Brief Structured Group Treatment of Depression: A Research Report

Angie H. Rice, PhD

Editor's Note: The following paper was presented in Chicago at the 1998 Annual Meeting as an Open Session and was also featured in Clinical Psychiatry as a result of the presentation.

In an age of increasing economic and political pressures, clinicians are challenged to develop creative models for mental health service delivery. Societal demands for accountability require these models to demonstrate reasonable effectiveness in alleviating the difficulties for which they were designed. Due to the increasing prevalence and debilitating nature of depression, the development and evaluation of treatment modalities is particularly important. Past research has shown persons improving regardless of the therapy received (Rehm, 1990).

The present study evaluated a structured 12-week model, which integrates a number of theoretical and practice orientations into a unified approach (Rice, 1994). The treatment approach capitalizes on the interactional framework of the small group to help members cope with depression. The model gives information on the theories and possible causes of depression, and uses a variety of activities from art work to writing to help members gain understanding of their depression and begin to make positive changes in their behavior. (A brief outline of the model is presented. A more detailed presentation of the model can be found in Rice, 1994.) The study uses multiple outcome criteria, and compares this treatment approach to an alternate group treatment and a wait-list control group (Bednar & Kaul, 1986, 1994; Flowers and Booraem, 1990; Brower & Garvin, 1989).

Methodology
The population consisted of 59 persons seeking outpatient treatment for depression at a community mental health center in a large urban area. Groups consisted of four to eight members each. Four groups received a structured model for treatment of depression over a 12-week period. The wait-list control group consisted of members who received check-up contacts, and who agreed to be on the waiting list and receive group treatment after the waiting period, if desired. Due to the clinical nature of the groups, there was no random assignment or other matching procedures. The groups were formed on the basis of diagnosis and treatment recommendations, the availability of treatment groups, and client agreement. The groups were led by one social worker, and they met weekly for one-and-one-half hours.

Multiple outcome measures were administered pre and post treatment. These measures included the Beck Depression Inventory (BDI) (Beck, et al., 1961), the Symptom Checklist-90-R (SCL-90-R) (Derogatis, 1983), the Automatic Thoughts Questionnaire (ATQ) (Kendall, et al., 1988), the Inventory of Interpersonal Problems (IIP) (Horowitz, et al., 1988), the Index of Self Esteem (ISE) (Hudson, 1992), and a Social Support Contact Form (Rice, 1996). Additionally, group process was measured three times during the course of the groups using the Group Climate Questionnaire (GCQ) (MacKenzie, 1983), and leader behavior was measured post-treatment by the Group Leader/Client Relationship Questionnaire (GLCRQ) (Robinson, 1989).

Results
Analysis of demographic characteristics revealed the severity and long-term nature of the difficulties encountered by the study population, which is typical of those served by a community-based mental health service. Nearly half of the participants were classified as middle-aged (40–50 years old), with most being females who were single, alone, and isolated. While half of the participants had received a high school diploma, more than half were unemployed or classified as disabled (57.6 percent). Income levels placed more than half of the sample in the lower socioeconomic stratum. Most of the participants reported chronic difficulty with depressive symptoms. Nearly half (45.8 percent) of the study participants had also been diagnosed with some type of personality disorder, again indicating long-term difficulties in adaptive functioning.

Multivariate analysis of variance (MANOVA) did not reveal any statistically significant pattern of improvement on the multiple outcome criteria. Univarariate analyses, however, revealed that there was significant change on four of the outcome measures: the BDI, the Global Severity Index of SCL-90-R, the ATQ, and the IIP. There were no significant differences among the three treatment conditions on the Index of Self Esteem or the social support measures. Post-hoc analysis of the outcome measures revealed that the structured treatment groups improved significantly more than the wait-list control group on the BDI, Global Severity Index of the SCL-90-R, ATQ, and the IIP. Members of the structured treatment groups thus improved with respect to symptomatology, depressogenic cognition, and interpersonal functioning. The structured treatment groups did not differ significantly from the alternate treatment groups on any of the outcome measures of the study. The alternate treatment groups improved more than the wait-list control group on only one variable of interest, the SCL-90-R Global Severity Index, a measure of overall symptomatology. Members of the wait-list control group showed a trend, although not statistically significant, for worsening of the symptoms of depression as measured by the outcome of this study. This trend is contrary to the tendency for improvement with the passage of time that other research has uncovered. (Bednar & Kaul, 1986).

Correlation analysis of the leadership, group process, and outcome variables showed that there were no significant relationships among these various measures. Research has indicated that perception of a positive group atmosphere and leader helpfulness contribute to improved outcomes for group participants (MacKenzie, 1983). In the present study, members of both the structured treatment groups and the alternate treatment groups gave high ratings for leader helpfulness. Members of both treatment conditions were fairly engaged with the group process as indicated by the Engagement subscale of the GCQ. Members also reported low to moderately low levels of conflict and some avoidance of issues. However, the overall climate or atmosphere of the groups was not related statistically to leader behavior.

Conclusion
This study validated the effectiveness of the structured treatment group model in relation to a wait-list control group. The structured groups, which showed higher levels of difficulties pre-treatment, showed improvement on four of the outcome measures, and the alternate groups improved on one measure. In addition to overall symptomatology, the structured treatment groups showed improvement in cognition and interpersonal functioning. While there were differences between the two group formats, these only approached statistical significance. More research is needed to further demonstrate the effectiveness of the model and illuminate issues of group process.

The present study showed that this model is effective with a community mental health population, and that quality services can be delivered in this setting and evaluated as to their effectiveness. This study was designed and executed by a single practitioner, demonstrating that this type of practice research is possible in the everyday world of mental health services where resources are often scarce and is not limited to university settings. Practitioners in community mental health services, just as in other settings, should be engaged in evaluating the outcomes of their work with clients and sharing this knowledge with others in the field.

References

Bender, R.L., & Kaul, T.J. (1994). Experiential group research: Can the canon fire? In Bergin, A.E., & Garfield, S. (Eds.), Handbook of Psychotherapy and Behavior Change, (4th ed.). New York: John Wiley & Sons, Inc.

Beck, A.T., Ward, C.H., Mendelson, M.M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry,4, 561-571.

Bednar, R.L. and Kaul, T.J. (1986). Experiential group research: Results, questions, and suggestions. In Bergin, A.E. and Garfield, S. (Eds.), Handbook of Psychology and Behavior Change, (3rd ed.). New York: John Wiley & Sons.

Brower, A.M. and Garvin, C. (1989). Design issues in social group work research. Social Work with Groups, 12 (3): 91-102.

Derogatis, L.R. (1983). SCL-90R Administration, Scoring and Procedures Manual. Towson, MD: Clinical Psychometric Research.

Flowers, J.V. & Booraem, C.D. (1990). Four studies toward an empirical foundation for group therapy. Advances in Group Work Research. New York: Haworth Press.

Horowitz, L.P., Rosenberg, S.A., Baer, B.A., Ureno, G. & Villasenor, V.S. (1988). Inventory of interpersonal problems: Psychometric properties and and clinical applications. Journal of Clinical and Consulting Psychology, 56 (6), 885-892.

Hudson, W.W. (1992). Computer Assisted Social Services: CASS. Tempe, AZ: Walmyr Publishing Co.

Kendall, P.C., Howard, B.L., and Hays, R.C. (1988). Self-referent speech and psychopathology: The balance of positive and negative thinking. Cognitive Therapy and Research, 13 (6), 538-598.

MacKenzie, K.R. (1983). The clinical application of a group climate measure. In MacKenzie, K.R., and Dies, R.R., (Eds.) Advances in Group Psychotherapy: Integrating Research and Practice. New York: International Universities Press.

Rehm, L.P. (1990). Cognitive and behavioral theories. In Wolman, B.B. & Stricker, G. (Eds.) Depressive Disorders: Facts, Theories and Treatment Models. New York: John Wiley & Sons.

Rice, A.H. (1994). Structured group treatment of depression. In Mackenzie, K.R. (Ed.). Effective Use of Groups in Managed Care. Washington, DC: American Psychiatric Association.

Rice, A.H. (1996). Structured Group Treatment of Depression. Ann Arbor, Michigan: UMI.

Robinson, D.S. (1989). Evaluating intrafamilial child sexual abuse treatment: Group process and outcomes in multi-site programs. Dissertation, Harvard University.

This article was published in the August 1998 issue of The Group Circle.