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Contribution of Group Therapeutic Factors to the Outcome of Cognitive–Behavioral Therapy for Patients with Panic Disorder
Archives of Psychiatric Nursing xxx (2016) xxx–xxx
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Contribution of Group Therapeutic Factors to the Outcome of Cognitive– Behavioral Therapy for Patients with Panic Disorder Andressa Behenck a,b, Ana Cristina Wesner a, Débora Finkler b, Elizeth Heldt a,b,⁎ a b
Graduate Program in Nursing, School of Nursing, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil Anxiety Disorders Program, Hospital de Clínicas de Porto Alegre, RS, Brazil
a b s t r a c t Background: Investigating the contribution of therapeutic factors arising from the collective nature or group therapy to treat mental disorders may help therapists maximize the outcome of therapy. Studies about the role of therapeutic factors in cognitive–behavioral group therapy (CBGT) for panic disorder (PD) patients are still scarce. Objectives: To identify the therapeutic factors rated as the most useful by patients during CBGT. Also, we aimed to investigate the relationship between patient rating of therapeutic factors and specific stages of CBGT. Design: Non-controlled clinical trial. Methods: A 12-session CBGT protocol was set up, covering psychoeducation, techniques for anxiety coping, cognitive restructuring, interoceptive and naturalistic exposure, and live exposure to avoidant behavior. PD symptom severity was assessed before and after the CBGT protocol. Yalom's Curative Factors Questionnaire was self-administered at the end of each session to evaluate the 12 therapeutic factors. Results: The sample consisted of 16 patients, who produced 192 assessments of therapeutic factors. Severity of symptoms improved at the end of CBGT, with a large effect size (N1.0). Different ratings were attributed to therapeutic factors at different phases of CBGT. Seven factors were rated as significantly helpful: altruism, interpersonal learning/input, guidance, identification, family reenactment, self-understanding, and existential factors. Conclusions: Therapeutic factors are dynamic and interdependent. Therefore, recognizing the impact of these factors during CBGT may potentially contribute to a better understanding of the therapeutic process. © 2016 Elsevier Inc. All rights reserved.
The therapeutic process of therapy groups is complex and arises from the interaction among participants and from the sharing of experiences, both of which promote change (Yalom & Leszcz, 2006). Therapy groups have several characteristic factors that are considered therapeutic because they facilitate the learning of new behaviors and thoughts. Thus, in addition to the specific techniques used by professionals to treat mental disorders, group therapeutic factors may in and of themselves be an instrument of change (Behenck, Gomes, & Heldt, 2016). GROUP THERAPEUTIC FACTORS Yalom and Leszcz (2006) have proposed a set of 12 therapeutic factors, all of which are related to the interaction among participants in the therapeutic group: altruism, group cohesiveness, universality, interpersonal learning/input, interpersonal learning/output, guidance, catharsis, identification, family reenactment, self-understanding, instillation of hope, and corrective recapitulation of existential factors. Previous studies with CBGT have shown a positive contribution of therapeutic factors to the outcomes of therapy. For example, it was found that group Conflict of interest: The authors report no conflicts of interest. ⁎ Corresponding Author: Elizeth Heldt, Ph.D., School of Nursing/UFRGS, São Manoel, 963–Porto Alegre, RS, Brazil, 90620-110. E-mail addresses: [email protected], [email protected] (E. Heldt).
cohesiveness contributes to the improvement of patients with social phobia (Taube-Schiff, Suvak, Antony, Bieling, & McCabe, 2007). Another study focusing on CBGT for social phobia showed that interpersonal learning-output, guidance, universality, and group cohesiveness played an important role in improvement (Choi & Park, 2006). Conversely, Oie and Browne (2006) did not identify a relationship between group cohesiveness and better response to CBGT in patients with mood and anxiety disorders. In a recent study by our group, we observed that the rating of therapeutic factors by individuals with obsessive–compulsive disorder varied over the course of CBGT. At the end of 12 CBGT sessions, identification and instillation of hope (Behenck et al., 2016) were rated as the most important factors by that group of patients. Taken together, the findings of these previous studies suggest that specific therapeutic factors may play a different role in distinct disorders and, furthermore, may vary throughout therapy. However, the specific therapeutic factors that are meaningful for PD patients undergoing CBGT have not been studied. Cognitive–Behavioral Group Therapy for Panic Disorder PD is a common disease that presents a chronic course. This disorder is characterized by sudden anxiety attacks that involve feelings of fear and intense discomfort (tachycardia, feeling of choking, dizziness, and
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Please cite this article as: Behenck, A., et al., Contribution of Group Therapeutic Factors to the Outcome of Cognitive–Behavioral Therapy for Patients with Panic Disorder, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.09.001
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A. Behenck et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
fear of dying, going crazy, or losing control). Within minutes, this abrupt surge of fear and discomfort reaches peak intensity. Panic attacks are usually followed by anticipatory anxiety (fear of suffering a new attack and/or persistent concern about the consequences of symptoms) and phobic avoidance (avoidance of places or situations associated with a previous panic attack) (American Psychiatric Association, 2014). Cognitive–behavioral therapy (CBT) is an effective first-choice treatment for PD. CBT is a relatively brief intervention (around 12 to 20 sessions) that relies on psychoeducation, cognitive restructuring, and modification of maladaptive behaviors (Manfro, Heldt, Cordioli, & Otto, 2008). Studies have shown a positive response to CBGT, with large effect size for overall symptom improvement in patients with PD (Heldt et al., 2006; Wesner, Gomes, Detzel, Guimarães, & Heldt, 2015). However, group therapeutic factors were not evaluated in these studies. The relevance of investigating the usefulness of therapeutic factors that are intrinsic to group therapy in the treatment of mental disorders arises from the possibility of guiding therapists to work out effective strategies to improve therapeutic responses (Cox, Vinogradov, & Yalom, 2012). Knowledge regarding the role of therapeutic factors is useful for nurses specializing in mental health, who must rely on evidencebased approaches and interventions to deal with different mental disorders (Hein & Scharer, 2015). However, as seen in a recent review, little research is available on the use of cognitive–behavioral strategies by nurses (Carvalho & Moncaio, 2010). Considering this scenario, the present study aimed to identify the therapeutic factors that emerge as useful according to patient perception during cognitive–behavioral group therapy (CBGT) sessions for panic disorder (PD). Also, we aimed to investigate the relationship between patient rating of therapeutic factors and specific stages of CBGT. METHODS We carried out an uncontrolled clinical trial of a 12-session CBGT intervention for PD. The study was approved by the Research Ethics Committee of Hospital de Clínicas de Porto Alegre (HCPA; no. CAAE: 20224513.1.0000.5327) and all participants signed an informed consent form prior to the start of CBGT. Participants Patients attending the Anxiety Disorders Program (PROTAN) at HCPA were consecutively invited to join the study between August 2013 and July 2014. Inclusion criteria were age between 18 and 65 years, diagnosis of PD with or without comorbid agoraphobia (American Psychiatric Association, 2014), being literate, no use of medication or in stable use to treat PD for at least four months prior to the study. Patients with psychotic symptoms, at risk of suicide, or presenting severe depression (defined as Beck Depression Inventory scores ≥30) were excluded. Of 29 patients evaluated for the study, nine did not meet inclusion criteria. Of the 20 patients initially enrolled in CBGT, four dropped out (two were unable to accommodate the schedule and two quit). Intervention Twelve weekly 90-min sessions of CBGT were carried out using psychoeducation, coping techniques for anxiety, cognitive restructuring, interoceptive and naturalistic exposure, and live exposure to avoided situations (Heldt, Cordioli, Knijnik, & Manfro, 2008). The groups were coordinated by two nurses (therapist and cotherapist) who are experts in mental health and who had previous experience with CBGT. The initial sessions of CBGT focused on cognitive understanding of fear and learning of techniques to deal with anxiety (muscle relaxation and diaphragmatic breathing). Subsequent sessions focused on automatic thoughts and explored the identification and evaluation of
evidence against or in favor of catastrophic interpretations. Interoceptive exposure was carried out during the intermediate phase of treatment, simulating physical symptoms. At the end of the protocol, live exposure to avoided situations was gradually introduced. The final sessions addressed management of relapse, which may occur after the end of treatment (Heldt et al., 2008). Instruments Patients were individually assessed before the start of the intervention. A 50-min interview was conducted by nurses specializing in mental health and by a psychologist to collect sociodemographic data. The Mini International Neuropsychiatric Interview (MINI) (Amorim, 2000) was used in order to confirm the diagnosis of PD and to investigate the presence of comorbidities. In addition, four symptom assessment instruments were applied before and after the completion of the 12 CBGT sessions. PD severity and treatment response were assessed using the Panic Disorder Severity Scale (PDSS) (Shear et al., 1997), a 7-item instrument that takes into consideration the intensity and frequency of panic attacks, degree of anticipatory anxiety and anxiety sensitivity, level of phobic avoidance, and social and professional impairment. The PDSS is especially sensitive to diagnose PD in patients presenting agoraphobia (99%) (Levitan et al., 2012). In the present study, PDSS scores were evaluated as a continuous variable. The Hamilton Scale for Anxiety (HAM-A) uses 14 items to determine the intensity of anxiety, ranging from absent (0) to maximum intensity (4) (Hamilton, 1959). This scale has been translated to Brazilian Portuguese and is widely used in studies evaluating anxiety symptoms (Ito & Ramos, 1998). The Beck Depression Inventory (BDI) is a self-report instrument with a validated version in Brazilian Portuguese (Gorenstein & Andrade, 1996). The BDI aims at identifying and quantifying mild, moderate, and severe depression. Both instruments have shown good psychometric properties, with Cronbach's alpha ranging from 0.82 to 0.92 for HAM-A (Shear et al., 2001) and 0.79 to 0.91 for BDI (Gorenstein & Andrade, 1996). The Clinical Global Impressions (CGI) scale is used to determine the global severity of disease (Guy, Hergueta, Baker, & Dunbar, 1998), with scores ranging from 1 (normal, not ill) to 7 (extremely ill). GCI is a wellestablished research-rating tool applicable to all psychiatric disorders (Heldt et al., 2006; Wesner et al., 2015). At the end of each of the 12 CGBT sessions, patients answered the Brazilian Portuguese (Yalom & Leszcz, 2006) version of the Yalom's Curative Factors Questionnaire, a self-report instrument including 60 questions through which patients evaluate therapeutic factors. The following therapeutic factors were rated: instillation of hope, universality, imparting information/guidance, altruism, corrective recapitulation of the primary family group (family reenactment), interpersonal learning/output, identification, interpersonal learning/input, group cohesiveness, catharsis, existential factors, and self-understanding. For each therapeutic factor, five items are rated with a 1 to 7-point scale, yielding a minimum score of 5 and a maximum score of 35 points (most positive rating). The questionnaire has good internal consistency, with Cronbach's alpha =0.98 (Behenck et al., 2016). Data Analysis The Statistical Package for the Social Sciences (SPSS) v. 20.0 was used. The level of significance was α = 0.05 with 95% confidence interval (95% CI). Continuous variables were expressed as mean ± standard deviation (SD) or standard error (SE). Categorical variables were expressed as absolute and relative frequency (percentage). Student's t test for paired samples was used to determine the response to CBGT, with effect size (ES) measured through Cohen's d. Evaluation of therapeutic factors in each session was performed using generalized estimating equations (GEE).
Please cite this article as: Behenck, A., et al., Contribution of Group Therapeutic Factors to the Outcome of Cognitive–Behavioral Therapy for Patients with Panic Disorder, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.09.001
A. Behenck et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx Table 1 Severity of Symptoms of Panic Disorder Before and After CBGT. Symptom severity
Global Clinical Impression (GCI) Panic Disorder Severity Scale (PDSS) Hamilton Anxiety (HAM-A) Beck Depression Inventory (BDI)
CBGT Before
After
4.5 (1.31) 15.1 (6.41) 30.6 (11.48) 19.3 (10.56)
2.4 (1.15) 4.75 (3.94) 11.8 (6.86) 8.5 (5.56)
p⁎
ES⁎⁎
b0.001 b0.001 b0.001 0.002
1.55 1.74 1.47 0.93
NOTE. Continuous variables were expressed as means and standard deviation (SD). CBGT, cognitive–behavioral group therapy; ES, effect size. ⁎ Dependent t test p b 0.05. ⁎⁎ Effect size (Cohen's formula).
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again in the 10th and 11th sessions, when the confrontation of feared situations takes place. A similar pattern was observed for the guidance factor. Rating of the identification factor was particularly high in the 7th and 8th sessions, during interoceptive exposure, and at the last session. In regard to the family reenactment factor, higher ratings were recorded in the 1st and 2nd sessions in relation to subsequent sessions, and then again a gradual increase happened from the 5th through the 7th sessions, when participants work with the group on catastrophic beliefs. The self-understanding factor was more prominent in the 4th and 5th sessions, when members begin to understand and identify automatic thoughts. The rating of existential and altruism factors increased gradually and markedly in the 11th and 12th sessions.
RESULTS DISCUSSION Sixteen patients enrolled in two CBGT groups (eight participants in each group) completed the protocol. Mean age was 36.2 years (SD = 9.98; range: 22–58 years), and 10 patients (62%) were female. Eight patients (50%) had higher levels of education, 12 (75%) reported having a partner, and 9 (56%) had some kind of occupation. Regarding clinical characteristics, 11 (69%) had at least one comorbidity with other anxiety disorders (generalized anxiety, social anxiety, and post-traumatic disorder) and 7 (44%) with a mood disorder (current depression, dysthymia, and bipolar disorder). At the time of study entrance, 11 (69%) patients used antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and/or tricyclic antidepressant, and half of the sample also used benzodiazepines. Thirteen participants (81%) reported having had individual psychotherapy previously. The response to CBGT was evaluated through symptom improvement (Table 1). According to the analysis, significant improvement was observed in CGI, PDSS, HAM-A, and BDI scores after CBGT, with a large effect size. Assessment of Therapeutic Factors in CBGT For evaluation of therapeutic factors, 192 assesments completed using Yalom's Curative Factors Questionnaire at the end of 12 CBGT sessions were analyzed. Patient rating of therapeutic factors varied in the course of CBGT, as shown in Table 2. The rating of the following factors increased significantly with time: altruism, interpersonal learning/ input, guidance, identification, self-understanding, family reenactment, and existential factors. A trend for significance was observed for instillation of hope (p = 0.065). The rating of therapeutic factors was different at different stages of CBGT (Fig. 1). For example, the rating of interpersonal learning/input increased in the 4th session, when cognitive techniques began, and then
The results of this study confirm the efficacy of CBGT for PD treatment (Heldt et al., 2006; Wesner et al., 2015). We also observed that the rating of therapeutic factors varied throughout the sessions; different combinations of factors seemed to operate at different stages of CBGT, with impact on cognition, emotion, and/or behavior. Understanding the mechanisms associated with therapeutic factors may help therapists maximize the effectiveness of interventions (Yalom & Leszcz, 2006). In the the early sessions, we observed an increase in the rating of the existential factor, which is concerned with life and its meaning. Particularly in PD patients, fear of dying is an aspect that determines avoidant situations, as an unadapted way of preventing other panic attacks (American Psychiatric Association, 2014; Manfro et al., 2008). Because all members understood and shared the meaning of this fear, the group environment might have been perceived as a welcoming and warm place to treat important issues related to life with PD, allowing a better understanding of reality vs. symptoms. In fact, anxiety usually increases at the beginning of therapeutic processes, and the set of therapeutic factors identified as the most useful at this stage can strengthen bonds and prevent patients from leaving the group (Yalom & Leszcz, 2006). In the intermediate phase, we observed a significant increase in the rating of altruism, self-understanding, and guidance, especially from the 4th to the 6th session. At this stage of CBGT, cognitive aspects such as the recognition of automatic thoughts and correction of distortion are emphasized using techniques that include Socratic questioning and decatastrophizing (Heldt et al., 2008). Having patients recognize their own thoughts and assist other members in identifying distortions, through the employment of cognitive tools, possibly contributes to the increased rating of the three factors mentioned (Yalom & Leszcz, 2006). When interoceptive exposure begins (exposure to panic symptoms intentionally aroused during the sessions), at the 6th and 7th
Table 2 Group Therapeutic Factors with Significantly Increased Rating over the Course of CBGT. Therapeutic factors
Mean (EP)⁎
IC 95%
B⁎⁎
Minimum–Maximum Altruism Cohesiveness Universality Interpersonal learning Input Output Guidance Catharsis Identification Family reenactment Self-understanding Instillation of hope Existential factors
P-value Time
Interaction
21.6 (1.35) 25.3(1.18) 24.1(0.95)
[18.9–24.2] [22.9–27.6] [22.2–26.0]
0.288 0.062 0.147
b0.001 b0.001 b0.001
0.006 0.555 0.148
17.3(1.49) 22.4(1.43) 19.5(1.69) 23.3(0.89) 16.6(1.44) 18.8(1.60) 22.6(1.31) 25.0(1.53) 22.3(1.63)
[14.4–20.2] [19.5–25.2] [16.1–22.8] [21.6–25.1] [13.8–19.8] [15.3–21.6] [19.7–24.8] [22.0–28.0] [19.5–25.9]
0.347 0.078 0.372 0.165 0.406 0.325 0.258 0.288 0.292
b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001
0.005 0.548 0.010 0.182 0.006 0.034 0.008 0.065 0.030
NOTE. SE, standard error; CI, confidence interval. ⁎ Mean (SE) of Yalom Questionnaire scores completed after each of the 12 sessions. ⁎⁎ Data analysis: Generalized Estimating Equations (GEE).
Please cite this article as: Behenck, A., et al., Contribution of Group Therapeutic Factors to the Outcome of Cognitive–Behavioral Therapy for Patients with Panic Disorder, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.09.001
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A. Behenck et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
Fig. 1. Therapeutic factors with significantly increased rating over 12 CBGT sessions for panic disorder.
sessions, we again noted an increase in the rating of factors such as identification and family reenactment. At this stage, participants observe each other during the performance of exposure exercises, also practiced by therapists (Heldt et al., 2008). Through identification, patients shape their behavior and are able to experience new, more adaptive ways of thinking and acting. Especially through mirroring exercises, the group setting has higher potential than individual therapy (White & Freeman, 2003). The rating of existential factor, guidance, and interpersonal learning/ input increased again in the final stage, between the 9th and the 11th sessions. At this stage, the implementation of gradual exposure of live avoided situations has begun (Heldt et al., 2008). The factors that were considered as the most useful at this stage promote interpersonal integration among members, adding greater support for dealing with the difficulties that are characteristic of hierarchical exposure situations (White & Freeman, 2003). The role of the guidance factor, which helps patients cope with their disease using therapist suggestions or guidelines as well as the suggestions made by other group members seems especially important (Yalom & Leszcz, 2006).
The rating of instillation of hope increased gradually, with a trend toward statistical significance, especially from the 9th to the 10th session and at the 12th session. At this stage, members combine tasks to enact exposures to the avoided situations, with intense exchange of experiences and learning (Heldt et al., 2008). A fundamental aspect in these sessions is the recognition of what each member was able to accomplish, even if the objectives were not fully achieved. At the last session, the group usually expresses a high level of hope. This can be attributed to the fact that patients see the improvement of other patients, which promotes the feeling of being capable of facing fears and allows patients to become aware that they can take their own time to improve, despite the end of the CBGT (Heldt et al., 2008). Therapeutic factors universality, catharsis, interpersonal learning/ output, and cohesiveness did not change significantly during the sessions. Particularly regarding cohesiveness, a crucial condition for the success of therapy, reported by previous studies as an important factor in group therapy (Choi & Park, 2006; Santos, Oliveira, Munari, Peixoto, & Barbosa, 2012), we can infer that the brief duration of our CBGT protocol was not enough to capture an impact of this factor.
Please cite this article as: Behenck, A., et al., Contribution of Group Therapeutic Factors to the Outcome of Cognitive–Behavioral Therapy for Patients with Panic Disorder, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.09.001
A. Behenck et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
Limitations Some limitations of the present study need to be considered. The absence of a control group and the small sample size may have compromised statistical power, and patient rating of therapeutic effects over a short period of time may have led to systematized responses. Nevertheless, the relatively high number of assessments completed by the patients (total of 192) and used to analyze the role of therapeutic factors at different stages of CBGT (a major objective of our study) served to counterbalance these shortcomings to some extent. Also, even though we focused on a specific age group (adults), the broad age range of participants (22 to 58 years) may limit the generalization of the present results, given the possibility of differences in cognitive and emotional status between younger and older adults. Thus, future studies should focus on narrower age ranges. However, this is the first study of its kind, and as such it is relevant for the clinical practice of mental health professionals. CONCLUSIONS The present results show that therapeutic factors are dynamic and interdependent. Therefore, recognizing the impact of these factors during CBGT will potentially contribute to a better understanding of the therapeutic process and enable maximization of group therapy outcomes. CBT in group format provides an environment that facilitates experimentation of new and more adaptive behaviors and contributes to the correction of cognitive distortions. This process of change is enhanced by the synergy with therapeutic factors, such as identification and self-understanding. Each member of the group serves as a model for others, and new behaviors can be tried and tested in order to develop possible solutions. Thus, the group enables identification of adaptive behaviors that are validated by other group members and by the therapist. Moreover, the identification and recognition of therapeutic factors may be useful to overcome the increased anxiety in the first sessions, and also to foster group exchanges, decrease pressure, and support the change in behaviors especially in intermediate and final CBGT sessions. CBGT is not yet widely employed in the context of Brazilian mental health care. One possible reason for this is the lack of professionals specializing in this type of treatment, including nurses. However, there is an increasing demand for mental health services and professionals in Brazil, especially in public institutions, and group therapy may be a cost-effective way to provide quality mental health care to a larger number of patients. As observed in other countries, nurses – who are well positioned at the forefront of patient care – are especially apt for training and application of CBGT. Future research should focus on randomized clinical trials developed with specific age groups to explore the role of group therapeutic factors in the success of CBGT. References American Psychiatric Association (2014). DSM-5: Manual diagnóstico e estatístico de transtornos mentais (5a ed.). Porto Alegre: Artmed.
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Amorim, P (2000). Mini International Neuropsychiatric Interview (MINI): Validation of a short structured diagnostic psychiatric interview. Revista Brasileira de Psiquiatria, 22(3), 106–115. Behenck, AS, Gomes, JB, & Heldt, E (2016). Patient rating of therapeutic factors and response to cognitive–behavioral group therapy in patients with obsessive– compulsive disorder. Issues in Mental Health Nursing. http://dx.doi.org/10.3109/ 01612840.2016.1158335. Carvalho, EC, & Moncaio, ACS (2010). Behavioral changes as a nursing care strategy: An integrative review. Revista Mineira de Enfermagem, 14(1), 110–118. Choi, YH, & Park, KH (2006). Therapeutic factors of cognitive behavioral group treatment for social phobia. Journal of Korean Medical Science, 21(2), 333–336. http://dx.doi.org/ 10.3346/jkms.2006.21.2.333. Cox, P, Vinogradov, S, & Yalom, I (2012). Terapia de grupo. In R. Hales, S. Yudofsky, & G. Gabbardd (Eds.), Tratado de psiquiatria clínica (pp. 1370–1415) (5ª ed.). Porto Alegre: Artmed. Gorenstein, C, & Andrade, L (1996). Validation of a Portuguese version of the Beck Depression Inventory and the State–Trait Anxiety Inventory in Brazilian subjects. Brazilian Journal of Medical and Biological Research, 29(4), 453–457. Guy, W, Hergueta, T, Baker, R, & Dunbar, G (1998). Clinical global impressions. In E. A. M. f. Psychopharmacology (Ed.), CGI (1976 ed.). Rockville (MD): US National Institute of Health, Psychopharmacology Research Branch. Hamilton, M (1959). The assessment of anxiety states by rating. The British Journal of Medical Psychology, 32(1), 50–55. Hein, LC, & Scharer, KM (2015). A modern history of psychiatric-mental health nursing. Archives of Psychiatric Nursing, 29(1), 49–55. http://dx.doi.org/10.1016/j.apnu.2014. 10.003. Heldt, E, Cordioli, AV, Knijnik, DZ, & Manfro, GG (2008). Terapia cognitivocomportamental em grupo para transtornos de ansiedade. In A. V. Cordioli (Ed.), Psicoterapias: Abordagens atuais (pp. 317–340) (3ª ed.). Porto Alegre: Artmed. Heldt, E, Gus Manfro, G, Kipper, L, Blaya, C, Isolan, L, & Otto, MW (2006). One-year followup of pharmacotherapy-resistant patients with panic disorder treated with cognitive–behavior therapy: Outcome and predictors of remission. Behaviour Research and Therapy, 44(5), 657–665. http://dx.doi.org/10.1016/j.brat.2005.05.003. Ito, LM, & Ramos, RT (1998). Escalas de avaliação clínica: Transtorno de pânico. Revista de Psiquiatria Clínica, 25(6), 294–302. Levitan, M, Chagas, M, Linares, I, Crippa, J, Terra, M, Giglio, A, & Nardi, A (2012). Transtorno do pânico: Diagnóstico. Associação Médica Brasileira (http://www. projetodiretrizes.org.br/diretrizes11/transtorno_do_panico.pdf. Accessed: 15.10.11). Manfro, GG, Heldt, E, Cordioli, AV, & Otto, MW (2008). Cognitive–behavioral therapy in panic disorder. Revista Brasileira de Psiquiatria, 30(Suppl. 2), s81–s87. http://dx.doi. org/10.1590/S1516-44462008000600005. Oie, TPS, & Browne, A (2006). Components of group processes: Have they contributed to the outcome of mood and anxiety disorder patientes in group cognitive–behaviour therapy program? American Journal of Psychotherapy, 60(1), 53–70. Santos, LF, Oliveira, LMAC, Munari, DB, Peixoto, MKAV, & Barbosa, MA (2012). Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paulista de Enfermagem, 25(1), 122–127. http://dx.doi.org/10.1590/S010321002012000100021. Shear, MK, Brown, TA, Barlow, DH, Money, R, Sholomskas, DE, Woods, SW, & Papp, LA (1997). Multicenter collaborative panic disorder severity scale. The American Journal of Psychiatry, 154(11), 1571–1575. http://dx.doi.org/10.1176/ajp.154.11.1571. Shear, MK, Vander Bilt, J, Rucci, P, Endicott, J, Lydiard, B, Otto, MW, & Frank, DM (2001). Reliability and validity of a structured interview guide for the Hamilton anxiety rating scale (SIGH-A). Depression and Anxiety, 13(4), 166–178. Taube - Schiff, M, Suvak, MK, Antony, MM, Bieling, PJ, & McCabe, RE (2007). Group cohesiveness in cognitive–behavioral group therapy for social phobia. Behaviour Research and Therapy, 45(4), 687–698. http://dx.doi.org/10.1016/j. brat.2006.06.004. Wesner, AC, Gomes, JB, Detzel, T, Guimarães, LS, & Heldt, E (2015). Booster sessions after cognitive–behavioural group therapy for panic disorder: Impact on resilience, coping, and quality of life. Behavioural and Cognitive Psychotherapy, 43(5), 513–525. http://dx. doi.org/10.1017/S1352465814000289. White, JR, & Freeman, AS (2003). Terapia cognitivo-comportamental para populações e problemas específicos. São Paulo: Roca. Yalom, ID, & Leszcz, M (2006). Psicoterapia de grupo: Teoria e prática (5ª ed.). Porto Alegre: Artmed.
Please cite this article as: Behenck, A., et al., Contribution of Group Therapeutic Factors to the Outcome of Cognitive–Behavioral Therapy for Patients with Panic Disorder, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.09.001
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Archives of Psychiatric Nursing journal homepage: www.elsevier.com/locate/apnu
Contribution of Group Therapeutic Factors to the Outcome of Cognitive– Behavioral Therapy for Patients with Panic Disorder Andressa Behenck a,b, Ana Cristina Wesner a, Débora Finkler b, Elizeth Heldt a,b,⁎ a b
Graduate Program in Nursing, School of Nursing, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil Anxiety Disorders Program, Hospital de Clínicas de Porto Alegre, RS, Brazil
a b s t r a c t Background: Investigating the contribution of therapeutic factors arising from the collective nature or group therapy to treat mental disorders may help therapists maximize the outcome of therapy. Studies about the role of therapeutic factors in cognitive–behavioral group therapy (CBGT) for panic disorder (PD) patients are still scarce. Objectives: To identify the therapeutic factors rated as the most useful by patients during CBGT. Also, we aimed to investigate the relationship between patient rating of therapeutic factors and specific stages of CBGT. Design: Non-controlled clinical trial. Methods: A 12-session CBGT protocol was set up, covering psychoeducation, techniques for anxiety coping, cognitive restructuring, interoceptive and naturalistic exposure, and live exposure to avoidant behavior. PD symptom severity was assessed before and after the CBGT protocol. Yalom's Curative Factors Questionnaire was self-administered at the end of each session to evaluate the 12 therapeutic factors. Results: The sample consisted of 16 patients, who produced 192 assessments of therapeutic factors. Severity of symptoms improved at the end of CBGT, with a large effect size (N1.0). Different ratings were attributed to therapeutic factors at different phases of CBGT. Seven factors were rated as significantly helpful: altruism, interpersonal learning/input, guidance, identification, family reenactment, self-understanding, and existential factors. Conclusions: Therapeutic factors are dynamic and interdependent. Therefore, recognizing the impact of these factors during CBGT may potentially contribute to a better understanding of the therapeutic process. © 2016 Elsevier Inc. All rights reserved.
The therapeutic process of therapy groups is complex and arises from the interaction among participants and from the sharing of experiences, both of which promote change (Yalom & Leszcz, 2006). Therapy groups have several characteristic factors that are considered therapeutic because they facilitate the learning of new behaviors and thoughts. Thus, in addition to the specific techniques used by professionals to treat mental disorders, group therapeutic factors may in and of themselves be an instrument of change (Behenck, Gomes, & Heldt, 2016). GROUP THERAPEUTIC FACTORS Yalom and Leszcz (2006) have proposed a set of 12 therapeutic factors, all of which are related to the interaction among participants in the therapeutic group: altruism, group cohesiveness, universality, interpersonal learning/input, interpersonal learning/output, guidance, catharsis, identification, family reenactment, self-understanding, instillation of hope, and corrective recapitulation of existential factors. Previous studies with CBGT have shown a positive contribution of therapeutic factors to the outcomes of therapy. For example, it was found that group Conflict of interest: The authors report no conflicts of interest. ⁎ Corresponding Author: Elizeth Heldt, Ph.D., School of Nursing/UFRGS, São Manoel, 963–Porto Alegre, RS, Brazil, 90620-110. E-mail addresses: [email protected], [email protected] (E. Heldt).
cohesiveness contributes to the improvement of patients with social phobia (Taube-Schiff, Suvak, Antony, Bieling, & McCabe, 2007). Another study focusing on CBGT for social phobia showed that interpersonal learning-output, guidance, universality, and group cohesiveness played an important role in improvement (Choi & Park, 2006). Conversely, Oie and Browne (2006) did not identify a relationship between group cohesiveness and better response to CBGT in patients with mood and anxiety disorders. In a recent study by our group, we observed that the rating of therapeutic factors by individuals with obsessive–compulsive disorder varied over the course of CBGT. At the end of 12 CBGT sessions, identification and instillation of hope (Behenck et al., 2016) were rated as the most important factors by that group of patients. Taken together, the findings of these previous studies suggest that specific therapeutic factors may play a different role in distinct disorders and, furthermore, may vary throughout therapy. However, the specific therapeutic factors that are meaningful for PD patients undergoing CBGT have not been studied. Cognitive–Behavioral Group Therapy for Panic Disorder PD is a common disease that presents a chronic course. This disorder is characterized by sudden anxiety attacks that involve feelings of fear and intense discomfort (tachycardia, feeling of choking, dizziness, and
http://dx.doi.org/10.1016/j.apnu.2016.09.001 0883-9417/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Behenck, A., et al., Contribution of Group Therapeutic Factors to the Outcome of Cognitive–Behavioral Therapy for Patients with Panic Disorder, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.09.001
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A. Behenck et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
fear of dying, going crazy, or losing control). Within minutes, this abrupt surge of fear and discomfort reaches peak intensity. Panic attacks are usually followed by anticipatory anxiety (fear of suffering a new attack and/or persistent concern about the consequences of symptoms) and phobic avoidance (avoidance of places or situations associated with a previous panic attack) (American Psychiatric Association, 2014). Cognitive–behavioral therapy (CBT) is an effective first-choice treatment for PD. CBT is a relatively brief intervention (around 12 to 20 sessions) that relies on psychoeducation, cognitive restructuring, and modification of maladaptive behaviors (Manfro, Heldt, Cordioli, & Otto, 2008). Studies have shown a positive response to CBGT, with large effect size for overall symptom improvement in patients with PD (Heldt et al., 2006; Wesner, Gomes, Detzel, Guimarães, & Heldt, 2015). However, group therapeutic factors were not evaluated in these studies. The relevance of investigating the usefulness of therapeutic factors that are intrinsic to group therapy in the treatment of mental disorders arises from the possibility of guiding therapists to work out effective strategies to improve therapeutic responses (Cox, Vinogradov, & Yalom, 2012). Knowledge regarding the role of therapeutic factors is useful for nurses specializing in mental health, who must rely on evidencebased approaches and interventions to deal with different mental disorders (Hein & Scharer, 2015). However, as seen in a recent review, little research is available on the use of cognitive–behavioral strategies by nurses (Carvalho & Moncaio, 2010). Considering this scenario, the present study aimed to identify the therapeutic factors that emerge as useful according to patient perception during cognitive–behavioral group therapy (CBGT) sessions for panic disorder (PD). Also, we aimed to investigate the relationship between patient rating of therapeutic factors and specific stages of CBGT. METHODS We carried out an uncontrolled clinical trial of a 12-session CBGT intervention for PD. The study was approved by the Research Ethics Committee of Hospital de Clínicas de Porto Alegre (HCPA; no. CAAE: 20224513.1.0000.5327) and all participants signed an informed consent form prior to the start of CBGT. Participants Patients attending the Anxiety Disorders Program (PROTAN) at HCPA were consecutively invited to join the study between August 2013 and July 2014. Inclusion criteria were age between 18 and 65 years, diagnosis of PD with or without comorbid agoraphobia (American Psychiatric Association, 2014), being literate, no use of medication or in stable use to treat PD for at least four months prior to the study. Patients with psychotic symptoms, at risk of suicide, or presenting severe depression (defined as Beck Depression Inventory scores ≥30) were excluded. Of 29 patients evaluated for the study, nine did not meet inclusion criteria. Of the 20 patients initially enrolled in CBGT, four dropped out (two were unable to accommodate the schedule and two quit). Intervention Twelve weekly 90-min sessions of CBGT were carried out using psychoeducation, coping techniques for anxiety, cognitive restructuring, interoceptive and naturalistic exposure, and live exposure to avoided situations (Heldt, Cordioli, Knijnik, & Manfro, 2008). The groups were coordinated by two nurses (therapist and cotherapist) who are experts in mental health and who had previous experience with CBGT. The initial sessions of CBGT focused on cognitive understanding of fear and learning of techniques to deal with anxiety (muscle relaxation and diaphragmatic breathing). Subsequent sessions focused on automatic thoughts and explored the identification and evaluation of
evidence against or in favor of catastrophic interpretations. Interoceptive exposure was carried out during the intermediate phase of treatment, simulating physical symptoms. At the end of the protocol, live exposure to avoided situations was gradually introduced. The final sessions addressed management of relapse, which may occur after the end of treatment (Heldt et al., 2008). Instruments Patients were individually assessed before the start of the intervention. A 50-min interview was conducted by nurses specializing in mental health and by a psychologist to collect sociodemographic data. The Mini International Neuropsychiatric Interview (MINI) (Amorim, 2000) was used in order to confirm the diagnosis of PD and to investigate the presence of comorbidities. In addition, four symptom assessment instruments were applied before and after the completion of the 12 CBGT sessions. PD severity and treatment response were assessed using the Panic Disorder Severity Scale (PDSS) (Shear et al., 1997), a 7-item instrument that takes into consideration the intensity and frequency of panic attacks, degree of anticipatory anxiety and anxiety sensitivity, level of phobic avoidance, and social and professional impairment. The PDSS is especially sensitive to diagnose PD in patients presenting agoraphobia (99%) (Levitan et al., 2012). In the present study, PDSS scores were evaluated as a continuous variable. The Hamilton Scale for Anxiety (HAM-A) uses 14 items to determine the intensity of anxiety, ranging from absent (0) to maximum intensity (4) (Hamilton, 1959). This scale has been translated to Brazilian Portuguese and is widely used in studies evaluating anxiety symptoms (Ito & Ramos, 1998). The Beck Depression Inventory (BDI) is a self-report instrument with a validated version in Brazilian Portuguese (Gorenstein & Andrade, 1996). The BDI aims at identifying and quantifying mild, moderate, and severe depression. Both instruments have shown good psychometric properties, with Cronbach's alpha ranging from 0.82 to 0.92 for HAM-A (Shear et al., 2001) and 0.79 to 0.91 for BDI (Gorenstein & Andrade, 1996). The Clinical Global Impressions (CGI) scale is used to determine the global severity of disease (Guy, Hergueta, Baker, & Dunbar, 1998), with scores ranging from 1 (normal, not ill) to 7 (extremely ill). GCI is a wellestablished research-rating tool applicable to all psychiatric disorders (Heldt et al., 2006; Wesner et al., 2015). At the end of each of the 12 CGBT sessions, patients answered the Brazilian Portuguese (Yalom & Leszcz, 2006) version of the Yalom's Curative Factors Questionnaire, a self-report instrument including 60 questions through which patients evaluate therapeutic factors. The following therapeutic factors were rated: instillation of hope, universality, imparting information/guidance, altruism, corrective recapitulation of the primary family group (family reenactment), interpersonal learning/output, identification, interpersonal learning/input, group cohesiveness, catharsis, existential factors, and self-understanding. For each therapeutic factor, five items are rated with a 1 to 7-point scale, yielding a minimum score of 5 and a maximum score of 35 points (most positive rating). The questionnaire has good internal consistency, with Cronbach's alpha =0.98 (Behenck et al., 2016). Data Analysis The Statistical Package for the Social Sciences (SPSS) v. 20.0 was used. The level of significance was α = 0.05 with 95% confidence interval (95% CI). Continuous variables were expressed as mean ± standard deviation (SD) or standard error (SE). Categorical variables were expressed as absolute and relative frequency (percentage). Student's t test for paired samples was used to determine the response to CBGT, with effect size (ES) measured through Cohen's d. Evaluation of therapeutic factors in each session was performed using generalized estimating equations (GEE).
Please cite this article as: Behenck, A., et al., Contribution of Group Therapeutic Factors to the Outcome of Cognitive–Behavioral Therapy for Patients with Panic Disorder, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.09.001
A. Behenck et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx Table 1 Severity of Symptoms of Panic Disorder Before and After CBGT. Symptom severity
Global Clinical Impression (GCI) Panic Disorder Severity Scale (PDSS) Hamilton Anxiety (HAM-A) Beck Depression Inventory (BDI)
CBGT Before
After
4.5 (1.31) 15.1 (6.41) 30.6 (11.48) 19.3 (10.56)
2.4 (1.15) 4.75 (3.94) 11.8 (6.86) 8.5 (5.56)
p⁎
ES⁎⁎
b0.001 b0.001 b0.001 0.002
1.55 1.74 1.47 0.93
NOTE. Continuous variables were expressed as means and standard deviation (SD). CBGT, cognitive–behavioral group therapy; ES, effect size. ⁎ Dependent t test p b 0.05. ⁎⁎ Effect size (Cohen's formula).
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again in the 10th and 11th sessions, when the confrontation of feared situations takes place. A similar pattern was observed for the guidance factor. Rating of the identification factor was particularly high in the 7th and 8th sessions, during interoceptive exposure, and at the last session. In regard to the family reenactment factor, higher ratings were recorded in the 1st and 2nd sessions in relation to subsequent sessions, and then again a gradual increase happened from the 5th through the 7th sessions, when participants work with the group on catastrophic beliefs. The self-understanding factor was more prominent in the 4th and 5th sessions, when members begin to understand and identify automatic thoughts. The rating of existential and altruism factors increased gradually and markedly in the 11th and 12th sessions.
RESULTS DISCUSSION Sixteen patients enrolled in two CBGT groups (eight participants in each group) completed the protocol. Mean age was 36.2 years (SD = 9.98; range: 22–58 years), and 10 patients (62%) were female. Eight patients (50%) had higher levels of education, 12 (75%) reported having a partner, and 9 (56%) had some kind of occupation. Regarding clinical characteristics, 11 (69%) had at least one comorbidity with other anxiety disorders (generalized anxiety, social anxiety, and post-traumatic disorder) and 7 (44%) with a mood disorder (current depression, dysthymia, and bipolar disorder). At the time of study entrance, 11 (69%) patients used antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and/or tricyclic antidepressant, and half of the sample also used benzodiazepines. Thirteen participants (81%) reported having had individual psychotherapy previously. The response to CBGT was evaluated through symptom improvement (Table 1). According to the analysis, significant improvement was observed in CGI, PDSS, HAM-A, and BDI scores after CBGT, with a large effect size. Assessment of Therapeutic Factors in CBGT For evaluation of therapeutic factors, 192 assesments completed using Yalom's Curative Factors Questionnaire at the end of 12 CBGT sessions were analyzed. Patient rating of therapeutic factors varied in the course of CBGT, as shown in Table 2. The rating of the following factors increased significantly with time: altruism, interpersonal learning/ input, guidance, identification, self-understanding, family reenactment, and existential factors. A trend for significance was observed for instillation of hope (p = 0.065). The rating of therapeutic factors was different at different stages of CBGT (Fig. 1). For example, the rating of interpersonal learning/input increased in the 4th session, when cognitive techniques began, and then
The results of this study confirm the efficacy of CBGT for PD treatment (Heldt et al., 2006; Wesner et al., 2015). We also observed that the rating of therapeutic factors varied throughout the sessions; different combinations of factors seemed to operate at different stages of CBGT, with impact on cognition, emotion, and/or behavior. Understanding the mechanisms associated with therapeutic factors may help therapists maximize the effectiveness of interventions (Yalom & Leszcz, 2006). In the the early sessions, we observed an increase in the rating of the existential factor, which is concerned with life and its meaning. Particularly in PD patients, fear of dying is an aspect that determines avoidant situations, as an unadapted way of preventing other panic attacks (American Psychiatric Association, 2014; Manfro et al., 2008). Because all members understood and shared the meaning of this fear, the group environment might have been perceived as a welcoming and warm place to treat important issues related to life with PD, allowing a better understanding of reality vs. symptoms. In fact, anxiety usually increases at the beginning of therapeutic processes, and the set of therapeutic factors identified as the most useful at this stage can strengthen bonds and prevent patients from leaving the group (Yalom & Leszcz, 2006). In the intermediate phase, we observed a significant increase in the rating of altruism, self-understanding, and guidance, especially from the 4th to the 6th session. At this stage of CBGT, cognitive aspects such as the recognition of automatic thoughts and correction of distortion are emphasized using techniques that include Socratic questioning and decatastrophizing (Heldt et al., 2008). Having patients recognize their own thoughts and assist other members in identifying distortions, through the employment of cognitive tools, possibly contributes to the increased rating of the three factors mentioned (Yalom & Leszcz, 2006). When interoceptive exposure begins (exposure to panic symptoms intentionally aroused during the sessions), at the 6th and 7th
Table 2 Group Therapeutic Factors with Significantly Increased Rating over the Course of CBGT. Therapeutic factors
Mean (EP)⁎
IC 95%
B⁎⁎
Minimum–Maximum Altruism Cohesiveness Universality Interpersonal learning Input Output Guidance Catharsis Identification Family reenactment Self-understanding Instillation of hope Existential factors
P-value Time
Interaction
21.6 (1.35) 25.3(1.18) 24.1(0.95)
[18.9–24.2] [22.9–27.6] [22.2–26.0]
0.288 0.062 0.147
b0.001 b0.001 b0.001
0.006 0.555 0.148
17.3(1.49) 22.4(1.43) 19.5(1.69) 23.3(0.89) 16.6(1.44) 18.8(1.60) 22.6(1.31) 25.0(1.53) 22.3(1.63)
[14.4–20.2] [19.5–25.2] [16.1–22.8] [21.6–25.1] [13.8–19.8] [15.3–21.6] [19.7–24.8] [22.0–28.0] [19.5–25.9]
0.347 0.078 0.372 0.165 0.406 0.325 0.258 0.288 0.292
b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001
0.005 0.548 0.010 0.182 0.006 0.034 0.008 0.065 0.030
NOTE. SE, standard error; CI, confidence interval. ⁎ Mean (SE) of Yalom Questionnaire scores completed after each of the 12 sessions. ⁎⁎ Data analysis: Generalized Estimating Equations (GEE).
Please cite this article as: Behenck, A., et al., Contribution of Group Therapeutic Factors to the Outcome of Cognitive–Behavioral Therapy for Patients with Panic Disorder, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.09.001
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A. Behenck et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
Fig. 1. Therapeutic factors with significantly increased rating over 12 CBGT sessions for panic disorder.
sessions, we again noted an increase in the rating of factors such as identification and family reenactment. At this stage, participants observe each other during the performance of exposure exercises, also practiced by therapists (Heldt et al., 2008). Through identification, patients shape their behavior and are able to experience new, more adaptive ways of thinking and acting. Especially through mirroring exercises, the group setting has higher potential than individual therapy (White & Freeman, 2003). The rating of existential factor, guidance, and interpersonal learning/ input increased again in the final stage, between the 9th and the 11th sessions. At this stage, the implementation of gradual exposure of live avoided situations has begun (Heldt et al., 2008). The factors that were considered as the most useful at this stage promote interpersonal integration among members, adding greater support for dealing with the difficulties that are characteristic of hierarchical exposure situations (White & Freeman, 2003). The role of the guidance factor, which helps patients cope with their disease using therapist suggestions or guidelines as well as the suggestions made by other group members seems especially important (Yalom & Leszcz, 2006).
The rating of instillation of hope increased gradually, with a trend toward statistical significance, especially from the 9th to the 10th session and at the 12th session. At this stage, members combine tasks to enact exposures to the avoided situations, with intense exchange of experiences and learning (Heldt et al., 2008). A fundamental aspect in these sessions is the recognition of what each member was able to accomplish, even if the objectives were not fully achieved. At the last session, the group usually expresses a high level of hope. This can be attributed to the fact that patients see the improvement of other patients, which promotes the feeling of being capable of facing fears and allows patients to become aware that they can take their own time to improve, despite the end of the CBGT (Heldt et al., 2008). Therapeutic factors universality, catharsis, interpersonal learning/ output, and cohesiveness did not change significantly during the sessions. Particularly regarding cohesiveness, a crucial condition for the success of therapy, reported by previous studies as an important factor in group therapy (Choi & Park, 2006; Santos, Oliveira, Munari, Peixoto, & Barbosa, 2012), we can infer that the brief duration of our CBGT protocol was not enough to capture an impact of this factor.
Please cite this article as: Behenck, A., et al., Contribution of Group Therapeutic Factors to the Outcome of Cognitive–Behavioral Therapy for Patients with Panic Disorder, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.09.001
A. Behenck et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
Limitations Some limitations of the present study need to be considered. The absence of a control group and the small sample size may have compromised statistical power, and patient rating of therapeutic effects over a short period of time may have led to systematized responses. Nevertheless, the relatively high number of assessments completed by the patients (total of 192) and used to analyze the role of therapeutic factors at different stages of CBGT (a major objective of our study) served to counterbalance these shortcomings to some extent. Also, even though we focused on a specific age group (adults), the broad age range of participants (22 to 58 years) may limit the generalization of the present results, given the possibility of differences in cognitive and emotional status between younger and older adults. Thus, future studies should focus on narrower age ranges. However, this is the first study of its kind, and as such it is relevant for the clinical practice of mental health professionals. CONCLUSIONS The present results show that therapeutic factors are dynamic and interdependent. Therefore, recognizing the impact of these factors during CBGT will potentially contribute to a better understanding of the therapeutic process and enable maximization of group therapy outcomes. CBT in group format provides an environment that facilitates experimentation of new and more adaptive behaviors and contributes to the correction of cognitive distortions. This process of change is enhanced by the synergy with therapeutic factors, such as identification and self-understanding. Each member of the group serves as a model for others, and new behaviors can be tried and tested in order to develop possible solutions. Thus, the group enables identification of adaptive behaviors that are validated by other group members and by the therapist. Moreover, the identification and recognition of therapeutic factors may be useful to overcome the increased anxiety in the first sessions, and also to foster group exchanges, decrease pressure, and support the change in behaviors especially in intermediate and final CBGT sessions. CBGT is not yet widely employed in the context of Brazilian mental health care. One possible reason for this is the lack of professionals specializing in this type of treatment, including nurses. However, there is an increasing demand for mental health services and professionals in Brazil, especially in public institutions, and group therapy may be a cost-effective way to provide quality mental health care to a larger number of patients. As observed in other countries, nurses – who are well positioned at the forefront of patient care – are especially apt for training and application of CBGT. Future research should focus on randomized clinical trials developed with specific age groups to explore the role of group therapeutic factors in the success of CBGT. References American Psychiatric Association (2014). DSM-5: Manual diagnóstico e estatístico de transtornos mentais (5a ed.). Porto Alegre: Artmed.
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Please cite this article as: Behenck, A., et al., Contribution of Group Therapeutic Factors to the Outcome of Cognitive–Behavioral Therapy for Patients with Panic Disorder, Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.09.001