Group Psychotherapy Column

Tom Treadwell, EdD, T.E.P. C.G.P.

Tom Treadwell, EdD, T.E.P. C.G.P.

Cognitive Experiential Group Therapy: A model for a variety of clinical and college counseling settings

Thomas Treadwell Ed.D., CGP, Deborah Dartnell, MA, MSOD, Ainsley Stenroos, MA, & Brittni Gettys, BA

Cognitive Experiential Group therapy is a powerful tool for growth and change. This model of group therapy is designed to include 10-12 individuals who meet face to face to share their struggles and concerns with 1-2 trained cognitive experiential group therapists. The power lies in the unique opportunity to experience, warming up, action, and sharing in a group environment allowing multiple perspectives, support, encouragement and feedback from other individuals in safe and confidential environment. 

Cognitive Behavioral Therapy (CBT) was established by Aaron T. Beck (1967, 1979), and involves several techniques to challenge negative thought patterns and increase engagement in positive and success-based experiences. Psychodrama group therapy was created based on work by Jacob. L. Moreno (1953), and involves experiential, interpersonal exercises to raise awareness and reduction of internal conflicts in order to change negative relational patterns. Although CBT is a robust, proven, and very effective treatment approach for many mental disorders, including the big ones like depression and anxiety it is sometimes criticized for being overly structured and intellectually oriented (Young & Klosko, 1994; 1996; Woolfolk, 2000).  As a result, some group therapists today use an approach based upon CBT or identify with a less structured approach called eclectic (Kellerman, 1992) that typically employs techniques that come from cognitive behavioral therapy and its related research.  Beck reports, “My employment of enactive, emotive strategies was influenced, no doubt, by psychodrama and Gestalt therapy” (A. Beck, 1991, p.196). Psychodrama is an eclectic tool to enhance the cognitive and behavioral change. Several practitioners have worked to integrate CBT into the Psychodramatic model by highlighting the ways CBT enhances psychodrama exercises (Boury, Treadwell, & Kumar, 2001, Treadwell, Kumar, & Wright 2004), adapting psychodrama to include the exploration of irrational beliefs (Kipper, 2002), and considering the way in which psychodrama could be considered a form of CBT (Baim, 2007; Fisher, 2007; Treadwell, Travaglini, Reisch, & Kumar, 2011; Wilson, 2009). The blending of the two models yields a complementary approach to multiple problem-solving strategies (Treadwell, Kumar, & Wright 2004):

  • Both the CBT and Psychodrama models stress the discovery process through Socratic questioning. The use of certain structured CBT techniques within the context of psychodrama provide ways to deepen self-reflection, problem-solving, and mood-regulation skills that can be rehearsed through psychodrama exercises.
  • Experiential role playing can provide individuals with opportunities to generate new ways of thinking and behaving. The spontaneity and creativity of individuals can be increased through the use of psychodrama techniques, thus helping to produce alternative thoughts.

Cognitive Experiential Group Therapy (CEGT) is an effective model for working with a variety of clinical and nonclinical populations. The model incorporates cognitive behavioral and psychodrama interventions, allowing group members to identify and modify negative thinking, behavior, and interpersonal patterns while increasing engagement in positive and success-based experiences (Treadwell, Dartnell, Travaglini, Staats & Devinney, 2016). The CEGT environment creates a safe and supportive climate where clients can practice new thinking and behaviors and share their concerns freely with group members (Treadwell, Kumar, & Wright, 2004).

Initially, all members are assessed using various instruments to establish the nature and severity of presenting issues and to uncover other relevant information. The first one or two sessions are devoted to establishing group norms, explaining Cognitive Behavior Therapy (CBT) and schemas, and describing the session format. The initial didactic sessions are intended to explain the group format as a problem-solving approach for working through various interpersonal, occupational, educational, psychological, and health-related conflicts. The sessions include information about the nature of the structured activities so participants have realistic expectations about how the group will run.  Each group member signs informed consent and audiovisual recording consent forms. The audiovisual recordings create an ongoing record of group activities and serve as a source for feedback when needed. The action model is introduced in session one, with the director/facilitator, introducing the Beck Depression Inventory-II (BDI), Beck Anxiety Inventory (BAI), and Beck Hopelessness Scale (BHS) (Beck, 1988; Beck& Steer, 1993; Beck, Steer, & Brown, 1996), and explains the importance of completing each scale on a weekly basis. The instruments are administered before the start of each session and are stored in personal folders to serve as an ongoing gauge of participants’ progress within the group (Treadwell, Kumar, & Wright, 2008).

In the second session, additional data on early maladaptive and dysfunctional schemas/core beliefs are obtained when group members complete Young’s (Young, Klosko, & Weishaar, 2003; Young & Klosko, 1994; Young, 1999) schema questionnaire. A list and the definitions of dysfunctional schemas and core beliefs are given to participants during the initial session (Treadwell, Kumar, & Wright, 2008).  Additionally, we administer the Therapeutic Factors Inventory (TFI) to identify four dimensions of group progress (Joyce, MacNair-Semands, Tasca, & Ogrodniczuk, (2011) during week 2, week 8, and week 16.

Each group session in CEGT is divided into three sections typically found in psychodramatic interventions: warm-up; action; and sharing (Moreno, 1934). Many CBT techniques (Beck, 2011) are utilized in the warm-up, including: identifying upsetting situations, automatic negative thoughts and triggered moods; writing balanced thoughts to counter negative automatic thoughts; and recognizing distortions in thinking and imprecise interpretations of difficult situations. The second portion, action, employs psychodramatic techniques such as role-playing, role-reversal, and mirroring, which facilitate the examination of various conflicting situations individuals experience within the group context. This enables group members to better understand the nature of negative thoughts triggered by situations and their effects on moods. The last stage, sharing, allows auxiliaries and group members to share their experiences with the protagonist. At this stage, the director may provide additional guidance to the protagonist regarding ways to begin resolving the actual situation in real life. Normally, the protagonist will be asked to complete a homework assignment that will be reviewed at the next session.

Warm-up

The Automatic Thought Record (ATR) (Greenberger& Padaskey, 1995,2015) is explained and demonstrated on a white board during warm-up.  Socratic questioning is utilized to improve their awareness of irrational thoughts, (negative automatic thinking), that allows them to consciously question their own irrational thoughts.  A group member volunteers his/her situation and facilitators walk the person through the seven columns.  This individual is referred to as the protagonist.

Action

The protagonist, selects a group member, to be her double.  The double communicates thoughts and feelings the protagonist is having but cannot express.  If the protagonist is agitated, she may have some difficulty getting into the psychodrama; in this case, the soliloquy technique would be helpful.  Implementing soliloquy technique, the protagonist walks around the room, thinking aloud, expressing concerns, discomfort, and hopes, allowing her to relax, focus, and prepare for the psychodrama. This is also useful in helping other group members focus on the upcoming action phase. The double walks with her, expressing thoughts he assumes she is thinking but not expressing. Doubling, modeling, and role-training are crucial in learning how to get unstuck from repeated negative behavioral patterns. Many protagonists are anxious when learning a new role; therefore, it is important to support them as they try it “on for size” in session.

Sharing

At the end of the psychodrama, group members share and discuss what occurred, commenting on their experience playing a particular role or on how the situation affected them.  Sharing is critical both for the protagonist and for each of the group members as they reflect, share, and learn from each other. Sharing is a fundamental component in enhancing group cohesion.  During the sharing stage, assigning homework to the protagonist is essential, as it encourages the continuation of work on the new role explored in the session.  Role development needs practice for habituation to take place and to move the protagonist to feel safe in her new role.

Summary

Utilizing principles of CBT and psychodrama create a powerful and effective group process, enabling participants to address problematic situations with the support of group members. Clients find CBT helpful in becoming aware of their habitual dysfunctional thought patterns and belief systems that play an important role in mood regulation; the action component allows them to actually see and feel the dysfunction.  The cognitive experiential approach enables the individual and group to explore events, concerns, or issues, both problematic and fulfilling, in the past, present, or future.

As an aside, we will be offering this as an all-day workshop at the American Group Psychotherapy Association (AGPA) Conference “Connections”, Houston Texas, March – 2018

References

Baim, C. (2007). Are you a cognitive psychodramatist? British Journal of Psychodrama and Sociodrama, 22(2), 23–31

Beck, A.T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Hoeber. Republished as Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press.

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press.

Beck, A. T. (1991). Cognitive therapy as the integrative therapy. Journal of Psychotherapy 

Integration, 1 (3), 191-198.

Beck, J.S. (2011). Cognitive behavioral therapy: Basics and beyond (2nd ed.). New York, NY: The Guilford Press.

Boury, M., Treadwell, T., & Kumar, V. K. (2001). Integrating psychodrama and cognitive therapy: An exploratory study. International Journal of Action Methods: Psychodrama, Skill Training, and Role Playing. 54 (1), pp 13–25.

Fisher, J. (2007). Congenial alliance: Synergies in cognitive and psychodramatic therapies.  Psychology of Aesthetics, Creativity, and the Arts. 1 (4), 237-242.

Greenberger, D. &  Padesky, C. (2015). Mind over mood: Change how you feel by changing the way you think. (2nd ed.). New York, NY: The Guilford Press.

Joyce, A.S., MacNair-Semands, R., Tasca, G.A., & Ogrodniczuk, J.S. (2011).  Factor structure and validity of the Therapeutic Factors Inventory – Short Form.  Group Dynamics, 15(3), 201-219.

Moreno, J. L. (1934). Who shall survive? A new approach to the problem of human interrelations. Washington, DC: Nervous & Mental Disease Publishing Co.

Treadwell, T., Kumar, V.K & Wright, J. (2004). Enriching psychodrama via the use of cognitive behavioral therapy techniques. Journal of Group Psychotherapy, Psychodrama, & Sociometry, 55, 55-65.

Treadwell, T., Travaglini, L., Reisch, E., & Kumar, V.K. (2011). The effectiveness of collaborative story building and telling in facilitating group cohesion in a college classroom setting. International Journal of Group Psychotherapy, 61 (4), 502-517.

Treadwell, T., Dartnell, D., Travaglini L., Staats, M., & Devinney, K. (2016). Group therapy workbook: Integrating cognitive behavioral therapy with psychodramatic theory and practice.  Parker, Colorado: Outskirts Press Publishing.

Wilson, J. (2009). An introduction to psychodrama for CBT practitioners. Journal of the New Zealand College of Clinical Psychologists, 19, 4–7.

Young, J. E., & Klosko, J. S. (1994). Reinventing your life. New York: Plume.

Young, J.E., Klosko, J.S., & Weishaar, M. (2003).  Schema therapy: A practitioner’s guide. New York, NY: The Guilford Press.

Young, J. E. (1999) Cognitive therapy for personality disorders: A schema-focused approach.  Sarasota, FL: Professional Resources Press.

Woolfolk, R. (2000). Cognition and emotion in counseling and psychotherapy. Practical Philosophy.3(3), 19–27.



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