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RESEARCH REVIEWS
RESEARCH REVIEWS RESEARCH REVIEWS
Cognitive-Behavioral Group Therapy in the Acute Care Inpatient Setting TOWNLEY PETERS, M.A., R.Y.T. NICK KANAS, M.D. Bechdolf, A., Knost, B., Nelson, B., Schneider, N., Veith, V., Yung, A. R., & Pukrop, R. (2010). Randomized comparison of group cognitive behavior therapy and group psychoeducation in acute patients with schizophrenia: Effects on subjective quality of life. Australian and New Zealand Journal of Psychiatry, 44, 144-150. Veltro, F., Vendittelli, N., Oricchio, I., Avino, C., Figliolia, G., & Morosini, P. (2008). Effectiveness and efficiency of cognitivebehavioral group therapy for inpatients: 4-year follow-up study. Journal of Psychiatric Practice, 14, 281-288.
T
ypically, patients who are in acute care inpatient settings tend to suffer from more severe illnesses and are more likely to have comorbid personality disorders than patients in outpatient or less acute settings (Huber, Brandl, Henrich, & Klug, 2002; Springer & Silk, 1996). Consequently, the generalizability from outpatient group therapy research to inpatient group interventions may be called into question. Cognitive behavioral therapy (CBT) has been used to successfully treat patients suffering from a variety of diagnoses, including schizophrenia (Turkington, Dudley, Warman, & Beck, 2004), and when used in individual therapy, it has been found to decrease psychotic symptoms (Garety, Fowler, & Kuipers, 2000). Group-based CBT offered in inpatient settings was once rare, but it has recently gained increased research attention (Wykes et al., 2005). Although the efficacious nature of individual-based CBT is well documented in controlled research and clinical studies,
RESEARCH REVIEWS 273
many questions remain for researchers and practitioners interested in acute care inpatient group-based CBT. For example, is group-based CBT treatment practical and effective in acute inpatient settings? Is the general effectiveness and efficiency of group-based CBT sustainable over time? Bechdolf and colleagues (2010) and Veltro and colleagues (2008) address such questions in their published studies, which will now be reviewed. Bechdolf and colleagues (2010) evaluated the differential efficacy of a brief group CBT intervention in comparison to a psychoeduation group intervention in patients with acute schizophrenia on a measure of quality of life at three different time-points: baseline, immediately post-treatment, and six-months post-treatment. Patients were recruited from consecutive acute admissions to the inpatient unit and had to meet criteria for schizophrenia or a related psychotic thought condition, such as schizoaffective or brief psychotic disorder. Patients were randomized to receive either CBT or psychoeducation. The CBT intervention consisted of sixteen sessions in eight weeks, while the psychoeducation program included one session every week. The CBT treatment used was based on the approach by Tarrier and colleagues (1993). It consisted of elements such as mutual sharing and discussing information about voices and delusions, improving self-esteem, and interventions directed toward reducing severity and occurrence of key problems. A few of the strategies employed by the group leaders included guided recovery, reality testing, symptom monitoring, distraction techniques, schema work, and motivational interviewing. The psychoeducation program was primarily didactic in nature and covered topics like symptoms, effects and side effects of medications, and relapse prevention. For both the CBT and psychoeducation interventions, sessions followed a semi-structured format lasting between 60 and 90 minutes. Sessions for both interventions were administered to eight patients at the same time in a group setting. Two therapists led the sessions in both interventions. The sessions began while patients were inpatients and continued when they were discharged during the eight-week study period. The 40 group CBT and the 48 group psychoeducation patients were similar in baseline demographic characteristics. Quality of life was measured using the Modular System for Quality of
274
RESEARCH REVIEWS
Life, which is a self-report instrument comprised of five modules: demographic, core, partnership, family, and professional occupation. In general, researchers found that patient quality of life improved over time for both the CBT and psychoeducation interventions, and no significant between-group differences were found at any of the three time points. Within-group differences showed significant improvement at post treatment for only the psychoeducation intervention group. However, at the six-month follow-up, both the CBT and the psychoeducation patients showed significant improvement. This was the first study to examine quality of life differences in acute patients with schizophrenia. The results suggest that CBT administered in a brief group format and group psychoeducation as an adjunct to routine care both have an impact on the quality of life in patients with schizophrenia. Despite the beneficial clinical implications, the study had a number of methodological weaknesses. First, the authors acknowledged that they were only able to administer the interventions to patients with acute schizophrenia, which makes generalizing the results to other clinical settings difficult. Second, patients in the CBT group received twice as much contact with the therapists as the patients in the psychoeducation group. Finally, the authors did not introduce a true control group (i.e., treatment as usual or standard care). Since both interventions demonstrated improved quality of life, the study’s conclusions are limited regarding the treatment’s true impact. Without a true control group, one cannot rule out whether the patients’ quality of life ratings may have improved independent of the two study interventions. Another study reporting a positive outcome of group therapy for inpatients was conducted by Veltro and colleagues (2008). In contrast to the previous study, Veltro and colleagues chose to use a quasi-experimental design to evaluate the effectiveness of a group CBT intervention from 2001 to 2005. In 2001, the researchers integrated CBT intervention into the routine care on a psychiatric inpatient unit and recruited patients with the following diagnoses: schizophrenia, major depression, bipolar disorder, or personality disorders. The researchers were interested in investigating resultant changes in voluntary and compulsory readmissions, patient satisfaction, ward atmosphere, length of stay,
RESEARCH REVIEWS 275
use of restraints, and costs and income. Groups were held five days a week in accordance with a treatment manual for 105-minute sessions; however, the article did not mention the number of patients treated in the groups. A professional facilitated the groups, although it was unclear what title that professional held. Although the sample was heterogeneous in terms of diagnosis, it is unclear whether the groups were homogeneous or heterogeneous in terms of diagnosis. Also, it was not uncommon to have a physician be part of the group as a co-facilitator. Compared to the baseline year (i.e., prior to the introduction of the CBT group intervention), the rates of readmissions were significantly reduced during each of the following four years. Additionally, among the four diagnostic groups investigated in this study, decreases in readmissions were only statistically significant for patients with diagnoses of schizophrenia and bipolar disorder. With regard to patient satisfaction, statistically significant improvement was observed; however, the majority of this improvement was predominately observed in the first two years of the intervention. Although the results were promising, the study had some limitations. The most important limitation was the lack of a true control group and a randomized design, since one cannot say with certainty that the CBT group intervention alone influenced the outcome measures. Additionally, it is not possible to generalize the results without the control group. A limitation that may have clinical implications was in regard to the CBT group intervention used. The authors described utilizing a dimensional approach rather than a categorical diagnostic approach. As such, there were optional “modules” made available that could be included in sessions depending on the symptoms observed on the unit in the morning. The issues targeted by these “modules” were addressed regardless of the patients’ primary diagnosis. Thus, there may have been lessons that might have been unhelpful to some of the patients in the group. Clinical Implications
The results of these two studies are promising in that they both provide support for the claims that 1) group CBT can be an ef-
276
RESEARCH REVIEWS
fective intervention and modality for acute settings across various outcome measures, and 2) several benefits appear to be sustained over time. If these findings hold up in future studies that are well controlled and well designed, then group CBT may be added to more traditional inpatient group therapy approaches (Kanas, 1996; Yalom, 1983) as an important psychotherapeutic adjunct, particularly for acutely ill patients with diagnoses on the psychotic spectrum. REFERENCES Garety, P. A., Fowler, D., & Kuipers, E. (2000). Cognitive-behavioural therapy for medication resistant symptoms. Schizophrenia Bulletin, 26, 73-86. Huber, D., Brandl, T., Henrich, G., & Klug, G. (2002). Outpatient or inpatient? A field study concerning the practice of psychotherapy indication. Psychotherapeut, 47, 16-23. Kanas, N. (1996). Group therapy for schizophrenic patients. Washington, DC: American Psychiatric Press. Springer, T., & Silk, K. R. (1996). A review of inpatient group therapy for borderline personality disorder. Harvard Review of Psychiatry, 3, 45-52. Tarrier, N., Beckett, R., Harwood, S., Baker, A., Yusupoff, L., & Ugarteburu, I. (1993). A trial of two cognitive-behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients. British Journal of Psychiatry, 162, 524-532. Turkington, D., Dudley, R., Warman, D. M., & Beck, A. T. (2004). Cognitive-behavioral therapy for schizophrenia: A review. Journal of Psychiatric Practice, 10, 5-16. Wykes, T., Hayward, P., Thomas, N., Green, N., Surguladze, S., Fannon, D., & Landau, S. (2005). What are the effects of group cognitive behaviour therapy for voices? A randomized control trial. Schizophrenia Research, 77, 201-210. Yalom, I .D. (1983). Inpatient group psychotherapy. New York: Basic Books. Townley Peters, M.A., R.Y.T. California School of Professional Psychology Alliant International University 1 Beach St. San Francisco, CA 94133 E-mail: [email protected]
RESEARCH REVIEWS
RESEARCH REVIEWS RESEARCH REVIEWS
Cognitive-Behavioral Group Therapy in the Acute Care Inpatient Setting TOWNLEY PETERS, M.A., R.Y.T. NICK KANAS, M.D. Bechdolf, A., Knost, B., Nelson, B., Schneider, N., Veith, V., Yung, A. R., & Pukrop, R. (2010). Randomized comparison of group cognitive behavior therapy and group psychoeducation in acute patients with schizophrenia: Effects on subjective quality of life. Australian and New Zealand Journal of Psychiatry, 44, 144-150. Veltro, F., Vendittelli, N., Oricchio, I., Avino, C., Figliolia, G., & Morosini, P. (2008). Effectiveness and efficiency of cognitivebehavioral group therapy for inpatients: 4-year follow-up study. Journal of Psychiatric Practice, 14, 281-288.
T
ypically, patients who are in acute care inpatient settings tend to suffer from more severe illnesses and are more likely to have comorbid personality disorders than patients in outpatient or less acute settings (Huber, Brandl, Henrich, & Klug, 2002; Springer & Silk, 1996). Consequently, the generalizability from outpatient group therapy research to inpatient group interventions may be called into question. Cognitive behavioral therapy (CBT) has been used to successfully treat patients suffering from a variety of diagnoses, including schizophrenia (Turkington, Dudley, Warman, & Beck, 2004), and when used in individual therapy, it has been found to decrease psychotic symptoms (Garety, Fowler, & Kuipers, 2000). Group-based CBT offered in inpatient settings was once rare, but it has recently gained increased research attention (Wykes et al., 2005). Although the efficacious nature of individual-based CBT is well documented in controlled research and clinical studies,
RESEARCH REVIEWS 273
many questions remain for researchers and practitioners interested in acute care inpatient group-based CBT. For example, is group-based CBT treatment practical and effective in acute inpatient settings? Is the general effectiveness and efficiency of group-based CBT sustainable over time? Bechdolf and colleagues (2010) and Veltro and colleagues (2008) address such questions in their published studies, which will now be reviewed. Bechdolf and colleagues (2010) evaluated the differential efficacy of a brief group CBT intervention in comparison to a psychoeduation group intervention in patients with acute schizophrenia on a measure of quality of life at three different time-points: baseline, immediately post-treatment, and six-months post-treatment. Patients were recruited from consecutive acute admissions to the inpatient unit and had to meet criteria for schizophrenia or a related psychotic thought condition, such as schizoaffective or brief psychotic disorder. Patients were randomized to receive either CBT or psychoeducation. The CBT intervention consisted of sixteen sessions in eight weeks, while the psychoeducation program included one session every week. The CBT treatment used was based on the approach by Tarrier and colleagues (1993). It consisted of elements such as mutual sharing and discussing information about voices and delusions, improving self-esteem, and interventions directed toward reducing severity and occurrence of key problems. A few of the strategies employed by the group leaders included guided recovery, reality testing, symptom monitoring, distraction techniques, schema work, and motivational interviewing. The psychoeducation program was primarily didactic in nature and covered topics like symptoms, effects and side effects of medications, and relapse prevention. For both the CBT and psychoeducation interventions, sessions followed a semi-structured format lasting between 60 and 90 minutes. Sessions for both interventions were administered to eight patients at the same time in a group setting. Two therapists led the sessions in both interventions. The sessions began while patients were inpatients and continued when they were discharged during the eight-week study period. The 40 group CBT and the 48 group psychoeducation patients were similar in baseline demographic characteristics. Quality of life was measured using the Modular System for Quality of
274
RESEARCH REVIEWS
Life, which is a self-report instrument comprised of five modules: demographic, core, partnership, family, and professional occupation. In general, researchers found that patient quality of life improved over time for both the CBT and psychoeducation interventions, and no significant between-group differences were found at any of the three time points. Within-group differences showed significant improvement at post treatment for only the psychoeducation intervention group. However, at the six-month follow-up, both the CBT and the psychoeducation patients showed significant improvement. This was the first study to examine quality of life differences in acute patients with schizophrenia. The results suggest that CBT administered in a brief group format and group psychoeducation as an adjunct to routine care both have an impact on the quality of life in patients with schizophrenia. Despite the beneficial clinical implications, the study had a number of methodological weaknesses. First, the authors acknowledged that they were only able to administer the interventions to patients with acute schizophrenia, which makes generalizing the results to other clinical settings difficult. Second, patients in the CBT group received twice as much contact with the therapists as the patients in the psychoeducation group. Finally, the authors did not introduce a true control group (i.e., treatment as usual or standard care). Since both interventions demonstrated improved quality of life, the study’s conclusions are limited regarding the treatment’s true impact. Without a true control group, one cannot rule out whether the patients’ quality of life ratings may have improved independent of the two study interventions. Another study reporting a positive outcome of group therapy for inpatients was conducted by Veltro and colleagues (2008). In contrast to the previous study, Veltro and colleagues chose to use a quasi-experimental design to evaluate the effectiveness of a group CBT intervention from 2001 to 2005. In 2001, the researchers integrated CBT intervention into the routine care on a psychiatric inpatient unit and recruited patients with the following diagnoses: schizophrenia, major depression, bipolar disorder, or personality disorders. The researchers were interested in investigating resultant changes in voluntary and compulsory readmissions, patient satisfaction, ward atmosphere, length of stay,
RESEARCH REVIEWS 275
use of restraints, and costs and income. Groups were held five days a week in accordance with a treatment manual for 105-minute sessions; however, the article did not mention the number of patients treated in the groups. A professional facilitated the groups, although it was unclear what title that professional held. Although the sample was heterogeneous in terms of diagnosis, it is unclear whether the groups were homogeneous or heterogeneous in terms of diagnosis. Also, it was not uncommon to have a physician be part of the group as a co-facilitator. Compared to the baseline year (i.e., prior to the introduction of the CBT group intervention), the rates of readmissions were significantly reduced during each of the following four years. Additionally, among the four diagnostic groups investigated in this study, decreases in readmissions were only statistically significant for patients with diagnoses of schizophrenia and bipolar disorder. With regard to patient satisfaction, statistically significant improvement was observed; however, the majority of this improvement was predominately observed in the first two years of the intervention. Although the results were promising, the study had some limitations. The most important limitation was the lack of a true control group and a randomized design, since one cannot say with certainty that the CBT group intervention alone influenced the outcome measures. Additionally, it is not possible to generalize the results without the control group. A limitation that may have clinical implications was in regard to the CBT group intervention used. The authors described utilizing a dimensional approach rather than a categorical diagnostic approach. As such, there were optional “modules” made available that could be included in sessions depending on the symptoms observed on the unit in the morning. The issues targeted by these “modules” were addressed regardless of the patients’ primary diagnosis. Thus, there may have been lessons that might have been unhelpful to some of the patients in the group. Clinical Implications
The results of these two studies are promising in that they both provide support for the claims that 1) group CBT can be an ef-
276
RESEARCH REVIEWS
fective intervention and modality for acute settings across various outcome measures, and 2) several benefits appear to be sustained over time. If these findings hold up in future studies that are well controlled and well designed, then group CBT may be added to more traditional inpatient group therapy approaches (Kanas, 1996; Yalom, 1983) as an important psychotherapeutic adjunct, particularly for acutely ill patients with diagnoses on the psychotic spectrum. REFERENCES Garety, P. A., Fowler, D., & Kuipers, E. (2000). Cognitive-behavioural therapy for medication resistant symptoms. Schizophrenia Bulletin, 26, 73-86. Huber, D., Brandl, T., Henrich, G., & Klug, G. (2002). Outpatient or inpatient? A field study concerning the practice of psychotherapy indication. Psychotherapeut, 47, 16-23. Kanas, N. (1996). Group therapy for schizophrenic patients. Washington, DC: American Psychiatric Press. Springer, T., & Silk, K. R. (1996). A review of inpatient group therapy for borderline personality disorder. Harvard Review of Psychiatry, 3, 45-52. Tarrier, N., Beckett, R., Harwood, S., Baker, A., Yusupoff, L., & Ugarteburu, I. (1993). A trial of two cognitive-behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients. British Journal of Psychiatry, 162, 524-532. Turkington, D., Dudley, R., Warman, D. M., & Beck, A. T. (2004). Cognitive-behavioral therapy for schizophrenia: A review. Journal of Psychiatric Practice, 10, 5-16. Wykes, T., Hayward, P., Thomas, N., Green, N., Surguladze, S., Fannon, D., & Landau, S. (2005). What are the effects of group cognitive behaviour therapy for voices? A randomized control trial. Schizophrenia Research, 77, 201-210. Yalom, I .D. (1983). Inpatient group psychotherapy. New York: Basic Books. Townley Peters, M.A., R.Y.T. California School of Professional Psychology Alliant International University 1 Beach St. San Francisco, CA 94133 E-mail: [email protected]
