Anxiety Disorders: Brief Intensive Group Cognitive Behavior Therapy

Tian P. S. Oei and Genevieve Dingle

University of Queensland

I. II. III. IV.

Development and Description of Treatment Theoretical Bases Empirical Studies Summary Further Reading

I. DEVELOPMENT AND DESCRIPTION OF TREATMENT

Modern psychotherapy has its roots in Europe, and it was not until after the Second World War that the United States began to lead this eld. During this period, psychotherapy ourished and grew at an enormous rate. Behavior therapy, and later cognitive behavior therapy (CBT), led the earlier growth and in 1974 when Michael Mahoney published his rst book in cognitive behavior therapy, the term CBT became entrenched. Accumulated empirical evidence shows that CBT is efcacious for the treatment of many psychological and psychiatric disorders, ranging from anxiety, to eating disorders and the psychoses. For many patients, it can be argued that CBT is the treatment of choice for these disorders. At the turn of the new millenium, CBT was generally accepted as an evidence-based psychotherapy that has beneted many people with mental health problems. Although CBT can be delivered in individual or group settings, it is individual CBT that has received the most research and thus provides the most clear-cut support for its efcacy. The application of CBT to group work has a much later history than individual CBT, and accordingly the evidence-based research is not nearly

GLOSSARY
brief intensive group cognitive behavior therapy (BIGCBT) A version of cognitive behavior therapy conducted in full-day sessions over a short time period (e.g., 3 consecutive days).

Brief intensive group cognitive behavior therapy (BIGCBT) is a version of cognitive behavior therapy conducted in full-day sessions over a short time period, for example, 3 consecutive days. This article presents the theoretical underpinnings and applications of BIGCBT, and a review of empirical studies showing the effectiveness of a BIGCBT program for outpatients with panic disorder with or without agoraphobia.

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Copyright 2002, Elsevier Science (USA). All rights reserved.

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Anxiety Disorders: Brief Intensive Group Cognitive Behavior Therapy TABLE 1 A Sample of the Brief Intensive Group CBT Program for Panic Disorder with and without Agoraphobia Time 08:00 09:00 10:30 11:00 12:30 13:15 13:45 14:00 16:0017:00 Day 1 Registration Introduction to anxiety and phobias Morning break Anxiety and panic control Lunch Planning Relaxation Exposure Group work/consultation Day 2 Group cognitive behavior therapy Morning break Breathing control control Lunch Planning Relaxation Exposure Feedback Day 3 Drug therapy Morning break Cognitive Lunch Planning Relaxation Exposure Positive thinking/ self-help. Closing.

Note: Adapted from Weir (2000). Health outcome of brief intensive group cognitive behavior therapy for anxiety disorders. Doctoral dissertation, University of Queensland, Brisbane, Australia.

as comprehensive. Since the success of individual and group CBT, researchers and clinicians have experimented with the delivery format of CBT. The format has ranged from brief to extended CBT. Brief CBT treatments comprise from one to four sessions, with a 1-hr session per week, while extended CBT treatments range from 30 to 52 weekly 1-hr sessions. The average length of time for individual CBT is about 10 weekly sessions, and the average length of group CBT is a weekly 2-hr session for 12 sessions. More recent, we introduced a BIGCBT intervention and demonstrated that it has efcacy in the treatment of anxiety and mood disorders. The BIGCBT is delivered over 3 consecutive days, with an attendance of 8 hrs per day. Psychiatrist Larry Evans and psychologist Bevan Wiltshire initially started the BIGCBT in the early 1980s for the treatment of patients with anxiety disorders, in particular panic disorder with agoraphobia. In 1984, a group of psychologists, Tian Oei, Justin Kenardy, and Derek Weir, joined the group and further developed and evaluated the treatment package. The BIGCBT was developed with the following principles in mind: 1. Self-help: We wanted patients to take an active role in the management of their disorders. We strongly encouraged them to do so by providing a rationale, actively teaching them self-help skills and encouraging them to experiment with solutions to their problems.

2. Problem versus sickness: We informed patients that to view their problems as a sickness did not promote their active role in the management of the problems, but could in fact hinder it. 3. Control versus cure: We emphasized that the main aim was for patients to take control of their anxiety and fear rather than to attempt to cure it forever. Being cured is a passive process that depends on someone doing something to you, whereas gaining control is an active process. We explained that control was a realistic and attainable goal. Gaining control of anxiety and fear would enable patients to take charge and learn how to help themselves. In addition to learning what techniques to use and how to use them, patients also need to understand why they are using these techniques. BIGCBT was delivered in a group format with the aim of making the program more cost effective. Referrals were made by the patients medical ofcers. Group sizes averaged 8 participants. The group format provided a structured setting in which to learn the skills delivered by the program. It also provided social support, and a more socially relevant context for behavioral and attitudinal change and reinforcement than would an individual CBT context. A team of experienced clinicians delivered BIGCBT, including psychiatrists, psychologists, and nurses. It was ensured that all clinicians had a good grounding of CBT and had observed the whole BIGCBT program before taking responsibility for the delivery of group sessions.

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No one clinician delivered the entire BIGCBT program. Clinicians were allocated to a session or sessions of the BIGCBT program based on interest, knowledge, and time availability. An example of the 3-day program with the contents of each session is presented in Table 1. There were three blocks of exposure sessions, taken by at least two clinicians. When group membership was greater than eight, three or more clinicians were used. Fellow clinicians were encouraged to sit in on other sessions in order to provide feedback and peer support to the therapist. The participation of Dr. Evans in every program provided stability, consistency, and quality assurance for the program.

II. THEORETICAL BASES

The theoretical basis of the BIGCBT was derived from the cognitive behavioral framework and encompassed the elements of clinical assessment and diagnosis, psychoeducation of cognitive and behavioral skill components, exposure, relaxation training, and homework assignments. The Quality Assurance Project of the Royal Australian and New Zealand College of Psychiatrists treatment guidelines also contributed to the design of the BIGCBT.

III. EMPIRICAL STUDIES

BIGCBT was run at a community outpatient clinic. Therefore, evaluation of the intervention used an effectiveness approach rather than an efcacy approach. Oei and colleagues previous publications address a diversity of topics, including the development of new instruments to measure catastrophic cognitions; the validation of outcome measures such as the fear questionnaire (FQ); psychopathology of panic attacks and panic disorders; and treatment effectiveness. In 1991, Evans, Craig Holt, and Oei reported the rst long-term follow-up data using the BIGCBT. They found that at posttreatment, BIGCBT was signicantly better than the no treatment waiting-list control on the outcome measures of the FQ and the fear survey schedule (FSS). However, there was no difference in the scores for the Maudsley personality inventory (MPI) and the hostility and direction of hostility questionnaire (HDHQ), suggesting that neither of these personality variables was affected by the BIGCBT treatment. One-year follow-up results showed that treatment gains were maintained. Clinical interview data conrmed the FQ and FSS self-report data by demon-

strating that at one year follow-up, 85% of the patients treated with BIGCBT were either symptom free or had signicant symptom reduction. The nding that personality variables were not changed by the BIGCBT treatment was supported by a study by Clair, Oei, and Evans in 1992, using the same measures with the addition of the Fundamental Interpersonal Relations Orientation-Behavior Scale (FIRO-B). This 1992 study showed that personality variables derived from the previously mentioned three instruments were no different between patients who responded and did not respond to the BIGCBT treatment. Similar to previous ndings, personality characteristics did not predict treatment outcome. A study by Weir in 2000, supervised by Evans and Oei, compared 71 waiting-list control patients with 206 patients with anxiety disorders, on clinical and functional outcome measures. Clinical outcome measures used were self-report scales such as FQ, MPI, FSS, the State Trait Anxiety Inventory (STAI) and the HDHQ. Clinician-rated measures such as Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HAM-D) were also used. The functional outcome measures were the Medical Outcome Study Short Form Health Survey (SF 36), the Quality of Life Inventory (QOLI) and the Health Schedule Utilization (HSU). Preto posttreatment comparison between the BIGCBT and control groups showed that the BIGCBT group made signicant improvements when compared to the control group, on all the clinical outcome measures. The reported effect sizes for the BIGCBT group ranged from large (HAM-A = 1.24; HAM-D = .99) to small (STAI = .22). There was a small but signicant effect size for the change in MPI and HDHQ scores. This personality change was not consistent with the earlier studies. An important part of Weirs study is that it reported on 6-year follow-up results. The results showed that the treatment gains made by BIGCBT patients were maintained over the long term. The ndings also showed that most of the gains were made at posttreatment, and that the length of time of follow-up (ranging from 1 to 6 years) did not improve the posttreatment gains. The most interesting nding from the Weir study was in regard to the functional outcome measures. The results from the SF-36 showed that up to 6 years after the BIGCBT treatment, the SF-36 proles of the treated group were almost the same as those of the general population, and much better than the SF-36 proles of people with anxiety disorder problems in the national survey. This implies that long after treatment, the patients with anxiety disorder who were treated with the

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Anxiety Disorders: Brief Intensive Group Cognitive Behavior Therapy

BIGCBT can expect to have almost the same general health perception as the general population. This nding was complemented by the results of the QOLI that indicated that patients treated with BIGCBT were relatively free of psychological distress and had a more realistic expectation of their living conditions. The long-term effectiveness of BIGCBT was also reported in a 1997 study conducted by Oei and Evans with Michael Llamas. This study investigated the possible impact of concurrent medication use on the long-term outcome of BIGCBT for panic disorder with or without agoraphobia. The researchers found that preexisting medication (antianxiety, antidepressant, or a combination of these) did not signicantly enhance or detract from the long-term outcome of the BIGCBT program. The BIGCBT has also been applied to the treatment of patients with comorbid alcohol use disorder and panic disorder with or without agoraphobia. The 2000 report by Bialkowska, supervised by Oei and Evans, documented that concurrent addition of the BIGCBT for panic disorder to the standard hospital treatment for alcohol abuse produced better clinical outcomes than the standard hospital treatment and a placebo treatment. It was found that BIGCBT had an impact on self-reported anxiety but not on alcohol outcome measures.

See Also the Following Articles

Cognitive Behavior Therapy I Cognitive Behavior Group Therapy I Panic Disorder and Agoraphobia

Further Reading
Bialkowska, G. (2000). The efcacy of a brief intensive group cognitive behavior therapy for panic disorder and comorbid alcohol dependent patients, Masters thesis, University of Queensland, Brisbane, Australia. Clair, A., Oei, T. P . S., & Evans, L. (1992). Personality and treatment response in agoraphobia with panic attacks. Comprehensive Psychiatry, 33, 310318. Evans, L., Holt, C., & Oei, T. P . S. (1991). Long term follow up of agoraphobics treated by brief intensive group cognitive behavior therapy. Aust New Zealand Journal Psychiatry, 25, 343349. Kenardy, J., Evans, L., & Oei, T. P . S. (1992). The latent structure of anxiety symptoms in anxiety disorders. American Journal of Psychiatry, 149, 10581061. Khawaja, N., Oei, T. P . S., & Baglioni, A. (1994). Modication of the Catastrophic Cognitions Questionnaire (CCQ-M) for normals and patients: Exploratory and LISREL analyses. Journal of Psychopathology and Behavioral Assessment, 16, 325342. Mahoney, M. J. (1974). Cognition and behavior modication. Cambridge, MA: Ballinger. Oei, T. P . S. (1999). A group Cognitive Behavior Therapy program for anxiety, fear and phobias: A Therapists Manual, CBT Unit, Brisbane. Oei, T. P . S., Llamas, M., & Develly, G., (1999). Cognitive changes and the efcacy of CBT with panic disorders with agoraphobia. Behavioral and Cognitive Psychotherapy, 27, 6388. Oei, T. P. S., Llamas, M., & Evans, L. (1997). Does concurrent drug intake affect the long-term outcome of group cognitive behavior therapy in panic disorder with or without agoraphobia? Behaviour Research and Therapy, 35, 851857. Oei, T. P . S., Moylan, A., & Evans, L. (1991). Clinical utility and validity of the Fear Questionnaire. Psychological Assessment, 3, 391397. Weir, D. (2000). Health outcome of brief intensive group cognitive behavior therapy for anxiety disorders. Doctoral dissertation, University of Queensland, Brisbane, Australia.

IV. SUMMARY
There is enough evidence to suggest that the BIGCBT is an effective treatment for anxiety disorders, in particular for panic disorder with and without agoraphobia. The exact mechanism for the effectiveness of this treatment is still unknown. Furthermore, the effectiveness of the BIGCBT is demonstrated by a single group of researchers in one place and needs to be replicated by different researchers and in different locations before anything more substantial can be said about the general clinical utility of the BIGCBT. What can be said with some degree of condence, however, is that our ndings add to the robustness of the delivery of CBT in the treatment of psychological disorders.