MOOD MANAGEMENT GROUP FOR TERTIARY STUDENTS Presenters: Sean Murray Charmaine Cameron

Rational IACS Accreditation Provide an alternative to individual counselling for students with long standing anxiety and depression issues When we were reviewed by IACS for re-accrediation it was recommended that we address our underdeveloped group counselling program At UCS, it is recommended that counsellors see students for a maximum of 10 sessions a year and many students with long standing anxiety and depression issues often need more input. This led to the decision to trial a 10 week structured program to provide clients with some useful skills to better manage ongoing difficulties.

Mood Management Group Program Group program delivered by counsellors at the University Counselling Services at Curtin University, Perth, Western Australia 10 week structured CBT program developed by Centre for Clinical Interventions (Nathan, P., Smith, L., Rees, C., Correia, H., Juniper, U., Kingsep, P., & Lim, L. (2004) with follow-up session after 4 weeks The program was developed using evidence based principles. Has been evaluated extensively over several years. The CCI is a state wide tertiary mental health service which provides specialist clinical treatments, training and education of mental health practitioners and clinical research programs. those who attend all 10 sessions benefit the most this is emphasised in first session. There is also a FU session 4 weeks after completion of the program.

Before Starting the Group… Who will run the group? How many in the group? Referral process Assessment – Inclusion and Exclusion criteria It is recommended that the same person or persons run the group for all 10 sessions and follow up. A further issue to consider is whether to run the group with 2 counsellors. If 2 counsellors run the group, it is recommended that there is consistency between them in presentation of concepts in the group sessions. It’s also useful to allow for time at the end of sessions to discuss group process and progress. CCI recommends that groups are run with a maximum of 12 people. For this number, it would be helpful to have second co-therapists. If the group is smaller, it may be decided to run it with one counsellor. For our first trial of the program, students were informed prior to starting that the group would be co-facilitated by 2 counsellors. As only 5 clients registered for the program, it was decided that the 2 counsellors would run alternate sessions rather than present together. For the review session, both counsellors ran the session and at the final session, both counsellors attended for the end of program party but only one counsellor than facilitated the session. Counsellors are given a handout at beginning of semester about the Mood Man Criteria with details about group timing etc. If they have existing clients with a clearly defined primary diagnosis of major depression or dysthymia, panic disorder/ agoraphobia, GAD, social anxiety, or adjustment disorder, they may refer them to the group. They can give the client a handout with details of course, what they may expect to learn in course. If clients are interested in the course, counsellors then assist them to register for course through reception at counselling and a week prior to course commencing they are given a phone call to confirm their attendance. Clients with substance abuse issues, eating disorders, long standing personality disorders or psychotic disorders are not suitable for the group. As part of assessment, it is important that counsellors discuss clients’ expectations for therapy. The group is not based on self-disclosure an non-specific support from other group members. Instead it is a structured approach which is similar to an adult education course. It is an opportunity for clients to gain a thorough understanding of their problems and learn some practical strategies for managing them. They are given a handout which gives them specific information about what to expect in the course. It is recommended to evaluate outcome using questionnaire measures at three points – intake, post and at follow up. The measures selected will depend on what you are interested in and what you have access to. For our purposes, the DASS was chosen as a comprehensive and readily available measure that is easy for students to complete in session. Feedback is also provided to clients which is a helpful indicator of change. It is also recommended that students complete an evaluation of the program. As homework is reviewed weekly, counsellors have the opportunity to regularly evaluate students’ progress.

Information Sheet for Counsellors This semester, there will be a 10 week Mood Management Group for students run by Sean and Charmaine. The aim of the group is to provide an alternative to individual therapy for clients (students only) with long standing anxiety and depression issues. The group is a structured CBT program designed by CCI. It will run on Wednesdays from 4-6pm, starting on 21st March and ending on 23rd May. A follow up session will be scheduled for 1st August. It is anticipated that the group will run with about 12 participants but 15 will be registered and a further few waitlisted. Registrations will close on Wed 7th March, two weeks prior to the start of group. Counsellors will need to facilitate the registration process for clients, the details of which will be held at reception. There will be a $5.00 charge for materials used in the program. The group will not be publicised and will be through counsellor referral only. Students will need to be assessed by counsellors as per our regular assessment processes. Use of specific measures such as the BDI is not required. Assessment criteria is based on the DSM-IV criteria for anxiety and depression, being mindful that the group is designed for dealing with long standing issues and not situational dependent or reactive mood disturbance. Clients with primary presenting issues that include eating disorders, substance abuse, personality disorders, or psychotic disorders are not suitable for this type of group. Clients will need to be made aware that participation in the group will use up their session entitlements and they will not be offered individual counselling in addition to the group program. The manual for the course is currently circulating among counsellors. Any queries about the group can be directed to Charmaine.

Before Starting the Group… Timing Expectations for therapy Pre and post evaluation Ongoing assessment – progress evaluated through regular homework monitoring Determine the best time to start the group eg mid year As part of assessment, it is important that counsellors discuss clients’ expectations for therapy. The group is not based on self-disclosure and non-specific support from other group members. Instead it is a structured approach which is similar to an adult education course. It is an opportunity for clients to gain a thorough understanding of their problems and learn some practical strategies for managing them. They are given a handout which gives them specific information about what to expect in the course. It is recommended to evaluate outcome using questionnaire measures at three points – intake, post and at follow up. The measures selected will depend on what you are interested in and what you have access to. For our purposes, the DASS was chosen as a comprehensive and readily available measure that is easy for students to complete in session. Feedback is also provided to clients which is a helpful indicator of change. It is also recommended that students complete an evaluation of the program. As homework is reviewed weekly, counsellors have the opportunity to regularly evaluate students’ progress.

The Program Manual based program Therapist notes provided Weekly session outline Handouts and worksheets for clients Weekly homework The MMC targets both anxiety and depression in the one course due to the high co-morbidity of both. The manual is written for clinicians by clinicians and presents a clinical guide based on strong empirical foundations and clinical evaluation. The manual provides clinicians with a comprehensive, detailed and systematic approach to treatment delivery. It is divided into sessions which describe the treatment components of the group therapy. It provides the content as well as the process by which the treatment is delivered. There are notes for each session which provide the clinician with content guidelines including details of activities, reminders of equipment needed and notes about issues which may arise for group members. Details about evaluation procedures are included as are activities and handouts for participants, self monitoring diaries and materials to be used by the clinician.

Program Content Expectations about change Psychoeducation about anxiety and depression Symptoms – physiological, cognitive, and behavioural Feedback loops - maintaining factors Goal setting Session summary and home work assignment Preview of next session Up and down process Rationale for depression and anxiety together. Categories of symptoms emphasised because directly related to strategies taught in program. Feedback loops presented on whiteboard and participants encouraged to apply to own situations and symptoms. Emphasis on goal setting during program – rationale given. Overall goal for therapy set. Weekly goal setting sheets provided including goals for HW for course, calming technique taught practice, thought monitoring, pleasant activity scheduling, exposure tasks and other behavioural goals

Strategies and Techniques Understanding the change process Behavioural activation Graded exposure Understanding the thinking-feeling connection Learning to challenge beliefs Recognising unhelpful thinking styles Relaxation training – calming breath technique and progressive muscle relaxation Worksheet on assessing negative consequences of current problem and it positive aspects compared with the personal benefits and costs expected from change. Using a weekly activity record to focus on current levels of fun and achievement and encouraging engaging in new pleasurable ones. This was encouraged regularly during course in the weekly goal setting exercise. Introduction of exposure as way of countering role of avoidance in maintaining anxiety. Also encouraged regularly through the weekly goal setting exercise. Detailed explanation of the cognitive perspective using the ABC model. Introduced to disputation process and looking for and against evidence for beliefs and then learning to develop more balanced thinking. Psychoeducation about the role of breathing in increasing anxiety and regular measuring tension levels before and after relaxation technique using SUDS at each session.

More Strategies and Techniques Mid way program review session Action planning Preparation for setbacks Emotion as trigger for mood change Physiological sensation as trigger for change Active coping (problem solving) Use of flashcards Self-management plan An opportunity to review content of course so far and for participants to review progress and discuss group related issues – what they are finding useful, what they would like to know more about, concepts they are finding difficult and general trouble shooting. Review of overall goals and progress in graded exposure goals Action plan as reminder of techniques to use when feeling down, anxious or if participants feel as if they’ve gone backwards. Skills focusing on same three areas of physiology, thinking and behaviour. Normalising setbacks and looking at reasons for these and how to prevent major setbacks in future. Introducing concept that emotion can sometimes be the activating event that triggers beliefs and associated consequences. For example, waking depressed as trigger. Anxiety sensitivity – tendency for anxious people to be oversensitive to bodily sensations and subsequently avoid situations that may alter physical state. Identifying and defining problem areas, generating alternative possible solutions/plans, evaluating alternatives, deciding on a plan of action, implementing the plan, and evaluating the outcome. Flashcards used as a means of summarising the most helpful aspects of techniques learnt particularly with regard to cognitive work and thought diaries. Ways of dealing with setbacks and development of action plans to cope with difficult situations that may be likely in future. Development of self maintenance plan to maintain gains made and emphasis on holistic approach to managing wellness

Outcomes DASS used to evaluate outcomes at 3 time points: pre-, post-, and follow-up.

Outcomes Increase post depression score due to the revealing of own perception of negative thoughts and beliefs about self.

Program Evaluation Some comments from feedback: “Topics covered were relevant” “Explanations and step-by-steps of topics were good” “Great course, it went by very quickly” “It was a little intense at times as it identified some of my hot thoughts/issues” Areas of course that were most useful: “Balanced thoughts, breaking the cycle” “Mood changes are normal for I used to think that feeling sad was a bad thing” “Thought diaries and identifying hot thoughts” “Group discussion”

Counsellor evaluation What we would do differently: Use only one therapist Run one program overlapping both semesters Running self contained modules Combine some modules – shorten program Multiple entry points Missed session can be caught up. Referral friendly Sessions can be repeated. Can