Behavioural and Cognitive Psychotherapy, 1998, 26, 219235 Cambridge University Press.

Printed in the United Kingdom

COMPARISON OF EFFECTIVENESS OF LARGE SCALE STRESS WORKSHOPS WITH SMALL STRESSANXIETY MANAGEMENT TRAINING GROUPS
June S. L. Brown
Institute of Psychiatry, London, U.K.

Ray Cochrane
University of Birmingham, U.K.

Carol F. Mack, Newman Leung and Teresa Hancox

South Birmingham Mental Health Trust, Birmingham, U.K. Abstract. This study investigates whether large-scale, day-long stress management workshops open to the general public can work as well as small, weekly groups run for referred clients. It is suggested that the self-referral route may enable some people who might otherwise have been ltered out from the traditional health services to get help for their stress-related problems. Analysis showed that the large-scale format was just as effective with a more distressed subgroup as was the small weekly format for formally referred clients, which suggests that the effectiveness of this approach is not only related to a restricted client group. It would appear that the low drop-out rate, the effectiveness of the workshops and the severity of problem handled within this format indicates potential value in this type of approach. Keywords: Large scale, day, workshops, small, anxiety management, groups.

Introduction Group-based stress and anxiety management training has traditionally taken place in small weekly sessions. Whilst these have been found to have had some effect, evaluations have often not been controlled (Campbell, Blake, & Rankin, 1993; Powell, 1987) andor shown a clear superiority over a control group (Eayrs, Rowan, & Harvey, 1984). Smith, Wood and Smale (1980) make the point, that control groups . . . often
Reprint requests to Dr June S. L. Brown, Psychology Department, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, U.K. 1998 British Association for Behavioural and Cognitive Psychotherapies

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also show substantial improvement, so that caution is necessary in ensuring that those in groups not only change but that they change more than do the controls (p. 117). Several investigators (Eayrs et al., 1984; White, Keenan, & Brooks, 1992) have also mentioned that non-specic factors may have affected the results when no clear differences have been found between different group interventions. Examples of nonspecic factors, i.e., those outside the specic therapeutic interventions, include giving clients the belief they could control their own lives, and clients having opportunities to talk to others in a similar position about their problems. Indeed, Yalom (1975) has postulated several non-specic curative factors in all group therapy including nding out you are not alone as well as gaining hope. Recent interest in larger-scale interventions has been stimulated by a number of different factors. A potentially large unmet need for mental health services has been identied by Goldberg and Huxley (1980, 1992). They suggest that 25% of the population are likely to experience mental health problems, albeit of varying degrees of severity, at sometime in their lives but that only 5% to 7% of this 25%, that is approximately 1.5% of the population, are likely to use the specialist mental health services. These authors have conceptualized a lter model which selectively limits the people likely to be referred to the specialist services. Within this model are suggested to be such processes as the willingness of an individual to consult a GP for mental health problems, the GPs ability to detect mental health problems, and the GPs decisionmaking regarding whether to refer someone to the specialist services or not. However, as at present, the mental health services are already struggling to cope, attempting to meet this unmet need with the existing conguration of services would put an impossible strain on them. Secondly, in trying to reach more people with mental health problems, larger-scale psychoeducational formats, where psychological skills are taught rather than used therapeutically, have been seen as potentially helpful (Butcher & de Clive-Lowe, 1985; White et al., 1992). It has also been suggested that the cognitive-behavioural approach might be well suited to this style of working as it concentrates on information-giving and on skills teaching. Finally, larger-scale interventions might also be seen as being relevant to those health promotion activities that aim to prevent problems developing in the rst place (Drummond, 1993). For example, smoking cessation groups can reduce the rate of physical problems like lung cancer and heart disease (Carroll, 1992). A large-scale format, such as a workshop, can be seen as particularly appropriate, as cost-effective prevention strategies often involve reaching large numbers of people. In deciding the kind of large-scale format to use, there are two major factors that may inuence the effectiveness of intervention generally, and stress and anxiety management training in particular. Size of group is one consideration; the other is whether the sessions are spaced (usually weekly) or massed (longer andor more frequent than once a week). Much of the literature has concentrated on small groupwork (Sank & Shaffer, 1984; Yalom, 1975) with relatively little written about working with large groups. Those few books and articles available on this subject have either looked at large psychotherapeutic groups of over 40 members (Kreeger, 1975) or large educational groups (Andresen, 1994).

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Various changes that can occur as the size of the group increases have been described (Schiff & Glassman, 1969; Rice, 1971). Some of the relevant differences are that groups with less than six members have a greater degree of intimacy, more face-to-face interactions, and quite uid leadership arrangements. However, as size increases and faceto-face interactions decrease, leadership roles become more structured, and sub-groups start to emerge. When groups get larger than 25, leadership is much clearer, with further development of sub-groups as face-to-face interactions continue to decrease. The second consideration is of the timing of the sessions. Spaced learning teaching formats have tended to be one-and-a-half-hour to two-hour weekly sessions spread over a number of weeks. Massed learning formats tend to consist of either more frequent, or longer, blocks of teaching, ranging from half a day to several days at a time. Classical learning theory would suggest that massed learning is most effective in establishing new behaviours but that, once established, spaced practice or intermittent reinforcement is more powerful in maintaining new behaviours (Gambrill, 1977). In contrast, some educationalists argue that studying is more effective when learning is spread over a longer period of time, rather than concentrated (Freeman, 1972). Some studies support the educationalists view. For example, Baddeley and Longman (1978) found that postal workers learned to type postal codes more effectively when learning was spaced (1 hour per day) rather than massed (2 hour sessions twice per day). Kimbles (1949) study also supports the advantage of spaced learning by showing that learning a complex task was best achieved using relatively short training periods, with longer rest periods. However, Adams and Reynolds (1954) found no differences between the effects of massed learning and spaced learning after the initial stages of the task. Clinical studies do not clarify the picture. A study, although not on stress, that suggests that massed learning might be more effective is that by Stern and Marks (1973) who found that two hours of prolonged sessions of ooding was more effective with chronic agoraphobics than four half-hour spaced sessions of the same procedure. They suggest that the intervals between exposure might facilitate incubation of the original fear which had been aroused during the therapeutic session and which may also be increased by cognitive rehearsal. The authors suggest that prolonging sessions increases the chances of some critical but unknown process occurring which facilitates improvement (p. 275). Alternatively, the conditioned avoidance response may be blocked by challenge, changing cognitions or all of these. On the other hand, the principles of systematic desensitization (Wolpe, 1958) would suggest that a spaced gradual approach might be most effective. The overall picture remains confused. There has been only one study that has used a large-scale weekly (or spaced) format for a therapeutic group intervention. White et al. (1992) ran six evening class workshops for 110 anxious patients; each workshop consisted of 16 to 20 people with diagnosed Generalized Anxiety Disorder. Experimental groups consisted of a cognitive, behavioural and a cognitive-behavioural group. There was also a placebo control group. They found that, compared to a waiting list control group, all patients in the experimental groups had improved signicantly on four of the six main measures of anxiety (Spielberger State scores, Fear Survey Schedule, Beck Depression Inventory and Modied Somatic Perception Questionnaire) when assessed immediately after treatment. Further changes were also found to have occurred between the end of treatment and

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follow-up at six months. Interestingly, participants in the placebo group also improved on three of the six measures (Spielberger State scores, Beck Depression Inventory and Modied Somatic Perception Questionnaire). In addition, it was found that consultations with GPs, as well as medication prescriptions, reduced in the six-month period after treatment in the experimental groups, although there were no data for the waiting list control group. Few studies have used the massed format for group intervention. No studies have investigated the small, massed format and there has been only one study that has used a large, massed format. Carson, Cowan, Gill and Titman (1988) ran a two-day workshop for 31 participants covering self-awareness and coping methods for anxiety and depression. The workshop was well appreciated by the attenders but was not formally evaluated. One common problem with any psychological intervention is a high dropout rate (Gareld, 1986). Butcher and de Clive-Lowe (1985) reported that the attrition rate with their 23 initial group members was 39% by the end of the course, which then went up to 57% at the three month follow-up. On the other hand, White et al. (1992) reported lower attrition rates: this was 10% at initial assessment; 9% for the rst session, and then a further 8% over the period from the second session to the nal sixth session. Numbers of people who were in contact at six months were not given, but it was stated that the dropout rate between the nal session and the six-month follow-up ranged from 10% to 19% for the different interventions. Powell (1987) reported a dropout rate of 17% at three-month follow-up. On the whole, these few studies would suggest that attrition rates may be lower than those reported with individual clients in ordinary clinic situations where, on average, in American studies at least, half of all clients have dropped out by the eighth session (Gareld, 1986). Much of the work reviewed above has related to people referred through the traditional services, but psychologists have made several attempts to reach people who might otherwise not get help from specialist services. For example, walk-in clinics have been described where clients have been able to self-refer (Cheston & Schmidt, 1994; Heller, 1994). In terms of severity of problem presented at such clinics, Mattsson (1992), quoted in Cheston and Schmidt (1994), has found that self-referrals are often in more need of psychological assistance than referrals coming through traditional channels. Heller (1994) described an evening walk-in clinic in South Tees that ran for 8.5 years. In an initial 12 week pilot period, she found that the most common problem was anxiety (18.4%), followed by relationship problems (16.5%) and depression (14.5%). She found that attenders were mainly female and from social classes 3, 4 and 5. Unfortunately, she does not report their distress levels, compared to clinical groups. Butcher and de Clive-Lowe (1985) offered members of the public twelve, weekly, two-hour long evening class sessions. The 23 participants were largely female (69.6%) with an average age of 30.5 years. The programme covered a number of different areas, which seemed to be effective, as measured by the Personal Causality Scale. Again, no initial distress levels are reported. In the present study, two large-scale day-long massed stress workshops were run and members of the general public were invited to self-refer. A comparison is made of

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the characteristics of these clients, as well as the effectiveness of these large-scale fullday workshops with small, weekly spaced anxiety management groups run by the Psychology Service. These data are compared with those obtained from a waiting list control group. The participants attending the large-scale day-long stress workshops will be known as the LMS (Large, Massed and Self-referred) group and those attending the weekly anxiety management groups will be known as the SSR (Small, Spaced and Referred) group. The waiting list control group will be known as the WLS (Waiting List Self-referred) group. Several predictions were made. First, it was hypothesized that the three sets of attenders would differ in background characteristics; Stress workshop attenders (LMS) and the waiting list control group (WLS) would be more likely to be female, employed and married compared to the small clinical (SSR) group. This was based on the ndings of Goldberg and Huxley (1980, 1992) that some people might not receive help for their mental health problems because they might be ltered out for a number of background characteristics such as age, gender, employment status, social class and marital status. Second, it was predicted that clients using the different referral routes would have different distress and stress levels; people referred to the psychology service (and then to SSR group) would be more distressed than those who referred themselves in the LMS group and the WLS group. This was based on the nding in some psychiatric studies (Goldberg & Huxley, 1980, 1992), that severity of problem is higher among those formally referred to the mental health services, such that those with psychotic problems would be virtually certain to be referred to the specialist mental health services, regardless of background. On the other hand, many of the mental health problems identied through community surveys are neurotic problems that vary in their severity (Bebbington, Hurry, Tennant, Sturt, & Wing, 1981). By implication, this would mean that, given the opportunity to self-refer, the range of people attending the workshops can be quite wide. Third, it was hypothesized that both the LMS and SSR groups would show more improvement than the WLS group. Given the contradictory ndings in the literature about the effectiveness of spaced and massed learning and the newness of the largescale workshop approach, no predictions are made about the relative effectiveness of the LMS format and the SSR format. Fourth, it was predicted that the dropout rate of the LMS group would be less than that for the SSR group during the intervention. This hypothesis was based on there being more opportunities for participants to drop out of weekly sessions whereas the day-long workshop offers fewer decision-making points for this to occur.

Method Design The large-scale stress workshops were run in the context of a city-wide Healthy Birmingham 2000 campaign that aimed to change the lifestyles of participants. Four workshops were run: two initial full-day workshops and two more for the waiting list control group at the end of the three-month waiting list period. Follow-up meetings

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were arranged three months after the workshops. Two other groups were also involved: the half-day group and a placebo control group, but these will be reported on separately (see Brown & Cochrane, 1998b). The small, weekly stress and anxiety management groups were only made available to those who had been referred to the local Psychology Service, either by their GP, a psychiatrist or another mental health professional as part of a routine clinical service. Subjects Publicity for the workshops started three months before the specic campaign month. Posters and information sheets were sent to GP surgeries, libraries, leisure centres and community centres: letters were also sent to GPs and Practice managers. The local radio station and the Health Authority newspaper also publicized the workshops. A telephone number was given, which members of the public could ring to book a place. One hundred and twenty-six people indicated they wished to take part in the programme. They were randomly allocated to the LMS group and to the WLS group. Fifty-two subjects were allocated to the LMS group and 74 subjects to the WLS group. However, as there were no restrictions on age or place of residence because of the citywide campaign, for the purposes of this comparison study, results for those who lived outside of the catchment area of the Psychology Service running the small anxiety groups, and those who were over 65 years old are not reported. Data are therefore reported for 36 subjects in the LMS group and 52 subjects in the WLS group. The SSR group consisted of 36 people who had been referred to South Birmingham Psychology Service and been assessed by interview as being suitable for attendance at an anxiety management group. All participants were aged between 16 and 65 years. Instruments The assessment measures were: Spielberger State-Trait Anxiety Inventory (Spielberger, Gorsuch, & Lushens, 1970) was used to measure changes in stable trait anxiety as well as state anxiety. It consists of 40 items, with 20 measuring State (or transitory) Anxiety, and 20 items measuring Trait (or stable) Anxiety. A shortened version of the Symptom Checklist 90 (SCL-90) (Derogatis, 1983) was used to measure distress at inception to the study These two instruments were thought to give a measure of overall distress as well as measures of anxiety. Intervention The stress workshop programme was designed to run over the course of one day from 9.30 am to 5 pm. There were 2024 participants in each of the four workshops (including those who lived outside the District and those over 65 years of age). The workshops were free, run on either a Saturday or a Sunday, in a leisure centre and led by a team of four psychologists.

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The SSR groups were run over either six or eight weeks. Each session typically lasted between 1.25 and 1.5 hours. There were, on average, six participants in each of the groups, which were run in Community Mental Health Centres. In all, ve small groups were run, each by a psychologist and a non-psychologist colleague. The content of the programmes was similar. The normality of anxiety was emphasized. The model of anxiety was cognitive-behavioural and used Langs (1968) tripartite model of physical, cognitive and behavioural aspects of anxiety. Information was given about the relationship between stress and anxiety as well as on healthy lifestyles. Physical relaxation exercises, cognitive methods, active behavioural methods were also taught. Further details of the programme are available in Brown and Cochrane (1998c). Procedure Subjects for the stress workshops (LMS and WLS groups) were invited to self-refer. All who rang to book a place were invited to attend an introductory talk at which they were given more information about the workshops, including practical details such as car parking, lunchtime arrangements etc. As well as the assessments previously mentioned, they were also asked to complete other pre-assessments for the later evaluation of the workshops. Following the full-day workshop, LMS attenders were asked to complete the evaluation forms again after three months. At this time, there was a follow-up meeting, at which difculties and achievements were discussed. Subjects in the WLS group were offered a place on a similar workshop three months later, immediately before which they again completed the evaluation forms. SSR group subjects were referred to the Psychology Service by their GP, psychiatrist or other mental health professional. They were then assessed by a psychologist and invited to join the group if they were suitable. The main selection criteria were that they had anxiety as their major problem and did not have psychotic symptoms. All subjects referred tted the criteria and were invited to join the group. All those invited were asked to complete the assessment forms before the start of the group. Attenders were asked to complete the evaluation forms after three months and invited to attend a follow-up meeting. Results Characteristics at inception into study The three groups did not differ on age, marital status or social class. However, two of the three relevant hypotheses were supported. There were differences on gender (ChiG 6.60, dfG2, pF.05) and in employment status (ChiG6.17, dfG2, pF.05) with more women andor employed people in the LMS and WLS Groups compared to the SSR group (see Table 1). Incomplete details given by subjects has led to lower data sets for social class and marital status. When the referred (SSR) group participants were compared with the self-referred (LMS and WLS) group members, they did not differ on initial Spielberger Trait scores. However, participants in the SSR group were more anxious on the Spielberger State

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Table 1. Sociodemographic and psychological details of groups Variable Gender male female Age (x) Employment status employed not employed Social Class 1 2 3 4 5 Marital status single divorced widowed married Psychological distress SCL-18 (x) Anxiety Spielberger State (x) Trait (x) LMS group (NG36) 9 (25%) 27 (75%) 44.92 25 (69.4%) 11 (30.6%) 4 (12.5%) 11 (34.3%) 12 (37.5%) 3 (9.4%) 2 (6.3%) 11 (30.6%) 4 (11.1%) 0 (0%) 21 (58.3%) 1.30 SSR group (NG36) 17 (47.2%) 19 (52.8%) 41.31 12 (33.3%) 17 (66.7%) 1 (6.7%) 1 (6.7%) 9 (60%) 3 (20%) 1 (6.7%) 10 (32.3%) 1 (3.2%) 0 (0%) 20 (67.7%) 1.76 WLS group (NG52) 12 (23%) 40 (76.9%) 43.12 34 (65.4%) 18 (34.6%) 7 (15.9%) 12 (27.3%) 20 (45.5%) 3 (6.8%) 2 (4.5%) 15 (29.4%) 2 (3.9%) 1 (2%) 33 (64.7%) 1.13

44.50 51.20

54.86 55.41

42.72 51.28

measure (FG10.59, dfG2,92, pF.01) and more distressed as measured by the SCL (FG 6.96, dfG2,94, pF0.5). Means for these groups are also given in Table 1. Our prediction that SSR participants would be more distressed was supported.

Attendance rate for interventions Of the 36 LMS group participants invited to attend the initial stress workshops, ve (13.8%) did not attend at all. Thus, 31 participants attended the two full-day workshops that were run. There were no further dropouts from these workshops. All but three of the participants either came to the follow-up or sent their forms in at the three-month follow-up point. The number of people still in touch at three months was, therefore, 28 (78%). With the SSR groups, the number who did not attend the groups at all was 6 (16.7%). The dropout rate over the course for the groups was 19.4%, with seven participants not nishing the programme. The non-contact rate at three months was 6 (16.7%). Thus, the number of people still in touch was 17 (47.2%).

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Table 2. Analysis of SCL scores (GSI av) A. Means and standard deviations of LMS, SSR and WLS groups Time 1 LMS group N Mean SD SSR group N Mean SD WLS group N Mean SD 28 1.256 0.75 17 1.64 0.86 36 1.13 0.49 Time 2 28 0.74 0.47 17 1.03 0.89 36 0.93 0.63

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B. Analysis of SCL scores using two way Analysis of Variance with repeated measures Source of variation Group Time GroupBtime Sum of squares 2.98 7.53 1.31 df 2,80 1,80 2,80 Var est. 1.49 7.53 0.65 F 2.10 42.24 3.67 Sig. NS pF.001 pF.05

C. Change scores on SCL for LMS, SSR and WLS groups LMS v WLS tG2.01, dfG62, SSR v WLS tG2.48, dfG53, LMS v SSR tG0.57, dfG45, pF.05 pF.05 NS

A Chi Square analysis comparing the number of subjects who attended and those who dropped out showed that the two formats differed signicantly (ChiG9.43, dfG 1, pF.01). Those in the SSR group were more likely to drop out of the group. Our hypothesis was therefore supported. Effectiveness of formats Results from both types of intervention were compared with those from the waiting list control group using a two-way Analysis of Variance with repeated measures (see Tables 24). On both the SCL and the Spielberger Trait measure, there were no group differences but the group-by-time interactions were signicant. A main group effect was found on the Spielberger State measure, but the group-by-time interaction just missed signicance. On all measures, the time effect was signicant. Our hypothesis

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Table 3. Analysis of Spielberger State scores A. Means and standard deviations of Spielberger State scores of LMS, SSR and WLS groups Time 1 LMS group N Mean SD SSR group N Mean SD WLS group N Mean SD 28 44.32 13.55 17 54.61 10.47 36 42.67 10.34 Time 2 28 37.00 10.64 17 44.11 16.74 36 40.86 10.34

B. Analysis of Spielberger State scores using two way Analysis of Variance with repeated measures Source of variation Group Time GroupBtime Sum of squares 1872.66 1617.92 516.74 df 2,79 1,79 2,79 Var est. 936.33 1617.92 258.37 F 4.80 19.26 3.08 Sig. pF.05 pF.001 NS

C. Analysis of change scores on Spielberger State scores for LMS, SSR and WLS groups LMS v WLS SSR v WLS LMS v SSR tG1.90, tG2.22, tG1.29, dfG62, NS dfG21.93, pF.05 dfG45, NS

that the two interventions would be more effective than the waiting list was therefore supported. Changes on the Spielberger Trait measure are shown in Figure 1. When change scores were compared, the full-day workshops appeared to be as effective as the weekly groups; the differences on the t-test were each signicant on two of the three comparisons made. Change score analyses were used to allow for scores on the different assessments to go in different directions; participants might experience less trait anxiety but increased state anxiety.

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Table 4. Analysis of Spielberger Trait scores A. Means and standard deviations of Spielberger Trait scores for LMS, SSR and WLS groups Time 1 LMS group N Mean SD SSR group N Mean SD WLS group N Mean SD 28 51.29 10.88 17 54.67 16.67 36 50.72 10.37 Time 2 28 44.25 10.13 17 48.44 13.90 36 50.11 9.11

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B. Analysis of Spielberger Trait scores using two way Analysis of Variance with repeated measures Source of variation Group Time GroupBtime Sum of squares 369.35 807.87 380.13 df 2,79 1,79 2,79 Var est. 184.68 807.87 190.06 F 0.86 17.52 4.12 Sig. NS pF.001 pF.05

C. Analysis of change scores on Spielberger Trait for LMS, SSR and WLS groups LMS v WLS SSR v WLS LMS v SSR tG2.01, tG1.86, tG0.51, dfG62, dfG20.20, dfG22.3, pF.05 NS NS

Analysis of more distressed and less distressed subgroups of LMS groups A more distressed subgroup of the LMS group was obtained by separating the top half (nG14) of the LMS on the initial Spielberger State measure for those participants for whom follow-up data were available. The State score was used for this analysis as the SSR and workshop groups only differed on the SCL and the State scores (Table 1); the latter was chosen because it better differentiated the two groups. The mean Spielberger State score of this group (to be known as LMS 1) was 54.86, which was almost identical to that for the total SSR group which was 54.61. A less distressed subgroup was obtained from those in the lower half (nG14) on the initial State measure. The

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Figure 1. Comparison of three groups on Spielberger Trait measure

mean score of this group (to be known as LMS 2) was 33.79. Means for all variables are shown in Table 5. Using a two-way Analysis of Variance with repeated measures to compare the more distressed (LMS 1) and less distressed (LMS 2) groups with the SSR and WLS groups, all three measures showed a main time effect ( pF.001) and a main group effect: the SCL (FG3.09, dfG3,79, pF.05), the Spielberger State measure (FG1556.34, dfG3,78, pF.001) and the Spielberger Trait measure (FG2.75, dfG3,78, pF.05). There were also two signicant group-by-time interactions on the Spielberger State measure (FG7.02, dfG3,78, pF.001) and the Spielberger Trait measure (FG3.08, dfG3,78, pF.001). The interaction for the SCL just missed signicance (FG2.67, dfG3,79, pG.053).
Table 5. Means and standard deviations of scores of LMS high stress and low stress sub-groups SCL scores n x SD LMS 1 LMS 2 (pre) (fu) (pre) (fu) 14 14 14 14 1.55 0.94 0.97 0.55 0.57 0.52 0.72 0.33 Spielberger State scores n x SD 14 14 14 14 54.9 39.1 33.79 34.93 7.20 10.7 9.51 10.5 Spielberger Trait scores n x SD 14 14 14 14 57.0 48.1 45.6 40.4 7.11 6.5 11.1 11.8

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Table 6. t-values and signicance levels from comparison of change scores between the LMS sub-groups with SSR and WLS groups SCL difference t LMS 1 v SSR LMS 1 v WLS LMS 2 v WLS LMS 2 v SSR LMS 1 v LMS 2 0.02 2.19 1.09 0.88 0.78 df 31 48 48 31 26 Sig. NS * NS NS NS Spielberger State difference t 1.04 4.45 0.9 2.22 4.54 df 30 48 48 30 26 Sig. NS *** NS * ***

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Spielberger Trait difference t 0.59 3.45 2.05 0.25 1.14 df 30 48 48 30 26 Sig. NS *** * NS NS

* pGF.05, ** pGF.01, *** pF.001.

An analysis of the change scores using the t-test was again also carried out. In the comparisons of the change scores of the intervention groups with the WLS group, the LMS 1 (high distress) group and WLS group differed signicantly on all three measures and the LMS 2 (low distress) group differed on only one measure. The other key nding was that the amount of change exhibited by the LMS 1 group and SSR group did not differ. The results of the change score analysis are shown in Table 6. Discussion Given an opportunity to refer themselves for psychological intervention in this study, more women were willing to do so than men, a nding congruent with other studies (Butcher & de Clive-Lowe, 1985; Heller, 1994). Another clearly signicant differentiator was employment status, which has commonly been associated with mental health (Banks & Jackson, 1982; Cochrane, 1983) as more working people attended the workshops than the SSR group sessions. It may be that because the workshops were held at weekends, more working people were able to attend. An alternative perspective is that the lter system, which operates to select people out of formal mental health care, tends to favour the unemployed being referred to the specialist services: there is evidence to show that unemployment may prompt GPs to recognize mental health problems (Goldberg & Huxley, 1980; Marks, Hallam, Connolly, & Philpott, 1979) although the contribution of unemployment to the decision to refer is not entirely clear. It is possible that the self-referral system offered in this study may have provided an alternative route for people who might otherwise have been ltered out. Surprisingly, and contrary to ndings in some other studies (e.g., Goldberg & Huxley, 1980), marital status was not a variable which differentiated the composition of the two groups. Sashidharan, Surtees, Kreitman, Ingham and Miller (1988), for example, found that single women were more likely to use the specialist psychiatric services than married women under the age of 35 years. However, it is likely that the result from this study may be an artefact of the selection procedure for the small group as the results from a larger study (Brown & Cochrane, 1998a) do show marital differences between self-referrals for the workshop and all clients treated by the Psychology Service. When the distress levels of participants in the LMS, SSR and WLS groups were compared before intervention, the Spielberger State and the SCL scores of the LMS

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and WLS groups were different from those of the SSR group. These indicate that those who had been referred to the specialist services in the traditional way were more overtly anxious and distressed at inception into the study than were the self-referrers. However, the average Spielberger Trait scores of the groups were not signicantly different, showing that the underlying pattern of worry for the three groups were more similar. It was, however, possible to identify a sub-group of workshop attenders whose initial distress levels were equivalent to that of those in the SSR group. This would indicate that when a self-referral route was opened, the range of distress of those enrolling for the stress workshops was quite wide so that those with minimal problems enrolled alongside those with really quite severe problems. These data do not support a commonly held idea that it is only the worried well who enrol in large-scale public workshops. Nor was the idea that only the least distressed would be capable of beneting from such an intervention supported. A reasonable conclusion from this study is that the LMS group format and the SSR group format appear to be equally effective. Both LMS and SSR groups showed signicant changes compared to the WLS group as a result of the intervention; two of the three measures indicated signicant group-by-time interactions in the expected direction, and the third measure just missed signicance. Further, the two treatment groups did not differ when the change scores were compared. This set of results suggests that a full-day workshop format can be seen as a realistic alternative to the traditional small weekly group. The analysis comparing the more distressed subgroup of the LMS group with the SSR group showed the full-day workshop was just as effective even with this more distressed group as was the weekly format for SSR participants. This would suggest that a large-scale workshop, with limited opportunities for one-to-one interactions and with limited weekly monitoring of homework assignments, can be very effective even with quite severely stressed clients. The drop-out rate for the small (SSR) groups was clearly higher than for the largescale day-long (LMS) workshops. It may be that deciding to come for a day involved quite a degree of commitment, so that once people had made the decision to come, they stayed for the full day. It may also be that a full day tends to reduce the amount of ambivalence that may be experienced when change is required (Clarkson, 1989; Perls, 1976). Alternatively, it could be that SSR group participants had more points at which to make a decision about whether or not to continue to come to sessions. On the other hand, participants in the day-long group could have decided not to return after any of the three breaks in the day, but may have needed to have been more assertive to opt out at these stages. Another factor may be that because the stress workshops were held at the weekend and in a leisure centre, it may have been a more convenient setting and time for people to participate than a more traditional mental health centre on a weekday. Apart from effectiveness and drop-out rate, a number of practical considerations will affect which format is chosen. These include convenience and time for the client. It might be easier to come for a full day rather than come to a series of weekly sessions, reducing the re-arrangements (e.g., transport, childcare) that may need to be made. Such a format might also reduce the travel time involved.

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Another issue is that of overall time involved in each format. The workshops lasted six hours. The weekly sessions lasted either 7.5 hours (6B1.25) or 12 hours (8B1.5). Yet the extra time of engagement did not lead to detectably superior outcomes. For group leaders too, there are also time considerations with travel and preparation time as well as re-orienting time at the beginning of each session. In considering these results, it is important to acknowledge that there were some methodological weaknesses. The range of measures used was limited to self-report symptomatic questionnaires as behavioural measures were difcult to obtain in the large-scale context of this study. In addition, no attempts were made to match the two interventions so that the two groups were seen in different settings, run by different group leaders and for different periods of time. A check on the interventions was not attempted. Future studies might include self-reports of behavioural changes such as frequency of going to the GP and medication taken. A randomized control design whereby self-referrals were randomly allocated to a small weekly group or to a large day-long workshop may be used to make the groups more comparable. There is a continuing debate concerning what the curative factors in group treatment might be. The suggestion that non-specic factors, such as the opportunity to talk to other people with similar problems, reported by Powell (1987) and repeated again by White et al. (1992) are important elements, may lead to the hypothesis that the kinds of coping skills taught may be less important factors than group leaders believe. Nevertheless, the difculties that some self-help groups, which indeed have offered opportunities to share problems with each other, have encountered, such as excessive dependence on the group as well as limited effectiveness (Maton, 1988) indicate a need for caution in coming to such a conclusion. In addition, dissatisfaction reported from an information-giving and physical exercise group run to help manage stress (see Brown, Cochrane, & Hancox 1998b) would suggest that the solutions are not necessarily simple. This study has shown that large-scale, day-long workshops open to the general public can be as effective as small, weekly groups run for referred clients. Whilst there were some differences in client psychological characteristics because of the different referral processes, an additional analysis showed that the large-scale format was just as effective with a more distressed subgroup as the small weekly format for formally referred clients, demonstrating that the effectiveness of this approach is not restricted to a less distressed client group. It would appear that the low drop-out rate, the effectiveness of the workshops, and the severity of problem handled within this format indicates potential value in this kind of approach, especially when large groups of people have to be reached. Acknowledgements Many thanks are due to the people who participated in the workshops and small groups. Many thanks also to South Birmingham Psychology Service for supporting the project. References
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