Peer-led group CBT
Reprinted from the "CBT" issue of Visions Journal, 2009, 6 (1), p. 16
In 2004, I was diagnosed with generalized anxiety disorder (GAD) at the Anxiety Disorders Clinic at UBC Hospital. I was fortunate to be referred to a group for GAD based on cognitive-behavioural therapy (CBT), led by three psychology residents specializing in CBT and anxiety. By the end of the 14-week group program, I felt like I’d been given my life back. So I asked if there were any volunteer opportunities to help others struggling with anxiety. AnxietyBC was seeking volunteers for their LEAF program.
The LEAF (Living Effectively with Anxiety and Fear) program is for people with mild to moderate panic disorder. It was developed by AnxietyBC in 2002. It has since offered CBT-based, peer-led panic management groups in various locations throughout BC, including Kamloops, Kelowna, Delta, Surrey and the Tri-Cities (Coquitlam, Port Coquitlam and Port Moody).
The LEAF group leaders are former anxiety sufferers who received cognitive-behavioural therapy to manage their anxiety. So leaders have first-hand knowledge of successfully overcoming problem anxiety using CBT techniques. Although I was diagnosed with GAD rather than panic disorder, the feelings of being overwhelmed by anxiety, the muscle tension and stomach distress, worry and avoidance are common to both disorders.
The peer-leader training involved an intensive two-day workshop. We learned how to conduct exposure to feared situations, how to challenge anxious thoughts and how to manage anxious feelings in the body. We were also instructed in the use of a 10-week group program manual.
We continue to receive weekly phone supervision from one of the clinicians/CBT specialists to troubleshoot any difficulties that may have arisen in the group and to review material for the upcoming session.
How the group works
Throughout the 10-session program, LEAF leaders teach and model evidence-based CBT strategies that will help group members manage their panic symptoms.
Twelve people is the optimal group size. The groups are co-ed (although women predominate, as anxiety tends to be more prevalent in women than in men) and multicultural. Young adults as well as seniors have been represented.
There are always two group leaders, both with the peer-leader training, to share the tasks of presenting the material and demonstrating techniques. Each leader has their own unique anxiety experiences and will answer group questions a little differently. This provides participants with a broader perspective on anxiety and coping strategies. And, it’s been my experience that group members tend to look to one particular co-leader for support, perhaps feeling that person is more in tune with their situation.
At the first session, we share our experiences with anxiety. As leaders, we are open about our own struggles and the successful treatment we’ve received. When the group members hear the personal stories of the leaders and how they’ve been able to overcome their fears with the help of CBT, they realize that it’s possible to manage anxiety, whatever its form. And, as a result of our openness, group members are more willing to share their own experiences
For many, this is the first time they have openly talked about their struggles. A group participant once said to me, “When I speak with my doctor, I know that he doesn’t have any idea what I’m talking about and cannot possibly understand what I go through. But you do because you’ve been there.”
In the first session, we also provide factual information about panic attacks and panic disorder so group members can begin thinking rationally, rather than emotionally, about what is happening to them when they have a panic attack. And they are given a book about anxiety and panic disorder (10 Simple Solutions to Panic: How to Overcome Panic Attacks, Calm Physical Symptoms, and Reclaim Your Life by Martin M. Anthony and Randi E. McCabe).
In week two we introduce relaxed breathing, and deep muscle relaxation is introduced in week four. These are useful skills for reducing overall anxiety. The group leaders always demonstrate each behaviour or technique prior to asking the members to join in.
At the end of each group session, the participants are given “homework.” Homework gives participants the opportunity to master the skills they’ve learned during sessions. They may be asked to read a chapter or two in the book they received. They work through exercises in a workbook to help them identify and overcome their personal fears. They learn to challenge some of the common types of thoughts that arise during a panic episode and identify a calming thought that can be substituted in place of the panic thoughts. They set goals they can work towards as the program progresses. And they are asked to continue with the relaxed breathing and deep muscle relaxation on a daily basis to “dial down” their general level of anxiety.
Homework is always reviewed at the following group and participants are encouraged to share. There is always reluctance at first. But as group members hear the experiences of others and discover that they’re not unlike their own, some of the stigma is removed and they begin to participate. Oftentimes, group members begin to brainstorm coping strategies for each other. This is very exciting because they are beginning to move from purely emotional thinking to more analytical and cognitive thought processes.
The most challenging session occurs about halfway through the program, when participants are asked to bring on the bodily sensations they fear. People with panic disorder may be afraid of sensations like a racing heart, light-headedness, dizziness and shortness of breath.
First, group leaders demonstrate bringing on these uncomfortable physical sensations, in a calm and matter-of-fact manner. For example, we might cause light-headedness by hyperventilating or make ourselves dizzy by spinning around, all the while explaining what we’re feeling. We acknowledge that, while we’ve made ourselves uncomfortable, what we’ve done is not dangerous. In fact, we’re able to report that, not long after we’ve stopped, all sensations are gone.
This exercise can be scary for many group members, but when we ask them to bring on a particular sensation along with us, very few refuse to do so. This is an important step for participants in understanding, experientially, that the physical sensations they fear aren’t dangerous.
The remainder of the program focuses on gradual and repeated exposure to feared situations, moving from the easiest towards the most feared. These are situations that have mostly been avoided in the past, such as driving over bridges or taking public transit. We also ask the group members to start thinking about a life outside of panic, where “harm avoidance” is not the primary focus.
At the final group, we usually end with a celebration. People bring food to share and many times members share upcoming events they have planned that wouldn’t have been considered before taking part in the group, like taking a trip that involves flying somewhere. We encourage participants not to let their panic management tools get rusty. We ask them to think about what they knew about anxiety at the beginning of the group and what they now know at the end. I also like to let them know that, in practising anxiety management techniques with them, I’m helping myself as well. In many ways, leading a group is my therapy.
LEAF has a positive impact
Data collected over the years shows that the LEAF program successfully reduces symptoms of panic, anxiety and associated depression in people who complete the program.1 Group participants fill out pre-treatment and post-treatment questionnaires. The majority, if not all the participants, have reported that the LEAF program helped them manage their panic and anxiety symptoms more effectively. Most participants would also recommend the program to others suffering from panic disorder.
Unfortunately, this program has not been offered on a regular basis due to inconsistent funding from the local health authorities. This is a situation I hope will change. Peer-led groups are a very cost-effective way to help people before their problems become more severe and they begin to access the health care system more frequently.
I’ve met many brave and wonderful people who’ve been struggling for years and who finally see a light at the end of the tunnel. They are my inspiration to continue helping those who haven’t yet benefited from any form of treatment and struggle to cope day by day.
About the authorShelly is the President of the board of directors of AnxietyBC. The organization is committed to increasing awareness, promoting education and improving access to programs that work for those suffering from anxiety disorders. She has co-led LEAF groups since 2005.
Miller, L.D., Robichaud, M., Whittal, M.L. et al. (2008, November). Dissemination of empirically supported treatment for panic in underserved communities. Paper presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, Orlando, FL.