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What Is Problem-Solving Therapy?

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

• Applying a positive problem-solving orientation to your life
• Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

• Knowing how to identify a problem
• Defining the problem in a helpful way
• Trying to understand the problem more deeply
• Setting goals related to the problem
• Generating alternative, creative solutions to the problem
• Choosing the best course of action
• Implementing the choice you have made
• Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

• Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
• Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
• Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
• Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

• Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
• Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
• Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

• Chronic stress due to accumulating minor issues
• Complications associated with traumatic brain injury (TBI)
• Emotional distress
• Post-traumatic stress disorder (PTSD)
• Problems associated with a chronic disease like cancer, heart disease, or diabetes
• Self-harm and feelings of hopelessness
• Substance use
• Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

• Death of a loved one
• Dissatisfaction at work
• Everyday life stressors
• Family problems
• Financial difficulties
• Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

• Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
• Confidence that you can handle problems that you face
• Having a systematic approach on how to deal with life's problems
• Having a toolbox of strategies to solve the issues you face
• Increased confidence to find creative solutions
• Knowing how to identify which barriers will impede your progress
• Knowing how to manage emotions when they arise
• Reduced avoidance and increased action-taking
• The ability to accept life problems that can't be solved
• The ability to make effective decisions
• The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

• Older adults
• People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

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Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

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Problem Solving Packet

Guide your clients and groups through the problem solving process with the help of the Problem Solving Packet . Each page covers one of five problem solving steps with a rationale, tips, and questions. The steps include defining the problem, generating solutions, choosing one solution, implementing the solution, and reviewing the process.

Be sure to talk to your clients about how the five problem solving steps can be useful in day-to-day life. Are there any steps that they usually skip? What questions or steps helped them work through their problem?

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To learn more or share these instructions, visit the Fillable Worksheet Instructions .

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Use custom worksheets for the purpose of education and treatment.

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Cognitive Behavioral Therapy

Solving problems the cognitive-behavioral way, problem solving is another part of behavioral therapy..

Posted February 2, 2022 | Reviewed by Ekua Hagan

• What Is Cognitive Behavioral Therapy?
• Take our Your Mental Health Today Test
• Find a therapist who practices CBT
• Problem-solving is one technique used on the behavioral side of cognitive-behavioral therapy.
• The problem-solving technique is an iterative, five-step process that requires one to identify the problem and test different solutions.
• The technique differs from ad-hoc problem-solving in its suspension of judgment and evaluation of each solution.

As I have mentioned in previous posts, cognitive behavioral therapy is more than challenging negative, automatic thoughts. There is a whole behavioral piece of this therapy that focuses on what people do and how to change their actions to support their mental health. In this post, I’ll talk about the problem-solving technique from cognitive behavioral therapy and what makes it unique.

The problem-solving technique

While there are many different variations of this technique, I am going to describe the version I typically use, and which includes the main components of the technique:

The first step is to clearly define the problem. Sometimes, this includes answering a series of questions to make sure the problem is described in detail. Sometimes, the client is able to define the problem pretty clearly on their own. Sometimes, a discussion is needed to clearly outline the problem.

The next step is generating solutions without judgment. The "without judgment" part is crucial: Often when people are solving problems on their own, they will reject each potential solution as soon as they or someone else suggests it. This can lead to feeling helpless and also discarding solutions that would work.

The third step is evaluating the advantages and disadvantages of each solution. This is the step where judgment comes back.

Fourth, the client picks the most feasible solution that is most likely to work and they try it out.

The fifth step is evaluating whether the chosen solution worked, and if not, going back to step two or three to find another option. For step five, enough time has to pass for the solution to have made a difference.

This process is iterative, meaning the client and therapist always go back to the beginning to make sure the problem is resolved and if not, identify what needs to change.

Advantages of the problem-solving technique

The problem-solving technique might differ from ad hoc problem-solving in several ways. The most obvious is the suspension of judgment when coming up with solutions. We sometimes need to withhold judgment and see the solution (or problem) from a different perspective. Deliberately deciding not to judge solutions until later can help trigger that mindset change.

Another difference is the explicit evaluation of whether the solution worked. When people usually try to solve problems, they don’t go back and check whether the solution worked. It’s only if something goes very wrong that they try again. The problem-solving technique specifically includes evaluating the solution.

Lastly, the problem-solving technique starts with a specific definition of the problem instead of just jumping to solutions. To figure out where you are going, you have to know where you are.

One benefit of the cognitive behavioral therapy approach is the behavioral side. The behavioral part of therapy is a wide umbrella that includes problem-solving techniques among other techniques. Accessing multiple techniques means one is more likely to address the client’s main concern.

Salene M. W. Jones, Ph.D., is a clinical psychologist in Washington State.

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75+ Free Mental Health Worksheets & Handouts

75+ free mental health worksheets, handouts, and forms for mental health professionals or self-help.

(Updated 2/13/24) This is a list of nearly 100 mental health worksheets, handouts, forms, and more for substance use, mental health, and wellness.

Please repost and share with anyone who might benefit! New resources are added on a regular basis.

For more free downloads, click here for a list of PDF workbooks, manuals, and self-help guides.

For free mental health worksheets and resources from other sites, check out TherapistAid , GetSelfHelpUK , and Taking the Escalator .

Mental Health Worksheets & Handouts

Group ideas & topics.

A 3-page handout for group facilitators with strategies for managing resistance, disruptive behaviors, and a lack of engagement in group therapy.

A list of topics for substance use groups.

A 2-page handout for clinicians who facilitate group therapy with (adult) clients and their families. The questions were developed for an inpatient SUD setting.

A list of specific topics for substance use groups, such as refusal skills, the difference between a lapse and a relapse, and fun in recovery.

A list of group openers for substance use groups; can also be used in individual counseling sessions.

A list of questions for exploring the following topics: Conversation starters, mental health, addiction, personal development, values, family, relationships, and emotions. These questions can be used in a group setting, individually, or as journal prompts.

Group Activities

A worksheet with prompts for writing a short autobiography to be presented to the group.

Intended audience: Adults

A worksheet for clients to pass around to group members so each person can write a positive affirmation.

Intended audience : Adolescents, Teens, Adults

Good for newly formed groups. Each group member writes down their “first impression” of other group members. The facilitator then reads off the different categories and group members have the opportunity to share their answers.

Intended audience : Adults

An icebreaker activity, good for new groups. Give group members 15-20 minutes to collect signatures. The first person to collect all signatures wins.

Clinical Film Discussion Questions

• Ben Is Back -Discussion Questions
• Girl, Interrupted -Discussion Questions
• Pay It Forward -Discussion Questions
• The Perks of Being a Wallflower -Discussion Questions
• Rachel Getting Married -Discussion Questions
• When a Man Loves a Woman -Discussion Questions

A printable deck of cards with 128 coping skills for managing stress, anxiety, and other difficult emotions. Each card includes one simple coping skill.

Print/cut the cards, fold, and place in a container. Group members take turns drawing the cards and answering the questions.

A printable deck of cards with 40 positive quotes that can be used as affirmations.

A printable card deck with 27 affirmations for healing and empowerment.

These cards can be used in a SUD inpatient or outpatient setting to facilitate group discussions about recovery. Group members take turns drawing a card and answering questions. The facilitator can vary things up by letting group members pick someone else to answer their question once they’ve finished sharing. Alternatively, group members can take turns drawing cards, but all group members are encouraged to share their answers. This activity works best with a working group.

This is a revised version of the Recovery Question Cards.

Rumi Quote Cards

25 cards with Rumi quotes on love, suffering, and healing.

A card deck with 104 cards with thought-provoking questions intended to promote discussion. Topics include goals, values, emotions, relationships, spirituality, and more.

These cards can be used in a group or individual setting. The last page of the PDF includes additional values exercises for journaling, clinical supervision, couples, and groups. Tip: Print the cards on patterned scrapbook paper (blank on one side).

Mental Health Handouts

4 ways to stay calm before a stressful event.

A 1-page handout with simple “in-the-moment” calming strategies for anxiety-provoking events.

A simple 1-page handout that shows the 6 basic emotions.

A comprehensive list of 12-step and other support groups , such as AA, NA, SMART Recovery, Dual Recovery Anonymous, NAMI, etc.

A 1-page DBT-based handout with 25 examples of dialectics (i.e., two things that seem opposite and are at the same time both true).

These journal prompts can also be used in a group setting. The prompts include questions about values, potential, expectations, and more.

Instructions for Living from the Dalai Lama

A 1-page handout with 25 quotes from the Dalai Lama on topics such as kindness and happiness. Can be used in a group setting.

A 1-page handout that debunks five common grief myths and provides the truth about each one.

A 2-page handout with nine creative and soothing outlets for grief , such as music, dance, light therapy, and aromatherapy.

A 2-page handout with journal prompts for recovery, based on material from The Sober Survival Guide (created with the author’s permission).

Kindness To-Do List

A to-do list of kind deeds with blank spaces to write in your own ideas for spreading kindness.

A colorful 3-page handout with ideas for hobbies that fall under the following categories: Animals/nature, arts/crafts, collections, cooking/baking, entertainment, home improvement/DIY, outdoor/adventure, self-improvement, sports, travel, and misc.

A list with links to online grief support groups, forums, and communities.

A 1-page handout on PTG and how it may impact a person’s life, and the factors that contribute to PTG.

A 1-page handout with resources for suicide , including recommended books, apps, crisis lines, and suicide warning signs.

A 2-page handout that describes seven uncommon grief experiences, such as delayed or disenfranchised grief.

A list of 38 unique coping skills for managing difficult emotions.

A 2-page handout that lists values. Can be used as a standalone handout or with the values card deck .

A 2-page handout with two exercise routines, one designed for beginners and the other for more advanced exercisers.

Mental Health Worksheets

A 1-page worksheet for identifying things to be grateful for in different life areas.

A 1-page checklist with 30 ideas for spreading kindness.

A 1-page worksheet for exploring what makes someone a good friend.

Art Activity: H-T-P Test

In the House-Tree-Person Test, the picture of the house is supposed to represent how the individual feels about their family. The tree elicits feelings of strength or weakness. The person represents how the individual feels about themselves. (Source: How Projective Tests Are Used to Measure Personality – Simply Psychology )

Art Activity: Outer & Inner Masks

This art activity can be done in a group setting or individually. Clients design both outer – what the world sees – and inner – the hidden self – masks. The third page has questions for discussion. This activity can be used to target all sorts of issues from body image to values to character defects (in addiction) and more.

Art Activity: Self-Portraits

This worksheet can be used in groups or as a homework assignment. Encourage clients to be creative; instead of just drawing or coloring, they can use magazine cutouts, stickers, photos, etc. Suggested questions for discussion: How did you decide which identities to portray? Which portrait best represents your true self? Which portrait do others see the most? What, if anything, would you like to change about your portraits?

A 2-page worksheet for exploring the consequences of addiction.

Coping with Cravings

A 3-page worksheet with DBT-based skills for coping with cravings.

Coping with Jealousy

A worksheet for understanding jealousy, its impact, whether it’s pathological, and how to manage jealous feelings.

Couples Exercise: Affirmations

A 3-page worksheet for sharing self-affirmations and partner affirmations, including suggested questions for discussion.

Couples Exercise: Our Bucket List

A 3-page worksheet for couples to create a shared list of meaningful “bucket list” items to do together.

Couples Exercise: Our Bucket List (with dates)

A shared bucket list that includes spaces to write in when an item was added to the list and when it was completed.

A 1-page worksheet for affirmations, positive self-talk, and problem-solving strategies for daily challenges.

A basic mood tracker with emoji faces.

A blank schedule with hourly slots starting at 6:00 a.m. and ending at 10:00 p.m. Can be used as part of a relapse prevention, for depression management, or as a planner.

A 3-page worksheet for substance use recovery for planning leisure activities and enhancing wellness/spirituality.

A letter template for individuals entering long-term residential treatment for substance use, to be opened and read at treatment completion.

An 8-page goal-setting worksheet for health/wellness, relationships/social health, emotional wellness, intellectual wellness, education/career, financial health, spirituality, and leisure.

A 3-page worksheet for identifying and managing substance use relapse triggers.

A 1-page worksheet for identifying things that promote addiction and ways to get rid of or avoid these things.

A 3-page goal-setting worksheet for short-term and long-term goals.

A 12-step-based worksheet for identifying and exploring resentments.

A worksheet for creating poetry; print, laminate, and cut out the words.

A 1-page worksheet for examining past substance use relapses and strategies for avoiding future relapses.

A 5-page template for creating a substance use relapse prevention plan.

A 1-page worksheet for exploring ways to resist urges to use in early recovery.

A 1-page checklist with quick tips, self-soothing, and indulgent ideas for self-care.

A 3-page worksheet for developing a colorful self-care “map” to explore patterns and identify new practices.

A 3-page template for creating a self-care “menu.”

A 2-page writing assignment for self-discovery and awareness.

A 2-page worksheet for developing self-esteem.

A 1-page worksheet for exploring motivation for substance use recovery.

A fun worksheet for creating a bucket list of things that are only possible in sobriety.

Stress Management Worksheet

This 6-page worksheet helps with identifying and exploring stressors. From there, the worksheet can be used to build a stress management plan.

7 pages of feelings words.

A 6-page worksheet for describing problem areas, identifying goals, and exploring what has (and has not) been helpful in the past. This worksheet can be used to develop a collaborative treatment plan.

A 2-page worksheet for identifying and exploring wants and needs.

A simple form for tracking daily meals and snacks for one week.

A 2-page worksheet for identifying things that are controllable versus things that can’t be controlled.

A 3-page narrative therapy worksheet for exploring a past substance use relapse.

Laminate and use with fine-tip dry erase markers.

Workbooks & Bonus Materials

100-page printable workbook for working through grief and loss.

A companion workbook meant to be used with the book Staying Sober Without God (created with the author’s permission).

Daily Self-Inventory for Mental Health Professionals

A 10th step-based inventory for self-reflection for counselors and other mental health workers.

Free Coloring Pages for Adults

Links to 15 websites with free printable coloring sheets for adults.

Miscellaneous Printables

A list of 20 openers for individual therapy sessions.

A 2-page form for case conceptualization with sections for demographics, key findings, background info, case formulation, interventions/plans, and requested feedback or suggestions.

A list of interventions (action words) for clinical documentation.

A template for tracking attendance, cases discussed, and any other group topics.

A foldable coloring book with eight different designs.

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29 thoughts on “75+ Free Mental Health Worksheets & Handouts”

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Thank you for giving away this valuable information. I am a Adult Mental Health Case Manager and I use things from here in my weekly group meetings!

I do also, but for juveniles. These tools are extremely helpful.

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Thank you so much for providing these free handouts. During these tough times, I find these handouts to be extremely useful. A million thank you’s!

These valuable materials are so much of a blessing, thank you so much for the gracious kindness!!!

I’m a drug and alcohol counselor and I find this site very helpful!

It is great to see that someone else wants to promote better care for clients and therapists alike using comprehensive resources (that are free!). Thank you!!!

I love this site i am a Mental Health Professional and I find these very helpful with my group sessions.

Thank you very much!! I have a son struggling with depression and suicide. This will help very much.

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This is a wonderful site. I deeply appreciate the effort and time it took to put this together. Thank you very much.

I can’t tell you how fortunate I am to have stumbled onto this. I am a Behavioral Health PSS in a drug and alcohol treatment facility and am looking forward to sharing some of these materials with our clients. I love the group activities and discussion prompts and will be using some in my next group. Fantastic resource! There is something for everyone here! Thank you so much for this. Be well 🙂

Hope you guys add a Domestic Violence section

Thank you for giving us free worksheets. It’s really helpful.

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Thank you!!

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I am a mental health therapist and I really struggle for group therapy ideas. Thank you for sharing. Your site has been very helpful for me to find new ideas.

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Group Therapy: How It Works, What It Helps, and More

Group therapy is a type of psychotherapy that involves treating multiple people at the same time. One or more therapists can lead this type of therapy. A typical group includes about 5 to 15 participants, and each session lasts about an hour or two per week, according to the  American Psychological Association (APA) .

What Is Group Therapy?

Led by a mental health professional, group therapy allows people to interact with others who may be going through similar challenges, share valuable feedback, and work together to solve common problems, notes the American Group Psychotherapy Association (AGPA) .

“You can relate other people’s situations to your own,” says Judith Belmont , a former psychotherapist, a current online mental health coach, and the author of 150 More Group Therapy Activities and Tips . “There’s a sense of universality in group therapy. You realize you’re not alone, and you can try out developing skills in a group setting. It’s a very powerful way of learning and growing.”

Many groups are designed to address a specific concern, such as how to cope with depression, anxiety, pain, substance abuse, low self-esteem, loneliness, or grief, says the APA. But a group can offer a safe environment for anyone who is interested in self-development, regardless of whether you have a specific mental health condition, per the AGPA.

“Although most are apprehensive at first and don’t understand why group [therapy] would be helpful, after several sessions they begin to understand the power of connecting to other people as a significant part of the healing process,” says Martyn Whittingham, PhD , a licensed psychologist, a certified group therapist, and the founder of Focused Brief Group Therapy, an eight-session group therapy approach.

Pros and Cons of Group Therapy

There are both benefits and disadvantages to participating in group therapy, depending on your situation.

According to the American Addiction Centers , some pros of group therapy include:

• It typically costs less than individual therapy.
• Participants are exposed to different points of view and can relate to the struggles others face.
• There’s an opportunity to give and receive support from others.
• Individuals learn to improve their communication skills, become more self-aware, and express their feelings.
• Participants can model the successful behaviors and reactions of others who face similar circumstances.

On the flip side, some potential downsides of group therapy are:

• Each individual is not the main focus in the therapy session, and some may have more opportunities to speak than others.
• There’s less scheduling flexibility, as groups usually meet at specific times and must accommodate the schedules of all group members.
• Some may feel uncomfortable sharing personal information in a group.
• Conflicts can happen within the group.
• Although all group members are told that what’s shared to the group is confidential, there’s potential for less patient confidentiality in a group setting than one-on-one.

When it comes to the issue of participant confidentiality, Dr. Whittingham says it’s important to ask about protocols. “Some places, such as Washington, DC, have laws stating that group members cannot break confidentiality, while other states rely on the promise of each group member,” he explains.

Different Types of Group Therapy

There are many types of group therapy and ways to structure the sessions, Whittingham says. “They can sometimes focus on a diagnosis, like depression, but there can also be theme groups, like dealing with grief or managing perfection,” he explains.

Though there are different approaches to group therapy, most models have a common goal of helping people acquire new skills by interacting with each other, says Belmont. “One misconception is that group therapy is not good for learning about yourself, but actually people learn the most about themselves through other people,” she says.

Common models used for group therapy, according to the American Addiction Centers, include:

• Psychoeducational Groups A therapist acts as an educator, teaching participants about their conditions and helping them identify ways to cope.
• Cognitive-Behavioral Therapy Groups In these settings, a therapist uses cognitive behavioral therapy techniques to help individuals identify and change unhelpful thinking and behaviors into more constructive ones.
• Skills Development Groups People learn specific and applicable skills within a group setting.
• Support Groups This model encourages participants to support each other via different strategies, such as group discussions or problem-solving activities.
• Interpersonal Groups A therapist helps participants gain an understanding of and improve their emotional development and behavior by analyzing their social interactions and interpersonal relationships with other group members.

Sometimes these approaches are combined, depending on the needs and goals of the group, per American Addiction Centers.

Additionally, group meetings can be open or closed, according to research . An open session allows new members to join at any time, but closed groups require members to join at the same time.

What Conditions Can Group Therapy Be Used to Treat?

Group therapy can benefit many people of different ages, races or ethnicities, gender identities, sexual orientations, or cultural backgrounds, according to the AGPA.

Group therapy may be particularly helpful for individuals who experience the following, according to StatPearls and the APA:

• Anxiety disorders
• Post-traumatic stress disorder (PTSD)
• Attention deficit hyperactivity disorder (ADHD)
• Eating disorders
• Social or behavioral challenges
• Grief or loss
• Chronic pain
• Substance use disorder

What Does Research Say About Group Therapy?

Studies show that group therapy can be an effective tool for a wide range of conditions, and it may work as well as individual therapy, notes the  APA .

In a review published in 2021 in The American Journal of Psychotherapy , researchers analyzed data from more than 329 studies that compared group therapy with individual therapy. They found group sessions are effective for helping reduce symptoms associated with these conditions:

• Bipolar disorder
• Schizophrenia
• Anxiety and panic disorders
• Obsessive-compulsive disorder
• Borderline personality disorder
• Substance use disorders

Evidence shows that therapy conducted in a group setting can also save resources and money.

Using group therapy to meet psychological needs in the United States could save more than $5.6 billion and require 34,473 fewer new therapists compared with individual therapy, according to an analysis published in 2023 in the journal American Psychologist , which Whittington co-authored. A persistent shortage of mental health providers is a common barrier to treatment in the United States, per the same study.

Some research suggests that group therapy conducted virtually may be as effective as in-person sessions. In a review of 40 studies, published online in May 2018 in the Journal of Telemedicine and Telecare , investigators found similar outcomes and levels of participant satisfaction between in-person group therapy and teleconference group sessions.

How to Get Started With Group Therapy

Here’s what you should know before starting group therapy.

What’s a Group Therapy Session Like?

Therapy groups typically meet for an hour or two each week, according to the APA. Group sessions can be conducted in person or online, per the AGPA. The total number of meetings for each group may vary. Short groups addressing specific issues can last from 4 to 20 sessions, whereas others continue long term, according to the AGPA.

The structure of the meetings varies depending on the treatment models used and the group’s overall goals. “It’s not just talking about your feelings. There are lots of structured activities and topics,” Belmont explains.

Although groups usually consist of 5 to 15 participants, therapists often encourage breaking up into smaller subgroups or pairs for activities and then regrouping for a larger discussion, Belmont says. Typically, activities will emphasize ways to improve communication, personal growth, and trust.

“For example, you might try a role-playing situation for how to speak up more confidently, how to assert yourself, or how to handle your anger,” says Belmont. “The beauty of a group setting is that you can practice these skills.”

Participants may attend group sessions exclusively as their main form of treatment, or some may choose to participate in individual therapy along with group therapy, notes the AGPA.

How to Find a Group Therapist

Group therapy is commonly a required component of other types of psychotherapy, such as dialectical behavior therapy , says Belmont. Often, group sessions take place in inpatient settings, hospitals, and community centers. Group therapy is rarely offered at private practices partly because it’s challenging to assemble a larger number of people at one time, adds Belmont.

A mental health professional can provide recommendations for groups in your area, Whittingham says. Additionally, the AGPA provides a  directory of certified group therapists in each state.

It’s a good idea to check with your health insurance company to see whether group therapy is covered prior to attending. As noted earlier, group therapy is typically less costly than individual therapy, and most insurance plans will cover both types, per AGPA.

When choosing a potential therapist, per the AGPA, you may want to ask the following questions:

• What is your background, and what educational training do you have?
• How effective do you think group therapy will be for me and my particular situation?
• What credentials do you have for group therapy?
• Do you have any special training to deal with my specific situation?

How to Prepare for a Group Therapy Session

Before attending a group therapy session, Whittingham says, you should ask the therapist:

• What to expect at sessions
• What is expected of you during sessions
• What the rules are about confidentiality
• If your goals align with the goals of the group

“If you are unsure of your goals for group [therapy], that’s perfectly okay, too,” Whittingham notes. “Most people are not sure how they want to get better, only that they don’t feel good and want to change.”

It might also help to write down what you plan to share with the group ahead of time.

Being open and honest is crucial for a positive experience. According to the University of North Carolina in Chapel Hill , you may want to prepare yourself to receive positive and negative feedback from other group members.

Who Shouldn’t Try Group Therapy?

While group therapy can be a beneficial tool for most people, some may do better with individual therapy, notes Whittingham. “For example, if you are in the middle of a severe crisis, such as a very recent, profound trauma that means you struggle to focus on other people, individual therapy can be a good place to find safety first,” he explains.

Group therapy may not be the best fit for people who are very antisocial, impulsive, or passive-aggressive, or who tend to be extremely shy, per American Addiction Centers. Whittingham adds that it’s best to talk with a mental health professional if you are questioning whether group therapy is a suitable option.

That said, if you are more reserved, you shouldn’t immediately discount group therapy, adds Belmont. “If one is starting out not feeling comfortable, they just don’t say as much. You don’t have to share, and some people might not feel ready for quite some time,” she explains. “But in my experience, people are very surprised by how comfortable they are sharing, especially during structured activities.”

Common Questions & Answers

Resources we trust.

• Mayo Clinic:  Support Groups: Make Connections, Get Help
• Cleveland Clinic:  Recovery Groups
• American Group Psychotherapy Association: What Is Group Psychotherapy?
• American Psychological Association: Psychotherapy: Understanding Group Therapy
• StatPearls: Group Therapy

Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy . We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.

• Malhotra A et al. Group Therapy. StatPearls . December 13, 2022.
• Psychotherapy: Understanding Group Therapy. American Psychological Association . October 31, 2019.
• What Is Group Psychotherapy? American Group Psychotherapy Association .
• Psychotherapy Guide: Group Therapy vs. Individual Therapy.  American Addiction Centers . March 20, 2023.
• Ezhumalai S et al. Group Interventions. Indian Journal of Psychiatry . February 2018.
• Group Therapy Is as Effective as Individual Therapy, and More Efficient. Here’s How to Do It Successfully. Monitor on Psychology . March 2023.
• Rosendahl J et al. Recent Developments in Group Psychotherapy Research. The American Journal of Psychotherapy . March 2021.
• Whittingham M et al. Mental Health Care Equity and Access: A Group Therapy Solution. American Psychologist . February-March 2023.
• Gentry MT et al. Evidence for Telehealth Group-Based Treatment: A Systematic Review. Journal of Telemedicine and Telecare . May 2018.
• Tips for Getting the Most Out of Group Therapy. University of North Carolina at Chapel Hill .

Seth Gillihan, PhD

Medical reviewer.

Julie Lynn Marks

Julie Marks is a freelance writer with more than 20 years of experience covering health, lifestyle, and science topics. In addition to writing for Everyday Health, her work has been featured in WebMD, SELF, Healthline ,  A&E ,  Psych Central ,  Verywell Health, and more. Her goal is to compose helpful articles that readers can easily understand and use to improve their well-being. She is passionate about healthy living and delivering important medical information through her writing.

Prior to her freelance career, Marks was a supervising producer of medical programming for Ivanhoe Broadcast News. She is a Telly award winner and Freddie award finalist. When she’s not writing, she enjoys spending time with her husband and four children, traveling, and cheering on the UCF Knights.

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Practical Approaches in Group Therapy: Techniques Explored

Group therapy offers a supportive environment where individuals can navigate their challenges together, learn from each other's experiences, and develop new coping strategies. The effectiveness of group therapy greatly depends on the techniques employed by the therapist. This article delves into some common techniques used in group therapy, their objectives, and how they enhance the therapeutic process.

Key Techniques in Group Therapy

In group therapy, a wide range of techniques are employed, each tailored to the unique needs of the group. Some of these techniques include:

1. Icebreakers: These are activities designed to help group members become more comfortable with each other, promoting an open, supportive environment. They can be as simple as introducing oneself or sharing a personal fact or experience.

2. Guided Imagery: This technique involves the therapist guiding the group through a mental exercise or visual journey, aiming to induce relaxation, reduce stress, or explore certain emotions or experiences.

3. Role-Playing: In role-playing activities, group members enact certain situations or dynamics, which allows them to explore different perspectives and behaviors.

4. Open Discussions: Open discussions allow group members to share their thoughts, feelings, and experiences on a given topic. The therapist may set a discussion topic or leave it open-ended.

5. Problem-Solving Exercises: These exercises encourage group members to collaborate in addressing a shared problem or challenge, fostering teamwork and shared learning.

Objectives of These Techniques

The techniques used in group therapy are designed to facilitate interaction, promote personal growth, and address the unique needs of the group. Their key objectives include:

1. Building Trust: Techniques like icebreakers and open discussions help to build trust among group members, creating a safe and supportive environment for sharing.

2. Promoting Insight: Techniques such as guided imagery and role-playing can facilitate self-insight and understanding, helping group members gain a deeper understanding of their feelings, thoughts, and behaviors.

3. Encouraging Shared Learning: Problem-solving exercises and open discussions promote shared learning, where group members can learn from each other's experiences and perspectives.

4. Facilitating Skill Development: Many techniques used in group therapy aim to develop skills such as emotional regulation, communication, and problem-solving.

How These Techniques Enhance the Therapeutic Process

Group therapy techniques play a crucial role in enhancing the therapeutic process by:

1. Facilitating Engagement: Techniques like icebreakers and open discussions encourage active participation, fostering engagement with the therapeutic process.

2. Fostering Therapeutic Relationships: The use of group therapy techniques can help foster therapeutic relationships among group members, enhancing the support and understanding available within the group.

3. Promoting Personal Growth: Techniques that promote insight and skill development contribute to personal growth, helping group members make positive changes in their thoughts, feelings, and behaviors.

4. Enhancing Coping Strategies: Techniques such as problem-solving exercises and role-playing can enhance coping strategies, equipping group members with practical tools to manage their challenges.

Through the utilization of various techniques, group therapy offers a supportive environment for personal growth and mutual learning. The techniques foster engagement, promote insight, and facilitate skill development, thereby enhancing the overall therapeutic process and outcomes for the group members.

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7 Helpful DBT Exercise Ideas for Anxiety

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11 CBT Group Therapy Activity Ideas With Examples

By Jamie Frew on Jul 01, 2024.

Fact Checked by RJ Gumban.

Introduction

Are you a mental health practitioner who wants to step up your group therapy? If yes, then you’re in luck! If you’re looking for fun, effective ways to engage your clients in some activities to improve their mental health, you’ve come to the right place. 

Who says you can’t put “fun” in “group therapy?” In this blog, we have researched and come up with some of the best group therapy activities for adults , as well as a range of game ideas for group therapy. Let’s dive in!

Overview on Cognitive-Behavioral Group Therapy (CBGT)

Firstly, let’s talk about CBT or Cognitive Behavioral Therapy. CBT aims to improve the mental health of a person. It focuses on enhancing the way a person thinks and behaves through therapy. The purpose of CBT is to address mental health issues, such as abuse, depression, anxiety, and more.

But the difference is CBGT or Cognitive Behavioral Group Therapy blends CBT in a group setting. The participants will engage in this therapeutic approach as a group. The CBT group therapy activities are an incredible way to develop social skills, learn from other participants, and improve thinking patterns and coping mechanisms.

It’s important to ensure that while conducting some CBT group activities, participants feel safe in the environment. This way, they can share their experiences in a non-threatening environment and receive the support they need from others.

There are different CBT group activities you’ll discover in this blog. Before we go any further, let’s see what makes CBGT effective.

Benefits of group CBT therapy

CBGT has many benefits for you and your clients, some of which are:

Cost-effective

CBGT is cost-effective because you can work with many participants in one session. This makes it more cost-friendly. How? Because people who want to improve their well-being can join CBGT rather than one-on-one therapy, which can be more expensive.

Improve skills

CBGT can also include the skills of participants through interactive CBT activities for group therapy. These can be their problem-solving skills, thinking patterns, communication skills, cognitive restructuring, and therapeutic techniques.

Learn different perspectives

This happens to any other group activities. Through CBGT, the participants will discover more about each other. As a result, they can learn about the different perspectives and experiences of others.

Build healthy habits

When the group therapy ends, each participant can bring the lessons they learned from the activities. It’s not a one-and-done kind of thing but continuous work. So through CBGT, they can build healthy habits even outside the therapy sessions.

Receive support

One of the best things about group therapy is not having to feel isolated and alone. The participants who are going through the same thing can get together, relate with each other, and provide support to boost their wellness.

Do these benefits sound good? Read on because, with these CBT group ideas, you’ll be able to gain insights and tips to make group therapy effective .

CBT group therapy activity ideas with examples

The following CBT group therapy ideas will help you and the participants achieve therapeutic goals. First, we have:

Social roleplay

Roleplay is an excellent way for self-expression. It helps participants engage in different social situations and learn what to do when they encounter them. This will lessen their anxiety and empower their social skills.

You can come up with different scenarios that you think will be helpful to the participants. For example, if some of them have low self-esteem, have them roleplay social scenes that will make them feel empowered.

Mindfulness meditation

The world moves fast. Sometimes, we need to keep ourselves grounded and keep in touch with our emotions and thoughts. That’s where mindfulness meditation comes into play.

It is a mental technique that will help your participants to concentrate, relax, and focus on the present. This can reduce negative thoughts, boost mental clarity, and strengthen self-control.

Gradual exposure

Gradual exposure means the participants will be gradually exposed to things that trigger or cause distress. The purpose of this is to reduce fear, anxiety, and avoidance of that specific situation or object.

For example, a participant has a phobia of insects. You can start by having them imagine the image of the insects. Then in the next session, there will be more vivid imaginations.

If successful and the participant feels safe enough, there can be real-life exposures, too. But make sure that the participant is comfortable with it and willing to work on their phobia. 

Successive approximation 

Goals can be overwhelming. So, the successive approximation is here to tackle these overwhelming goals by breaking them into smaller steps. Through this, participants can achieve a bigger goal and mastery by taking small steps every day.

Skills training

Skills training is designed to help individuals learn new skills and use them for their own growth. These could include communication skills, social skills, assertiveness, or other general psychological skills.

For example, you can train the participants to be kind to themselves and improve self-talk. They can also practice breathing exercises, mindfulness, and other activities that will improve their mental health and other skills.

Relaxation breathing training

When things get hard, we forget to pause and breathe. Sometimes, that can cause anxiety and panic attacks. 

So through relaxation breathing training, participants can reduce the symptoms, such as rapid heart rate, shortness of breath, trembling, etc.

Problem-solving

This CBT exercise is designed to help participants or clients be proactive in solving their problems during challenging times. Problem-solving exercises allow participants to take control of their emotions and navigate difficult situations. To put this into practice, you can come up with CBT games for groups tailored to highlight their problem-solving skills.

Worry journaling

Journaling can help us slow down, gather our thoughts, and calm our minds. If your participants are stressed or suffering from anxiety, you can advise them to do worry journaling.

You can give them prompts to answer, so they know what to write. For example:

• What are you grateful for today?
• What are you looking forward to?
• What’s the highlight of your day?
• What are some of the worries you need to let go of?

 They can do this every morning, night, or whenever they have racing thoughts or worry.

Discussing trauma

Discussing trauma can help participants process their thoughts and emotions about the traumatic events. 

To start with this exercise, you can brainstorm discussion questions for group therapy to get the conversation started. If you have participants who are dealing with substance-use problems, there are a great number of group topic ideas for substance abuse so participants can talk about their experience.

Make sure that participants feel safe discussing their traumatic experiences and that they are comfortable talking about them.

Focusing on self-care

Self-care doesn’t mean you have to do it alone. There are group activities for self-care that will encourage participants to implement together but will benefit themselves.

Some group activities that stimulate self-care are: 

• Playing board games
• Exercising together
• Practicing mindfulness
• Starting new hobbies together
• Having lifting and mindful conversations

Aren’t these activities exciting? 🤩

All in all, group activities can improve themselves as individuals while thriving in a supportive environment. The more counseling group therapy ideas you have, the more lively you can turn therapy will. It doesn’t need to have a nerve-racking atmosphere.

By using the activities mentioned above, you can create a fun-loving environment that participants will enjoy and feel safe in. And that plays a big role in achieving the best outcomes for your clients.

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Further Reading:

• Cognitive behavioral group therapy for anxiety: recent developments
• 13 Topics to Discuss in Group Therapy

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Group Therapy: Types, How It Works, & What to Expect

Author: Matt Glowiak, PhD, LCPC

Matt Glowiak PhD, LCPC

Matt specializes in major depressive disorder, anxiety disorder, bipolar I and II, BPD, OCD, PTSD, and schizophrenia.

Benjamin Troy MD

Dr. Benjamin Troy is a child and adolescent psychiatrist with more than 10 years. Dr. Troy has significant experience in treating depression, bipolar disorder, schizophrenia, OCD, anxiety, PTSD, ADHD, and ASD.

Group therapy is an affordable and effective form of treatment in which a small group of participants and one or more facilitators meet to interact and discuss a variety of different topics. 1 Groups generally consist of 5-15 participants and meet on a consistent schedule. 1 Topics and style vary widely by need, and are available in-person and online.

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What Is Group Therapy?

Group therapy is different from individual therapy options as it relies on the power of a skilled, competent leader in combination with group cohesion to promote change. Most groups focus on specific mental health topics, have 5-15 members, and meet regularly. When everyone is working together, the support provided can be more significant than anything accomplished alone or by just two people.

By participating in a group, members begin to feel normalized in a community of people who “get it.” Group members also possess unique insights into techniques and coping mechanisms that may or may not have worked in the past, empowering other members to try these strategies as well.

There are twelve therapeutic factors upon which group therapy is built: 2

• Cohesiveness
• Corrective recapitulation of the primary family experience
• Development of socializing techniques
• Existential factors
• Imitative behavior
• Imparting information
• Installation of hope
• Interpersonal learning
• Self-understanding
• Universality

In combination, these characteristics are what make group therapy unique.

Group Therapy Vs. Support Groups

While group therapy and support groups may seem similar in many ways, the biggest difference lies in their purpose: group therapy aims to help people change, while support groups exist to help people cope. Support groups are especially important for people who find themselves in situations that cannot be changed, like grieving the loss of a loved one. Group therapy is best for people who have the agency to change their lives for the better with the social, emotional, cognitive, and behavioral skills to make it happen, which they can gain in the group therapy setting.

What Can Group Therapy Help With?

Topics for group therapy can vary greatly, depending on the needs of the community. Group therapy may be utilized by people dealing with any variety of issues including substance misuse, eating disorders, anxiety and depression, and life transitions like divorce.

While substance use is commonly addressed in group therapy, other group therapy topics include:

• Grief and loss
• Low self-concept
• Interpersonal skills issues
• Major life transitions
• Eating disorders
• Bipolar disorder
• Personality disorders

If Someone Is in Group Therapy, Do They Also Need Individual Therapy?

For many people in group therapy, individual therapy may also be helpful. With certain populations, engaging in both individual and group therapy increases someone’s chances for success in achieving lasting change in their life. 3 If a person’s progress in individual therapy seems to be plateauing, supplementing their treatment with group therapy can reignite momentum in their individual work.

For those who are in crisis or are experiencing suicidal thoughts, individual therapy is warranted. Group therapy can then be explored as a treatment option once the person is stabilized and no longer in crisis. 4

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Types of Group Therapy

Given the wide diversity of group topics and participant needs, there are numerous types of group therapy, but psychotherapy and self-help groups are two of the most common. While some are more conversational, others are more informational or task-oriented. Some are open (meaning anyone may attend at any time), while others are closed. Many people find online group therapy to be a helpful resource, while others may prefer going in-person.

Here are the most common types of therapy groups:

Psychotherapy Groups

Psychotherapy groups are led by a trained mental health professional and include two or more participants. The focus of these groups is to understand and identify life problems as well as the thoughts, emotions, and behaviors that contribute toward them.

Group members process their problems and work to develop healthy coping and problem-solving skills with the goal of regaining control and improving overall well-being. Psychotherapy groups are generally offered at hospitals, residential and outpatient treatment centers, group recovery environments, and community mental and behavioral health clinics.

Cognitive Behavioral Groups

While cognitive behavioral therapy (CBT) groups will utilize the same therapeutic principles as individual CBT treatment, there are some unique aspects to CBT group therapy . Group therapy offers more opportunities for normalization, positive peer modeling, and social exposure, not to mention valuable social support. However, research shows that individual and group CBT are equally effective, with no significant differences in outcomes for those who engage in CBT group therapy or individual therapy using CBT. 5

Interpersonal Groups

Group interpersonal therapy, also known as group IPT, is a time-limited, evidence-based approach to address mood disorders by aiming to improve a client’s relationships and social functioning. 6 Delivered in a group setting, clients are asked to pay close attention to their thoughts, feelings and reactions as the group progresses, offering valuable in vivo insight into the inner workings of their interactions with others. 7

Skill Development Groups

Often used in treating anxiety, depression, substance use disorders, and PTSD, skill development groups aim to teach clients valuable skills to improve their daily functioning. 8 Skill development groups focus on teaching and practicing positive coping skills to equip group members to better manage their mental health challenges.

Self-Help Groups

Self-help groups are self-governing and are run by member volunteers who have demonstrated maintained recovery. Such groups are built upon the concept of reciprocal healing, meaning that the members share a common problem and exchange social support. Twelve-step groups such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Dual Recovery Anonymous (DRA), and so on, are some of the more common self-help groups.

Process Groups

Process groups focus on processing an experience, emotion, or problem. Rather than look at things superficially, process groups dig deeper into understanding the why, who, what, when, where, and how. Though there is not always an answer to everything, working it through provides further insight, which leads toward acceptance. Being in the group setting, this also affords the benefit of multiple perspectives.

Task Groups

Task groups focus on successfully achieving a meaningful goal of a client, group, or entire community. For instance, a group of mental health professionals may come together to devise an awareness or prevention campaign, such as with topics of suicide or substance use. These groups require the appropriate personnel, identification of an issue, adequate planning, thoughtful delivery, and evaluation of outcomes.

Support Groups

Support groups are unique from group therapy in that they exist to help people cope with difficulties in their lives through valuable peer support. The focus of support groups is to provide a like-minded community where people can share their stories, give and receive empathy and validation, and make social connections. Support groups exist for people from all walks of life, including chronic illness, cancer, bereavement, and addiction.

Common Group Therapy Activities

Depending on the age and needs of the group as well as the creativity of the facilitator(s), group therapy activities may range from something more interconnected to something more introspective.

More interconnected activities may include cooking, cultural exploration, and music, offering members the opportunity to connect over the shared experience. More introspective activities may include journaling, meditation, or creating something artistic. Upon connecting with oneself on this personal level, group members may reflect upon the experience together. Though the activity was done solo, many group members find connections among what they did, how they did it, and why it was done.

The Benefits of Group Therapy

With more people to provide support and hold one another accountable in group therapy, the likelihood of successful outcomes increases. Those reluctant to attend group therapy, particularly if they are more introverted or socially anxious, oftentimes find that group participation even leads toward improved social skills and interest. 1

Here are some of the more common advantages of group therapy: 1

• Groups can act as a support network and a sounding board.
• Other members of the group often help you come up with specific ideas for improving a difficult situation or life challenge, and hold you accountable along the way.
• Regularly talking and listening to others helps you put your own problems into perspective.
• It can be a relief to hear others discuss what they’re going through, and realize you’re not alone.
• By seeing how other people tackle problems and make positive changes, you can discover a whole range of strategies for facing your own concerns.

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Group Therapy Examples

The focus of group therapy may vary by type. For instance, psychoeducational groups educate members on a particular topic—providing useful information, coping skills, and other helpful resources. Process groups focus on processing an experience, emotion, and so on. Task groups focus on successfully achieving a meaningful goal of a client group or entire community.

Group Therapy for Divorce

Divorce is a period of significant life change, and it can be traumatic for many people. A person going through a divorce may have lost a significant number of people that they relied on for support. The group setting provides a platform for members to speak their truths while having the camaraderie of others who have also gone or are currently going through divorce.

Group Therapy for Substance Use & Addiction

Addiction groups are especially powerful at holding others accountable—breaking down barriers of denial while acknowledging and amending past wrong-doings. This is significant, as acknowledging the problem and taking accountability are two of the most challenging steps toward recovery. Practicing these things in a group setting helps clear the pathway toward successful recovery.

Group Therapy for People With a Mentally Ill Family Member

These groups provide support for those who are struggling with a family member with mental illness. The stress and heart-break of such an experience leaves many individuals feeling unheard, unloved, and disregarded. Sharing one’s experience and receiving support, in return, can help alleviate these feelings.

Is Group Therapy Right for You?

There are many potential benefits to participating in group therapy, however group therapy isn’t necessarily right for everyone. In order to make the best decision regarding your treatment, there are a few things that are important to consider, like your ability to be open with people you don’t know as well, and the potential that you may need to try a few groups before finding the “right fit.” Also, if you’re in a crisis, individual therapy would be a better option.

Here are some factors that can help you determine whether or not group therapy is right for you:

You Need to Be Willing to Share

Group therapy is only effective if all group members are actively engaged and committed to consistently participating in the group. Having the vulnerability to share your story with the group will not only benefit your own therapeutic journey, but will also be beneficial to others in the group, as you will likewise benefit from hearing their stories.

It is important to note that, though confidentiality is highly valued in group therapy, it is not guaranteed. While self-disclosure is critical to the group process, there are more people present to hear sensitive material as opposed to individual therapy. 9

You Might Need to Try More Than One Group to Find the Best Fit

Just as finding the right individual therapist can take time, selecting a therapy group that is the best fit for you can also be a process.

When exploring group therapy options, ask yourself:

• Do you prefer small or large groups?
• Is the group’s meeting place easily accessible to you?
• What days and times can you commit to meeting?
• What are the facilitating therapist’s qualifications?
• Do you agree to the group’s guidelines?

Group Therapy Isn’t for Crises

Group therapy is not appropriate for a person in crisis. If someone is experiencing suicidal ideation, or otherwise in crisis, individual therapy (and sometimes hospitalization) is indicated in order to help stabilize the person.

How to Find Group Therapy Near You

Many organizations offering group therapy have websites available online. Conducting a web search along the lines of “group therapy near me” plus the specific topic is a great place to start. From there, you can contact the organization or facilitator directly to ask any questions and assess if it’s the right fit for you.

Who Is Able to Offer Group Therapy

Professionally led group therapy must be conducted by a licensed or certified mental and/or behavioral health professional or supervised clinical intern. This may include, but is not limited to, psychiatrists, psychologists, social workers, professional counselors, and substance abuse counselors. Many professionals also have other specialized certifications, such as marriage and family, equine-assisted, music, substance abuse, yoga, social justice, et cetera.

Can You Do Group Therapy Online?

Online group therapy is a relatively new treatment offering that provides increased access to services for people in remote areas, those who have transportation barriers, or those with other challenges that make online therapy a more attractive alternative. Studies have shown that online therapy is promising in terms of its efficacy. 10 However, some unique challenges exist in the online group therapy setting, such as a therapist’s lack of control over the online environment, absence of in-person interaction, and the slower development of group cohesion. 11 While online group therapy may not be the best fit for everyone, some clients find it even more beneficial than in-person groups.

Key Questions to Ask When Considering Group Therapy

Without careful consideration, the risk for dropping out of group therapy increases, which may ultimately lead to disinterest in groups all together. It’s important to ask questions regarding specific topics covered, group demographic, cost, and more to determine whether the group is right for you.

Here are some questions to ask the facilitator before joining a therapy group:

• Is the group topic specific to what I am experiencing?
• Do I prefer attending an open or closed group?
• Is the group demographic make-up one in which I feel comfortable (e.g., age, gender)?
• Is the location one to which I have reliable transportation?
• Will the group schedule work with my schedule so that I may attend consistently and on time?
• Is the cost affordable? Do I have sufficient out of pocket funds and/or coverage through my managed care plan?

Cost of Group Therapy

Group therapy is generally less expensive than the cost of individual psychotherapy . A primary reason for this is because it essentially splits the cost of the professional’s time across multiple members. Further, many providers offer sliding scale rates and pro bono services for those demonstrating financial need.

Reimbursement rates from managed care organizations such as insurance companies, Medicaid, and Medicare are also lower than individual psychotherapy, which reduces cost. Many plans will cover group therapy so long as the group is evidence-based, run by a professional, and is medically necessary.

It is also common for many self-help groups to provide free services. Many of these groups are run by government or grant funding as well as donations and voluntary contributions by members. Because facilitation is generally done by a volunteer member, there is no cost for a trained professional. As such, the cost makes it an especially appealing form of treatment, however it may not be appropriate for more serious mental health problems.

What to Expect at Your First Group Therapy Session

During someone’s first group therapy session, the facilitator generally acclimates new members to the group’s process and rules. At this stage, many members are reluctant to share their experiences and emotions as a result of not knowing what is expected, how others will relate to them, and trust issues.

Icebreaker activities are commonly used when groups first meet or are introducing a new member. These activities help members get to know one another by perhaps sharing their name, a personal experience, something motivating, something fun, et cetera.

It is also common for members to test boundaries with one another. The good news is that constructive confrontation and vocalization of issues early on leads towards more constructive work in the later stages of therapy. If one member has an issue with another member, it is important to resolve the issue immediately so it does not become a much larger issue in the future.

Perhaps the most rewarding part of what to expect is leaving the group meeting with additional support. Again, the immense value of having this support cannot be underestimated.

How Long Will I Be in Group Therapy?

Most therapy group sessions are 50-120 minutes long and meet once or twice a week, depending on the intervention model. Most time-limited group interventions last anywhere from 6-20 weeks. Research shows that client improvement in a group therapy setting usually happens in a short period of time, between 2 and 3 months. 12

Is Group Therapy Effective?

The American Psychological Association concluded that about 75% of people who enter psychotherapy demonstrate at least minimal improvement. 13 The National Alliance on Mental Illness (NAMI), National Institute of Health (NIH), National Institute on Drug Abuse (NIDA), Mayo Clinic, Centers for Disease Control (CDC), and Substance Abuse and Mental Health Services (SAMHSA)—among others—have also concluded that group therapy has proven benefits as compared to not participating in treatment.

The American Psychological Association had the following to say about group therapy: 14

• Group therapy appears to be gaining popularity for two reasons: More clients are seeking it out as a more affordable alternative to one-on-one psychotherapy, and more research is demonstrating its effectiveness, say psychologists who practice it.
• For many conditions, group therapy works as well as individual therapy. More than 50 clinical trials have compared patients who were randomly assigned to individual or group treatment, and all of those studies showed that the two formats produced the same level of improvement for many disorders.
• Group therapy exceeds Society of Clinical Psychology standards for efficacy for major depressive disorder, bipolar disorder, panic disorder, post-traumatic stress disorder, social phobia, obsessive-compulsive disorder, bulimia nervosa, binge-eating disorder, substance use disorder, schizophrenia, borderline personality disorder and general personality disorder.
• Research is finding that the most effective groups have a common identity and a sense of shared purpose, according to a meta-analysis of 40 studies.
• When it comes to a group format, new research shows two leaders are better than one. Members of co-led groups experience greater benefits than those of individually led groups. That second set of eyes and ears makes a big difference when group leaders are trying to follow multiple interactions.
• Research is also shedding light on exactly how groups help people heal. One important factor is the ability to interact with peers.
• Numerous studies have found that peer interactions tap into many therapeutic factors.
• Hearing from peers may be more helpful than receiving guidance from a therapist since peers can identify with one another. Those peer interactions appear to translate to real-world gains. A meta-analysis of five studies found that sexual abuse survivors improved markedly after participating in group therapy.
• Group therapy also offers advantages for the psychologist: The approach allows therapists to observe relational patterns. Rather than rely on the accuracy (or inaccuracy) of self-reports, patients reveal their problems through interactions with other members.

Risks of Group Therapy

Although there are many benefits to group therapy, there are also risks. One such risk is that of member drop-out. 15 If members are inconsistent with attendance or unwilling to fully participate, treatment outcomes will be compromised. Individual factors for risk include negative leadership, group process, or patient characteristics. 16 With addictions groups there is also the potential of individuals selling drugs to other members.

Downsides of Group Therapy

Especially when groups are not led by a licensed or certified professional or supervised intern, there is potential for the leader to be ill-equipped. People who have a fear of public speaking may find the group setting uncomfortable. 4 Those who struggle interpersonally may find themselves in continued conflict with other group members.

Another consideration is that of confidentiality. While it is one thing to keep sessions between a therapist and client confidential, it is much more challenging when additional group members are involved. 4

Group Therapy Vs. Individual Psychotherapy

Individual psychotherapy involves working one-on-one with a mental health professional toward selected individual goals. Sessions focus on processing thoughts, emotions, and behaviors while participating in various “homework assignments” to help the client work toward healthy coping and problem-solving skills.

It is relatively common for mental health professionals to recommend that clients participate in both individual psychotherapy and group therapy. 1,4 In this case, individual psychotherapy meets the individual needs of the client while group therapy provides additional support. If the mental health provider and group facilitator are on the same page, then much of what is said in one setting will be reinforced in the other.

Mandated Group Therapy

Mandated group therapy is intended to remediate a condition that may prove detrimental to the well-being and safety of that individual and/or others.

Common issues for court mandated group therapy include: 17

• The person has been convicted of a sex crime. Some states’ sex offender registries require participation in sex offender treatment.
• The person has lost custody of their child because of abuse, neglect, or addiction.
• The person is involved in a child custody dispute, and the court thinks one or both parents need either a psychiatric evaluation or mental health treatment.
• The person has a mental health condition or addiction and the court offers treatment as an alternative to jail or prison time.
• The person is incarcerated, and the parole board offers treatment as a condition of early release.
• The person is a threat to themselves or others. A person with intense suicidal ideation may be ordered to get a psychiatric evaluation or be held in a mental health facility for a set period of time. People with homicidal or violent thoughts may also undergo coerced treatment.
• The focus of the type of group therapy assigned is specific to the presenting issue. Accordingly, treatment may focus on addiction recovery, anger management, parenting, skills-building, trauma processing, and so on.

The History of Group Therapy

The history of group therapy began in Boston, MA in 1906, when Dr. J.H. Pratt provided group instruction while treating patients with tuberculosis (TB). The initial intent here was to provide group instruction to those who could not afford institutional assistance. 4 While conducting these groups he noted “beneficial emotional side effects,” which may serve as some of the earliest notes on the efficacy of group therapy. 4

Group therapy was then proven especially useful in treating World War II veterans who experienced extreme reactions to combat. Upon the US Army releasing a report in 1944 commending positive outcomes, group therapy become a progressively more popular treatment modality. 4

June 10, 1935 celebrates the founding of Alcoholics Anonymous (AA), which is still the leading support group for addiction recovery. One notable statistic from a study conducted by the National Institute on Alcohol Abuse and Alcoholism specific to AA is that an “eight-year follow-up showed that 46% of those who chose formal treatment were abstinent while 49% of individuals who attended AA were abstinent.” 18 It is interesting to note the 3% higher rate of success for members over an 8-year period who actively participated in AA versus traditional treatment. Again, there is power in numbers.

Additional Resources

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For Further Reading

• Mental Health America
• National Alliance on Mental Health
• MentalHealth.gov

Best Online Therapy Services

There are a number of factors to consider when trying to determine which online therapy platform is going to be the best fit for you. It’s important to be mindful of what each platform costs, the services they provide you with, their providers’ training and level of expertise, and several other important criteria.

Best Online Psychiatry Services

Online psychiatry, sometimes called telepsychiatry, platforms offer medication management by phone, video, or secure messaging for a variety of mental health conditions. In some cases, online psychiatry may be more affordable than seeing an in-person provider. Mental health treatment has expanded to include many online psychiatry and therapy services. With so many choices, it can feel overwhelming to find the one that is right for you.

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Choosing Therapy strives to provide our readers with mental health content that is accurate and actionable. We have high standards for what can be cited within our articles. Acceptable sources include government agencies, universities and colleges, scholarly journals, industry and professional associations, and other high-integrity sources of mental health journalism. Learn more by reviewing our full editorial policy .

Psychological Association. (2019). Psychotherapy: Understanding group therapy. Retrieved from https://www.apa.org/topics/group-therapy

Yalom ID, Leszcz M (2005). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books. p. 272. ISBN 978-0-465-09284-0.

Holgersen, K. H., Brønstad, I., Jensen, M., Brattland, H., Reitan, S. K., Hassel, A. M., Arentz, M., Lara-Cabrera, M., & Skjervold, A. E. (2020). A combined individual and group-based stabilization and skill training intervention versus treatment as usual for patients with long lasting posttraumatic reactions receiving outpatient treatment in specialized mental health care – a study protocol for a randomized controlled trial. Trials , 21 (1), 432. https://doi.org/10.1186/s13063-020-04297-z

McRae, K. (2013). What are the advantages and disadvantages of group therapy? Retrieved from https://www.connollycounseling.com/advantages-disadvantages-group-therapy/

Wergeland, G. J., Fjermestad, K. W., Marin, C. E., Haugland, B. S., Bjaastad, J. F., Oeding, K., Bjelland, I., Silverman, W. K., Ost, L. G., Havik, O. E., & Heiervang, E. R. (2014). An effectiveness study of individual vs. group cognitive behavioral therapy for anxiety disorders in youth. Behaviour research and therapy , 57 , 1–12. https://doi.org/10.1016/j.brat.2014.03.007

Rajhans, P., Hans, G., Kumar, V., & Chadda, R. K. (2020). Interpersonal Psychotherapy for Patients with Mental Disorders. Indian journal of psychiatry , 62 (Suppl 2), S201–S212. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_771_19

MacKenzie, K. R., & Grabovac, A. D. (2001). Interpersonal psychotherapy group (IPT-G) for depression. The Journal of psychotherapy practice and research , 10 (1), 46–51.

Ezhumalai, S., Muralidhar, D., Dhanasekarapandian, R., & Nikketha, B. S. (2018). Group interventions. Indian journal of psychiatry , 60 (Suppl 4), S514–S521. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_42_18

Lasky, G. B., & Riva, M. T. (2006). Confidentiality and privileged communication in group psychotherapy. International journal of group psychotherapy , 56 (4), 455–476. https://doi.org/10.1521/ijgp.2006.56.4.455

Ruwaard, J., Lange, A., Schrieken, B., & Emmelkamp, P. (2011). Efficacy and effectiveness of online cognitive behavioral treatment: a decade of interapy research. Studies in health technology and informatics , 167 , 9–14.

Weinberg H. (2021). Obstacles, Challenges, and Benefits of Online Group Psychotherapy. American journal of psychotherapy , 74 (2), 83–88. https://doi.org/10.1176/appi.psychotherapy.20200034

Center for Substance Abuse Treatment. Brief Interventions and Brief Therapies for Substance Abuse. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 34.) Appendix A –Bibliography. Available from: https://www.ncbi.nlm.nih.gov/books/NBK64944/

American Psychological Association. Understanding psychotherapy and how it works. 2016. http://www.apa.org/helpcenter/understanding-psychotherapy.aspx

Patural, A. (2012). Power in numbers: Research is pinpointing the factors that make group therapy successful. Retrieved from https://www.apa.org/monitor/2012/11/power

Thimm JC, Antonsen L. Effectiveness of cognitive behavioral group therapy for depression in routine practice. BMC Psychiatry. 2014;14:292. Published 2014 Oct 21. doi:10.1186/s12888-014-0292-x

Roback H. B. (2000). Adverse outcomes in group psychotherapy: risk factors, prevention, and research directions. The Journal of psychotherapy practice and research, 9(3), 113–122.

Coviello, D. M., Zanis, D. A., Wesnoski, S. A., Palman, N., Gur, A., Lynch, K. G., & Mckay, J. R. (2013). Does mandating offenders to treatment improve completion rates? Journal of Substance Abuse Treatment, 44 (4), 417-425. doi: 10.1016/j.jsat.2012.10.003

Wagener, D. (2020). What is the success rate of AA? Retrieved from https://americanaddictioncenters.org/rehab-guide/12-step/whats-the-success-rate-of-aa

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Cognitive Remediation Therapy: 13 Exercises & Worksheets

This can result in concentration, organizational, and planning difficulties that impact their quality of life and independent living.

Cognitive Remediation Therapy (CRT) helps by increasing awareness of intellectual difficulties and improving thinking skills. While originally designed for people with thinking problems associated with schizophrenia, it has also proven successful for those with other diagnoses (Bristol Mental Health, n.d.).

CRT works by encouraging a range of exercises and activities that challenge memory, flexible thinking, planning, and concentration problems.

This article explores CRT and its potential to help clients and includes techniques, activities, and worksheets to build effective therapy sessions.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into Positive CBT and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is cognitive remediation therapy (crt), how does cognitive remediation work, 8 techniques for your sessions, 7 exercises, activities, & games, 6 helpful worksheets and manuals, implementing online crt programs, 3 best software programs for helping your clients, a take-home message.

“Cognitive remediation is a behavioral treatment for people who are experiencing cognitive impairments that interfere with daily functioning” (Medalia, Revheim, & Herlands, 2009, p. 1).

Successful cognitive functions, including memory, attention, visual-spatial analysis, and abstract reasoning, are vital for engaging with tasks, the environment, and healthy relationships.

CRT improves cognitive processing and psychosocial functioning through behavioral training and increasing individual confidence in people with mental health disorders (Corbo & Abreu, 2018). Training interventions focus on the skills and supports required to “improve the success and satisfaction people experience in their chosen living, learning, working, and social environments” (Medalia et al., 2009, p. 2).

Exercises typically focus on specific cognitive functions, where tasks are repeated (often on a computer) at increasing degrees of difficulty. For example:

• Paying attention
• Remembering
• Being organized
• Planning skills
• Problem-solving
• Processing information

Based on the principles of errorless learning and targeted reinforcement exercises , interventions involve memory, motor dexterity, and visual reading tasks. Along with improving confidence in personal abilities, repetition encourages thinking about solving tasks in multiple ways (Corbo & Abreu, 2018).

While initially targeted for patients with schizophrenia, CRT is an effective treatment for other mental health conditions , including mood and eating disorders (Corbo & Abreu, 2018).

CRT is particularly effective when the cognitive skills and support interventions reflect the individual’s self-selected rehabilitation goals. As a result, cognitive remediation relies on collaboration, assessing client needs, and identifying appropriate opportunities for intervention (Medalia et al., 2009).

Cognitive remediation vs cognitive rehabilitation

CRT is one of several skill-training psychiatric rehabilitation interventions. And yet, cognitive remediation is not the same as cognitive rehabilitation (Tchanturia, 2015).

Cognitive rehabilitation typically targets neurocognitive processes damaged because of injury or illness and involves a series of interventions designed to retrain previously learned cognitive skills along with compensatory strategies (Tsaousides & Gordon, 2009).

While initially done in person, they can subsequently be performed remotely as required (Corbo & Abreu, 2018; Bristol Mental Health, n.d.).

Well-thought-out educational software provides multisensory feedback and positive reinforcement while supporting success, choice, and control of the learning process. Its design can target either specific cognitive functions or non-specific learning skills and mechanisms (Medalia et al., 2009).

CRT successfully uses the brain’s neuroplasticity and is often more effective in younger age groups who haven’t experienced the effects of long-term psychosis. It works by increasing activation and connectivity patterns within and across several brain regions involved in working memory and high-order executive functioning (Corbo & Abreu, 2018).

The Neuropsychological Educational Approach to Cognitive Remediation (NEAR) is one of several approaches that provide highly individualized learning opportunities. It allows each client to proceed at their own pace on tasks selected and designed to engage them and address their cognitive needs (Medalia et al., 2009).

NEAR and other CRT techniques are influenced by learning theory and make use of the following (Medalia et al., 2009):

• Errorless learning Encouraging the client to learn progressively, creating a positive experience without relying on trial and error.
• Shaping and positive feedback Reinforcing behaviors that approximate target behaviors (such as good timekeeping) and offering rewards (for example, monthly certificates for attendance).
• Prompting Using open-ended questions that guide the client toward the correct response.
• Modeling Demonstrating how to solve a problem.
• Generalizing Learning how to generalize learned skills to other situations.
• Bridging Understanding how to apply skills learned inside a session outside  in everyday life.

Encouraging intrinsic motivation (doing the tasks for the satisfaction of doing them rather than for external rewards) and task engagement are also essential aspects of successful CRT programs (Medalia et al., 2009).

Therapy is most effective when it successfully supports clients as they transfer learning skills into the real world.

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Cognitive remediation techniques must be selected according to the skills and needs of the client and typically fall into one of three major intervention categories (Medalia et al., 2009):

• Planning exercises, such as planning a trip to the beach to practice cognitive strategies
• Cueing and sequencing , such as adding signs or placing reminder notes at home to encourage completing everyday tasks (for example, brushing teeth)

Such techniques rely on several key principles, including “(1) teaching new, efficient, information processing strategies; (2) aiding the transfer of cognitive gains to the real world; and (3) modifying the local environment” (Medalia et al., 2009, p. 5).

• Restorative approaches Directly target cognitive deficits by repeating task practices and gradually increasing difficulty and complexity; along with regular feedback, they encourage accurate and high levels of performance.

Practice is often organized hierarchically, as follows:

• Elementary aspects of sensory processing (for example, improving auditory processing speed and accuracy)
• High-order memory and problem-solving skills (including executive functioning and verbal skills)

This technique assumes a degree of neuroplasticity that, with training, results in a greater degree of accuracy in sensory representations, improved cognitive strategies for grouping stimuli into more meaningful groups, and better recall.

• Repetition and reaching for increasing levels of task difficulty
• Modeling other people’s positive behavior
• Role-play  to re-enact experienced or imagined behavior from different perspectives
• Corrective feedback to improve and correct unwanted or unhelpful behavior

Complex social cognitive processes are typically broken down into elemental skills for repetitive practice, role-play, and corrective feedback.

Professor Dame Til Wykes: cognitive remediation therapy

It is vital that activities within CRT are interesting and engaging for clients. They must foster the motivation required to persevere to the end of the task or game.

The following three games and puzzles are particularly valuable for children and adolescents (modified from Tchanturia, 2015):

SET is a widely available card game that practices matching based on color, shape, shading, etc.

Clients must shift their thinking to identify multiple ways of categorizing and grouping cards, then physically sort them based on their understanding.

It may be helpful to begin with a limited set of cards to reduce the likelihood of the clients becoming overwhelmed by the game or finding it less enjoyable.

2. Rush Hour

Rush Hour is another fun game that balances problem-solving skills with speed.

Puzzles start simple and increase in complexity, with additional elements involved. Skills developed include problem-solving and abstract thinking, and the game requires a degree of perseverance.

Other activities require no specialist equipment and yet can be highly engaging and support clients in learning transferable skills (modified from Tchanturia, 2015).

• Bigger picture thinking This involves the client picturing a shape in their minds or looking at one out of sight of the therapist. They then describe the shape (without naming it), while the therapist attempts to draw it according to the instructions. This practice is helpful with clients who get overwhelmed by detail and cannot see the bigger picture.
• Word searches Word searches encourage the client to focus on relevant information and ignore everything else – an essential factor in central coherence. Such puzzles also challenge memory, concentration, and attention.
• Last word response Last word response is a challenging verbal game promoting cognitive flexibility. The first player makes up and says a sentence out loud. Each subsequent player makes up a new sentence, starting with the last word of the previous player’s sentence. For example, ‘ I like cheese’ may be followed by the next player saying, ‘ Cheese is my favorite sandwich ingredient ,’ etc.
• Dexterity Using your non-dominant hand once a week (for example, combing your hair or brushing your teeth) stimulates different parts of your brain, creating alternative patterns of neuron firing and strengthening cognitive functions.

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The following therapy worksheets help structure Cognitive Remediation Therapy sessions and ensure that the needs of clients are met using appropriately targeted CRT interventions (modified from Medalia et al., 2009; Medalia & Bowie, 2016):

Client referral to CRT

The Cognitive Remediation Therapy Referral Form captures valuable information when a client is referred from another agency or therapist so that the new therapist can identify and introduce the most appropriate CRT interventions. The form includes information such as:

Primary reasons

Secondary reasons

• Self-confidence
• Working with others
• Time management
• Goal-directed activities

Cognitive Appraisal for CRT

The Cognitive Appraisal for CRT form is helpful for identifying and recording areas of cognitive processing that cause difficulty for the client and require focus during Cognitive Remediation Therapy sessions.

Clients are scored on their degree of difficulty with the following:

• Paying attention during conversation
• Maintaining concentration in meetings
• Completing tasks once started
• Starting tasks
• Planning and organizing tasks and projects
• Reasoning and solving problems

Software Appraisal for CRT

The Software Appraisal for CRT form helps assess which software would be most helpful in a specific Cognitive Remediation Therapy session. It provides valuable input for tailoring treatment to the needs of the client.

For example:

• Level of reading ability required
• Cognitive deficits addressed by the software
• What is the multimedia experience like?
• How much input is required by the therapist?

Appraisal records become increasingly important as more software is acquired for clients with various cognitive deficits from multiple backgrounds.

Software Usage for CRT

The Software Usage for CRT form helps keep track of the software clients have tried and how effectively it supports them as they learn, develop, and overcome cognitive deficits.

The client considers the software they use and whether they practiced the following areas of cognition:

• Concentration
• Processing speed
• Multitasking
• Logic and reasoning
• Organization
• Fast responses
• Working memory

Thought Tracking During Cognitive Remediation Therapy

Thought Tracking During Cognitive Remediation Therapy is valuable for identifying and recording the client’s goals for that day’s Cognitive Remediation Therapy session and understanding how it relates to their overall treatment goals.

Planning to Meet Goals in CRT

The Planning to Meet Goals in CRT worksheet is for clients requiring support and practice in planning, goal-setting, and goal achievement.

Working with the client, answer the following prompts:

• What goal or project are you working toward?
• What date should it be completed by?
• Are there any obstacles to overcome to complete the goal?
• Are there any additional resources required?
• Then consider the steps needed to achieve the goal.

Other free resources

Happy Neuron provides several other free resources that are available for download .

Consider the five Cs when selecting online CRT programs (modified from Medalia et al., 2009):

• Cognitive – What target deficits are being addressed?
• Client – What interests and level of functioning does the client have?
• Computer – What computing requirements and compatibility factors need to be considered?
• Context – Does the software use real-world or fantasy activities and environments? Are they age and cognitive ability appropriate?
• Choice – Is the learner given choice and options to adapt the activity to their preferences?

Once you’ve ordered the software, give it a thorough review to understand when it is most appropriate to use and with whom.

For online CRT programs to be effective as teaching tools and activities, they should include the following features (modified from Medalia et al., 2009, p. 53):

• Intrinsically motivating
• Active use of information
• Multisensory strategies
• Frequent feedback
• Control over the learning process
• Positive reinforcement
• Application of newly acquired skills in appropriate contexts
• Errorless learning – challenging yet not frustrating

Therapists must become familiar with each program’s content and processes so that targeted deficits are fully understood and clients are engaged without confusion or risk of failure.

17 Science-Based Ways To Apply Positive CBT

These 17 Positive CBT & Cognitive Therapy Exercises [PDF] include our top-rated, ready-made templates for helping others develop more helpful thoughts and behaviors in response to challenges, while broadening the scope of traditional CBT.

Created by Experts. 100% Science-based.

A great deal of software “targets different skills and offers a variety of opportunities for contextualization and personalization” (Medalia et al., 2009, p. 43).

We focus on three suppliers of extensive CRT software resources below (recommended by Medalia et al., 2009).

1. Happy Neuron

Happy Neuron provides a wide variety of online brain training exercises and activities to stimulate cognitive functioning in the following areas:

• Visual-spatial

When you’re performing well, the exercises become increasingly difficult.

The exercises are grouped into the following areas:

• Brain speed
• People skills
• Intelligence

3. Games for the Brain

Cognitive difficulties, such as challenges with paying attention, planning, remembering, and problem-solving, can further compound and exacerbate mental health issues

While initially created for schizophrenia, CRT is also valuable for other mental health problems, including eating and mood disorders. Treatments are effective in one-to-one and group sessions, and lessons can be transferred to the outside world, providing crucial gains for a client’s mental wellbeing and social interaction.

Through repeated and increasingly challenging skill-based interventions, CRT benefits cognitive functioning and provides confidence gains to its users. The treatment adheres to learning theory principles and targets specific brain processing areas such as motor dexterity, memory, and visual-spatial perception, along with higher-order functioning.

Involving clients in treatment choices increases the likelihood of ongoing perseverance, engagement, and motivation as activities repeat with increasing degrees of difficulty.

This article offers a valuable starting point for exploring CRT and its benefits, with several worksheets and forms to encourage effective treatment.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Bristol Mental Health. (n.d.). Cognitive remediation therapy: Improving thinking skills . Retrieved December 15, 2021, from http://www.awp.nhs.uk/media/424704/cognitive-remediation-therapy-022019.pdf
• Corbo, M., & Abreu, T. (2018). Cognitive remediation therapy: EFPT psychotherapy guidebook . Retrieved December 15, 2021, from https://epg.pubpub.org/pub/05-cognitive-remediation-therapy/release/3
• Medalia, A., & Bowie, C. R. (2016). Cognitive remediation to improve functional outcomes . Oxford University Press.
• Medalia, A., Revheim, N., & Herlands, T. (2009). Cognitive remediation for psychological disorders: Therapist guide . Oxford University Press.
• Tchanturia, K. (2015). Cognitive remediation therapy (CRT) for eating and weight disorders . Routledge.
• Tsaousides, T., & Gordon, W. A. (2009). Cognitive rehabilitation following traumatic brain injury: Assessment to treatment. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine , 76 (2), 173-181.

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To my surprise this is a treatment that has not been discussed in the area I live and work. I just stumbled upon this when I was researching cognitive impairments with schizophrenia. I currently work on a team with multiple mental health professionals that go out into the community, to work with people diagnosed with Schizophrenia. It seems like most of what we do is manage and monitor symptoms. Are you aware of anyone or any agency in Buffalo, NY that uses this method of treatment? I am trying to figure out how to get trained and use it in practice, if that is possible. Any help will be greatly appreciated.

This looks like the treatment my daughter needs. She has struggled for years with the cognitive problems associated with depression. How do we find a therapist near us who can use these techniques?

I’m sorry to read that your daughter is struggling. You can find a directory of licensed therapists here (and note that you can change the country setting in the top-right corner). You’ll also find that there are a range of filters to help you drill down to the type of support you need: https://www.psychologytoday.com/us/therapists

I hope you find the help you need.

– Nicole | Community Manager

I clicked the link you provided. Unfortunately there is not a filter for Cognitive Remediation Therapy (CRT). Do you have a suggestion of how to find a provider who is trained in CRT?

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The Mental Desk

Mental Health & Life Improvement Tips

39 Engaging Group Therapy Activities

Updated: 03/20/2024

Welcome to this comprehensive guide on group therapy activities.

These activities are designed to foster connection, promote personal growth, and enhance the overall therapy experience.

In the following sections, we’ll explore a variety of engaging exercises, each tailored to specific group settings and needs. From icebreakers for initial sessions to specialized group counseling activities for adults and teens, this guide offers a wealth of information for both mental health professionals and individuals considering group therapy.

Let’s embark on this journey to discover how these activities can transform the therapeutic process.

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Ice Breakers for Group Therapy

Imagine stepping into a room full of unfamiliar faces. Your heart races, your palms sweat, and a wave of unease washes over you. This is a common experience for many individuals attending their first group therapy session. But, there’s a simple, fun solution to ease this tension – icebreakers!

Icebreakers are activities designed to help people feel more comfortable in group settings. They encourage conversation, foster connections, and create a welcoming environment. Let’s explore a few examples.

One popular icebreaker is “Two Truths and a Lie.” In this game, each person shares two true statements and one false statement about themselves. The rest of the group then tries to guess which statement is the lie. This activity not only sparks conversation but also allows participants to learn more about each other in a light-hearted way.

Another engaging icebreaker is the “Common Ground” game. Here, participants find shared experiences or interests with others. This activity promotes a sense of unity and understanding among group members.

Why are icebreakers so beneficial in group therapy? Well, they help to break down barriers and foster open communication. They allow individuals to express themselves freely, creating a safe space where everyone feels heard and valued. Icebreakers can turn a room full of strangers into a supportive community, making the therapeutic journey less daunting and more enriching.

Interactive Group Therapy Activities for Adults

In my experience, the power of group therapy lies in its interactive nature. It’s not just about sitting in a circle, sharing stories. It’s about engaging with others, learning from their experiences, and growing together. Interactive activities play a crucial role in this process. They foster communication, build trust, and promote personal growth.

Let me share with you five interactive activities that I have seen work wonders in group therapy sessions for adults:

• Role-Playing: This activity allows participants to step into someone else’s shoes, helping them understand different perspectives. It’s a powerful tool for empathy-building and conflict resolution.
• Trust Walk : In this activity, one person is blindfolded and guided by another. It’s a simple yet effective way to build trust and cooperation among group members.
• Problem-Solving Challenges: These could be puzzles or brainteasers that the group solves together. They encourage teamwork, improve communication, and foster a sense of accomplishment.
• Storytelling Circle: Each person shares a personal story related to a chosen theme. This activity promotes empathy and understanding, as participants connect over shared experiences.
• Artistic Expression: This can involve drawing, painting, or even sculpting. It’s a non-verbal way for individuals to express their feelings and experiences. Plus, it sparks insightful discussions about the created artworks.

From my experience, these activities can transform a group therapy session. They break down walls, encourage open dialogue, and create a supportive environment where everyone feels heard and understood. I have witnessed individuals open up, form connections, and make significant strides in their mental health journey, all thanks to these interactive activities.

Also read: Mental Health Group Therapy Activities & Games For Adults

Fun Group Therapy Activities for Teens

Navigating the teenage years can be a roller coaster ride, filled with ups, downs, twists, and turns. As a mental health advocate, I’ve seen how group therapy can provide a safe space for teens to express their feelings, share their experiences, and support each other.

But therapy doesn’t have to be all serious talk. Incorporating fun activities can make the process more engaging and enjoyable for teens. Here are six activities that I’ve seen bring smiles, laughter, and meaningful connections in group therapy sessions:

• Music Jam : In this activity, teens are encouraged to bring their musical instruments and create a group song. It’s not about perfect harmony but about expressing emotions through music and bonding over shared creativity.
• Photo Voice Project : Teens are given cameras (or they can use their phones) to capture images that represent their feelings or experiences. They then share these photos with the group and explain their significance. This activity promotes self-expression and understanding in a unique, visual way.
• The Compliment Game : Each teen writes their name on a piece of paper and passes it around. Everyone writes a compliment on each paper. This activity boosts self-esteem and fosters a positive group environment.
• Goal-Setting Workshop : Teens are guided to set personal goals and share them with the group. They then brainstorm ways to achieve these goals together. This activity promotes personal growth and teamwork.
• Improv Games : These are quick, fun games that require teens to think on their feet and work together. They help improve communication skills, promote quick thinking, and, most importantly, bring lots of laughter!
• Nature Walks : The group goes for a walk in a nearby park or nature reserve. This activity provides a relaxed setting for conversation and reflection, while also promoting appreciation for the natural world.

In my experience, these activities not only make therapy sessions more enjoyable for teens but also enhance their effectiveness. They allow teens to open up, connect with others, and learn important life skills in a fun, relaxed manner. I have witnessed the transformation that these activities can bring about – from hesitant, closed-off individuals to confident, expressive young adults ready to face their challenges head-on.

CBT Group Therapy Activities

Cognitive Behavioral Therapy (CBT) is a powerful tool in the realm of mental health. As an advocate, I’ve seen how it can help individuals understand their thoughts, feelings, and behaviors, and learn strategies to manage them effectively. In a group setting, CBT activities can foster shared learning and support. Let’s delve into three CBT activities that I’ve found particularly impactful:

• Thought Record Exercise : This activity involves identifying negative thoughts, challenging them, and replacing them with more positive or balanced thoughts. Each group member shares a negative thought they’ve had, and the group works together to reframe it. This exercise promotes self-awareness and helps individuals realize that they have the power to control their thoughts.
• Behavioral Experiments : Here, group members identify a belief they hold and design an experiment to test its validity. For instance, if someone believes they’re bad at public speaking, they might be encouraged to give a short talk to the group. This activity helps challenge and change unhelpful beliefs through direct experience.
• Mindfulness Meditation : The group participates in guided mindfulness exercises, focusing on their breath or sensations in their body. This practice helps individuals stay in the present moment, reducing anxiety and promoting relaxation.

From my experience, these CBT activities can be transformative. They provide practical tools that individuals can use in their daily lives to manage their thoughts and behaviors. I’ve seen group members become more self-aware, confident, and resilient through these exercises.

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Motivational Group Therapy Activities

Motivation is a powerful force that can propel us toward our goals and help us overcome challenges. In the context of group therapy, motivational activities can inspire individuals to take active steps toward their mental health recovery. Over my career, I’ve seen the transformative power of these activities.

Here are five motivational group activities that have proven to be effective:

• Vision Board Creation : Group members create a visual representation of their goals and aspirations using images and words. This activity helps individuals visualize their path to recovery and keeps them focused on their goals.
• Inspirational Story Sharing : Each member shares a personal story of overcoming adversity. This activity fosters a sense of hope and resilience, showing members that they too can overcome their challenges.
• Gratitude Journaling : Group members are encouraged to write down things they are grateful for each day. This practice helps shift focus from negative thoughts to positive ones, boosting mood and motivation.
• Affirmation Exchange : Each member writes a positive affirmation for another member. This activity promotes positivity and boosts self-esteem, motivating individuals to believe in their abilities.
• Goal-Setting and Progress Tracking : Members set personal recovery goals and track their progress in achieving them. This activity provides a sense of direction and accomplishment, keeping members motivated on their recovery journey.

As I said, these activities can significantly boost motivation in group therapy members. They foster a positive and hopeful mindset, empowering individuals to take charge of their recovery. I’ve encountered individuals who transformed from feeling stuck and hopeless to being motivated and proactive, all thanks to these activities.

Group Therapy Games

Group therapy games are more than just fun and entertainment. They are powerful tools that therapists use to encourage communication, build trust, and promote personal growth within the group. From my observations, these games can transform a therapy group session, making it more engaging and effective.

Here are seven therapy games that have proven to be impactful in group counseling activities:

• The Feelings Game : A large piece of paper is divided into various sections, each labeled with a different emotion. Members of the group are then asked to write or draw something that represents that emotion for them. This game encourages individuals to explore and share their thoughts and feelings with the group.
• The Trust Fall : This classic team-building activity involves members of the group taking turns falling backward, trusting the group to catch them. It’s a powerful way to build trust and foster a sense of safety within the group.
• The Name Game : Everyone in the group takes turns saying their name followed by a positive adjective that starts with the same letter. For example, “Brave Brian.” This game boosts self-esteem and helps members remember each other’s names.
• The Puzzle Game : The group is given a jigsaw puzzle to solve together. This activity promotes teamwork and cooperation, essential skills for any type of group therapy.
• The Hot Seat : One member sits in the “hot seat,” and others take turns asking them non-threatening questions. This game encourages open communication and helps members get to know each other better.
• Pass the Ball : A ball is passed around the circle, and whoever has the ball shares something about themselves. This game fosters a sense of unity and understanding among the group members.
• The Drawing Game : The therapist instructs the group to draw something related to a specific topic, like a happy memory or a future goal. Afterward, everyone shares their drawings and explains their significance. This activity allows individuals to express themselves creatively and share their experiences with the group.

From my vantage point, these games can make a significant difference in group therapy. They create a relaxed, engaging environment where individuals feel comfortable opening up and connecting with others. I’ve seen group members become more open, supportive, and understanding through these games.

Also read: Therapy Games To Play On Zoom

Self-Esteem Group Therapy Activities

Self-esteem is the foundation of a person’s mental well-being. It influences how we see ourselves and interact with the world. In my journey running The Mental Desk, I’ve noticed how group therapy can significantly boost self-esteem.

Here are three activities that have proven effective in enhancing self-esteem among group members:

• Positive Affirmation Exchange : Each person in the group writes a positive affirmation about themselves on a piece of paper. These are then mixed up and distributed randomly. Each member reads out the affirmation they received, claiming it as their own. This activity encourages individuals to see themselves in a positive light and share these affirmations with the group.
• Strengths Circle : Group members take turns stating one strength or positive trait of the person to their right. This activity helps individuals recognize their strengths and hear positive feedback from others.
• Gratitude List : The therapist will ask the group to make a list of things they are grateful for about themselves. Group members write down their lists and then share them with the group. This activity promotes self-appreciation and a positive self-view.

From my perspective, these activities can have a profound impact on an individual’s self-esteem. They provide an opportunity for group members to focus on their positive attributes and hear affirming feedback from others. I’ve seen individuals grow more confident and self-assured through these activities, which is a testament to their effectiveness.

Addiction Group Therapy Ideas

Addiction is a complex issue that affects not only physical health but also emotional health. It often coexists with other mental health conditions like depression and anxiety . I’ve observed how group therapy allows individuals struggling with substance use to share their experiences, learn from others, and improve their mental health.

Here are three effective activities used in addiction group therapy:

• Coping Skills Workshop : The group explores different coping skills to handle cravings and triggers. Each member shares a coping skill that works for them, fostering a collective learning environment. This activity equips individuals with practical tools to manage their addiction.
• Role-Playing Scenarios : The group engages in role-play exercises where they enact situations that could potentially lead to substance use. This activity helps individuals practice refusal skills and develop strategies to handle high-risk situations.
• Emotional Check-In : A ball is passed around the room, and the person holding the ball shares their current emotional state and any challenges they’re facing. This activity promotes emotional awareness and allows group members to support each other.

These activities provide a supportive environment for individuals battling addiction. They promote the development of social skills, emotional health, and coping mechanisms, all crucial for recovery. I have known individuals who have gained strength, resilience, and hope through these activities, making significant strides in their journey toward sobriety.

Art Therapy Group Activities for Adults

Art has a unique way of reaching into our deepest emotions, making it an effective tool for addressing mental health issues. I personally love how art therapy group activities provide a fun and easy way for members to share their feelings and experiences.

Here are three engaging activities that have proven effective in art therapy groups:

• Collage Making : Each member creates a collage that represents their feelings or experiences. This activity allows individuals to express themselves visually when words may be hard to find. The collages are then shared with the group, fostering understanding and empathy among group members and leaders.
• Group Mural : The group works together to create a large mural on a theme chosen by the group or the therapist. This activity promotes teamwork and allows individuals to contribute to a shared goal, fostering a sense of belonging and accomplishment.
• Music and Art : Group members listen to a piece of music and create artwork inspired by the music. This activity combines the therapeutic benefits of music and art, allowing individuals to explore their emotions in a multi-sensory way.

Research has shown that group therapy activities like these can have a profound impact on individuals dealing with various mental health challenges. They provide a safe, creative outlet for expression and can lead to significant breakthroughs in therapy. Through these exercises, individuals can find their voice, making art therapy an effective group therapy approach.

Outdoor Group Therapy Activities for Adults

The great outdoors can be a powerful setting for healing and personal growth. It’s no surprise that outdoor group therapy activities can foster connection, resilience, and well-being among adults dealing with various mental health challenges.

Here are four outdoor activities that have proven effective in group therapy:

• Nature Walks : Group members go for a walk in a nearby park or nature reserve. This activity provides a relaxed setting for conversation and reflection, while also promoting physical activity and appreciation for nature.
• Gardening Projects : The group works together to plant and care for a garden. This activity fosters teamwork, patience, and a sense of accomplishment. Plus, it’s therapeutic to work with your hands in the soil.
• Outdoor Yoga : The group participates in a guided yoga session outdoors. This activity combines physical movement with mindfulness, promoting relaxation and body awareness.
• Scavenger Hunt : The therapist sets up a scavenger hunt with items or landmarks in nature. This fun and engaging activity promotes teamwork, problem-solving, and a sense of adventure.

These outdoor group counseling activities provide a refreshing change of scenery from the traditional therapy room. They allow individuals to connect with nature, engage in physical activity, and work together in a relaxed environment. During these activities, people tend to become more open, resilient, and connected, making outdoor group therapy a valuable approach in the journey toward mental health recovery.

Group Therapy Activity Resources

In the realm of group therapy activities, having the right resources can make all the difference. Here are some hand-selected tools and materials that my therapist friends found to be particularly effective in facilitating meaningful and productive group therapy sessions.

“ 150 More Group Therapy Activities & TIPS ” is a practical resource packed with hands-on and easy-to-use activities, worksheets, and quizzes to help develop effective life skills. Authored by Judith A. Belmont, this book offers a mix of strategies inspired by DBT, CBT, ACT, and positive psychology. It’s a great tool for anyone leading group therapy sessions or looking to improve their communication skills, manage stress, and build self-esteem. This book is like a treasure chest of ideas to make group therapy more engaging and effective. Get it on Amazon now .

“ 103 Group Activities and TIPS ” is a practical, hands-on guide filled with innovative exercises to enrich any group therapy session. Authored by Judith Belmont, this book is a treasure trove of ideas, from icebreakers and role plays to mindfulness and communication skills. It’s a great resource for anyone leading group therapy or looking to enhance their group interactions. If you’re seeking to make your group sessions more dynamic and impactful, this book could be a game-changer. Find it on Amazon today .

“ The Group Therapy Card Deck: CBT, DBT, ACT and Positive Psychology Tips and Tools ” is a versatile tool for anyone facilitating group therapy sessions. Created by Judith Belmont, a psycho-educational learning expert, this deck of 99 cards offers a variety of therapeutic exercises drawn from the most effective approaches in therapy. These cards are designed to help clients understand therapeutic concepts, build coping skills, and apply these skills outside of the group. It’s like having a pocket-sized therapist, ready to help at any moment. Check it out on Amazon now .

In conclusion, mental health group therapy activities offer a unique and effective approach to healing and personal growth. They provide a supportive environment that allows group members to work together, share experiences, and learn from each other. These activities can be a powerful supplement to individual therapy, offering different perspectives and a sense of community that can be incredibly beneficial.

From icebreakers to art therapy, these activities are designed to engage group members in various ways. They address different aspects of mental and physical health, fostering self-awareness, resilience, and interpersonal skills. Whether it’s through a fun game, a challenging outdoor activity, or a deep dive into cognitive behavioral techniques, these group activities can make psychotherapy more engaging and impactful.

These group counseling activities can turn a room full of strangers into a supportive community, making the therapeutic journey less daunting and more enriching.

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Researcher and author dedicated to mental health awareness. After struggling with my own mental health issues as a teen, I decided to dedicate my life to helping others deal with mental health challenges and maximizing their potential.

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McMurran M, Crawford MJ, Reilly J, et al.; on behalf of the PEPS Trial Collaborative Group. Psychoeducation with problem-solving (PEPS) therapy for adults with personality disorder: a pragmatic randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of a manualised intervention to improve social functioning. Southampton (UK): NIHR Journals Library; 2016 Jul. (Health Technology Assessment, No. 20.52.)

Psychoeducation with problem-solving (PEPS) therapy for adults with personality disorder: a pragmatic randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of a manualised intervention to improve social functioning.

Chapter 2 methods.

The PEPS trial was a two-arm, parallel-group, pragmatic randomised controlled superiority trial comparing PEPS therapy plus treatment as usual with treatment as usual alone. Participants were individually randomised at a ratio of 1 : 1, and stratified by sex and centre.

An economic analysis was conducted alongside the trial to determine the costs and cost-effectiveness of PEPS therapy compared with treatment as usual (see Chapter 5 ). In addition, a qualitative component sought to explore participants’ experiences of PEPS therapy and treatment as usual (see Chapter 6 ).

• Study setting and participants

Study participants were recruited from three NHS trusts providing mental health services in central and north-west London, South Wales and the North-East of England.

We recruited participants from mental health services including community mental health teams (CMHTs), crisis resolution teams, primary care liaison teams, psychology services and on discharge from inpatient care.

Eligibility criteria

At the point of randomisation participants were required to have one or more PD, including a PD not otherwise specified, identified through the International Personality Disorder Examination (IPDE) completed as part of the study-specific procedures at the screening visit. In addition, eligible participants were aged ≥ 18 years, living in the community (including residential or supported care settings) and proficient in spoken English and had capacity to provide informed consent.

Exclusion criteria were a primary diagnosis of major functional psychosis, insufficient degree of literacy, comprehension or attention to be able to engage in trial therapy and assessments, engagement in a specific programme of psychological treatment for PD or likely to start such treatment during the trial period and participation in any other trial.

Identification of participants

Participants were identified by their mental health team. The initial approach about the study was made by a member of the potential participant’s mental health team, who sought verbal agreement from the potential participant to meet with the research team to discuss the study. Referral to the research team was made according to local procedures at each site.

All potential participants referred to the research team were recorded on the Participant Screening and Enrolment Log, whether or not they were enrolled in the trial.

Recruitment

Potential participants providing verbal agreement were referred to the research team who assessed eligibility according to the available clinical information, and invited potentially eligible participants to consider taking part in the trial. Potential participants were provided with written and verbal information about the trial and were given a minimum of 24 hours to consider whether or not to participate.

All participants joining the study provided written, informed consent. Participants were free to withdraw from the study at any time without giving a reason. If participants declined to complete follow-up assessments when originally approached, the researcher sought verbal consent to contact them again at a later stage to see if they were willing to complete the assessments.

Recruitment strategy

The identification and recruitment of participants was actively managed at each site to reduce potential delays and group waiting times. Problem-solving group start dates were determined in advance, allowing a time-limited baseline and randomisation period to be specified, based on recommended minimum and maximum waiting times before commencement of treatment and between the individual and group components of PEPS therapy. The specifications were that psychoeducation should be completed a maximum of 4 weeks before the problem-solving group started. The maximum wait between randomisation and the group starting should be 10 weeks and the minimum should be 5 weeks. This enabled completion of the individual treatment sessions and first follow-up prior to the start of the problem-solving group.

Within each recruitment phase there was an approximate 5-week period within which baseline assessments and randomisation were completed for participants in a particular recruitment phase. Randomisation was completed as soon as possible after baseline assessments and in all cases this should have been done within 1 week.

A minimum starting group size of six was recommended. During the randomisation period, local teams aimed to randomise a minimum of 12 participants to ensure an adequate minimum starting group size. It was recommended that starting group sizes should generally be no more than 10 participants. However, local teams could use discretion in determining the appropriate group starting size according to local circumstances, current waiting times and recruitment rates.

To confirm eligibility for the trial the following screening measures were undertaken before randomisation:

• The presence of PD was confirmed using the IPDE. 52 The IPDE is a 99-item, semistructured interview that allows both diagnostic and dimensional scores to be extracted for each PD according to either Diagnostic and Statistical Manual of Mental Disorders (DSM) 53 or International Classification of Diseases 54 criteria. DSM criteria were used in this trial. Each item is scored as the behaviour or trait being absent or normal (score 0), exaggerated or accentuated (score 1), or at the criterion level or pathological (score 2). Diagnostic scores were calculated in accordance with the scoring manual. A minimum of one ‘probable’ score on any diagnostic category including PD not otherwise specified was required to be eligible for the trial.
• Adequate literacy was required to engage in trial therapies and assessments. In the majority of cases this was assessed by the investigator or authorised designee in conjunction with the participant’s usual-care team. Adequate literacy was determined in discussion with the participant and their clinical team, based on the ability to participate in the trial therapy and assessments. The Basic Skills Agency’s, Fast Track 20 Questions 55 was available as an additional screening measure to aid assessment of literacy if required, but was not used. Study recommendations were that a score of ≥ 3 on the literacy component of the Fast Track 20 Questions indicated that additional consideration may be required, but did not prohibit further involvement in the trial. The final decision about inclusion or exclusion was made by the therapist in consultation with the referrer, the client and, if necessary, the site coinvestigator or site clinical supervisor.
• Interventions

This was a two-arm trial comparing PEPS therapy in addition to treatment as usual with treatment as usual only.

Psychoeducation with problem-solving therapy

Psychoeducation with problem-solving therapy is a complex cognitive–behavioural intervention that integrates individual and group therapies. There are two distinct components – individual psychoeducation and group problem-solving therapy – with optional individual support sessions.

Psychoeducation

Psychoeducation consists of up to four sessions delivered by a mental health worker trained to administer the procedure. The number of sessions depends on the duration of sessions and the speed at which the participant can comfortably work through the session content. Although the guidance is to work in 1-hour sessions, some participants prefer to have longer and less frequent sessions to maintain the flow of the content.

The sessions are conducted as a one-to-one collaborative dialogue and are designed to fulfil both general and specific functions. In general, the aims are to build rapport with participants and enhance their motivation for the subsequent problem-solving therapy. This is done specifically by asking participants their views on how their personality leads to problems in interpersonal relationships and social functioning, introducing them to and discussing their PD diagnoses, and explaining how therapy can help people ameliorate their problems.

Interviewers follow a set procedure described in a facilitator’s manual (see Appendix 1 ). Participants are first asked about their understanding of personality and any personality-related problems that they experience in a brief interview consisting of six questions:

• What does the word ‘personality’ mean to you?
• Do you think your personality causes you problems? In what way?
• Do you think your personality causes problems for other people? In what way?
• Would you like to change the way you handle problems?
• Some people are diagnosed as having a PD. Do you know what a PD is?
• Have you ever been told you might have a PD?

Information on personality and PD is then provided, following an information sheet explaining the concept of personality in terms of it being the way people typically think, feel and behave, and PD being personality styles that persistently cause difficulties and distress. The suggestion that problem-solving therapy can help ameliorate problems is then introduced. Participants are asked to complete a checklist of what problems they experience in relation to their PD. The interviewer completes a checklist that takes the individual through their PD diagnoses, as identified prerandomisation using the IPDE, 52 which is a structured clinical assessment. The interviewer and the participant discuss information about the individual’s personality problems from both perspectives. Participants are then guided to identify specific problems that they want to change, and prioritise those to be addressed in the subsequent problem-solving therapy sessions. The interviewer summarises the progress made in psychoeducation and logs the problems to be addressed in problem-solving therapy on a summary pro forma. This summary is used to convey the information to the problem-solving therapy facilitators. The content of psychoeducation is also summarised in a personalised booklet (see Appendix 2 ) that the participant is given to keep.

Problem-solving therapy

Problem-solving therapy is a 12-session manualised (see Appendix 3 ) group intervention designed to teach people a strategy for solving interpersonal problems. Problem-solving therapy is delivered by two mental health professionals trained to administer the therapy. The recommended starting group size was between 6 and 10 participants, but local sites were advised to use discretion so that when trial recruitment was slow, groups could start without undue delay; actual group sizes were between 5 and 12 participants. Sessions lasted approximately 2 hours, divided into 75 minutes of problem-solving work, a 15-minute break and 30 minutes of problem-solving work.

In each session, one participant worked through an actual problem that was identified in collaboration with one of the group facilitators prior to the group session. The problem selected could be an emotional or interpersonal problem, rather than a practical problem, and would be one that was current and important but not excessively distressing or unsuited to sharing in a time-limited group. Participants were then guided to learn the steps of the problem-solving process, based on the work of D’Zurilla and Nezu: 56 , 57

• orientation – identifying negative feelings and using these as a cue for initiating the problem-solving process
• problem definition – defining their problem clearly and accurately, breaking down large problems into smaller, more manageable ones
• goal-setting – setting specific goals for change
• generating alternatives – generating solution options
• decision-making – considering the consequences of each option to themself and others in both the short and the long term
• action-planning – selecting potentially effective options and organising these into a means-end action plan.

Participants were then expected to implement the action plan and were offered optional fortnightly individual support sessions throughout the 12-week problem-solving group therapy to help with implementation. Progress with the action plan was reviewed in the next group session.

The problem-solving process is translated into colloquial questions, which are shown in Table 1 , along with the formal stages of the process and the skills learned in each stage.

The problem-solving process

Throughout this process, attention was paid to improving optimism and hope for change, which is identified as of equal importance to problem-solving skills. This was done by helping participants experience success in problem-solving through guiding them through the problem-solving process, giving them support in their efforts to solve problems, identifying their strengths and highlighting problem-solving successes.

The process of problem-solving through addressing the key questions was recorded on a flip chart as the session progressed. The flip chart could be written by a group member or one of the facilitators, depending on the abilities of group members. This material was then transcribed to A4 sheets, which were given to the participant for his or her records, and a copy retained for the facilitators’ records. Individual support sessions of 1-hour duration were offered fortnightly to help the individual carry out problem-solving action plans. Additionally, participants were encouraged to work through problems independently outside sessions in order to generalise the new skills. A worksheet was provided to assist with independent working.

Problem-solving therapy was provided in mixed- or single-sex groups, depending on the stage of the trial (described in Changes to the intervention during the trial ), the number and suitability of referrals received, and participant preference. Participants allocated to PEPS therapy were expected to attend every session, and regular attendance was encouraged in accordance with normal clinical practice. A record of attendance at sessions was maintained for all participants. Participants were not withdrawn from trial therapy for reasons of poor attendance. Owing to variable group attendance rates, a prespecified minimum attendance at group treatments was defined for participants to be considered to have received therapy per protocol. The agreed hypothesis was that attending ≥ 6 of the maximum 12 group sessions of problem-solving therapy would be associated with improved outcomes on the SFQ.

Changes to the intervention during the trial

Within the trial, problem-solving groups were originally intended to be single sex. This was to ensure consistency with the pilot study and in response to preferences expressed by service user representatives advising on the design of the study during protocol development. However, the requirement for single-sex groups was found to cause delays while awaiting the accrual of sufficient participants to form a group. This was a particular issue for male participants because fewer men were referred to the study.

After consulting with the Trial Steering Committee (TSC), the study team took the decision to allow problem-solving therapy to be offered in mixed-sex groups. The reasons for this were:

• Mixed-sex groups are routine practice in community-based clinical services already offering PEPS therapy.
• Mixed-sex groups may help to reduce waiting times and delays between recruitment and randomisation.
• Mixed-sex groups can provide clinical benefits (e.g. helping participants to address issues with relating to people of the opposite sex).

An amendment was submitted to the Research Ethics Committee to introduce this change in August 2011, approximately halfway through the recruitment period. Following implementation of this amendment, allocation to mixed- or single-sex groups was made in accordance with usual clinical practice, incorporating participant preference where possible.

Treatment as usual

Usual treatment was provided by participants’ usual-care teams in accordance with normal clinical practice. No restrictions were placed on access to other treatments during the trial period, although engagement in a specific programme of psychological treatment for PD was an exclusion criterion applied at the point of enrolment.

The original protocol included a standardised form of treatment as usual as the control. Shortly after the start of the recruitment period, it became apparent that there was substantial variability in the level and type of care provided to people with PD at each of the participating sites. Many potential participants were being assessed by mental health services and discharged without treatment. To exclude these people would seriously compromise recruitment to the trial. For this reason, the study team could not impose a standardised form of treatment as usual on the referring clinical services. The study team felt that this issue was likely to become more pressing as NHS cuts at the time caused CMHTs to reduce services. As a result, it was agreed that the trial should compare PEPS therapy with treatment as usual in whatever form that took, and the planned requirement for a standardised form of treatment as usual was removed from the protocol in August 2010. The standardised form of treatment as usual, outlined in the original protocol, was recommended as a minimum standard of care but this was not imposed on clinical services referring participants to the trial.

Treatment fidelity

Manualised assessment and treatments.

The IPDE schedule, psychoeducation and problem-solving therapy are all comprehensively manualised.

Training and supervision

Therapists were qualified mental health nurses or psychology graduates with clinical experience. All IPDE assessors attended training in administering and scoring the structured interview from a qualified and highly experienced clinician and researcher. Each lead clinician who delivered psychoeducation and problem-solving therapy was trained to conduct the intervention. Problem-solving therapy groups were facilitated by two facilitators. Most cofacilitators also attended training in delivery of the intervention; however, on the rare occasions that this was not possible, groups could be cofacilitated by a facilitator who had not completed the training, provided that they were fully briefed by the lead therapist and were aware of the limitations of their involvement. A minimum of one fully trained and assessed facilitator was present at every group session.

Psychoeducation training was delivered after IPDE training and consisted of informing therapists of the rationale for psychoeducation, explaining the delivery mode of an educational dialogue and familiarising therapists with the materials and their sequence of delivery. Problem-solving therapy training consisted of 3 days in which groups of participants were given the theory, outcome evidence and role-play practice.

In each case (IPDE, psychoeducation and problem-solving), training followed an existing training protocol. Training was conducted centrally by experienced clinicians and researchers. After training, regular supervision was provided, both centrally and locally.

Competence checks

Audiotapes of treatment delivery were scrutinised by the trainers to ensure that each therapist was adhering to the treatment specification. Competence checklists were constructed for this assessment (see Appendices 4 – 6 ). These specified the key activities for conducting the IPDE and delivering psychoeducation and problem-solving sessions according to the intended treatment model. Cut-off scores for competence were agreed in advance and therapists were assessed for competence in delivering the treatment. None of the therapists failed to meet the competence criteria on any of the measures. Having assessed the therapists as competent to deliver the treatment according to the model and the protocol, no further checks were made. This was considered to reflect actual clinical practice in which staff are trained in a procedure and, if they meet the standards set by the trainers, they commence practice and the quality of their continued practice is monitored through supervision.

Fidelity checks

Treatment fidelity was assessed in three ways:

• Measuring adherence to protocol implementation (e.g. frequency and duration of treatment sessions).
• Assessing adherence to therapy, as specified in the treatment manual.
• Clinical supervision.

Adherence to psychoeducation was self-rated by the therapist after the end of all psychoeducation sessions, using a standard protocol (see Appendix 7 ). Adherence to problem-solving group sessions was rated by experienced clinicians, based on a sample of audiorecorded sessions.

• Outcome measures

Primary outcome

The primary outcome was social functioning as measured by the SFQ. 45 This is an 8-item self-report scale, on which each item is scored from 0 to 3. The total SFQ score ranges from 0 to 24. A reduction (i.e. an improvement) of ≥ 2 points on the SFQ at the 72-week follow-up was the specified clinically significant change.

Secondary effectiveness outcomes

• Scheduled and unscheduled health-service use collected through a retrospective review of mental health service and general practitioner (GP) records.
• Mood, measured by the HADS, 58 a 14-item self-report questionnaire with scores in the range of 0 to 42, and on which higher scores are less desirable.
• The referring clinician’s judgement of the participant’s overall level of psychosocial functioning assessed by the GAF. 53
• The client’s assessment of severity, on a scale from not at all distressing (0) to very distressing (10), of the three problems they considered most important (three main problems).

Process measures

The following measures were intended as measures of the processes of change during PEPS therapy:

• Therapeutic relationship was assessed using the Working Alliance Inventory – Short Revised (WAI-SR), 59 a 12-item scale rated by both client and therapist to assess agreement on the tasks of therapy, agreement on the goals of therapy, and the bond between client and therapist, with a range of scores between 12 (poor) and 48 (good).
• Social problem-solving abilities were measured by the SPSI-R, 28 a 25-item self-report questionnaire that measures problem-solving orientations and styles, with five items in each of the five subscales: positive problem orientation, negative problem orientation, rational problem-solving, impulsivity/careless style and avoidance style. Effective social problem-solving is indicated by higher scores on positive problem orientation, rational problem-solving and the SPSI-R, and lower scores on negative problem orientation, impulsivity/careless style and avoidance style. A total social problem-solving score ranges from 0 to 25, in which a higher score is more desirable.

Health economic outcomes

• Receipt and cost of services were collected using the Client Service Receipt Inventory (CSRI). 60
• Quality of life was assessed by the European Quality of Life-5 Dimensions (EQ-5D), 61 a health status measure used to generate quality-adjusted life-years (QALYs).

Participants’ views and experiences

Qualitative semistructured interviews were completed with participants allocated to PEPS therapy after psychoeducation and after problem-solving therapy to seek participants’ views on treatment. Further interviews were completed with all participants after the final follow-up to seek participants’ views on the experiences of PEPS therapy and usual treatment.

Safety and tolerability measures

Adverse events occurring in trial participants were recorded and monitored. For the purposes of this trial, a recordable adverse event was defined as any of the following:

• death for any reason
• inpatient hospitalisation for any reason
• any other serious, unexpected adverse event.

Adverse events were reported for all participants from consent to trial completion or early withdrawal from trial follow-up. If a participant withdrew from treatment but agreed to remain in trial follow-up, data collection, including adverse event reporting, continued in accordance with the protocol.

Premature withdrawal from the trial therapies or follow-up was reported, with reasons for withdrawal documented when these were given.

• Statistical methods

Statistical analysis

The analysis and reporting of the trial was in accordance with Consolidated Standards of Reporting Trials (CONSORT) guidelines. 62 – 65 Analyses were detailed in a statistical analysis plan, which was finalised prior to completion of data collection and database lock. All analyses were conducted using Stata version 13 (StataCorp LP, College Station, TX, USA).

Preliminary analyses

Descriptive statistics of demographic and clinical measures were used to examine the balance between the randomised arms at baseline.

Primary analysis

The primary analysis compared the mean SFQ score between PEPS and usual treatment at the 72-week postrandomisation follow-up, adjusted for baseline SFQ score and stratification variables (centre and sex), and implemented using maximum likelihood-based generalised linear modelling. The primary analysis compared individuals as randomised, regardless of treatment actually received or if 72-week follow-up SFQ data were observed (intention-to-treat principle). The effect is presented as an adjusted difference in means, 95% confidence intervals (CIs) and p -value for the comparison.

Imputation of missing primary outcome data

The pattern of missing data was investigated by examining variables recorded at baseline that were associated with ‘missingness’ of SFQ score at the 72-week follow-up. Multiple imputation and analysis of multiple imputed data sets were conducted using ‘mi’ procedures in Stata. The imputation model contained site, age, sex, ethnicity, social status, PD category (simple or complex), SFQ at baseline and 24 weeks, baseline EQ-5D health state score, baseline HADS score, baseline SPSI-R score and baseline three main problems score, and 20 data sets were imputed.

Missing item data

For all outcomes that are a scale comprising a number of items, the following procedure was undertaken when > 0% and ≤ 15% of items were missing:

• Step 1: calculate the scale mean for each participant (denoted by m1 for those with > 0% and ≤ 15% of items missing).
• Step 2: calculate the mean of scale means for participants with complete scale data only (denoted by M1).
• Step 3: calculate each item mean for all participants with observed data for that item (denoted by S1).
• Step 4: for each item, calculate M1 – S1 (denoted by d).
• Step 5: impute missing item data using m1 – d.

When > 15% of items were missing, the total scale score was regarded as missing and imputed using multiple imputation.

Clustering in psychoeducation with problem-solving arm

In this trial there were two potential sources of clustering in the PEPS arm only: by therapist in the first treatment phase and by the problem-solving therapy group in the second treatment phase. Data for the former were not available for some participants, or else treatment in the first phase was delivered by a single therapist per centre. Furthermore, any clustering effect was expected to be dominated by the latter. Therefore, we obtained clustered sandwich estimates of variance by specifying the ‘cluster’ option in all regression models, which relaxes the assumption that all observations are independent.

Sensitivity analyses

We conducted the following sensitivity analyses of the primary outcome:

• Repeated the primary analysis with additional adjustment for any variables displaying marked imbalance between the arms at baseline.
• Repeated the primary analysis restricted to those participants with observed primary outcome data at 72 weeks.
• To examine treatment efficacy, complier average causal effect (CACE) estimates 66 were calculated using instrumental variable regression methods for those participants in the PEPS arm who received the intervention in line with the treatment protocol. The definition of treatment received as per protocol was having completed psychoeducation according to the therapist assessment and attended a minimum of six of the group problem-solving sessions.

Subgroup analyses

Although no subgroup analyses were specified a priori, we conducted two exploratory subgroup analyses by including appropriate interaction terms in the regression model for the primary outcome. We investigated whether or not there was any evidence of differential effects of treatment on SFQ score at 72 weeks according to (1) study site (central and north-west London, South Wales and North-East England); (2) PD category (simple, complex); and (3) borderline PD diagnosis at baseline.

Secondary outcomes

Analysis of secondary outcomes was conducted using a similar approach as for the primary outcome, except that missing data were not imputed, and choice of regression model and presentation of the estimated between-group effect was dependent on outcome type (continuous, binary, ordinal, rate). We used proportional odds logistic regression for ordinal data and we checked the goodness-of-fit assumption for the Poisson regression analysis of count data using the Pearson test. Descriptive data are presented for each time point, but formal comparisons were only conducted for 72-week data. The exception to this is the SPSI-R total score, for which a repeated measures analysis was conducted including data at both the 24- and 72-weeks follow-up to examine whether any treatment effects were sustained or emerged later. This was tested formally with an interaction term between treatment group and time in the model, and in the absence of any evidence of a time effect, a repeated measures analysis generates an average effect size over the duration of follow-up.

Between-group differences in health-care service use and adverse events were estimated using binomial/Poisson regression modelling and allow for multiple events per individual.

Interim analysis

No formal interim analyses for effectiveness were planned or undertaken, however, unblinded data were periodically reviewed by the Data Monitoring and Ethics Committee (DMEC) during routine meetings.

Sample size

The sample size calculation for the study was based on the primary hypothesis that those randomised to PEPS therapy in addition to usual treatment would have improved social functioning at 72 weeks after randomisation compared with those randomised to usual treatment only. We powered the trial to detect a difference of 2 points on the SFQ score (standardised effect size of 0.44). This is agreed to be a clinically significant and important difference. 67 We based our sample size estimate on a conservative (i.e. largest) estimate of standard deviation (SD) of 4.53 points.

To detect a difference in mean SFQ score of 2 points with a two-sided significance level of 1% and power of 80%, with equal allocation to two arms, would require 120 patients in each arm of the trial. In anticipation of a 30% loss to follow-up at 72 weeks after randomisation, we planned to randomise 340 participants (170 in each arm).

Randomisation

Following recruitment and completion of screening and baseline assessments, participants were randomly allocated to receive PEPS therapy in addition to usual treatment or usual treatment alone at a ratio of 1 : 1.

Randomisation was based on a computer-generated pseudo-random code using random permuted blocks of randomly varying size, created by the Nottingham Clinical Trials Unit (NCTU), in accordance with its standard operating procedure and held on a secure server. The randomisation was stratified by recruiting centre and sex. The sequence of treatment allocations was concealed until recruitment, data collection and all other trial-related assessments were complete.

The investigator, or an authorised designee, accessed the treatment allocation for each participant by means of a remote, internet-based randomisation system developed and maintained by the NCTU. Allocation was therefore fully concealed from recruiting staff.

• Study procedures

Preparatory phase

Site initiation visits were completed prior to the start of recruitment to ensure that all site staff were trained in the protocol and study-specific procedures.

Visit schedule

The duration of follow-up was 72 weeks post randomisation. The study schedule is shown in Figure 1 .

Schedule of visits. TAU, treatment as usual.

Data collection

Follow-up visits were completed in person or by telephone. To improve response rates at the final follow-up, the SFQ was posted to participants who could not be contacted by another means.

The majority of data were collected through the use of standardised, self-report assessment measures completed by participants during scheduled follow-up visits. Research staff involved in data collection were provided with guidance on the principles of standardised assessment and on the specific measures employed in the trial. Assessments were self-completed by participants or read aloud to participants by the researcher if required. In this case, questions were read out verbatim and were not reworded. No test feedback was given to participants.

The Service Use Record Check was completed by the research assistants after the final assessment measures had been collected. Service use data were collected from GP and mental health records retrospectively for the duration of the trial, according to a data collection manual that outlined procedures for accessing GP records, procedures for dealing with incomplete or inconsistent data, and definitions of key terms; standardised data collection forms were used (see Appendix 8 ).

In pragmatic trials of this type, as in usual clinical practice, it is not possible to blind participants or clinicians to whether they are in the intervention or control arm of the trial; therefore, participants, mental health workers delivering the interventions and participants’ usual-care teams were aware of the treatment allocation. Most of the outcome data were obtained from self-report questionnaires from participants who were not blind to treatment allocation. However, outcome measures were administered by research assistants blinded to treatment allocation in order to reduce assessment bias as far as possible. Data analysts remained blinded to allocation during the study by having access to only aggregate data and no access to data that could reveal treatment arm, such as course attendance. Final analyses were conducted using treatment labels A/B, with allocation decodes released only after completion of analyses. Data that could reveal allocation were analysed following release of allocation decodes.

At the start of each follow-up, participants were reminded of the importance of not disclosing their treatment allocation to the research assistant using a suggested unblinding script (see Appendix 9 ). If the research assistant was inadvertently unblinded to treatment allocation before completing the final follow-up, a record of the incident of unblinding was made. Researchers also reported whether or not they were aware of the treatment allocation at the time of completing the primary end-point assessments. Owing to changes in personnel over the course of the trial, in some cases, end-point assessments were conducted by researchers who were not unblinded. A record was made of the blinding status of the researcher conducting the final follow-up data collection.

Payments to participants

Participants reaching the final follow-up were offered a non-contingent voucher payment in recognition of their contribution to the trial. Contact with the participant at the final follow-up was sufficient for provision of the voucher (i.e. payment was not contingent on completion of the final follow-up assessments). This voucher payment was introduced in an amendment in April 2013, approximately halfway through final follow-up completion.

Reimbursement of travel expenses incurred in relation to attendance at research appointments was offered, and travel expenses incurred by participants in conjunction with the treatments provided in the trial were paid in accordance with normal clinical practice at the local sites.

Patient and public involvement

Two service users were involved in the protocol development and in the preparation of the participant information sheet and consent form. Service user representatives on the Trial Management Group (TMG), TSC and DMEC contributed to the management and oversight of the trial.

• Research governance

The study was conducted in accordance with the principles of good clinical practice and the Research Governance Framework for Health and Social Care . 68

Ethical approval for the study, including amendments, was given by the South Wales Research Ethics Committee (reference number 09/WSE03/48).

The final approved protocol was version 6.0, dated 3 April 2013. The original approved protocol was version 1.0, dated 18 September 2009. For a summary of amendments implemented during the trial see Appendix 10 .

A number of committees were assembled to ensure the proper management and conduct of the trial, and to uphold the safety and well-being of participants. The general purpose, responsibilities and structures of the committees were described in the protocol, with separate charters developed for the independent oversight committees.

The TMG comprised members of the study team and met regularly throughout the trial to oversee the day-to-day management of the trial. The TMG met approximately once a month for the duration of the trial, with meetings held face to face and by teleconference for those unable to attend in person. The TMG reviewed recruitment and data completion rates, as well as identifying and addressing any issues arising during the course of the trial.

Independent oversight of trial conduct was provided by the TSC and DMEC.

The independent TSC monitored, reviewed and supervised the progress of the trial. The TSC also monitored pooled data to consider safety and efficacy indications, and considered reports from the DMEC.

An independent DMEC was established, with access to unblinded data, to provide independent reviews and recommendations to the TSC regarding continuation of the study in light of potential treatment effect. The DMEC was advisory to the TSC. During routine conduct of the trial, the DMEC was the only group with access to unblinded data. The DMEC reviewed unblinded data at routine meetings held during the course of the trial. The data that were presented included listings of reported adverse events and reported hospitalisations collected from the CSRI.

For the schedule of meetings of the DMEC and TSC see Appendix 11 .

Safety monitoring

Local procedures were implemented at each site to ensure adverse events were recognised and reported, including asking participants about adverse events during each contact and asking the participant’s clinical team to inform the site principal investigator if an adverse event was identified. The participant’s responsible clinician was also contacted by letter to request information on adverse events throughout the trial. In addition, in the event of loss to follow-up, the participant’s clinical team and/or GP were contacted to alert the responsible clinician to the participant’s loss to follow-up and to request information on any unreported adverse events to ensure that safety data remained accurate and up to date. All adverse events were reported to the trial co-ordinating centre within 24 hours of the study team becoming aware of them.

Adverse event reports were reviewed on receipt at the co-ordinating centre, and were assessed for relatedness and expectedness by the chief investigator in accordance with the National Research Ethics Service guidance on adverse event reporting in trials that do not include medicines. To guide this assessment, the adverse event form collected information on all possible and suspected causes identified from the available clinical information, including clinical notes and participant self-report. A categorical assessment of ‘relatedness to the trial’ was also made by the person reporting the event.

Adverse events were also classified by the person reporting them according to whether or not there were indications of ‘psychological antecedents’. Events that were deemed to have psychological antecedents were defined as mental health-related events. Mental health-related events were further categorised as follows:

• self-harm, including drug or alcohol overdose
• deterioration in mental health
• suicidal ideation
• suicide or attempted suicide
• planned/respite hospital admission
• other (specify).

The primary classification only was recorded. Adverse events were classified by the person reporting the event on the basis of the information available at the time (e.g. through participant self-report or clinical notes). For example, attempted suicide was recorded when this was the reason given by the participant, and it does not necessarily relate to the severity of harm caused or evidence of clear intent (i.e. events recorded as ‘attempted suicide’ are not necessarily life-threatening).

All adverse events were routinely reported to the Research Ethics Committee, DMEC and TSC as part of the regular reporting requirements. In addition, serious adverse events that were deemed to be both related to administration of any of the trial procedures and that were not identified as expected occurrences were subject to expedited reporting to the Research Ethics Committee, as required by the National Research Ethics Service guidance for studies that are not clinical trials of investigational medicinal products in the UK.

Included under terms of UK Non-commercial Government License .

• Cite this Page McMurran M, Crawford MJ, Reilly J, et al.; on behalf of the PEPS Trial Collaborative Group. Psychoeducation with problem-solving (PEPS) therapy for adults with personality disorder: a pragmatic randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of a manualised intervention to improve social functioning. Southampton (UK): NIHR Journals Library; 2016 Jul. (Health Technology Assessment, No. 20.52.) Chapter 2, Methods.
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Problem-Solving Therapy for Depression

What is problem-solving therapy?

Problem-solving therapy (PST) is a form of psychotherapy. It may help you develop coping skills to manage upsetting life experiences.

“It’s the notion of focusing on the problem in the moment as opposed to psychodynamic therapy, which focuses on both the problem and the underpinnings,” explains Jaine L. Darwin, Psy.D., a psychologist and psychoanalyst in Cambridge, Massachusetts.

PST is also known as:

• short-term therapy
• problem-solving treatment
• structured problem solving

If you have depression and your doctor suspects that it stems from everyday life problems, they may recommend PST. This therapy may help you develop strategies to resolve those problems. In turn, it may relieve your depression symptoms.

What does PST treat?

Your doctor may recommend PST if you have depression. It may also help you manage other mental conditions or situations, such as:

• deliberate self-harm
• interpersonal relationship problems
• unhappiness at work or home

What does PST involve?

During PST, your therapist will teach you how to use a step-by-step problem-solving process. They will help you:

• identify problems
• come up with several realistic solutions
• select the most promising solution
• develop and implement an action plan
• assess how effective the problem-solving attempt was

Your therapy will likely include:

• psycho-education to teach you skills to cope with depression
• interactive problem-solving exercises
• enhancing communication skills
• motivational homework assignments

PST typically involves eight to 16 sessions. It can be delivered by a therapist during one-on-one or group sessions. You may also receive PST in a primary care setting from a general practitioner, such as your family doctor. Your insurance might cover some of the treatments.

What are the different types of PST?

There are three general types of problem-solving therapy:

• Social PST: Your therapist will help you identify solutions to everyday problems in social settings. You will learn how to adapt to different situations, rather than use a single coping strategy.
• Self-examination PST: Your therapist will help you determine life goals, assess barriers to your goals, and apply problem-solving strategies to achieve them. They will also help you learn to accept uncontrollable situations.
• PST for primary care settings: A primary care physician will provide your PST.

What do experts say?

Problem-solving therapy may help you manage the symptoms of depression. But it probably won’t provide a cure on its own.

“With problem-solving therapy, you identify a circumscribed problem and together figure out behavioral or actionable strategies,” explains Jeffrey L. Binder, Ph.D., a professor of psychology at Argosy University in Atlanta. “Depression, in general, would be too broad a problem. You’d have to identify a particularly negative symptom or set of symptoms of depression or a particular environmental circumstance that is contributing to or causing the problem. The therapy is focused on very concrete problems.”

Ask your doctor for more information about PST. They can help you understand the potential benefits and risks. They may encourage you to combine PST with other treatments, such as medication. They may also recommend other forms of therapy.

How we reviewed this article:

• Bell, A. C.,& D’Zurilla, T. J. (2009, June). Problem-solving therapy for depression: Ameta-analysis. Clinical PsychologyReview, 29 (4), 348-353 http://www.ncbi.nlm.nih.gov/pubmed/19299058
• Problem-solvingtherapy for depression. (n.d.) https://www.div12.org/psychological-treatments/disorders/depression/problem-solving-therapy-for-depression/
• What isproblem-solving therapy? (n.d.) http://www.div12.org/sites/default/files/WhatIsProblemSolvingTherapy.pdf

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Study shows cognitive behavioral therapy can lead to brain changes in depression patients

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Cognitive behavioral therapy, one of the most common treatments for depression, can teach skills for coping with everyday troubles, reinforce healthy behaviors and counter negative thoughts. But can altering thoughts and behaviors lead to lasting changes in the brain?

New research led by Stanford Medicine has found that it can -; if a therapy is matched with the right patients. In a study of adults with both depression and obesity -; a difficult-to-treat combination -; cognitive behavioral therapy that focused on problem solving reduced depression in a third of patients. These patients also showed adaptative changes in their brain circuitry.

Moreover, these neural adaptations were apparent after just two months of therapy and could predict which patients would benefit from long-term therapy.

The findings add to evidence that choosing treatments based on the neurological underpinnings of a patient's depression -; which vary among people -; increases the odds of success. 

The same concept is already standard practice in other medical specialties.

"If you had chest pain, your physician would suggest some tests -; an electrocardiogram, a heart scan, maybe a blood test -; to work out the cause and which treatments to consider," said Leanne Williams, PhD, the Vincent V.C. Woo Professor, a professor of psychiatry and behavioral sciences, and the director of Stanford Medicine's Center for Precision Mental Health and Wellness.

"Yet in depression, we have no tests being used. You have this broad sense of emotional pain, but it's a trial-and-error process to choose a treatment, because we have no tests for what is going on in the brain."

Williams and Jun Ma, MD, PhD, professor of academic medicine and geriatrics at the University of Illinois at Chicago, are co-senior authors of the study published Sept. 4 in  Science Translational Medicine.  The work is part of a larger clinical trial called RAINBOW (Research Aimed at Improving Both Mood and Weight).

Problem solving

The form of cognitive behavioral therapy used in the trial, known as problem-solving therapy, is designed to improve cognitive skills used in planning, troubleshooting and tuning out irrelevant information. A therapist guides patients in identifying real-life problems -; a conflict with a roommate, say -; brainstorming solutions and choosing the best one.

These cognitive skills depend on a particular set of neurons that function together, known as the cognitive control circuit.

Previous work from Williams' lab, which identified six biotypes of depression based on patterns of brain activity, estimated that a quarter of people with depression have dysfunction with their cognitive control circuits -; either too much or too little activity.

The participants in the new study were adults diagnosed with both major depression and obesity, a confluence of symptoms that often indicates problems with the cognitive control circuit. Patients with this profile generally do poorly on antidepressants: They have a dismal response rate of 17%.

Of the 108 participants, 59 underwent a year-long program of problem-solving therapy in addition to their usual care, such as medications and visits to a primary care physician. The other 49 received only usual care.

They were given fMRI brain scans at the beginning of the study, then after two months, six months, 12 months and 24 months. During the brain scans, the participants completed a test that involves pressing or not pressing a button according to text on a screen -; a task known to engage the cognitive control circuit. The test allowed the researchers to gauge changes in the activity of that circuit throughout the study.

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"We wanted to see whether this problem-solving therapy in particular could modulate the cognitive control circuit," said Xue Zhang, PhD, a postdoctoral scholar in psychiatry who is the lead author of the study.

With each brain scan, participants also filled out standard questionnaires that assessed their problem-solving ability and depression symptoms. 

Working smarter

As with any other depression treatment, problem-solving therapy didn't work for everyone. But 32% of participants responded to the therapy, meaning their symptom severity decreased by half or more.

"That's a huge improvement over the 17% response rate for antidepressants," Zhang said.

When researchers examined the brain scans, they found that in the group receiving only usual care, a cognitive control circuit that became less active over the course of the study correlated with worsening problem-solving ability.

But in the group receiving therapy, the pattern was reversed: Decreased activity correlated with enhanced problem-solving ability. The researchers think this may be due to their brains learning, through the therapy, to process information more efficiently.

"We believe they have more efficient cognitive processing, meaning now they need fewer resources in the cognitive control circuit to do the same behavior," Zhang said.

Before the therapy, their brains had been working harder; now, they were working smarter.

Both groups, on average, improved in their overall depression severity. But when Zhang dug deeper into the 20-item depression assessment, she found that the depression symptom most relevant to cognitive control -; "feeling everything is an effort" -; benefited from the more efficient cognitive processing gained from the therapy.

"We're seeing that we can pinpoint the improvement specific to the cognitive aspect of depression, which is what drives disability because it has the biggest impact on real-world functioning," Williams said.

Indeed, some participants reported that problem-solving therapy helped them think more clearly, allowing them to return to work, resume hobbies and manage social interactions.

Fast track to recovery

Just two months into the study, brain scans showed changes in cognitive control circuit activity in the therapy group.

"That's important, because it tells us that there is an actual brain change going on early, and it's in the time frame that you'd expect brain plasticity," Williams said. "Real-world problem solving is literally changing the brain in a couple of months."

The idea that thoughts and behaviors can modify brain circuits is not so different from how exercise -; a behavior -; strengthens muscles, she added.

The researchers found that these early changes signaled which patients were responding to the therapy and would likely improve on problem-solving skills and depression symptoms at six months, 12 months and even one year after the therapy ended, at 24 months. That means a brain scan could be used to predict which patients are the best candidates for problem-solving therapy.

It's a step toward Williams' vision of precision psychiatry -; using brain activity to match patients with the therapies most likely to help them, fast-tracking them to recovery.

"It's definitely advancing the science," Zhang said. "But it's also going to transform a lot of people's lives."

Researchers from University of Washington, University of Pittsburgh School of Medicine and The Ohio State University also contributed to the work.

The study received funding from the National Institutes of Health (grants UH2 HL132368, UH3 HL132368 and R01 HL119453).

Stanford Medicine

Posted in: Medical Research News | Medical Condition News

Tags: Blood , Blood Test , Brain , Chest Pain , Clinical Trial , Cognitive Behavioral Therapy , Depression , Disability , Exercise , Geriatrics , Heart , Medicine , Mental Health , Neurons , Neuroscience , Obesity , Pain , Primary Care , Psychiatry , Research

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Brain Rewiring: How Cognitive Behavioral Therapy Combats Depression

Introduction.

Cognitive behavioral therapy, one of the most common treatments for depression, can teach skills for coping with everyday troubles, reinforce healthy behaviors and counter negative thoughts. But can altering thoughts and behaviors lead to lasting changes in the brain? New research led by Stanford Medicine has found that it can - if a therapy is matched with the right patients.

Main Digest

In a study of adults with both depression and obesity - a difficult-to-treat combination - cognitive behavioral therapy that focused on problem solving reduced depression in a third of patients. These patients also showed adaptative changes in their brain circuitry.

Moreover, these neural adaptations were apparent after just two months of therapy and could predict which patients would benefit from long-term therapy.

The findings add to evidence that choosing treatments based on the neurological underpinnings of a patient's depression - which vary among people - increases the odds of success.

The same concept is already standard practice in other medical specialties.

"If you had chest pain, your physician would suggest some tests - an electrocardiogram, a heart scan, maybe a blood test - to work out the cause and which treatments to consider," said Leanne Williams, PhD, the Vincent V.C. Woo Professor, a professor of psychiatry and behavioral sciences, and the director of Stanford Medicine's Center for Precision Mental Health and Wellness. "Yet in depression, we have no tests being used. You have this broad sense of emotional pain, but it's a trial-and-error process to choose a treatment, because we have no tests for what is going on in the brain."

Williams and Jun Ma, MD, PhD, professor of academic medicine and geriatrics at the University of Illinois at Chicago, are co-senior authors of the study published Sept. 4 in Science Translational Medicine. The work is part of a larger clinical trial called RAINBOW (Research Aimed at Improving Both Mood and Weight).

Problem Solving

The form of cognitive behavioral therapy used in the trial, known as problem-solving therapy, is designed to improve cognitive skills used in planning, troubleshooting and tuning out irrelevant information. A therapist guides patients in identifying real-life problems - a conflict with a roommate, say - brainstorming solutions and choosing the best one.

These cognitive skills depend on a particular set of neurons that function together, known as the cognitive control circuit.

Previous work from Williams' lab, which identified six biotypes of depression based on patterns of brain activity, estimated that a quarter of people with depression have dysfunction with their cognitive control circuits - either too much or too little activity.

The participants in the new study were adults diagnosed with both major depression and obesity, a confluence of symptoms that often indicates problems with the cognitive control circuit. Patients with this profile generally do poorly on antidepressants: They have a dismal response rate of 17%.

Of the 108 participants, 59 underwent a year-long program of problem-solving therapy in addition to their usual care, such as medications and visits to a primary care physician. The other 49 received only usual care.

They were given fMRI brain scans at the beginning of the study, then after two months, six months, 12 months and 24 months. During the brain scans, the participants completed a test that involves pressing or not pressing a button according to text on a screen - a task known to engage the cognitive control circuit. The test allowed the researchers to gauge changes in the activity of that circuit throughout the study.

"We wanted to see whether this problem-solving therapy in particular could modulate the cognitive control circuit," said Xue Zhang, PhD, a postdoctoral scholar in psychiatry who is the lead author of the study.

With each brain scan, participants also filled out standard questionnaires that assessed their problem-solving ability and depression symptoms.

Working Smarter

As with any other depression treatment, problem-solving therapy didn't work for everyone. But 32% of participants responded to the therapy, meaning their symptom severity decreased by half or more.

"That's a huge improvement over the 17% response rate for antidepressants," Zhang said.

When researchers examined the brain scans, they found that in the group receiving only usual care, a cognitive control circuit that became less active over the course of the study correlated with worsening problem-solving ability.

But in the group receiving therapy, the pattern was reversed: Decreased activity correlated with enhanced problem-solving ability. The researchers think this may be due to their brains learning, through the therapy, to process information more efficiently.

"We believe they have more efficient cognitive processing, meaning now they need fewer resources in the cognitive control circuit to do the same behavior," Zhang said.

Before the therapy, their brains had been working harder; now, they were working smarter.

Both groups, on average, improved in their overall depression severity. But when Zhang dug deeper into the 20-item depression assessment, she found that the depression symptom most relevant to cognitive control - "feeling everything is an effort" - benefited from the more efficient cognitive processing gained from the therapy.

"We're seeing that we can pinpoint the improvement specific to the cognitive aspect of depression, which is what drives disability because it has the biggest impact on real-world functioning," Williams said.

Indeed, some participants reported that problem-solving therapy helped them think more clearly, allowing them to return to work, resume hobbies and manage social interactions.

Fast Track to Recovery

Just two months into the study, brain scans showed changes in cognitive control circuit activity in the therapy group.

"That's important, because it tells us that there is an actual brain change going on early, and it's in the time frame that you'd expect brain plasticity," Williams said. "Real-world problem solving is literally changing the brain in a couple of months."

The idea that thoughts and behaviors can modify brain circuits is not so different from how exercise - a behavior - strengthens muscles, she added.

The researchers found that these early changes signaled which patients were responding to the therapy and would likely improve on problem-solving skills and depression symptoms at six months, 12 months and even one year after the therapy ended, at 24 months. That means a brain scan could be used to predict which patients are the best candidates for problem-solving therapy.

It's a step toward Williams' vision of precision psychiatry - using brain activity to match patients with the therapies most likely to help them, fast-tracking them to recovery.

"It's definitely advancing the science," Zhang said. "But it's also going to transform a lot of people's lives."

Researchers and Funding

Researchers from University of Washington, University of Pittsburgh School of Medicine and The Ohio State University also contributed to the work.

The study received funding from the National Institutes of Health (grants UH2 HL132368, UH3 HL132368 and R01 HL119453).

Related Information

• Why People End Cognitive Behavioral Therapy : Research study on why many people end cognitive behavioral therapy before end of recommended course of treatment.
• Cognitive Behavioral Therapy Appears Beneficial for Adults with ADHD : Throughout treatment self-reported symptoms were also significantly more improved for cognitive behavioral therapy.
• Hypochondriasis: Online Cognitive Behavioral Therapy : Internet-based cognitive-behavioral therapy (CBT) is an effective treatment for people with hypochondriasis.
• Cognitive Behavior Therapy Effects On Parents of Children with Autism : Study reveals when parents are partners in therapy with children, they experience improvements in their own depression and emotion regulation.
• The Power of Talk Therapy for Children with Anxiety Disorders : A brain scan with functional MRI can predict which patients with pediatric anxiety disorder will respond to talk therapy and may not need psychiatric medication.

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