This study sought to shed light on the old adage, showing up is half the battle, an adage certainly applicable to the psychotherapy enterprise. And as seasoned therapists know, compliance with treatment, including regular attendance, is often no easy feat for many patients seeking mental health services, particularly when substance use is involved. Supporting this observation are the results from a recent meta-analysis that found that dropout rates for patients undergoing cognitive behavioral therapy were highest for those with SUD (Fernandez et al., 2015). The present study sheds additional light on the issue of attendance rates for patients receiving two group-based treatments for SUD and post-traumatic stress disorder (PTSD).
Grundmann, J., Lotzin, A., Sehner, S., Verthein, U., Hiller, P., Hiersemann, R., Lincoln, T.M., Hillemacher, T., Schneider, B., Driessen, M., & Scherbaum, N. (2020). Predictors of attendance in outpatient group treatment for women with posttraumatic stress disorder and substance use disorder. Psychotherapy Research, 1-12.
In a sample of 226 women receiving treatment for SUD and PTSD, the authors examined several patient characteristics, including socioeconomic status, employment status, PTSD severity, SUD severity and abstinence status, and treatment motivation, as predictors of treatment attendance. The two group-based CBT treatments were Seeking Safety (SS), which was developed to concurrently treat PTSD and SUD, and Relapse Prevention Training (RPT), which was originally developed to treat alcohol dependency. The authors also tested treatment by predictor interactions to identify treatment-specific predictors of attendance.
Perhaps not surprisingly, findings revealed that patients who were unemployed and reported greater substance use severity attended fewer sessions across both treatments. One treatment-specific predictor emerged, namely whether patients were currently abstinent or not. Abstinent patients compared to those who were not, more regularly attended treatment but only in the RPT condition.
These findings provide additional evidence for therapists to keep in mind the role of contextual factors on group treatment attendance. Whereas this is not the first study to examine the importance of contextual factors—such as SES, employment status, and other factors within a group treatment context—this study serves as an important reminder of the importance of client context when seeking to improve treatment attendance and utilization. This finding is even more relevant given the devastating impact of COVID on many individuals’ work and employment status. Group providers need to be cognizant of the many barriers that patients may face when seeking mental health treatment, particularly for SUD and PTSD. Group therapists should also be aware of the impact of substance use severity on treatment attendance for SUD and PTSD group treatments. These findings echo the unfortunate reality noted by Yalom & Leszcz (2020) that too often the rich get richer, in that patients with greater resources and higher functioning are often better able to access and regularly attend group-based mental health services. Group therapists need to be cognizant of ways that we can address contextual factors to enhance treatment attendance, particularly for under-resourced patients.
Stirred by the recent recognition of group psychotherapy as a specialty by the American Psychological Association, there has been an increased effort to document the effectiveness of group psychotherapy for a variety of disorders, including mood disorders, as reflected in the following report of a meta-analysis
Janis, R. A., Burlingame, G. M., Svien, H., Jensen, J., & Lundgreen, R. (2020). Group therapy for mood disorders: A meta-analysis. Psychotherapy Research, 1-17.
The present study by Janis and colleagues offer one such effort by conducting a comprehensive and rigorous meta-analysis of the effectiveness of group psychotherapy for treating mood disorders, a diagnosis with high prevalence in the United States (Kessler et al., 2003; Merikangas et al., 2007). Some 42 randomized controlled trials (RCTs) from 1990 to 2018 that compared group treatment for mood disorders with waitlist control (WLC) groups, treatment as usual (TAU) conditions, and medication were included in the review.
Again, perhaps not surprisingly, findings revealed the superiority of group therapy over WLC and TAU for depression and over TAU for bipolar disorder. Additionally, group therapy was found to be equivalent in outcomes to antidepressant medication. One interesting and important critique of research examining active treatments compared to TAU, such as this meta-analysis, is related to the question about how treatment as usual is defined. Wampold and colleagues (2011) shed light on this question with their finding that the TAU conditions in their meta-analysis significantly differed from one another, ranging from minimal or non-existent treatments to mental health treatments provided by trained professionals. Moreover, they found that the effect size of psychotherapy for depression and anxiety compared to TAU varied as a function of the type of TAU. Other scholars have continued to acknowledge the importance of critically examining what is considered TAU in psychotherapy trials in order to accurately interpret these findings.
There are several implications for evidence-based group practice given the findings from the meta-analysis by Janis and colleagues. First, group therapists should be cognizant of the difficulties in interpreting the effect of group therapy treatments compared to TAU conditions without critically examining what the TAU condition represents. These comparisons may represent the effect of group therapy to no treatment or to more active and bona fide evidence-based treatments, which represents two vastly different comparisons. Second, although individual treatments have been identified as efficacious for mood disorders historically, group therapists should be cognizant of the growing evidence supporting the utility and effectiveness of group treatments for depression and bipolar disorder. Taken together with findings from other research about the cost-effectiveness of group therapy (Burlingame et al., 2016), practitioners should consider group therapy as a front-line approach for treating depression and bipolar disorders that is both cost-effective and efficacious.