Group Behavioral Therapy for Depression

Description of the Strategy

Group cognitive behavior therapy (CBT) originated with Peter Lewinsohn in the late 1960s and was later titled the “Coping With Depression” course. Although many minor variations have been integrated by clinicians and researchers, the basic group CBT conceptualization and interventions have remained the same since that time. The CBT conceptualization of depression suggests that depression is a product of both behavioral and cognitive errors. Behaviorally, depression is seen as the result of a downward spiral fueled by a synergistic relationship between a lack of activities and low motivation. Thus, depression can develop when an individual foregoes activities that would normally be pleasurable or provide a sense of accomplishment. Not participating in activities increases depression and reduces motivation to participate in other activities. This increased depression further reduces participation in activities, and so on. In addition, depression can be caused or exacerbated by a preponderance of aversive activities, such as negative interactions with family members. Cognitively, depression is conceptualized as the product of depressogenic automatic thoughts about self, the environment, and the future (e.g., I will fail the test; Others will reject me because I have failed; I will always fail), arising from core schematic beliefs (e.g., If I don't succeed at everything I try, I am a failure as a person) that may have developed in childhood. Group CBT for depression uses the group environment to facilitate the development of behavioral and cognitive coping skills to reduce depressive symptoms.

Group CBT for depression is typically time limited and structured. Sessions are structured with agendas, and methods of change include education, modeling, in-session practice, feedback, and homework. Although these groups may span between 4 and 20 sessions, most traditional CBT depression groups last approximately 12 sessions. Usually, group CBT for depression begins with a focus on behavior change, followed by cognitive change strategies. Behavioral interventions typically include the group leaders presenting the downward-spiral rationale (The less you do, the worse you feel, the worse you feel, the less you do….) coupled with each group member developing specific, measurable, and attainable goals for increasing pleasurable and mastery activities. In addition, some CBT group protocols target skills deficits with assertiveness training, social skills training, and/or relaxation training. Cognitive interventions begin with the group leaders presenting the cognitive model of depression that highlights how extreme, unhelpful, or rigid thinking can cause or exacerbate depression. Group members then learn how to identify the role of their own distorted beliefs in maintaining negative views of the self, the environment, and the future. In particular, group members identify thinking errors that include overgeneralization (e.g., Because I failed the test last week, I am a failure); catastrophizing (e.g., Everyone will reject me if I fail the test); all-or-nothing thinking (e.g., Either I pass the test or I am a failure); mistaking possibilities for certainties (e.g., I will fail the test); and using extreme words (e.g., never, always). Then, group members learn to challenge their beliefs with questions such as: What is the evidence that the automatic thought is true or not true? Is there an alternative explanation? What's the worst that could happen? Could I live through it? What's the most realistic outcome? Through this questioning, alternative more helpful beliefs are identified and practiced. Behavioral experiments may also be designed to challenge some beliefs (e.g., deliberately fail a quiz and observe the actual consequences). Some groups include cognitive interventions for identifying and challenging overarching beliefs or core schemas that may predispose members to experience depressogenic automatic thoughts. An example of a core schematic belief for a client who demands constant perfection from himself or herself may be, “If I do not succeed at everything I do, I am completely worthless.”

...