Research reportThe utilization of unified protocols in behavioral cognitive therapy in transdiagnostic group subjects: A clinical trial
Introduction
In the last thirty years, behavioral-cognitive therapy (CBT) has been achieving successful results when compared to those of other treatments (Pehlivanidis et al., 2006). The evidence of this approach varies and benefits not only patients but also physicians and other healthcare professionals due to a better assent to treatment (Pehlivanidis et al., 2006, Kraus et al., 2011, Lambert, 2013). The following benefits exist: a more accessible therapeutic relationship, techniques that provide patients with more autonomy, a treatment plan that is built up with the patient and based on goals as discussed in the therapy sessions, and the short-term behavioral changes acquired during the course of treatment (Button et al., 2012).
Research shows that since it is a direct and structured approach, the CBT has advantages as to the prognosis of treatment when it utilizes protocols (Pehlivanidis et al., 2006, Kraus et al., 2011, Lambert, 2013, Button et al., 2012). The unified protocol was created in 2011 by Barlow and colleagues and bases itself empirically on CBT. During therapy sessions, approach techniques such as psychoeducation, bibliotherapy, socratic questioning, relaxation, diaphragmatic breathing, exposure, cognitive restructuring, and training of social abilities are implemented. The purpose is to reach pre-established goals designed at the beginning of the process as well as emotional balance (de Ornelas et al., 2013, Barlow et al., 2011a, Barlow et al., 2011b). It may be utilized in either individual or transdiagnostic patient groups functioning as a guide of 12 or more therapy sessions (de Ornelas et al., 2013, Barlow et al., 2011a, Barlow et al., 2011b, Norton et al., 2014). Due to the ease of implementation, studies suggest the use of the unified protocol as an important tool to both providers and patients subjected to it (Button et al., 2012, de Ornelas et al., 2013, Barlow et al., 2011a, Barlow et al., 2011b, Norton et al., 2014).
In the psychotherapy process, the practice of the unified protocol in groups has the goal to: (1) socialize the patient to the CBT model; (2) encourage goal-setting in treatment; (3) provide a sense of mutual help amongst group members and providers; (4) identify predisposing factors that may also maintain what conflict is considered by each group member; (5) focus on what is truly desired; (6) train social and affective relation abilities; (7) allow for cognitive restructuring against dysfunctional beliefs; (8) modify behavior and (9) prevent relapses (Button et al., 2012, de Ornelas et al., 2013, Barlow et al., 2011a, Barlow et al., 2011b, Norton et al., 2014).
Studies show that when the patient undergoes a psychotherapy individual treatment as being associated with the use of medication for depression and anxiety, the results related to quality of life are inferior when compared to those of group treatment. Group treatment allows for the increase of a positive-emotions repertoire such as self-acceptance, autonomy, purpose in life, positive relationships with others, environment control, and personal growth (Leichsenring and Salzer, 2014, Wood and Joseph, 2010, Wood-Dauphinee, 1999).
In regards to pathological anxiety, studies point to several limitations to the patient׳s life and that – when exposed to a group of patients with a diversity of anxiety disorders – symptoms are similar amongst patients serving as an identifying point in common. It takes place from the threatening stimulus up to the negative avoidance behavior, freezing behavior and escape. Improvement in therapy appears to be continuous as to anxiety disorders as it was with a follow-up of a 6-month post-treatment research of a group of 37 participants diagnosed with panic, generalized anxiety, agoraphobia, and obsessive–compulsive disorders. This was prior to the unified protocol (M=30.0, SD=12.6) and after treatment (M=19.61, SD=12.1, Hedge׳s g=−0.77) which showed an evidence of continuous improvement (Boswell et al., 2013 Sep).
Studies reveal that psychoeducation and cognitive restructuring techniques, when utilized in group, afford patients with insights regarding functional anxious thinking and, furthermore, it shows that the motivational feature of the group environment might serve as a predictor of meaningful improvement in patients who seek a more socially-accepted behavior (de Ornelas et al., 2013; Barlow et al., 2011). In a research in which the group unified protocol was employed, a reduction in both depressive-related (F=78.62; p<0.001) and anxiety-related (F=19.64; p<0.001)(de Ornelas et al., 2013) symptoms was found.
This study aims to evaluate the efficacy of CBT unified protocols in the treatment of depression and anxiety disorders of transdiagnostic patients.
Section snippets
Methodology
Forty eight patients with depressive and multiple anxiety disorders were assessed and diagnosed with the structured interview MINI (Mini International Neuropsychiatric Interview) (Sheehan et al., 1998, Amorim, 2000). All of the subjects were obtained from a waiting list of 300 patients who sought psychological treatment in the county of Resende in the State of Rio de Janeiro. From the 48 patients aforementioned, 24 underwent a CBT unified group-protocol intervention and the remaining 24 were
Results
Sociodemographic data was described on Table 1, being both groups sub-divided as follows: with and without therapy, sex, education, profession, and religion. From this data, the only one that differs from the others is the level of education of the group submitted to the unified protocol therapy in which patients had a higher level of education as compared with those of the control group. The group treated with the unified protocol was favored from this result since the CBT is an approach which
Discussion
The results showed that the treatment in the form of group with the unified protocol for depression and anxiety disorders was effective thus corroborating with the current literature published (Pehlivanidis et al., 2006, Kraus et al., 2011, Lambert, 2013, Button et al., 2012, de Ornelas et al., 2013). A meta-analytic review of 35 studies compared the group CBT with the use of medication for the treatment of generalized anxiety disorder (GAD); the result was similar in both interventions for CBT
Conclusion
The format of the group CBT is less frequently implemented than the individual; however, the group format may be better implemented in public environments allowing for a greater number of patients seen and for a lower cost.
Group CBT treatment when applied by means of an unified protocol may become more well-structured and simple to both providers and patients.
Role of funding source
The first author is a researcher and doctoral candidate of Department of the Institute of Psychiatry of the laboratory of panic and respiration and has monthly contribution of doctoral scholarship from CAPES, which is a Federal Government agency in Rio de Janeiro. This contribution was used to collect the data, having the procedure with the unified group Protocol, statistical analyses and writing the article.
Conflict of interest
No conflict of interest.
Acknowledgments
The contribution of each author was paramount for this project and article and in the application of Mini interview as well as BAI and BDI both in patients who have undergone therapy and those in the control group (1,2,3); also crucial in the implementation of the text about the group therapy, cognitive-behavior therapy and unified protocol (1) and in revising the manuscript (1,2,3).
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