GROUP TREATMENT IN THE 21ST CENTURY: OUTCOMES AND MECHANISMS OF CHANGEGARY M BURLINGAME, PH.D.

GROUP PSYCHOTHERAPY CONFERENCE

TURIN, ITALY

OVERVIEW

• A century of clinical and research accomplishments in group therapy

• Experimental and naturalistic evidence comparing group/individual

• What do we know about group therapy’s effectiveness with different psychiatric disorders?

• Therapeutic relationship with outcome in group

• Assessing the therapeutic relationship—Group Questionnaire: GQ

• Using the GQ to identify and reverse relationship failure

THREE EPOCHS OVER PAST CENTURYBURLINGAME & BALDWIN, 2011

• Foundational—1900’s to 1930’s• Medical applications—Joseph Pratt 1905 “thought control” classes for TB; Lazell treated schizo. In 1919 with PEG

• Development of a separate identity from psychoanalysis—Burrow treated “neurotics” with group analysis in 1928

• “group therapy” coined by Moreno in 1932 APA meetings; Dreikurs private practice groups & Slavson child groups

• Expansion of theories and practice—1940’s-1970’s• Groups applied by Roger’s (client-centered), Perls (Gestalt), Lazarus/Meichenbaum (CT/CBT) and other orientations

• Encounter, T- and Yalom groups emerge with analytic splitting on individual (Slavson/Wolf) & group (Bion, Foulkes) focus; AGPA (Slavson--individual) 1943 & American Society of Group Psychotherapy/Psychodrama (Moreno--group)1942

• Specific groups for specific populations—1980’s-present• Explosion of research-supported small group treatments for specific disorders; stronger efficacy & effectiveness

• CBT emerges as dominant model by sheer number of studies—5:1 ratio

COMPARISONS OF INDIVIDUAL & GROUP IN PAST RESEARCH--

• Produced mixed results

• Flawed by between study and within study effects

• Have not statistically tested if identical and non-identical treatments (protocol, dose, patients, settings, etc.) explain mixed findings

• Have not tested group properties (group size, composition, etc.) that have been shown to moderate outcome in past group meta-analyses (e.g., Burlingame, Fuhriman, & Mosier, 2003; Burlingame, McClendon, & Alonso, 2011; McRoberts et al., 1998)

Records identified through database searching (N=202)

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analyses and reviews(N=312)

Records after duplicates (14) removed (N=202+298) = 500

Records screened Records excluded277

Full-text assessed for eligibility 223

Full-text articles excluded: 141N too small 26No useable data 14No direct comparison 39Review, meta-analysis or unpublished 38Duplicate sample 4No psychiatric focus 5Cost effective study 3Not translatable with available resources 12

Articles included in meta-analysis (N=70, plus N=5

articles reporting additional outcomes or follow-up

GROUP = INDIVIDUAL OUTCOMES

vIdentical treatments (46 studies)

vprimary measure ES=-.01, very low and nonsignificant heterogeneity ;

vsecondary measure = -.04 but sign heterogeneity I=38.5%

vNonidentical treatments = -.04, high heterogenity I=53% BUT power to detect = 95% (.20) and 77% (.15); allegiance predicts mixed findings; no difference in primary and secondary measures

vNo difference in short- (-.01) or long-term follow up (.00)

vNo differences in acceptance (n=14), dropout (n=52), remission (n=11) and improvement (n=5)

vReplication—83% of past pre-post effect size estimates for depression and 70% for anxiety from the best meta-analyses fell within CI of our study.

Burlingame et al (2016)—70 studies with random or matched assignmentvAvg. effect size = -.03’ Controlled (WLC) effect = .72;

Naturalistic Study comparing group only, individual only and conjointBurlingame et al., 2016

Black=Conjoint; Blue=Individual only; Red=Group only; G=I; C≠I or GN is I=11,764, C=1557 & G=152Weeks Sessions

CONCLUSIONS ON FORMAT OUTCOME

• When identical treatments—individual and group—are compared there are no differences in outcome, acceptance, dropout, remission and improvement in highly controlled randomized clinical trials—N=70

• When an identical outcome measure is used in daily practice where over 13,000 patients are referred to a few hundred providers to receive either individual only, group only or conjoint there are no differences between individual and group only outcomes

• This is the strongest evidence that has ever existed testing differential format outcomes

Explaining group outcomesBurlingame, et al., (2004, 2013).

Do not copy or disseminate without permission

EVIDENCE FOR THE STRUCTURAL PROPERTIES & PROCESSES FOR EFFECTIVE GROUPS

Group-basedguidelines

Group-basedguidelines

Do not copy or disseminate without permission

General model of group dynamics Burlingame et al 2008, 2013

Group properties & processes

Group Structure – AnatomyGroup as vehicle of change

Emergent Structure:•Group development•Subgroups•Norms

Imposed Structure:•Pre-group preparation•Early formatting•Composition•Member selection

Foundational Social Processes:•Reciprocal role functioning•Conformity, power & conflict•Performance•Decision-making•Leader style –characteristics•Social identity theory

Emergent Processes:•Therapeutic Factors•Interpersonal feedback•Self-disclosure•Cohesion-climate•Leader interventions

Group Processes – PhysiologyInterpersonal exchange as mechanism of change

Formal Change Theory

Patientand

Therapist Factors

Do not copy or disseminate without permissionHigh-level ordering of evidence

Burlingame, Fuhriman & Johnson, 2002 & 2004; Burlingame, Strauss & Johnson 2008

Dimension Excellent to very good

Promising to good (GRQ)

Mixed to untested

Imposed Structure

•Pre-group preparation•Early format•Composition•Member selection

•Interaction patterns

Emergent Structure

•Interaction patterns•Development•Subgroups

•Norms & roles

Dimension Excellent to very good (GQ)

Promising to good (GCQ/GQ)

Mixed to untested(GCQ/GQ)

Emergent Processes

•Feedback•Alliance

•Leader verbal style •Climate•Cohesion•TF: value X setting

•Member self-disclosure•TF: dynamic interplay

Social Psy.Processes

- Conformity, power, & conflict- Perform. & decisions-Social identity-LeadershipDo not copy or disseminate without permission

High-level ordering of evidenceBurlingame, Fuhriman & Johnson, 2002 & 2004; Burlingame, et al. 2008

Do not copy or disseminate without permissionARE THERE GROUP ESTS?

Protocol

Diagnosis

Burlingame, G., MacKenzie, K.R., & Strauss, B. (2004) Small Group Treatment: Evidence for Effectiveness and Mechanisms of Change. In: M. J. Lambert (Ed.): Bergin and Garfield´s Handbook of Psychotherapy and Behaviour Change (5th Ed.), New York, John Wiley & Sons, 647-696.

*Mixed diagnoses groups—anxiety, mood, PTSD, substance & ED

UseofGroupTreatment

VeryGoodtoExcellent PromisingtoGood MixedtoUntested

Groupasprimary SocialphobiaPanicDisorderObsessive-compulsivedisorderBulimianervosaEatingDisorders

MooddisordersPanicDisorderObsessive-compulsivedisorder

Mooddisorders*Elders

Groupasadjunct SPMI—schizophreniaPersonalityDisordersTrauma-relateddisordersMedical—cancerSubstanceabuse

*Medical—HIVPersonalitydisorder—homogenousSexualabusevictimPain/somatoformInpatient

*DomesticviolenceSubstance-relateddisorders

THERAPEUTIC RELATIONSHIP BEST PREDICTOR OF OUTCOME40 STUDIES TESTING COHESION-OUTCOME LINK=R = .25 BURLINGAME ET AL 2011

•Relationship is stronger with• Age—younger

• Tx length—13-19 sessions

• Size—5-9 members

• Location—classroom

• Focus—interactive vs. problem

REFINING THE GROUP THERAPEUTIC RELATIONSHIP (JOHNSON ET AL., 2005)

Positive Working Relationship

Positive Bonding Relationship

Negative Relationship

Member-Member

Member-Leader

Member-Group´

GROUP QUESTIONNAIRE: GQ

• Positive Bonding Relationship• The emotional connection or attachment to the group. It

includes member engagement with the group, positive empathy, and cohesion.

• Positive Working Relationship• Collaborative engagement in therapeutic work towards

treatment goals. It focuses on the working alliance.

• Negative Relationship• Aspects of the group process that may adversely affect member

attachments or impede the therapeutic work. It includes paucity of leader/member empathy and unproductive conflict between group members.

• Structure—Mem-Mem, Mem-Leader, Mem-Group

CONSTRUCTS ASSESSED BY GQ

GQSubscales

Member-Member

Member-Leader

Member-Group

Positive Bond

Cohesion Alliance Climate

PositiveWork

Task/goals Task/goals None

Negative Relationship

EmpathicFailure

Alliance Rupture

Conflict

GQ CHANGE AND STATUS ALERTS• Change = Reliable change (improve or deteriorate) from last session—early warning system

• Positive Bond = 10; Positive Work = 9; Negative Relationship = 11

• Status = Change from “average” score to an extreme score (e.g., very low bond)—relationship failure

________________________________________________________________________________________Positive Bond Positive Work Negative Relationship10% 90% 10% 90% 10% 90%

_________________________________________________________________________________________

Counseling Center 63 89 25 52 11 31

Non-Clinical 60 86 17 48 14 34

European Inpatient 51 84 26 50 16 39

SMI Inpatient 44 87 18 53 9 39

Total 56 88 23 51 13 35

Note. Negative alerts for positive bond and positive work are generated at the 10% cut score and for negative relationship at

Weekly GQ Feedback Report All alerts are from your last group session

Leader Name: Professor Dumbledore Group ID: 1 Date of Group: 10/9/2013 (Session #3) DID NOT COMPLETE: Draco Malfoy (OQ-45, GQ) Did Not Attend: Draco Malfoy

GQ EARLY WARNING ALERT - Change Relative to Previous Session Positive Bond Positive Work Negative Relationship

Harry Potter Negative Change Positive Change No Significant Change Clinician Rpt Draco Malfoy Did not Attend Did not Attend Did not Attend Clinician Rpt Ron Weasley No Significant Change Negative Change No Significant Change Clinician Rpt Hermione Granger Positive Change No Significant Change No Significant Change Clinician Rpt Neville Longbottom No Significant Change Negative Change No Significant Change Clinician Rpt Ginny Weasley Positive Change No Significant Change Negative Change Clinician Rpt

GQ ABSOLUTE ALERTS based on cut scores

J = above 95th Percentile, L = at or below 10th Percentile

Positive Bond Positive Work Negative Relationship

Harry Potter Clinician Rpt Draco Malfoy Did not Attend Did not Attend Did not Attend Clinician Rpt Ron Weasley Clinician Rpt Hermione Granger J J J

Clinician Rpt Neville Longbottom L

Clinician Rpt

Ginny Weasley L Clinician Rpt

OQ ALERTS Initial

Score Current

Score Admin Date

Current Distress

Level

Change From Initial

Alert Status

Harry Potter 54 51 10/9/2013 Low No Reliable Change

White Clinician Rpt

Draco Malfoy 44 Did Not Attend

Did Not Attend

Did Not Attend

Did Not Attend

Did Not Attend

Clinician Rpt

Ron Weasley 118 117 10/8/2013 High No Reliable Change

Green Clinician Rpt

Hermione Granger

98 98 10/9/2013 Moderately High

No Reliable Change

Green Clinician Rpt

Neville Longbottom

39 30 10/9/2013 Low No Reliable Change

White Clinician Rpt

Ginny Weasley

40 33 10/9/2013 Low No Reliable Change

White Clinician Rpt

Do not copy or disseminate without permissionSample GQ Individual Report from OQ-A

GENERAL FINDINGS FROM GQ FEEDBACK RESEARCH

• Improvement in GQ over time correlated with symptom improvement

• Negative change alerts (early warning) predicts status alerts (relationship failure)

• Group leaders working with difficult/long-term patients can never accurately predict their group member’s relationship status, and it takes 9-sessions for leaders working with less disturbed group members to accurate predict relationship status

• Leaders who received negative change alerts can reverse deterioration within 1-2 sessions avoiding overall relationship failure compared to those who don’t receive feedback

• Leaders who receive status alerts—relationship failure—can return members to average relationship status within 1-3 sessions compared to those who don’t receive feedback

Questions?