescents has become an important focus of research work. Group prevention programs are based on standard cognitive behavioral therapy (CBT) strategies and are aimed at preventing anxiety disorders as early as possible. Numerous cognitive behavioral group therapies for children as well as adults have been well studied. There are many CBT protocols that have been developed for treating specific anxiety disorders. Now, specialized CBT programs are available for individuals who suffer from different anxiety disorders, enabling them to be treated together in groups.

Anxiety and cognitive behavioral therapy

Anxiety disorders are currently one of the most common types of disorders in the general population.^1-3 They are classified into different disorders (eg, panic disorder with or without agoraphobia, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, specific phobia, post-traumatic stress disorder), which share similar characteristics of fear and excessive anxiety, and lead to behavioral disturbances.¹ These disorders often have a substantial impact on peoples' daily lives.^4-6 Furthermore, anxiety disorders are characterized by high comorbidity along with other mental disorders (eg, mood, substance-abuse, or personality disorders).⁷ Research has shown the effectiveness of cognitive behavioral therapy (CBT) in the treatment of anxiety disorders.^8-12 CBT is a practical and structured form of psychotherapy. Several different strategies and techniques are used to understand and manage the cognitive, behavioral, and physiological components of anxiety.^13,14 Each patient benefits from a thorough assessment that is systemically carried out at the beginning of his or her therapy, so that individualized treatment plans can be put into action and goals can be set.

Next, the therapist provides the patient with information on how to deal with anxiety by using psychoeducation. When the patient has a good understanding about his or her anxiety, he or she can start to learn new skills to manage the symptoms better. Different techniques such as strategies of relaxation, cognitive restructuring, and exposure can be used. Throughout the treatment there is a constant evaluation performed. The therapist can then adapt the therapy more effectively to the patient's needs, characteristics, and anxiety level. CBT interventions are based upon a collection of scientific research. They are often offered individually, but can also be offered in groups, which can have some real advantages. First, therapists can work with more people in one session than with individual treatments. Second, many participants find it helpful to meet others who live with similar difficulties; they can help each other and share their experiences. For individuals with social fears, group formats can provide social exposure opportunities.¹³ Nevertheless, there can be some disadvantages to group models. When following a program with complete strangers, each patient must be willing to share personal experiences and fears, and be able to express him- or herself freely. Group interventions may also be less practical because of differing schedules, and therefore may not be convenient for everyone. Managing groups requires a certain know-how and organization. Therapists must keep in mind the characteristics of the participants, because these characteristics may affect the group atmosphere and cohesion. It is also important to have an interactive and lively group, rather than a classroom atmosphere.¹³

In general there exist two types of intervention groups: preventive and treatment. These have continued to develop, and have led to several different models.

Group-based prevention programs

The impact of anxiety on the daily lives of children and adolescents is very high, and therefore research has been oriented towards developing anxiety prevention programs.¹⁵ These programs are normally proposed at an early stage, while the symptoms are still at a subclinical stage, and before the onset of rigid response patterns. These programs can therefore have a significant impact on general incidence reduction of anxiety disorders.^16,17 The meta-analytic review carried out by Fisak et al in 2011¹⁵ was aimed at providing a complete review of child and adolescent group prevention programs and their effectiveness. The authors describe two types of preventive programs, “targeted programs” and “universal programs.” These targeted programs were concentrated on individuals who were at high risk of having anxiety disorders and of children who had already presented anxiety symptoms but had not really fulfilled the criteria for a specific DSM-IV anxiety disorder. The universal prevention programs can be offered to the general population with or without specific risk factors, and can be integrated easily into the school system. The results of the meta-analytic review indicated that the anxiety prevention programs seem to be a promising strategy for reducing anxiety disorder incidence rates. For example, the FRIENDS program is a well-studied school-based universal prevention program using cognitive and behavioral strategies.^18,19 It can be used as a preventive or treatment program and is often used for children between approximately 8 and 11 years old.^20,21 It consists of 10 weekly sessions, two parents' sessions, and two optional booster sessions. Parent sessions consisted mainly of psychoeducation. Recent studies have evaluated the efficiency of this school-based program of children aged between 9 and 12 years old. The results indicate a significant reduction of anxiety symptoms up to 12 months after the intervention.^22,23

Group-based treatment programs

Several studies have evaluated the effectiveness of CBT group programs in the treatment of anxiety disorders.^24-26 Manual-based treatments proposed to individuals or groups have an equal effectiveness in the reduction of anxiety symptoms in children.^21,27,28 CBT group-based programs are extensively studied for several reasons. Group models may offer more positive peer modeling opportunities, reinforcement, and social support. They are also a convenient option with regard to the limited availability of child-focused CBT therapists.^21,14 Child and adolescent group programs are aimed at treating one specific, already existing anxiety disorder.^29,30 However, most of these programs were created to treat several disorders together in the same group. The Coping Cat program³¹ has been the most evaluated CBT program for treating children. It is a 16-week program intended for children between 8 and 17 years old, and can be used as a group program.²⁷ The first eight sessions are centered around the basic CBT concepts. During the following eight sessions, the child learns how to use new skills in different situations of anxiety. The FRIENDS program, mentioned earlier, is an Australian adaptation of the Coping Cat program. In 2005 Flannery-Schroeder et al conducted a study in a group of children aged between 8 and 14 years old. They concluded that the Coping Cat program had a positive effect, at least up to the 1-year follow-up.²⁷

Concerning adult treatment, a number of cognitive-behavioral group therapies have been developed for specific anxiety disorders, such as social phobia,³² obsessive-compulsive disorder,³³ panic disorder with agoraphobia,³⁴ and other disorders such as insomnia³⁵ and depression.³⁶ These specific group-based programs have proven their effectiveness, but it could be costly for mental health clinics to offer different specific treatments, or to obtain enough participants who suffer from the same anxiety disorders.³⁷ More recently, studies have focused on the high rate of comorbidity and the similarities between the anxiety disorders.^37,38 The majority of treatment programs have a lot of similarities (eg, psychological education, cognitive restructuring, graduated exposure).^37,39 There are certain authors who are specifically interested in the development of a unique protocol for treatment of all anxiety disorders combined. A general approach is used, and focuses on excessive fear of something rather than on specific fears that characterize specific anxiety diagnostics. In 2012, Norton published a transdiagnostic treatment manual for therapists who wanted to set up a CBT group.¹³ His CBT protocol focused mainly on psychoeducation, cognitive restructuration, exposure, and relapse prevention. Before publishing the manual, Norton examined the effectiveness of the 12-week transdiagnostic therapy group.^40,41 The efficacy of the transdiagnostic treatment model for different multiple anxiety disorders was confirmed. In 2007, Erickson et al performed a random clinical trial and evaluated the protocol's effects based on traditional CBT techniques in groups.³⁷ The participants presented different anxiety disorders. The results showed that the CBT transdiagnostic treatment had positive results. Currently, this unified approach is being extensively studied.^42,43 This type of group treatment may provide better access to evidence-based treatments accessible to a larger amount of individuals.^13,37,44 Treatment studies have also been carried out by using the transdiagnostic group approach for other types of disorders such as eating disorders.⁴⁵

Conclusion

Over the last few years, CBT group-based interventions have taken on an important role in the prevention and treatment of anxiety, in many different ways. These group models help give better access to evidence-based treatments and better clinical efficiency. These criteria are essential in providing easier access to an appropriate form of treatment.⁴⁶ Compared with individual CBT treatment formats, providers must be aware of several influential factors that must be taken into account in order to have positive and productive group sessions.⁴⁷ However, it is still important to continue studying these group models and to set new research goals. Currently, part of the research conducted is based on better understanding of the factors that will influence the evolution of anxious symptomatology during group-based programs.⁴⁸ Further studies should be done on the question of fidelity and adaptation in the creation of well-established CBT group programs.⁴⁹