‘i've lost my husband, my house and i need a new knee … why should i smile?’: action...

‘I’ve lost my husband, my house and I need a new knee . . . why should Ismile?’: Action research evaluation of a group cognitive behaviouraltherapy program for older adults with depression

LISA RICHARDSON & CORINNE REID

School of Psychology, Murdoch University, Murdoch, Western Australia, Australia

AbstractThe current paper details an action research approach to developing and evaluating a group cognitive-behavioural therapy(CBT) program for older adults (65þ years) experiencing depression. This approach allowed the development of a novelprogram and for each component of the program to be evaluated and modified in an iterative, developmental fashion – aparticularly important, ethically responsive feature when working with vulnerable populations. Formative and summativeevaluations allowed the identification of beneficial, cohort-specific elements of an intervention without compromisingindividual wellbeing. A mixed methods data design was used to triangulate multiple and repeated quantitative and qualitativemeasures; in essence, a formalisation of usual clinical practice. The outcomes from the pilot study will be discussed in thecontext of a methodology that uniquely facilitates microanalytic research while maintaining therapeutic accountability,making replication and program accountability available to all clinicians.

Keywords: Action research, CBT, evaluation, group therapy, mixed method, older adult

Older adults represent a unique and vulnerable group

in mental health. They are impacted upon by

significant developmental changes when ageing

normally and may experience highly distressing

psychiatric conditions that require idiosyncratic

management strategies (Brodaty, Harris, Peters,

Boyce, & Hickie, 1993; Mulsant & Ganguli, 1999).

The gerontological clinical literature emphasises the

use of medications yet acknowledges the complica-

tions of physical decline and polypharmacy (Baldwin,

2002; Salzman, 2000; Wood, 2002). There are

relatively few existing studies of psychotherapeutic

approaches and these are beset by issues of patient

drop-out, lack of replication, relative lack of differ-

ence between theoretically diverse therapies and lack

of component evaluation (Dick, Gallagher-Thomp-

son, & Thompson, 1999; Eyesenck, 1994; Floyd &

Scogin, 1998; DeRubies et al., 1990). Moreover,

existing manualised mood programs are generally

written for young adults and the exercises and

examples are not culturally relevant (Free, 1999;

Yoshioka, 1999). Those that are specifically designed

for older adults are written for individuals rather than

for a group format (Gallagher & Thompson, 1982;

Thompson, Gallagher-Thompson, & Dick, 1992).

They are also quite long and thus likely to increase

drop-out rates in clinical populations (Shapiro et al.,

1994; Yost, Beutler, Corbishley, & Allender, 1986).

Thus, although cognitive-behavioural therapy (CBT)

is generally supported as an intervention model with

individual older adults, its efficacy as a brief, group

intervention is currently unresolved (Clijpers, 1998;

Gatz et al., 1998; Robinson, Berman, & Neimeyer,

1990; Woods & Roth, 1996).

The aims of the present study were twofold: to

develop, then evaluate, a brief group therapy mood

management program specifically for older adults. In

searching for an existing program to serve as a

framework, the authors encountered the problems

outlined above and little, other than post hoc

rationalisation, by way of explanation of these

variable outcomes (Greenburg & Newman, 1996;

Scogin & McElreath, 1994; Woods & Roth, 1996).

For progress to be made it seemed clear that a new

program would need to be developed and a micro-

analytic approach required to answer questions

regarding component effectiveness as the program

progressed.

Correspondence: C. Reid, School of Psychology, Murdoch University, Murdoch, WA 6150, Australia. E-mail: [email protected]

Clinical Psychologist, Vol. 10, No. 2, July 2006, pp. 60 – 66.

ISSN 1328-4207 print/ISSN 1742-9552 online ª The Australian Psychological Society Ltd

Published by Taylor & Francis

DOI: 10.1080/13284200600690453

Such microanalysis required a fluid approach to

emergent problems. Action research is one such

dynamic research design offering opportunities to

evaluate components of the program as it progresses

(formative evaluation) and to evaluate the effective-

ness of the program after it is completed (summative

evaluation) (Power, Dale, & Jones 1991; Sharp &

Frechtling, 1997). It is a model that is ideally suited to

research that is formative and quasi-experimental in

nature, and incorporates a cycle of action, reflection,

hypothesis generation, data collection/action and

analysis/reflection again. Although this cycle of

‘‘research activities’’ is similar to those of conven-

tional experimental research in human sciences,

action research differs by its accommodation of

contextual information, experiential reflection, and

shared boundaries between participants and re-

searchers as valuable data reflecting ‘‘the real

world’’ rather than as contaminating variables or bias

that need to be controlled (Wadsworth, 1998). While

the participant status of the researcher potentially

compromises objectivity, it offers expert opportunity

for noting unexpected and fortuitous outcomes from

the perspectives of both the participants and facil-

itators (Collins, Murphy, & Bierman, 2004).

The case study approach used in action research in

conjunction with the real-time capture of data and the

iterative use of that data in a program development

feedback loop, makes it most suitable for use in testing

an innovative program with vulnerable client groups

(Davey, 1991). In constantly monitoring the effective-

ness of each session for each client, and being respon-

sive in weekly session planning, this approach is

ethically responsible and clinically accountable (Bar-

nett et al., 1999; Woolley, Butler, & Wampler, 2000).

Hence, this paper will focus, not on the program

alone, but on describing an innovative approach to

evaluating intervention programs that is accessible to

the ordinary practitioner. Through both formative

and summative evaluation, this approach has helped

us unpick the elements of an intervention that might

hold promise for particular groups of older parti-

cipants (aged 65 and above). The process and

outcomes of this journey will be discussed below,

and are organised thematically around clinically

relevant issues. We hope that this takes us one step

closer to fulfilling our professional responsibilities as

scientist – practitioners. The salient parameters of

this 12-week CBT group therapy program will be

illuminated as the discussion progresses.

Accountability

In applied settings, the demands of research can often

conflict with the clinical demands to ‘‘do no harm’’,

especially if the research methodology requires strict

adherence to a pre-set intervention program (Slonim-

Nevo, 1997). Action research describes a model of

evaluation that encourages multiple iterations of a

program to be evaluated as it progresses. It draws

intentional and unintentional elements, from various

perspectives, into the data set, directly contributing to

program development (Power et al., 1991; Tyson,

1992). One of the criticisms of both ‘‘fixed’’ or

manualised and ‘‘adaptive interventions’’ is that

expert-generated rules for the inclusion or removal

of components of an intervention are determined by

clinicians who are not familiar with the idiosyncratic

needs of each participant group of individuals, which

can systematically reduce the reliability of interven-

tions (Collins et al., 2004).

Each session in our program was assessed prior to,

and at the conclusion of the interaction to evaluate

successes, failures, opportunities and redundancies.

This information was then used to better target the

needs and capabilities of the participants in sub-

sequent sessions; thereby enhancing accountability.

This process revealed that, despite intensive ground-

work and preparation in the current study (in the

form of expert interviews and literature review),

many of the uniquely developed content features and

process considerations failed to adequately address

the needs of the client group. One such formative

outcome was the finding that participants failed to

comprehend the ABC model (i.e., antecedents/

activating event-belief/thought-emotional consequence

(Beck, Rush, Shaw, & Emery, 1979)), which is

central to CBT treatment programs for depression.

As a result, much of the session’s script was rewritten

and presented again during the next session using the

same exercises/examples, but with more diary-like

format (rather than the traditional columnar format)

and more cohort-relevant labels to enhance compre-

hension. Results from each subsequent assessment

showed that participants’ understanding of the con-

cepts had improved, and participants were able to

progress to the next stage of the CBT process. Had the

research design not allowed for ongoing changes to

both content and tailored evaluation surveys, the parti-

cipants’ comprehension might have been hindered by

jargon and their subsequent insight and behaviour

change masked by unfair and unrealistic assessment

item design. Thus an action research approach

increased clinical accountability through the respon-

sive modification of session content and process in a

structured, evidence-based way rather than merely

presenting ad hoc observations of client – program fit

as limitations to the study after the fact (Greenburg &

Newman, 1996; Sutton, 1989; Tyson, 1992).

Contextualisation of intervention

Action research emphasises the participatory

nature of research, and encourages fluidity between

Older adults & group CBT programs 61

boundaries of ‘‘participant’’ and ‘‘expert’’ through

the recording of collective processes and summative

outcomes to determine what is ‘‘. . . deemed useful by

those whose problematic situation led to the research

in the first place’’ (Wadsworth, 1998:12, also see

Power et al., 1991). Participants are service con-

sumers and service providers. In the formative aspect

of this study, both group members and group

facilitators contributed significantly to the data set.

Moreover, local experts were involved in the process

of program design to supplement the literature review

of relevant programs (Thompson, Gallagher-

Thompson, & Dick, 1992; Yost et al., 1986). A

comprehensive series of 14 interviews with local

experts identified a range of age-specific issues as well

as issues specific to their work with older adults in the

local context. A circumscribed package of CBT that

accommodated time and content limits was devel-

oped with a unique script for each session, and local

and age-specific examples.

In the first draft of the manual, expert interviews

resulted in several technical accommodations includ-

ing (a) the considerable expansion of time to socialise

participants to the unfamiliar experience of therapy,

(b) highlighting grief and loss as particularly pertinent

to the mood of older adults, (c) incorporating a flexible

approach to setting and using homework tasks, and (d)

the restriction of the program to 862-hr sessions to

prevent drop-out. Other process and content recom-

mendations for maximising the efficacy of the program

and troubleshooting were also included for facilitators,

as a separate section at the beginning of each session

script. These included modifications in environment

and presentation strategy, such as (a) using two

therapists; (b) modifying room layouts to accommo-

date tremors, involuntary movements, walking frames

and sensory impairments; (c) changing jargon to lay

terms; (d) increasing font sizes on handouts; (e)

providing age-relevant examples, suggestions and

strategies; (f) increasing break frequency; and (g)

increasing time for reviewing session material. These

modifications were aimed at enhancing and facilitating

the more standard CBT features of this program,

which included symptom psychoeducation and the

ABC model, thinking errors, self-talk, behavioural

activation and self-monitoring.

Feedback from participants about the experience of

participating in the intervention was also sought as the

intervention unfolded, to guide existing theory toward

real world practice and action, rather than evaluating

the degree to which participants deviate from expert

or professional expectation (Wadsworth, 1998).

Complex issues but small samples

Action research engages the mixed methods data

collection approach, which encourages the synthesis,

or triangulation of both qualitative and quantitative

types of data from multiple sources including

therapists and group participants. This transforms

that which is generally considered a weakness of

clinical research, namely small sample size, into a

design strength (Galassi & Gersch, 1993; Power

et al., 1991; Sharp & Frechtling, 1997). The mixed

method approach utilises single case study metho-

dology, emphasising depth and breadth of analysis

with each individual to draw contextualised, clini-

cally rich and, arguably, more valid and reliable

conclusions (Barnett et al., 1999; Davey, 1991;

Slonim-Nevo, 1997). In many ways, it formalises

what clinicians have always done: to monitor their

client from multiple perspectives and to draw out

inferences from complex data sets involving observa-

tions, inferences, reflections, failures and deviations

from expected procedures.

In our research the pilot program was completed by

five participants with a mean age of 81.3 years. Each

participant was assessed individually on 18 separate

occasions, using four standardised quantitative

assessment tools and several qualitative assessments.

Quantitative measures included the General Health

Questionnaire (GHQ-12; Goldberg & Williams,

1988), Geriatric Depression Scale (GDS; Yesavage

et al., 1983), Beck Anxiety Inventory (BAI; Beck &

Steer, 1993) and a Mood Rating Form (MRF)

designed by the researchers. These were implemen-

ted before and after intervention and at 3-month

follow-up. The qualitative measures included one

assessment of physical symptom change in addition

to measures of knowledge acquisition, concept

recognition, retention and application at the begin-

ning and end of each session, and again at follow-up.

Thus, despite having so few participants in the pilot

study, conclusions were drawn from a total of 65

separate data points, from the perspective of both

the participants and group facilitators. Results

were presented as a portfolio of information where

disparate or small pieces of data about the same

subject were combined into a richer whole before

conceptual re-sorting of data and re-analysis (Barnett

et al., 1999). Each analysis yielded important results.

The former alerted us to individual progress, the

latter to broader success of particular program

components. Thus, the systematic case study ap-

proach illuminated individual change but also shed

light on therapy/change processes (Davey, 1991;

Greenburg & Newman, 1996; Tyson, 1992).

Statistical versus clinical significance of change

The triangulation or synthesis of multiple sources of

data is a core element of action research and serves to

integrate apparently disparate sources of sometimes

gross, quantitative data with finer, qualitative data to

62 L. Richardson & C. Reid

titrate their combined contribution to global variable

change (Barlow, Hayes, & Nelson, 1984; Sharp &

Frechtling, 1997). Baseline and repeated measures of

clinically and functionally relevant knowledge, skills

and behaviour were undertaken in addition to

changes in mood. To assess program efficacy on a

micro level in our program, a weekly MRF was

constructed that assessed symptoms as they more

typically present in the older population. To assess

knowledge and skill development, data were gathered

about the participants’ immediate (in-session) under-

standing of information presented, and was

triangulated with delayed recall of information (the

following week) and their ability to demonstrate

comprehension through application to relevant ex-

amples and descriptions of their own behaviour

change. Items were developed to reflect key themes

from each session plan. These criteria helped us to

ascertain what degree and type of change was being

achieved when compared to preexisting levels of

knowledge, skills and behaviour measured. For

example, in the case of a client who did not apply

the ABC model correctly in their homework task, it

was important to ascertain whether there was an initial

processing problem (e.g., not hearing the material

being presented), an interpretive problem (e.g., not

understanding the concept despite being able to

repeat what had been said), a memory problem

(e.g., if they scored highly on comprehension one

week, but low on recall of the material in a subsequent

week), or a motivational problem in application for

homework tasks. Similarly, for those who scored

highly on all conceptual elements of the program it

was important to assess whether they were learning

this material in the group (which is the desired aim) or

already knew it before entering the program but had

been having problems implementing it in their daily

lives. This process allowed the program to be better

targeted to the needs and abilities of each client. The

aim of this process was also to determine what

participants believed was important. Results of the

recall data were able to be translated immediately to

modification of subsequent sessions, with the aim of

enhancing processing of information and the pro-

gram’s overall efficacy. These measures were used in

conjunction with more traditional standardised and

norm-referenced symptom measures and qualitative

feedback regarding therapeutic/change processes.

These formative assessments resulted in changes to

the duration of sessions, frequency of breaks, use of

multimedia, and presentation style due to the impact

of physical, sensory and cognitive impairment.

Drop-outs

The changing physical and medical circumstance of

older adults was recognised as an important logistical

feature of this target group, and a degree of partial

nonattendance or complete drop-out was expected.

Individuals traditionally labelled as missing data or

nonparticipants, are usually removed from final

results due to their threat to sample bias, degrees of

freedom and overall quality of the research (Sutton,

1989). However, the recognised features of ‘‘drop-

out’’ in this target group support the inclusion of the

non-missing parts of the so-called ‘‘missing data’’.

The action research approach accommodates this.

Participants who drop out provide insight into

personal or environmental hurdles to completion of

a therapy group, the adequacy of the program to

meet the needs and expectations of participants and

how they typically respond when it does not.

For our completer participants, missing data

occurred with noteworthy frequency, as expected,

due to illness-related absences, transport problems

and sensory deficits, as expected. Commencing with

seven participants but concluding with five, exit

interviews were conducted. The data obtained from

interviews with drop-outs (who remained involved

with the service but not the group) support the

observation that interventions for older persons must

accommodate the specific challenges they bring to

therapy. Through formative session reviews, facil-

itators observed that external events could mean that

participants could be physically present but not

participating in the program. Poor concentration

and a loss of confidence was one outcome for

participants’ mental state and emotions following

falls or injury. Discussing the past weeks’ key events

provided essential forewarning for facilitators to

engage with participants in ways that accommodated

variations in attention or cognition. Compared to

generic adult populations, our findings further

support the recommendation to make explicit

accommodation for lifestyle features when designing

psychological interventions for older clients.

Homework

The CBT literature strongly advocates the use of

homework as a vital component of the therapeutic

process. According to many of the experts who were

interviewed, the success in implementing homework

tasks and obtaining useful personal data on which to

build sessions is a less than automatic assumption

when working with an older participant. The choice of

descriptive label for the task, the amount of self-

directed work required, the medium in which tasks

are set, and the amount and availability of instruction,

all impact on whether the participant completes

homework tasks. The likelihood of homework com-

pletion in a short-term group setting with an older

group of participants was untested prior to this study,

but most interviewed practitioners agreed that tasks


would need to be short and simple, have clear

instructions that could be referred to out of the

session, and which were not described as ‘‘home-

work’’, but rather as ‘‘take-home tasks’’, or ‘‘help/

information for the therapist’’. Requesting too much

writing was identified as one likely reason for failure,

while setting a task that was partially undertaken

outside the session but which could be elaborated

upon in session, was considered more likely to be

successful.

In this study, homework was planned for every

session, as per CBT doctrine, and professional

recommendation. However despite multiple presen-

tations and iterations, memory prompts and

changing formats, homework tasks remorselessly

changed from formal written exercises to verbal

recollections of recent events that would be elabo-

rated on or discussed in detail the following session.

Although not formal homework tasks, these remin-

ders and prompts did seem reasonably effective in

generating examples and issues for ongoing session

work. The conclusion we drew was that despite the

well-documented value of homework to CBT pro-

gress for general adult participants, a flexible

approach to how it looks and its purpose (i.e., to

generate in-session examples for group discussion

and problem solving rather than individual insight-

oriented work) was necessary in order for our

participants to benefit from the exercise.

Personal narrative

Every professional interviewed prior to developing this

program mentioned the need for facilitators to allow

time for older participants to recount their personal

narrative, while also maintaining the group focus on

the session goals. This study’s formative observations

(in the form of behavioural observations, monitoring

of elapsed time between time on task and ‘‘story-

telling’’, and objective measures of amount of content

completed during the session compared to expected

content amount) supported the observation of this

age-related response set. While all group participants

may need to contextualise their experience of therapy

with their own life experiences, and describe signifi-

cant elements of their personal narrative, the need for

story-telling appears greater for the older therapy

participant. This apparently consistent feature of their

experience may reflect a tradition of passing on

historical fact by spoken word, as well as an

opportunistic response to having a like-minded, and

tolerant audience. ‘‘Memory meandering’’ (Thomp-

son, Gantz, Del Maestro, Bryan, & Gallagher-

Thompson, 1991), and a need to externally process

the thoughts and feelings associated with intervention-

specific factors in a verbal narrative form, are also likely

to play a part. For clinicians, however, rather than

being a hindrance, these stories can be drawn upon at a

later stage, to highlight examples of unhelpful beha-

viours, thoughts and beliefs that the client can directly

challenge in therapy, and with which the rest of the

group may identify, and verbally engage.

With regard to assessment of progress, unlike that

which is typically seen in younger adult groups,

responses were not ‘‘parroted back’’ as they had been

described during the session but were described as

personal experiences (e.g., ‘‘become less active’’, is

replaced with ‘‘stop doing the gardening’’). With the

researcher as intervention facilitator, use of open-

ended questions and the recording of significant in-

session focus points, individual responses and the

learning they reflected, were able to be interpreted.

Such responses in all likelihood would be marked

incorrect on a standardised questionnaire. However,

through triangulation of data, and multiple assess-

ments, a group participant could demonstrate an

understanding of concepts better when asked to

describe the experience in more detail, or explain the

management strategies he or she could use. The

research design allowed participants to demonstrate

applied knowledge in multiple ways. These observa-

tions suggest that failure to recall labels or technical

terms may reflect a tendency to personalise informa-

tion encoding and recall, as opposed to a failure to

comprehend or apply the information to behaviour.

It is important to accommodate this different

cohort style of processing information when asses-

sing knowledge or behaviour change. Subsequently,

participants’ responses to learning questionnaires

were sometimes assessed on the basis of personal

narrative (and therefore in terms of their application

of knowledge to their own situation) rather than

solely on their ability to restate the content of the

sessions as described in the manual.

Personal narrative can also identify, as it did in this

study, an issue that is central to therapeutic change

for a particular cohort yet which had been under-

appreciated in program design. In this case the issue

was grief and loss. The preponderance of sponta-

neous personal narrative related to the theme of loss

of loved ones or change of personal circumstances

alerted the facilitators to the centrality of this issue in

the experience of depression and anxiety in this

cohort. The relationship between loss, grief and

depression was consequently allocated a much more

significant profile in the program. For our group,

these issues were very tangible and were blocking

progress on other depression-related issues until it

was fully addressed.

Summative evaluation outcomes

Taken together, results suggest that 50 – 80% com-

prehension or application of most elements included


in this program was sufficient to significantly reduce

the level of symptomatic distress as measured on

standardised assessments (GDS, BAI, GHQ and

MRF) at the conclusion of an 8-week intervention. It

would seem, however, that partial comprehension and

application of most elements in this program was not

sufficient to prevent resurgence in symptomatic

distress (to clinically significant levels for nearly all

participants on the GDS), measured on the same

assessment tools, when participants were no longer

engaged in a therapeutic intervention. Despite nearly

100% comprehension and application of knowledge

and skills related to relapse prevention planning, nearly

every participant recorded a partial return of depres-

sive or anxious symptoms at 12-week follow-up. The

reasons for this failure in prophylaxis may be related to

intervening health crises (noted in recording of

hospital admissions or incidences of specialist medical

treatment), but also perhaps to a need for intermittent

top-up sessions: several participants indicated that they

had wanted to contact group facilitators in the

intervening weeks but ‘‘did not want to be a burden’’

or were unsure how to approach such a contact.

It is these discrepancies between the participant’s

knowledge or behaviour, and their standardised mood

assessment results, which highlight the value of the

current study’s research design to elucidate genuine

possible causes for change, as opposed to post hoc

speculations regarding limitations of the study.

Summary

It seems that an action research approach has been

critical to the success of developing and evaluating this

novel approach to group treatment. Although the final

program that was delivered differed from the original

manual, the changes to program content and process

outlined above reflected responsiveness to accumulat-

ing evidence rather than stasis in the face of client

difficulty. The therapy manual generally retains its

content and process features, but some sections

required several iterations before the best fit of content

or practice could be determined to match the needs of

the clients. The summative results of this study point

to a positive outcome for participants both in terms of

symptom relief as measured by standardised assess-

ment tools, self-reported behaviour change, subjective

mood assessment, and participant satisfaction. Long-

term follow-up suggested the importance of top-up

sessions as relapse prevention given the variable

medical health status of this cohort group and the

negative impact that health challenges have on self-

reported depression and anxiety management.

The success of the research as both an exploratory

study of program development and outcome was

dependent on several factors: (a) the involvement of

experienced practitioners in the design process, and

an active hypothesis testing between that which the

literature proposed and that which experienced

clinicians enacted; (b) the utilisation of an action

research methodology, which accommodated forma-

tive evaluation processes and allowed the researcher/

clinicians to make modifications as the research

progressed (to some extent, and due to the particular

challenges of working with the older adult population,

our results would have been unrealistically and

unfairly unimpressive if we had not); (c) the

measurement of knowledge change, behaviour and

mood change, which allowed us to determine

whether, as a preliminary step, learning was taking

place, and whether it was being translated to action

and finally resulting in mood change (combining

quantitative and qualitative data helped to unpick

these relationships), and similarly (d) the consi-

deration given to information processing, recall and

longer term retention as unique challenges to therapy

with the older adult; finally (e) the participant –

researcher stance adopted in this study was invalu-

able in melding clinical expertise with the research

process.

The formative results highlighted the value of the

feedback loop inherent in the action research model,

which added a dimension to this study both in terms

of the quantity of data (potentially to have been

undermined by a small sample size) and the quality

of claims made about the intervention’s impact on

functionally and clinically relevant behaviour change.

These elements can be missing in psychological

research but are critical in applied contexts to ensure

that (a) component analysis occurs to reduce

unnecessary redundancies and streamlines the most

efficacious treatments for the discerning health

consumer; (b) ethical obligations to clients are met,

and (c) the dissemination of cumulative expertise

gained from clinicians’ daily work is not thwarted by

the realities of small numbers. Using such a model

means that we can formalise our usual clinical

practices in a considered way, and use the framework

as a reflective learning tool as well as a research

strategy. By drawing together multiple sources of

data to understand complex cases, we can be

inventive in finding ways to assess small, individua-

lised but important changes, and focus on possibility

for our clients rather than probability.

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