Over the past three decades, cognitive-behavioral therapy (CBT) building on many empirical studies has evolved into one of the predominant forces in psychotherapeutic practice (e.g., Mahoney, 1974; Norcross, 1986; Sanderson and Woody, 1995; Chambless et al., 1996; DeRubeis and Crits-Cristoph, 1998; Nathan and Gorman, 1998; Chambless and Hollon, 1998; Young et al., 2001). More important with regard to the current chapter is the mounting evidence demonstrating the efficacy and utility of cognitive, behavioral, and combined CBT approaches in the group treatment of a variety of mental health problems for a range of age groups (White and Freeman, 2000). For example, this evidence is growing for the treatment of anxiety disorders in children (Silverman et al., 1999; Muris et al., 2002), including posttraumatic stress disorder in Latino immigrant children (Kataoka et al., 2003), and social phobia in adolescents (Hayward et al., 2000; Garcia et al., 2002). Recent research also supports the use of CBT group protocols with adults to treat generalized anxiety disorder (Dugas et al., 2003), obsessive-compulsive disorder (Cordieli et al., 2003), insomnia (Backhaus et al., 2001), and social anxiety in schizophrenics (Halperin et al., 2000), as well as psychological distress in both Chinese HIV patients (Molassiotis et al., 2002) and patients with irritable bowel syndrome (Tkachuk et al., 2003).

Although several recent literature reviews and meta-analyses (e.g., Gatz et al., 1998; Teri and McCurry, 2000; Pinquart and Sörensen, 2001; Sörensen et al., 2003) have helped synthesize many of the successful outcome studies that use CBT with older adult clients, the majority of CBT-based outcome studies and clinical case examples in the treatment literature on older clients are based on individual treatment models. These successful treatment protocols range from later life depression (e.g., Fry, 1984; Steuer et al., 1984; Scogin et al., 1987; Thompson et al., 1987, 2001; Gallagher-Thompson and Steffen, 1994) and generalized anxiety disorder (e.g., Stanley et al., 2003; Wetherell et al., 2003), to sleep disorders (e.g., Morin et al., 1993, 1994; McCurry et al., 1998; Gatz et al., 1998), and family caregiver distress (e.g., Gallagher-Thompson et al., 2000a, 2003; Coon et al., 2003a, b). Despite a limited number of studies focused on group CBT with older adults, there is a growing interest in the development and use of group CBT interventions with older populations to take advantage of some of the inherent benefits of this treatment approach (White and Freeman, 2000; DeVries and Coon, 2002).

In this chapter, we provide an introduction to the use of CBT-based group interventions. We begin by discussing key advantages supporting the rationale of CBT group work with clients and highlight basic CBT techniques that are easily adapted for groups. We then build on these concepts by presenting the essential components of an empirically supported CBT protocol that was developed through our clinical experience and intervention research at the Older Adult and Family Center (OAFC) of the Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine. This individually based protocol has been easily be adapted for group work with older clients and some of its key components have also been modified and used successfully in psychoeducational skill-building classes for depressed older adults and family caregivers of frail or cognitively impaired elders. To illustrate further these protocols, we include a case example from our clinical intervention research experience conducting CBT-based psychoeducational classes with dementia family caregivers. The chapter closes with a review of several issues that warrant future consideration in both clinical intervention research and clinical practice involving CBT-based group work.

Toseland, in his book Group Work with the Elderly and Family Caregivers (1995), identifies several benefits of group interventions. While his book focuses on older adults and their families, most of the benefits he outlines are easily applicable to other populations: (1) groups have the potential for providing a sense of belonging and affiliation that can help counter social isolation and loneliness and bolster social support; (2) group treatment provides a more objective and emotionally detached perspective that can help clients put problematic experiences in perspective; and (3) group participation offers an opportunity for participants to have their experiences validated and affirmed.

In addition to these aspects, we find that CBT group interventions in particular can provide several advantages for both clients and therapists in comparison not only with individual CBT interventions, but also to groups grounded in other theoretical orientations. CBT groups, which emphasize the development and practice of new coping skills, are less likely to feel stigmatizing to clients with a variety of backgrounds. Sharing perceptions and reactions to their situations allows group members to see that they are not suffering alone and that other people face similar problems, including similar challenges in the development and practice of skills necessary in overcoming their negative mood states (DeVries and Coon, 2002). Moreover, a CBT group format typically helps to empower its members to adopt the belief that self-control of thoughts, behaviors, and feelings is not only desirable, but possible. In many cases, CBT group therapy may provide the first opportunity for many clients to obtain constructive feedback on their behavior from their peers (Freeman et al., 1993), and these interventions allow their members to engage in multiple roles in which they can both give and receive support in the development and implementation of new skills designed to alleviate their distress. This can encourage participants to develop addition interpersonal skills useful in the treatment of most disorders by helping them to learn to give and receive appropriate feedback, and to consider a range of alternative perspectives, creative ideas, and insights (Toseland, 1995; DeVries and Coon, 2002).

CBT group settings also promote collaboration through a number of procedures, including goal setting, agenda setting, role-playing, and creation of homework exercises (Freeman et al., 1993; White, 2000). The collaborative process that occurs in groups also works to combat the resistance that sometimes surfaces in individual therapy. An example of this form of resistance is demonstrated through complaints such as: ‘You [the therapist] don't understand what I am going through.’ Groups often help overcome this type of resistance as it is much more difficult for older clients to ignore the evidence of their peer participants who have had similar experiences (Freeman et al., 1993). CBT groups can also effectively balance individual and group needs by allowing clients to collaborate actively with leaders and other group members to individualize strategies to better meet the nuances of their situations and experiences (Thompson et al., 2000).

Groups also aid the therapist in other ways such as providing a more accurate assessment of participants’ behavioral patterns and coping skills, including their repertoire of interpersonal responses such as the ability to be assertive and give and receive feedback. In groups, therapists do not have to depend solely on client self-reports of how others react to them (Freeman et al., 1993; White, 2000). Finally, group CBT, from a practical perspective, may be a more economical and time effective way to deliver treatment by helping organizations and their clinicians to provide services more quickly to more clients at any one time (Coon et al., 1999; Thompson et al., 2000).

Most studies investigating the effectiveness of group CBT interventions for the treatment of distress have focused on two types of group approaches: traditional and psychoeducational groups (e.g., Yost et al., 1986; Beutler et al., 1987; Teri and McCurry, 2000; Thompson et al., 2000; DeVries and Coon, 2002). Both approaches use similar techniques, but there are important distinctions between them that are worth highlighting. In psychoeducational groups, sessions are highly structured, with specific topics predetermined for each meeting. The length of time for the treatment is planned to correspond to the amount of material to be covered, and specific, individual issues of the participants are addressed only to the degree that they are relevant to the material presented. In more traditional CBT groups, however, there is more emphasis on the individual problems of each client, with more flexibility in the issues being addressed in the group, which allows for more tailoring of topics, examples, particular intervention techniques, group examples, and homework strategies designed to meet the needs of individual participants (Thompson et al., 2000).

Despite these differences, both psychoeducational and traditional therapy groups are grounded in cognitive and behavioral theories that emphasize the acquisition of various cognitive and behavioral skills for the management of negative emotions. Although the exact strategies and techniques introduced during a group will depend in part on the intended focus of the intervention, there are a few strategies and related tools that are typically viewed as cornerstones to the effective implementation of CBT. In the Introduction to Cognitive-behavioral group therapy for specific problems and populations (White and Freeman, 2000), White (2000) provides an excellent review of key methods and strategies commonly used in group CBT. In sum, participants are often taught to maintain records of their automatic thoughts, to recognize unhelpful and dysfunctional beliefs, and to challenge or replace these ideas with more helpful and functional thoughts. Behavioral change strategies are usually highlighted as well, by helping participants learn to monitor their mood, set behavioral goals, track the frequency of targeted behaviors (such as daily pleasant events or other activity monitoring), and to identify and modify antecedents and/or consequences of the targeted behavior to help reinforce behavioral change (Thompson et al., 2000; White, 2000; DeVries and Coon, 2002). Problem-solving and relaxation strategies (e.g., meditation, imagery, progressive muscle relaxation, breathing exercises, physical exercise, and biofeedback) are also methods commonly incorporated into CBT-based groups. Arousal hierarchies, including descriptions of anxious triggers and the use of graded exposure exercises, are often central to the treatment of anxiety in CBT groups. Regardless of the group's focus, homework assignments are always introduced with each of these methods and strategies to reinforce skill acquisition and provide important examples for group discussion each week. These homework examples can help to not only foster discussion about barriers to skill development, but also provide models of successful paths to goal attainment. The amount of time spent introducing and explaining these CBT strategies to a group tends to decrease gradually after the first few sessions, and more time begins to be spent on addressing the particular problems each individual group member is experiencing.

Many of today's clients in need of mental health treatment represent a diverse population that encompass individuals with various sociocultural histories and cohort experiences; and, therefore, they may differ in their suitability for different types of CBT group interventions. As a result, clinicians need to conduct thorough assessments to be sure a given treatment is appropriate for each individual (see DeVries and Coon, 2002 and Thompson et al., 2000 for assessment suggestions). For instance, many of today's older adults are not acquainted with the process of psychotherapy, and can hold outmoded beliefs about how group content and process can be used to alleviate their emotional distress. Consequently, it is important to socialize these clients into groups by clarifying goals and expectations, explaining the assumptions of the CBT model that will be used in therapy (which often helps demystify the process), and setting ground rules for participation. Considering the wide range of cohorts of older adults (i.e., World War I, Depression Era, World War II, etc.), it is also essential to be sensitive to the language of different client cohorts. Few older adults today have been heavily influenced by pop psychology and the self-help psychology movements. They are less likely to use ‘depression’ or ‘depressed’ as self-descriptors, and more likely to use terms such as ‘blue’ or ‘sad’ and to reveal somatic complaints such as sleep interruptions and general fatigue often indicative of negative mood states (Gallagher-Thompson and Coon, 1996). There are also sensory changes in hearing and vision associated with normal aging that can affect the learning and retention of material presented, so adaptations of CBT groups with older adults might include using various forms of auditory and visual presentation, slowing the pace of presentation, and frequently repeating and summarizing the material discussed. Many of these issues may also be applicable to other underserved groups (e.g., ethnic minority clients or disabled persons) that face barriers to treatment, including economic, linguistic, or environmental barriers that negatively impact access, and organizational or provider insensitivity to cultural differences that restricts service availability or acceptability.

Finally, the variety and sequencing of specific procedures, strategies, and techniques used in group CBT interventions can vary considerably depending on the clients’ problems, ability levels, personality differences, whether a group has a fixed number of sessions or is ongoing, whether it is closed or open to new clients, and whether the group has a specific or general focus. We frequently suggest a closed group run for a fixed time period of approximately 10–12 weekly sessions, during which the focus of the therapy is on the development of several basic skills. Often, these weekly sessions are subsequently followed up by several monthly boosters to reinforce skill development, enhance maintenance of therapeutic gains, and help with relapse prevention. At the end of the group, the clients are evaluated clinically to determine what worked as well as what was not effective for them. Clients then can choose to discontinue therapy, enter a new group with a different problem focus, or repeat the group to continue to strengthen their development of basic skills (Thompson et al., 2000).

The CBT group interventions presented in the remainder of this chapter build on the empirically supported clinical protocols develop by Thompson and Gallagher-Thompson and their colleagues for brief individual CBT with depressed older adults (e.g., Gallagher-Thompson and Steffen, 1994; Thompson et al., 2001; Laidlaw et al., 2003) and distressed family caregivers of cognitively impaired or physically frail older adults (e.g., Coon et al., 2003a; Gallagher-Thompson et al., 2000a, 2001, 2003). These protocols have been implemented over the past two decades with hundreds of older adults and family caregivers at the OAFC of the VA Palo Alto Health Care System and Stanford University School of Medicine. The next two sections of this chapter provide a succinct overview of two types of CBT groups conducted through the OAFC: a CBT group for depressed older adults and a psychoeducational classes conducted with dementia family caregivers. Treatment manuals relevant to these protocols are currently available from Dolores Gallagher-Thompson (Older Adult and Family Center, VA Medical Center, and Stanford University School of Medicine, 795 Willow Road, Mail Code: 182C/MP, Menlo Park, CA 94025, USA. E-mail: dolorest@stanford.edu).

The manualized, individual OAFC protocol (Dick et al., 1996; Thompson et al., 1996) and our CBT groups for depressed older adults modify and extend the work of Beck (Beck et al., 1979), Lewinsohn (Lewinsohn, 1974; Lewinsohn et al., 1986) and other CBT theorists (Burns, 1980; Young, 1999) to meet the needs of older adult clients. Our work builds on Beck's theory (Beck et al., 1979) that negative thoughts and beliefs lead to the creation of a negative ‘lens’ through which appraisal of the world is distorted, resulting in automatic erroneous thinking and negative schemas. In this cognitive model of depression, it is proposed that negative schemas interact with negative life events to produce depressive symptomatology. Treatment focuses on modifying unhelpful thoughts to change affect and behavior by teaching clients to identify their negative thinking patterns, and subsequently, to systematically challenge these negative cognitions to foster more adaptive ways of perceiving situations and themselves.

In contrast to Beck, Lewinsohn's theory (Lewinsohn, 1974; Lewinsohn et al., 1986) states that depression is the result of the repeated absence of pleasant events or activities in the person's life. As the number of pleasant or adaptive behaviors decreases in an individual's daily life, the individual experiences fewer positive social interactions and less pleasure, resulting in behavioral withdrawal, which then becomes a vicious downward cycle into depression, where the individual does less, then feels more depressed, and subsequently, does less again. Consequently, CBT teaches clients to recognize the relationship between engagement in pleasant activities and the maintenance of positive mood by encouraging clients to increase everyday pleasant activities so that negative patterns of withdrawal can be eliminated.

As mentioned earlier, an important initial step in group treatment is to begin to socialize clients into the CBT model by describing the general content and format of the group during the initial contact and in the group's first session. For example, our CBT groups for later life depression have a closed format and run for fixed time periods of 16–20 sessions, with each group session lasting 90–120 minutes. Another key first step is to use various examples relevant to older adults to help introduce the CBT model and demonstrate the relationship between thoughts, behavior, and mood. Chapter 1 of our CBT treatment manual (Dick et al., 1996) provides an example of dysfunctional thinking relevant to older clients that we also use to present the CBT model in our depression groups:

We use this and similar examples to engage clients in discussing what they might have said, how they might have felt in, and how they would have responded in a similar situation. One of CBT's major tenets makes CBT particularly useful for older individuals who are experiencing numerous and substantive losses, as the experience of loss per se does not necessarily lead to depression, but rather it is how loses are perceived and what its meaning is to the individual that determines whether or not depressive symptoms will arise (Thompson et al., 2000).

Once clients seem to understand the CBT model through the use of examples such as the case of John, we discuss the primary goal of the group, which is to decrease and eventually eradicate feelings of depression among its group members. We then emphasize the importance of clients’ active participation and collaboration in the group by sharing their difficulties with others in the group, engaging in problem solving with others in the group, and completing homework assignments. We also work with clients to identify up to three target complaints to address over the course of treatment. Common issues that older adults choose to address in groups include loneliness, interpersonal difficulties, problems with functioning related to chronic illnesses, inadequate resources, and severe emotional disturbances.

After the initial group meeting, the rest of the group contacts consist of initial instruction or continued elaboration of specific CBT techniques for the therapist to address that week followed by a group discussion of group members’ specific issues. At the beginning of each session, clients are asked to discuss their homework assignments and any problems that emerged since the last group meeting. The therapist then works with the clients to determine whether any specific problems should be added to the agenda. Generally, over the course of therapy, each group member will be given the time to discuss each new technique with the group and to obtain feedback from the group to facilitate mastering of a new technique. Whenever a new technique is introduced in a session, demonstration and practice time is set aside before the end of each session to maximize implementation and homework compliance. Homework assignments typically focus on asking group members to practice part or all of the technique just reviewed in session, and to tailor specific group assignments through group discussions to match each group member's individual goals. Clients take an active role in the design of their homework assignments, based on the collaborative nature of our CBT group interventions. Across sessions, successive approximation is used as a tool to remind clients that reaching goals in treatment is not immediate, but rather that requires continued practice and refinement of skills using the homework assignment to try out these skills in their daily lives. Each group session ends with a summary of what was discussed in the group asking for input from members, as well as the solicitation of questions or comments from group members about previous and current strategies, techniques and homework assignments introduced in the group. Our experience has taught us to protect some group time to actively solicit feedback and questions from the group members given that many older adults, compared with younger group members, are often less likely to ask questions even when they need clarification.

Taking care of a relative with health problems, especially older care recipients with dementia, can have detrimental mental and physical health effects for caregivers, including depression, anxiety, anger, and increased risk for health problems (Schulz et al., 1995; Bookwala et al., 2000; Vitaliano et al., 2003). Over the last 15 years, Gallagher-Thompson and her colleagues at the OAFC have developed and refined several empirically supported, CBT-based psychoeducational skill building classes for family caregivers to older adults. Several of these protocols have been shown to significantly reduce various forms of caregiver distress such as depressive symptoms, anger/ frustration, and negative coping strategies, as well as to enhance caregiver self-efficacy and positive coping strategies in comparison with either wait-list control conditions (e.g., Gallagher-Thompson and DeVries, 1994; Gallagher-Thompson et al., 2000a, 2001; Coon et al., 2003a) or traditional community support groups (Gallagher-Thompson et al., 2003). Moreover, results from recent outcome studies indicate that these psychoeducational skill building classes can be tailored effectively to meet the cultural needs of Latinas caring for family members with dementia (Gallagher-Thompson et al., 2001, 2003).

In this section, we provide a brief overview of these various CBT-based, manualized psychoeducational classes for family caregivers. These classes, in contrast to our CBT groups for depression, focus on teaching caregivers to cope with the stresses of prolonged caregiving by tailoring cognitive and behavioral change strategies to address the personal situations and needs of distressed caregivers, and by bolstering the caregivers’ self-management skills through the use of strategies such as relaxation training, problem solving, or increasing pleasant activities in their lives. Generally, these interventions are conducted in small groups (eight to 10 participants), for structured periods of time (2 hours with a 20-minute break for refreshments and socializing), and duration and frequency (8–10 weekly sessions followed by 2–8 monthly booster sessions). A detailed agenda is set at the beginning of each group meeting, specifying the goals of the class. Homework is reviewed at the beginning of each session, then, a brief presentation about a topic or a new skill is conducted. A brief break then follows, which allows for class leaders to help any members who have difficulty understanding the material. After the break, role-plays and discussions of material just presented occurs in small breakout groups or dyads to facilitate learning, to practice the techniques to be used in the following week, and to troubleshoot any potential difficulties in completing homework assignments. Questions are addressed throughout the group meeting. A brief review at the end of the class highlights any problems that arose in the practice and discussions, reiterates the topics or techniques discussed in that week's class, and reminds caregivers of their homework assignments for the upcoming week.

At the OAFC, we have developed several distinct psychoeducational classes specifically designed for family caregivers: (1) a ‘Coping with the Blues’ class for increasing life satisfaction (Thompson et al., 1992); (2) a ‘Coping with Frustration’ class to learn to manage anger and frustration (Gallagher-Thompson et al., 1992); and (3) an ‘Increasing Problem-Solving Skills Class’ based on the theoretical work of D'Zurilla (1986) that teaches a six-step model for problem solving we adapted for caregivers. Although these psychoeducational classes begin in the same manner, they emphasize distinct CBT techniques to help address different feelings and issues. For instance, the ‘Coping with Frustration’ class targets caregivers’ feelings of anger, frustration, and/or hostility by teaching cognitive techniques, self-talk, and active listening and assertive communication techniques to deal with daily stressors. The emphasis of this class is on learning to identify and modify thoughts that foster feelings of frustration, as well as learning to express feelings appropriately by being assertive in order to reduce the counterproductive use of aggressive or passive communication styles in frustrating situations. In contrast, the ‘Coping with the Blues’ class contains several components similar to those found in our CBT groups for depressed older adults. This class focuses on addressing feelings of depression by introducing behavioral techniques such as mood monitoring, and helping caregivers develop a plan to increase pleasant events in their lives by creating a potential list of pleasant activities, and discussing barriers to adding these pleasant activities into their busy schedules.

More recently our ‘Coping with Caregiving’ (CWC) class (Gallagher-Thompson et al., 1996) adopted the most useful aspects of these preceding classes and was culturally tailored to help reduce psychological distress among both Latinas and Caucasian female caregivers. Results of a study of 122 Caucasian women and 91 Latinas randomly assigned to either CWC or a traditionally based community support group demonstrated the superiority of the CBT-based CWC class for both groups of women (Gallagher-Thompson et al., 2003). The CWC teaches a limited number of CBT mood management skills through two key approaches that are drawn primarily from the work of Beck (Beck et al., 1979) and Lewinsohn et al. (1986). First, an emphasis is placed on reducing the negative affect by teaching caregivers how to relax in stressful situations, appraise the care recipient's behavior more realistically, identify and challenge unhelpful thinking, and communicate more assertively. Second, an emphasis is placed on increasing positive mood through the acquisition of such skills as seeing the contingency between mood and activities, developing strategies to do smaller, everyday pleasant activities, and learning to set self-change goals and reward oneself for accomplishments along the way. Table 5.2 outlines the CWC's key phases and classes and presents their related goals and homework assignments. Although these various psychoeducational classes for caregivers emphasize different cognitive and behavioral techniques during the intensive phase of the treatment, they all end by reviewing and reinforcing the skills taught in class and identifying and discussing problem areas that caregivers think they might face and how they can apply their skills effectively in those future situations.

Homework remains an essential part of group CBT, just as it does in individual treatment. A growing amount of empirical research demonstrates that homework can facilitate therapeutic improvement (e.g., Neimeyer and Feixas, 1990; Burns and Spangler, 2000; Kazantzis et al., 2000), and some of our own empirical work suggests that homework compliance is a significant predictor of treatment outcomes with older adult clients (e.g., Thompson and Gallagher, 1984; Coon and Thompson, 2003). Therefore, we remind therapists to consider that no matter how many insights and changes occur during the session, group members will not solve their problems or improve their depression unless significant cognitive and behavioral changes are made outside of treatment as well. Alleviation of later life distress comes through practicing skills learned in therapy out in the real world by using homework assignments to try out new ways of thinking and more adaptive behaviors (Persons, 1989; White, 2000; Coon and Gallagher-Thompson, 2002; Coon et al., in press).

However, the design of effective homework assignments requires substantial patience, persistence, problem solving, and advance planning on the part of both the group's leader and the group participants to successfully dismantle attitudinal and logistical barriers to its completion. We find that the most effective homework assignments are those that are closely tied to client target complaints and treatment goals, that build on in-session themes, and that are perceived by the older clients as both realistic and important to complete. It is also crucial to allow the group to maintain an active role in making homework decisions, demonstrating CBT's collaborative approach in which the group works together to help one another reach their treatment goals (Thompson et al., 2000). If a high level of teamwork and cooperation are not achieved, group members may lose interest and motivation, or become resentful. Therapists must also quickly establish homework as a priority and foster ongoing adherence from the very beginning of the group. The consistent presence of homework on each session's agenda, both in terms of the review of previously assigned homework as well as the development and reinforcement of next week's assignment sends the right message to clients about its importance and potential utility. Difficulties with homework are likely to increase if the group members are not held accountable for any lack of participation in homework assignments (Thompson et al., 2000; Coon and Gallagher-Thompson, 2002).

Numerous factors can arise and impact homework compliance from practical barriers such as illness and overextension of responsibilities, to memory problems or concerns from the older adult about taking up time in the group to ask for further clarification on an assignment (Coon et al., in press). Some other beliefs that can interfere with homework compliance are the fear that others will require the client to do things that are not actually in the client's best interest or that homework is not a necessary part of the psychotherapeutic process (Persons, 1989). These types of beliefs provide insight into the distortions a client may bring to a group. Another reason for homework noncompliance may be that some group participants are embarrassed to ask questions when they do not understand an assignment, especially in the initial stages of the therapy (Thompson et al., 2000). Often depressed individuals may feel so hopeless that they do not want to try homework assignments because they believe they will not work, or because failure is considered ‘certain’ (Thompson et al., 2000). It also can be important to use alternative terms for homework assignments as necessary to foster compliance. For some clients, particularly those with little formal education or who performed poorly in school, homework can hold unpleasant connotations or be construed as demeaning. And, homework may increase worry on the part of disabled persons or older adults with sensory limitations that impact reading and writing assignments if modifications have not been introduced and discussed. Therefore, we always encourage therapists and group leaders to collaborate with clients to find more acceptable terms for homework using the group's own language and experience as a backdrop for the discussion. Finding terms such as ‘experiments’, ‘practice sheets’, ‘journal writing’, or ‘mind exercise’ can help reduce concerns about criticism and support homework completion (Coon et al., in press).

Any difficulty with homework should be addressed immediately in order for the group to be as helpful as possible for its members. We find it is essential to problem-solve with the clients from the very beginning rather than labeling these difficulties as resistance. If clients avoid homework, we engage them in dialogues around the homework tasks and problem-solve to find strategies to foster completion and support skill development. Discussions also should transmit the idea that improvement requires substantive efforts by the client, rather than just the therapist alone (Persons, 1989). One of the most useful and successful ways to combat homework noncompliance is to engage the entire group in helping to figure out how homework assignments can help them (Thompson et al., 2000). Finally, more detailed discussions regarding the use of homework with older adults, including ways to facilitate homework completion and address issues of noncompliance, are available in the literature (Coon and Gallagher-Thompson, 2002; Coon et al., in press).

Latinas Unidas Cuidando y Hablando Abiertamente (Latinas United Caring and Speaking Openly; Gallagher-Thompson et al., 2002), a psychoeducational skill-building class for Latinas caring for loved ones with memory loss met at a local adult day healthcare center, and consisted of six Latina family dementia caregivers and two female co-facilitators. Each participant agreed to attend a total of 13 weekly 2-hour sessions. English was the primary language spoken but occasionally the participants spoke in Spanish to better describe certain thoughts and emotions. Only one caregiver will be described in detail for the purposes of this case illustration, although each participant was asked to attend all of the classes and complete and discuss each of the homework activities described. Please note that the names and details of the class participants have been modified sufficiently to protect their privacy and maintain confidentiality.

One of the participants, Valeria, is a 57-year-old Latina caring for her 64-year-old husband, Ernesto. Ernesto was diagnosed with Alzheimer's disease a little over a year ago, and in this short period of time, he had his driver's license revoked and had lost contact with many of his friends. Valeria came to the group stating that even after 25 years of marriage, she was having a difficult time understanding Ernesto's behavior. The couple's 18-year-old grandson also lives with them, however, he provides very minimal assistance with Ernesto's care.

The first class session explained the goals and guidelines of the group and provided an overview of memory loss and dementia. The caregivers were taught how to rate their current level of stress/tension and were asked to participate in the first of a series of relaxation exercises designed to reduce their stress. Valeria responded well to the class information and willingly completed the homework assignments or home practice activities given at the end of each class.

During the second session, the class facilitators with Valeria's permission the Behavior Log (see Table 5.3) see completed as part of her home practice activities on to the whiteboard for the other caregivers to see and use as a way to reinforce their own skill development. Valeria shared with the group how bothered she is when her husband wakes up each morning, and asks her repeatedly ‘Where is my grandson?’ Although Valeria explains to him that their grandson has left for work, 15 minutes later he looks out of the window at the driveway, notices their grandson's car is missing, and asks Valeria again about their grandson's whereabouts. By the end of the day, Ernesto has asked the same question at least 10 times.

The facilitators asked the class members to brainstorm triggers that might cause or encourage Ernesto's behavior and to provide suggestions to Valeria about what she might change in the environment to eliminate or at least decrease her husband's repetitive questions:

During a subsequent session when caregivers were asked to complete a more detailed behavior log for home practice, Valeria volunteered to share her responses (see Table 5.4). She was feeling frustrated and angry because Ernesto continued to insist on wearing the same clothes day after day. The facilitator reminded Valeria and the other caregivers that changing behavior often involves a lot of trial and error, and asked the class once again to brainstorm possible alternative strategies for Valeria to try in the weeks ahead. The group came up with the following four strategies for her to add to her toolbox:

• Set out fresh clothes for him and reward him when he wears it. Maybe give him a compliment on how nice he looks or make him his favorite breakfast.

• Hide the outfit he really likes in a place where he cannot find it.

• Buy him several pairs of the same pants and shirt so that he thinks he is wearing his favorite outfit.

• When he goes to bed, take his clothes and put them in the laundry machine. Set the machine on the soak cycle so that if he looks for them and notices that they are wet, he will be forced to find something else to wear.

Valeria liked the ideas given by the facilitator and caregivers and agrees to try some of them out. She returns the next week with the completed homework assignment that appears in Table 5.5. Although her husband got irritated after she tried the strategy of putting his clothes in the washer to soak, he did seem to get over it fairly quickly, and then decided it was OK to wear a different outfit.

For the next few weeks, Valeria continued to attend the sessions and participate in the discussions, role-plays, and relaxation exercises. She got along well with all of the women and began to take more risks and open up about her thoughts and feelings. Perhaps the most emotional class meeting for Valerie occurred in Class 7 when she shared that she was ‘feeling lousy because Ernesto had lost all of their money.’ She was feeling a mixture of anger and guilt, but was having difficulty challenging her unhelpful thoughts about the situation. The facilitator asked Valeria if she would complete a Thought Record with the help of the group regarding this specific situation. Valeria agreed and allowed the facilitator to write the responses on the whiteboard for all the class participants to see and use as a way not only to help Valeria, but also to reinforce their own skill development. She began to see that by taking control of the finances she would be taking better care of both of them. Valeria was also reminded that this was not Ernesto's or her fault. Her husband had dementia. The completion of this Thought Record (see Table 5.6) by Valeria and the group also initiated the following discussion about loss:

Both our clinical and intervention research experiences at the OAFC have taught us that group CBT is effective in reducing depression in older adults and alleviating emotional distress in family caregivers to older adults with dementia or physical challenges. CBT group approaches are also emerging as promising treatment options for depression and other disorders such as sleep problems, chronic pain associated with medical conditions, and anxiety disorders that affect both older adults and their younger counterparts (White and Freeman, 2000; DeVries and Coon, 2002). However, there remains a dearth of clinical intervention research on the efficacy and effectiveness of CBT groups with racial and ethnic minority clients (Gallagher-Thompson et al., 2000b; Organista, 2000; Thompson et al., 2000), disabled persons, and rural populations, as well as lesbian, gay, bisexual, and transgendered individuals (Coon and Zeiss, 2003). Organista (2000) and Gallagher-Thompson et al. (2000) have decried the neglect of cultural influences in the application of CBT, and have championed the need to culturally tailor group interventions by incorporating culturally appropriate engagement strategies, problem areas, intervention strategies, and homework assignments. There also exists a lack of research regarding the maintenance of therapeutic gains in many of the outcome studies mentioned in this chapter, pointing to the need for clinical outcomes research that follows clients for longer periods of time and helps to identify predictors of long-term gains. Such intervention research should incorporate trials that investigate various options to enhance longer-term outcomes such as the appropriate spacing of in-person booster sessions, telephone follow-ups or internet coaching to reinforce the use of skills acquired during the regular course of therapy. Future research also needs to help us better understand other individual differences that may influence treatment outcomes in different populations (Coon et al., 1999). For example, several variables have emerged in the literature that may influence treatment outcomes with older clients, such as major shifts in depressive mood (M. Thompson et al., 1995), length of time in stressful situations such as family caregiving (Gallagher-Thompson and Steffen, 1994), the quality of the therapeutic alliance (Gaston et al., 1988), and whether significant endogenous symptoms are present (Gallagher and Thompson, 1983). Finally, recent work points to the need to examine the effective integration of technology, including the use of telemedicine strategies into a variety of CBT group treatments (e.g., Hopps et al., 2003; Vincelli et al., 2003). Clinical research into each of these areas combined with the sharing of new developments in the clinical literature by practitioners will help us to continue to better adapt both group and individual CBT interventions for the future.