Peer Response

Response to Slava Chuklansev

Hello Slava,

Great work with your post! Your review of CBT settings and their differences is quite comprehensive, particularly the systemic focus of family CBT. To address concerns about confidentiality in group CBT, one effective strategy involves the use of agreements for confidentiality to be signed by participants at the outset. According to Nakao et al., 2021, such agreements should be emphasized throughout the sessions to build trust: Peer Response.

Also, a safe space can be created by modelling respect and empathy regularly, which will encourage openness and keep group cohesion. This would help in dissipating anxiety about sensitive information being disclosed.

Regarding family CBT, resistance from family members may impede progress. One may use motivational interviewing techniques to resolve ambivalence. Chand et al., (2023) note that it is helpful to frame the therapy as a joint effort rather than placing blame on one party to decrease defensiveness.

Including psychoeducation about the process of therapy can also help to gain more understanding and buy-in from family members. How have you handled resistance or conflict in your practice within therapeutic settings?

References

Chand, S. P., Kuckel, D. P., & Huecker, M. R. (2023, May 23). Cognitive Behavior Therapy (CBT). National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470241/

Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive–Behavioural Therapy for the Management of Mental Health and Stress-Related Disorders: Recent Advances in Techniques and Technologies. BioPsychoSocial Medicine, 15(1), 1–4. https://doi.org/10.1186/s13030-021-00219-w

Response to Beyene Edo Edessa

Hello Beyene,

Great post! Your discussion of CBT settings and their differences is in-depth, especially the systemic focus on family CBT. For the issues of confidentiality in group CBT, confidentiality agreements upon the start of treatment could serve as one measure. Bischof et al., (2021) advise reassuring participants of these agreements throughout sessions to build trust. It will also minimize anxiety caused by a belief that secret information might leak.

Concerning the family CBT approach, passive attitudes from family members may pose a major challenge. One of the action plan interventions is motivational interviewing to tackle ambivalence. According to Reuman et al., (2020), avoiding the assignment of blame enhances the possibility of cooperation since therapy is presented as a teamwork process.

Psychoeducation, which has to do with the therapy process, can also help enhance others’ comprehension and cooperation in the family setting (Reuman et al., 2020). In what ways have you engaged in conflict with patients or other therapists or treatment providers in your practice?

References

Bischof, G., Bischof, A., & Rumpf, H.-J. (2021). Motivational Interviewing: an Evidence-Based Approach for Use in Medical Practice. Deutsches Aerzteblatt Online, 118(7), 109–115. https://doi.org/10.3238/arztebl.m2021.0014

Reuman, L., Thompson-Hollands, J., & Abramowitz, J. S. (2020). Better together: A review and recommendations to optimize research on family involvement in CBT for anxiety and related disorders. Behaviour Therapy, 52(3). https://doi.org/10.1016/j.beth.2020.07.008

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Student 1: Slava Chuklansev

Humans are habitual creatures with the potential to create habits, good and bad, unconsciously. Our experiences result in positive or negative feelings and emotions that our mind processes and stores as memory. The mind then uses these memories to either prevent or avoid situations that may result in negative feelings and emotions or strives to recreate experiences likely to result in positive feelings and emotions. Many people fall into a pattern of habitual negative thinking, often without even knowing it, causing significant challenges in various aspects of their lives.

Unfortunately, negative and distorted thoughts haunt us all, but there are ways we can combat these thoughts, break the pattern/habit, and recreate new thoughts from a positive perspective. Psychotherapy has proven effective in treating various psychiatric conditions. Cognitive behavior therapy (CBT) is one form of psychotherapy that assists patients with identifying negative and distorted thoughts, challenging those thoughts, and reframing them through a realistic and positive perspective.

CBT has been identified as the gold standard in the treatment of anxiety and mood disorders (Paul et al., 2024). It may be implemented in various therapeutic settings, including individual, group, and family, with each setting presenting advantages and disadvantages.

Implementing CBT in an individual setting provides privacy, allowing the patient to feel comfortable discussing highly personal matters. The individual setting places all focus on one patient, allowing the therapy session to be tailored completely to the patient’s needs. This setting narrows all interaction to two people, the therapist, and the patient, which promotes building a deeper and more intimate rapport.

Melero et al. (2021) compared the effectiveness of group vs. individual therapy, incorporating CBT, in helping children increase prosocial skills and decrease problems with their peers, with results showing significantly greater outcomes with the children receiving individual therapy than those receiving group therapy. These results were related to the children in individual therapy receiving more modeling and feedback on skills tailored to their individual behavioral needs directly from their therapist (Melero et al., 2021).

Implementing CBT in a family setting provides a controlled environment for each family member to feel comfortable openly communicating their perspective. The therapist provides guidance and mediates discussion, ensuring appropriateness and setting boundaries, which may not always happen at home. It allows each individual in the family to be heard and have their perspective validated while allowing the therapist to monitor their interactions and implement CBT strategies to assist the family in identifying negative and distorted patterns in behaviors. The family can then understand their collective responsibility and implement therapeutic interventions to minimize conflict and promote unity.

Implementing CBT in a group setting is cost-efficient compared to an individual setting, considering one therapist can treat multiple patients simultaneously (Villabø et al., 2018). Additionally, the group setting provides an environment where the participants can feel relatable, which fosters discussion, learning, and healing. With the therapist’s guidance, participants can discuss their personal experiences and strategies that help them cope with their symptoms.

Members can find strength in numbers and feel a sense of community and togetherness. Furthermore, it allows participants to become emotionally vulnerable in front of others, knowing they will not be judged but instead understood and validated. However, group therapy poses its challenges.

In all settings, the therapist must always act in the best interest of all participants, which can be especially challenging in group settings. Melero et al. (2021) concluded that group therapy presents various challenges for therapists, including adjusting the pace of therapy, managing conflict, missed information resulting from absences, and the need for limit setting. Having a dominant member in a group setting can limit the other participant’s ability to participate in treatment.

In this scenario, the therapist must mediate interactions and ensure all participants have equal time to participate. Another potential barrier to group settings is participant conflict. To minimize conflict, the therapist must communicate clear rules and expectations at the beginning of the session and ensure all participants abide by the set rules and expectations. By setting boundaries, expecting respect, communicating clearly, mediating discussions, and providing guidance, the therapist may minimize group therapy-related issues and maintain a therapeutic group environment.

In conclusion, there are situations in which one of the settings may be favorable, while in other situations, the patient may benefit from multiple settings. Concerning the treatment of hoarding disorder, Bodryzlova et al. (2018) identified that individual and group CBT resulted in significantly favorable outcomes for the patient. Therefore, there is no reason to limit patients to one therapy setting when they may benefit from multiple settings differently. It is the therapist’s responsibility to ensure all participants are provided an equal opportunity for receiving optimal treatment in all therapeutic settings.

References

Bodryzlova, Y., Audet, J., Bergeron, K., & O’Connor, K. (2018). Group cognitive‐behavioural therapy for hoarding disorder: Systematic review and meta‐analysis. Health & Social Care in the Community, 27(3), 517–530. https://doi.org/10.1111/hsc.12598Links to an external site.

Melero, S., Morales, A., Espada, J. P., Méndez, X., & Orgilés, M. (2021). Effectiveness of group vs. individual therapy to decrease peer problems and increase prosociality in children. International Journal of Environmental Research and Public Health, 18(8), 3950. https://doi.org/10.3390/ijerph18083950Links to an external site.

Paul, S., Zhu, L., Mizevich, J., & Slater, L. (2024). Depression, anxiety, and personal recovery outcomes after group vs individual transdiagnostic therapy: A brief report. Scientific Reports, 14(1). https://doi.org/10.1038/s41598-024-55093-7Links to an external site.

Villabø, M. A., Narayanan, M., Compton, S. N., Kendall, P. C., & Neumer, S.-P. (2018). Cognitive–behavioral therapy for youth anxiety: An effectiveness evaluation in community practice. Journal of Consulting and Clinical Psychology, 86(9), 751–764. https://doi.org/10.1037/ccp0000326Links to an external site.

Student 2: Beyene Edo Edessa

Cognitive behavioral therapy (CBT) is a popular therapeutic strategy that assists people in recognizing and altering harmful thought patterns and behavior. It can be used in various contexts, such as family therapy, group therapy, and individual therapy (Nakao et al., 2021). Although CBT’s fundamental ideas are universal, the dynamics and difficulties vary depending on the situation. Psychiatric-mental Health Nurse Practitioners (PMHNPs) must comprehend how CBT works in these situations to apply it effectively and appropriately to promote individuals’ well-being.

How is CBT used in groups compared to Individual vs Family?

Group CBT: the focus of group CBT involves a therapist guiding a group of people dealing with similar problems (for instance, depression, and anxiety) (Guo et al., 2021). It is still based on cognitive-behavioral concepts but is less customized than one-on-one therapy. According to Moloud et al. (2022), the group members assist one another in this CBT method, practice cognitive behavioral therapy, and discuss their experiences since clients learn from one another and the therapist, group dynamics are crucial to promoting patient emotional well-being. Thus, group CBT is beneficial in providing good social support and validation, minimizing feelings of isolation, and allowing individuals to learn from others with similar challenges or issues.

Individual CBT: The focus of individual CBT is very personalized and to identify specific behavioral patterns and cognitive distortions, the therapist works closely with the patient. The emphasis is on each person’s unique ideas, emotions, and behaviors. The therapist customizes interventions in individual CBT to meet each client’s unique needs.

Because it’s a one-on-one interaction, trust can be developed, personal difficulties can be thoroughly explored, and a highly customized treatment plan may be developed. Individual CBT is also beneficial as it is more direct and personalized, and the individual has a private place to explore sensitive topics (Nakao et al., 2021).

Family CBT: When it comes to family CBT, the therapy focuses on the relationships and dynamics within the family, and finding and addressing thought and behavior patterns that impact the entire family is the goal.  The therapist’s collaboration with family members is also important to increase communication, resolve conflict, and alter dysfunctional family dynamics. In family cognitive behavioral therapy, every member participates in the therapy process and their roles within the family system are evaluated.

Family CBT is also important and successful, especially when the problems originate in or impact the family structure, as in the cases of substance abuse, eating disorders, or behavioral challenges in children. It promotes comprehension and constructive adjustments to the family unit (Herres et al., 2023).

Challenges PMHNPs might Encounter when using CBT

The PMHNP may encounter challenges when using CBT in a group setting. Managing the varying personalities and levels of participation of group members is one challenge that PHMNP may face during group CBT. Some people might control the conversation, while others might be afraid or unwilling to share any experience. It can be challenging to guarantee balanced participation, especially in a group context, as certain participants might experience discomfort or stigma.

Moreover, confidentiality issues may be another problem in group CBT as group trust progressively develops.  Participants in group therapy must trust one another, and privacy can be difficult to maintain, and the therapeutic process may be hindered if sensitive information discussed in the group is disclosed outside of the session (Marmarosh et al., 2022).

The other challenge that PMHNP may encounter is in the family CBT setting. According to the study conducted by Marmarosh et al., 2022, family members’ resistance to admitting or altering dysfunctional behaviors is a major challenge in family cognitive behavioral therapy. For instance, a family member may not believe in the therapy process or may be unwilling to acknowledge their part in a dispute.

There may be resistance to the PMHNP, particularly if there is a long-standing family conflict. Family systems are frequently complicated with many levels of interpersonal dynamics, past problems, and power disparities. In addition to addressing the systemic problems that contribute to the issue, a PMHNP must manage these complex relationships and make sure that every family member feels heard.

In conclusion, although CBT can be useful in family, group, and individual contexts, the dynamics and difficulties are very different. While family CBT is useful for systemic problems but may be hindered by family resistance, group CBT provides peer support but poses a challenge in controlling group dynamics. To guarantee success in both situations, PMHNPs should be skilled at handling group dynamics and negotiating complex relational dynamics.

References

Guo, T., Su, J., Hu, J., Aalberg, M., Zhu, Y., Teng, T., & Zhou, X. (2021). Individual vs. Group Cognitive Behavior Therapy for Anxiety Disorder in

Children and Adolescents: A Meta-Analysis of Randomized Controlled Trials. Frontiers in psychiatry, 12, 674267.

https://doi.org/10.3389/fpsyt.2021.674267Links to an external site.

Herres, J., Krauthamer Ewing, E. S., Levy, S., Creed, T. A., & Diamond, G. S. (2023). Combining attachment-based family therapy and cognitive

behavioral therapy to improve outcomes for adolescents with anxiety. Frontiers in psychiatry, 14, 1096291.

https://doi.org/10.3389/fpsyt.2023.1096291Links to an external site.

Marmarosh, C. L., Sandage, S., Wade, N., Captari, L. E., & Crabtree, S. (2022). New horizons in group psychotherapy research and practice

from third wave positive psychology: a practice-friendly review. Research in psychotherapy (Milano), 25(3), 643.

https://doi.org/10.4081/ripppo.2022.643Links to an external site.

Moloud, R., Saeed, Y., Mahmonir, H., & Rasool, G. A. (2022). Cognitive-behavioral group therapy in major depressive disorder with focus on

self-esteem and optimism: an interventional study. BMC psychiatry, 22(1), 299. https://doi.org/10.1186/s12888-022-03918-yLinks to an external site.

Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive-behavioral therapy for management of mental health and stress-related disorders:

Recent advances in techniques and technologies. BioPsychoSocial medicine, 15(1), 16. https://doi.org/10.1186/s13030-021-00219-wLinks to an external site.