Patient Experiences and Opinions of a Behavioral Activation Group Intervention for Depression

Abstract

Purpose:

Major depressive disorder is the leading cause of disability worldwide. This study is part of a mixed methods pilot trial, exploring the effectiveness, acceptability, and feasibility of providing behavioral activation (BA) treatment in a group format.

Methods:

Using an applied, descriptive approach, qualitative data were collected from individual interviews (18) and focus groups (5) at multiple data points throughout the trial and feedback given to group facilitators, who adapted the program accordingly.

Results:

Group BA is an effective and acceptable treatment format when a client-centered, flexible approach is utilized. This contrasted with findings from the comparison intervention, a peer support group, from which participants reported no benefit.

Conclusions:

Group BA is beneficial in a fiscally responsible evidenced-based health-care culture. Comparator groups need to be carefully selected. Engaging patient and clinician perspectives when designing and implementing new clinical interventions is vital in informing future research and social work practice.

Keywords

behavioral activation depression client centered or patient centered qualitative

Major depressive disorder (MDD) is the leading cause of disability worldwide, with an estimated 350 million people suffering from it (World Health Organization [WHO], 2004, 2012). MDD is characterized by depressed mood, loss of interest or pleasure, and other symptoms such as fatigue, difficulties with concentration and decision-making, and feelings of worthlessness and guilt. Some individuals may also experience suicidal ideation or attempt suicide (American Psychiatric Association, 2013). These symptoms often lead to social isolation and a reduction in activities (American Psychiatric Association, 2013). The magnitude of this global health-care problem illustrates an immediate need for accessible and cost-effective treatments to meet the needs of those affected with depression. The importance of developing and researching effective treatments for depression cannot be overemphasized.

Behavioral activation (BA) is a component of cognitive behavioral therapy (CBT) that was originally proposed as a stand-alone treatment of depression by Jacobson and colleagues in 1996. BA targets withdrawal and avoidance behaviors, commonly seen in patients with MDD, which may exacerbate depressive symptoms (Jacobson, Martell, & Dimidjian, 2001). To assist patients with depression and address these patterns of behavior, BA provides patients with skills and support systems to engage in a variety of mastery and pleasurable activities that act as antidepressant behaviors (Jacobson et al., 2001). BA adopts a goal-oriented approach and utilizes tools such as activity tracking and scheduling, graded task assignments, and problem-solving strategies to help clients achieve their goals, thus increasing activation and the likelihood of experiencing positive reinforcement (Soucy & Provencher, 2013). In essence, BA modifies an individual’s environment to intervene with depressive thoughts and behaviors, rather than targeting their thoughts directly (Jacobson et al., 2001).

A Cochrane review investigating the effectiveness of BA found low to moderate evidence that BA is equally effective as other psychological treatments (e.g., CBT, psychodynamic therapy, and interpersonal therapy). The review suggested that recruiting larger samples with improved reporting of design would improve the quality of this evidence (Shinohara et al., 2013). When compared to antidepressant medications, BA outperformed medications in terms of percentage of participants both adhering to treatment and reaching remission, while also producing equal outcomes on both self-report and clinical ratings (Dimidjian et al., 2006). Furthermore, BA has many potential advantages over other forms of treatment. Specifically, individuals with poor verbal skills or significant cognitive deficits can participate in BA, BA is structured and easy to deliver, and it is less costly than CBT and pharmacological interventions (Sturmey, 2009). Although normally delivered by a therapist one-on-one with the client, recent studies have investigated the use of a group format for BA which can further address the current gap between available treatment options and demand for these services by delivering it to several patients at once (Porter, Spates, & Smitham, 2004). It has been hypothesized that perhaps the social interaction in a group may serve as a positive reinforcer in its own right (Porter et al., 2004). Current literature reveals promising results, showing that group BA produces statistically significant therapeutic outcomes for individuals with MDD (Houghton, Curran, & Saxon, 2008; Porter et al., 2004; Richardson et al., 2005; Wesson, Whybrow, Gould, & Greenberg, 2014). BA’s ease of access, minimal time investment, and cost-effectiveness make this therapy an appealing alternative to traditional forms of treatment. Before BA can be recommended as a mainstay therapy in a resource-limited health-care setting, more research is needed to determine whether the results of preliminary research can be replicated using randomized controlled trials (RCTs) and other evidenced-based methodologies. The importance of including client experiences to shape both the intervention protocol and the clinically relevant outcomes (Crow et al., 2002; Guyatt, Montori, Devereauz, Schinemann, & Bhandari, 2004; Lawton, Rankin, & Elliot, 2013) is a key factor in research and one that we view as essential in health-care systems claiming to be client centered. Additionally, it has been suggested that qualitative research has a central role to play in feasibility studies for RCTs, and this developing area requires more attention (O’Cathain et al., 2015). Thus, the current study aims to engage and encourage patients in contributing to our main RCT to test the effectiveness of a BA group for depression. Given social workers’ prominent role in counseling and psychotherapy, the profession has much to gain from knowledge of the current research on innovative and effective treatments for depression.

Objectives

This article describes the development and implementation of the qualitative component of a mixed methods RCT pilot study (Samaan et al., 2015, 2016). BA is usually provided as an individual therapy, and we set out to explore the effectiveness, acceptability, and feasibility of enhanced BA in a group format with outpatients diagnosed with MDD. In the process of doing this, we also demonstrate a method of rigorously soliciting and incorporating client feedback to enhance the intervention under study in a research trial with the aim of ensuring a client-centered intervention.

Method

In this section, we provide a brief description of the pilot trial followed by a more detailed explanation of our qualitative methods. We have previously described the development of this project alongside the aims and measures for both the quantitative and qualitative portions of the trial in detailed study protocols (Samaan et al., 2015, 2016).

The aim of the mixed methods pilot trial was to establish the feasibility and acceptability of a group BA intervention for patients with MDD. Recruitment was through a Mood Disorders Outpatient Program. Potential participants were approached by their clinicians and, if interested, they participated in an initial screening for eligibility. Inclusion criteria required a primary diagnosis of MDD. As shown in Figure 1, the participants were randomized to either the enhanced BA intervention group (n = 10) or the patient-led peer support control group (n = 10). In each group, there were six women and four men. Table 1 shows the age distribution of all participants. In the first phase, both groups met for 2 hr twice weekly for 10 weeks. In the second phase, the intervention group met individually with a group facilitator once a week for 6 weeks and as a group once a week for 2 weeks. The individual meetings were an opportunity to review and consolidate the core information of BA. Facilitators (a social worker, an occupational therapist, and a recreational therapist) trained in BA provided the intervention. In the second phase, the comparator group met together once weekly for 8 weeks. The facilitators for this group were mental health nurses (registered nurses without BA training) who had the goal of encouraging and supporting a peer-led group. This type of comparator group was selected by the team as we wanted to explore, and potentially rule out, if merely attending a clinic group twice per week and making contact with supportive peers was activation enough to improve mood and functioning. Leaving the house and attending a group is in itself a change of behavior or BA, and we questioned whether this would be an active ingredient as compared to the BA treatment protocol. All patients continued their preexisting course of treatment for MDD throughout this pragmatic pilot trial.

Figure 1.
Flow diagram for participants included in study.

Table 1.
Age Groups of Participants.

Age in Years BA Intervention Peer Group Control

25–35 1 1

36–45 2 3

46–50 2 3

51–60 4 1

61–70 1 2

Total 10 10

Note. BA = behavioral activation.

The enhanced BA protocol was developed using evidence and information from a variety of clinician, research, and patient sources (Samaan et al., 2015, 2016). The enhanced BA protocol included all the core components of BA and, in addition, sessions on assertiveness/communication, mindfulness, rumination, problem-solving through cooperative games, healthy eating, sleep, information on volunteering and returning to work, and community outings planned by the participants. Participants wore activity tracking devices (Fitbit One) that provided real-time and weekly computerized individualized progress reports (Chum et al., 2017).

This study was conducted at an outpatient specialized mood disorders clinic in urban Ontario, Canada. Recruitment through this tertiary clinic resulted in many of the patients falling on the most severe and chronic range in terms of their depression symptoms and length of illness. The pilot study was approved by the Hamilton Integrated Research Ethics Board.

Qualitative Study Design

We used the methodology of qualitative description, as described by Sandelowski (2000). This methodology is appropriate for a study that aims to produce findings that are close to the data and are not interpreted into a grander theory. Qualitative description studies take a naturalistic approach to the phenomenon under study. The aim of this applied research study was to gather client perspectives at multiple points and integrate suggestions for improvement into the intervention as the pilot study progressed. This iterative process contributes to the design of an enhanced BA group intervention, which is client centered and promotes a positive experience to achieve high participant retention. Interviews encourage the telling of personal stories and often generate valuable information for the researchers, as participants are able to share their lived experiences (Whittaker, 2009) of depression and the impact of the BA group and the peer support comparator group.

Table 2 shows the multiple data collection points for the qualitative study. All 20 participants were invited to contribute and 18 completed the study. Two participants (one from each group) withdrew from the trial due to surgery (BA group) and a psychiatric admission (peer group).

Table 2.
Data Collection Points.

Participant Type Week 2 Week 4 Week 5 Week 18

Session 4 Session 8 Postsession 28

BA intervention group Individual interviews Focus group Focus group

Peer support control group Individual interviews Focus group Focus group

Facilitators Focus group Feedback session Feedback session

Note. BA = behavioral activation.

Data collection began with 18 semistructured individual interviews lasting approximately 1 hr. The purpose of these initial interviews was to gather information about the group experience (i.e., what was helpful and what needed to be adjusted or changed). Individual interviews provided a venue should the participants wish to discuss more personal experiences of depression or aspects of the group that they were reluctant to discuss in the focus group setting. It became clear in the first focus groups that participants felt comfortable discussing personal experiences of depression and the benefits and critiques of their respective group’s content and process. Thus, postgroup individual interviews were not conducted.

Data collection proceeded with multiple focus groups held with the BA, control, and facilitator groups. These groups were held separately; six to eight participants attended each of the patient focus groups. Four of the five facilitators attended the facilitator focus group.

Focus groups enabled participants to build off each other’s ideas and respond to the feedback shared by other participants. The questions asked were not particularly personal or sensitive, and therefore, this method was an appropriate way to collect data (Kitzinger, 1995; Sim, 1998). The focus group discussions concentrated on the participants’ experiences and views of their respective groups in order to obtain feedback that might be used to modify the BA protocol for the main trial. Participants were informed their opinions and suggestions would be implemented immediately where possible and would all be considered when planning the main study. A semistructured interview guide was used, and the facilitator permitted discussion to flow freely and to allow participants to raise issues important to them while acknowledging the research process and the socially constructed nature of that which is being studied (Charmaz, 2000, 2006; O’Grady & Skinner, 2012). The approximately 1-hr focus groups were facilitated by L.O. and M.V. One facilitator of the focus groups asked questions and led the discussion, while the other wrote field notes, observing group dynamics, body language, and other aspects that are not recorded on audiotape (Kitzinger, 1995).

Facilitators from both arms of the study participated in a facilitator focus group during the intervention to explore their experiences and opinions about the content and process of their relative groups. The longitudinal design with multiple data collection points allowed a researcher (L.O.) to meet the facilitators in order to provide two feedback sessions about participant experiences and suggestions. Where possible, the facilitators used this feedback to adjust the groups as necessary to foster a client-centered approach in the development and implementation of the intervention arm of the study and to modify the study protocol planned for the main trial. Adjustments to the programming were made when it was possible to do so without disrupting theoretically relevant content for the trial. This collaboration between patients, clinicians, and researchers aligns with the aspiration to provide client-centered care, whereby the development of new services or treatments is responsive to patients’ values, preferences, and requirements (Guyatt et al., 2004; Lawton et al., 2013).

Data Analysis

The focus groups and individual interviews were audio-recorded and transcribed verbatim for analysis (Poland, 1995). A staged analysis was conducted based on grounded theory coding techniques including line-by-line coding, thematic coding, and constant comparative analysis (Boeije, 2002; Corbin & Strauss, 2008; Poland, 1995). The data were reread and reanalyzed as themes were identified. Following some initial analysis, the qualitative researchers (L.O. and M.V.) also met with the principal investigator of the trial (Z.S.) to discuss and develop a framework of themes for data coding and further analysis.

Results

BA for depression is usually delivered on an individual basis. Our analysis established that an enhanced BA group was effective, acceptable, client centered, and feasible in the treatment of depression. We also demonstrate the possibility of using a research-based approach to solicit and integrate client input over the course of an intervention-based trial. Four key findings emerged during data analyses, which are of interest to those who wish to adopt individual BA to a group format and will guide our main study. First, effectiveness was attributed by participants to the strong connection between improved mood, functioning, and social cohesion. Second, the structure, frequency, and content of the BA group were acceptable to participants. These three components were found to improve BA or functioning and nurture group cohesion. Third, a flexible, client-centered approach was found to best meet the needs of this complex population who often have multiple diagnosis or health-care needs. Fourth, feasibility was demonstrated by participant feedback on the logistics of the program. Implementing participant suggestions within the pilot trial and later in our main trial was also feasible. An unexpected finding that has implications for our main trial and future research is the selection of comparator groups. The peer-led support group showed no benefit but, more importantly, it may be detrimental in this specific population: individuals with a severe, chronic depression diagnosis.

Effectiveness—Improved Mood, Functioning, and Social Cohesion

All participants entered this study with severe and chronic depression. Participants in the enhanced BA group described an improvement in their mood, functioning, and increased social support (family and peer). Participants in the comparator group did not report the same positive changes. Early interviews from both groups confirmed that depression has a strong impact on functioning, affecting activities such as sleep, motivation, work, relationships, and social isolation:
There are days where I will not leave the house. If I’m lucky, I will get dressed, likely I won’t shower or get washed, and I will move from the computer, back to the couch, to the bed, back to the computer, putter around the kitchen, wash some dishes, and that’s about it.
During the early interviews, participants expressed personal goals and hopes that included finding happiness in being around others, restoring their motivation and energy, feeling more positive about self, returning to the workforce, doing more activities with family, returning to hobbies/activities, and getting out of the house more.

After the groups were completed, participants were asked what progress they had seen toward their goals. Participants in the peer support group did not report reaching any of their hoped for goals with the majority citing no change (two participants described very small changes in their behavior or functioning, e.g. citing coming to the group as a change in behavior). In contrast, the BA group participants reported the following outcomes, “learning how to prioritize with no more wasting time on stuff,” setting and achieving goals, going from avoiding all phone calls and family/friends activities to using the phone daily to connect with family and friends, and attending family functions. BA participants had not returned to work (a couple were taking courses or working on action plans leading to a return to work), but they widely reported increased activity levels and functioning. One single parent stated the BA program gave her “a chance to refocus, to get perspective, and make decisions about the future.”

Participants in the BA group connected these positive changes to specific strategies learned in the group, to the structure and frequency of the group, and to the interaction with other group members. Common sentiments included: “I feel better, I look forward to coming here, my attitude has changed” and “When we leave here, we’re all pretty much more up” (improved mood). Some participants described family members and friends remarking on the improvement. For example, a BA participant who rarely left home and isolated herself from her husband within their home reported her spouse’s positive comments on her progress in doing more tasks inside and outside the home. She described the BA group as integral in making changes:
I feel absolutely that I’ve had a breakthrough…it was for sure the flash of a light-bulb experience and that’s why, for me, doing this twice per week, to have that continuous reinforcement [from peers, facilitators and now her husband] and because I can recognize something invaluable that I don’t want to lose. I feel it’s [BA] allowing me to make the changes I want to make. So, thank you.
BA participants emphasized the importance of a friendly environment where their feelings and experiences could be discussed openly, and this compassionate group milieu decreased social isolation and increased social support. The following statement illustrates the importance of social cohesion or connectedness in recovery.
I have a small family, we all live together in the same house and I know they love me, but they cannot understand the depression, and I’m having such a hard time being at home. So, this is my safe haven. I cannot wait to come here, like I said here before, no one is judging, everyone understands.
The BA therapists also noticed and understood the significance of the strong connections or cohesion that developed among the participants over time and the gains subsequently made.
I could really see how people were much more comfortable in connecting and being open about their personal lives, whereas at the beginning, that wasn’t so much the case. So, I really saw cohesiveness and kind of a social connectedness, and also, they were really talking about their goals, they were asking each other about, “oh so did you make it to the gym last week?” and that kind of thing, like asking each other and challenging each other a little bit. So, I think that was adding to that reinforcement that we’re trying to do in the group.

Acceptability—the Structure, Frequency, and Content

Participants suggested that there were several components of the BA intervention program which contributed to their improved mood, functioning, and social cohesion, including the frequency of the sessions (twice per week for 2 hr), the structure, and the content of the sessions. These factors contributed to the acceptability of the enhanced BA program and are illustrated in the following statements.
For me, the way it is structured currently is effective because it kind of splits the week in half, and I need that refocusing every three days, and with that, even though, it seems rigorous, and yeah even overwhelming, it’s bringing things together for me. The dots are starting to connect, all the different topics [session structure and content]. It’s like, ‘Whoa, not only do I have this tool, now I’m finding this tool works well with this other tool in dealing with this [depression].
It feels like mental sit-ups. If you only do sit-ups once a week, you know you aren’t going to get anywhere.

A major component of the structured BA group was to encourage all participants to plan and complete goals outside of the sessions (homework). The participants chose for themselves their specific and individualized goals rather than having facilitator-generated goals. This provided an opportunity for collaboration with peers and facilitators when considering personal goals; this opportunity contributed to a sense of team collaboration as well as promoting autonomy. BA participants stated they found the homework practice between sessions beneficial, as it helped them identify and work on specific issues and to apply the new skills they were learning into their “real life,” which supported increased activities or functioning.
I noticed that the homework is what helped me. We are doing worksheets daily. It’s actually helped me stay focused on the program. It helps me to see patterns. I personally enjoy it because it’s changed patterns in my own personal life.
In contrast to the BA group, we received markedly negative feedback from the peer support group, despite having the same frequency of sessions and much more opportunities for group interaction given the unstructured nature of this group. The peer support group was designed to have a peer-led structure with group members initiating and leading the discussion with minimal facilitator intervention. The majority of support group members expressed frustration with the unstructured approach and requested more structure from the group facilitators. Many reported the sessions were a waste of their time. Two individuals noted that while they would rather have a structured group, they still found value in the free-flowing sessions, as it was an opportunity to hear from others experiencing depression.

One noteworthy challenge with the peer-led format identified by all participants was that it was difficult for them to generate topics and lead conversations, due to the lack of initiative and low motivation that characterize depression.
It’s kind of hard to put the onus or the initiative for people that have depression, but I mean like if I don’t do the dishes at home, I’m not going to necessarily drive the conversation [here] either. There are some weeks that people don’t say anything. They just listen, but they won’t contribute. Again, asking people who are unmotivated to be motivated to make change. Talking about it, but not actually getting it done.
Surprisingly, the structure of the BA sessions (with less actual time to talk and interact freely) was found to encourage even nurture group cohesion or connectedness. Meanwhile, the unstructured peer support group did not report feelings of group cohesion or connectedness. This finding was triangulated through participant and facilitator report and observation by the interviewers during focus groups. Researchers observed significant differences in group dynamics, attitudes, and mood between the BA and peer support groups. On entering the peer support focus group, we observed participants sitting quietly, waiting for us to begin the focus group. There was no discussion between group members, and the mood of the room was subdued, even gloomy. In contrast, when we entered the BA focus group, the participants were chatting loudly with each other, laughing, teasing each other, and the mood of the room was very upbeat. During the BA focus group, the laughing, teasing, and camaraderie continued and is apparent in the transcript.

Initially, we wondered if a twice-weekly group in the morning would result in reduced attendance in both groups due to the nature of depressive symptoms (reduced motivation, fatigue), but this was not found. Further, the findings suggested that the frequency of attendance was not a factor in improved mood noted by BA participants, as the same finding was not noted by attendees of the peer support group. The key elements in the effectiveness and acceptability of the group BA program included twice-weekly structured sessions led by facilitators and a format that encouraged patients to share personal struggles. Meanwhile, participant contributions and sharing fostered group cohesiveness and led to support from peers based on a shared understanding of their lived experiences with depression.

Flexible and Client-Centered Approach

Client-centered programming was important to the research team because it contributed to ethical research, positive patient experiences, and improved outcomes. We worked toward creating a client-centered intervention by repeatedly soliciting and integrating feedback from participants and adapting the intervention correspondingly. Through this iterative process, we were able to accommodate the diverse needs of the participants. Participants in both groups were somewhat diverse in terms of sex, age, educational background, employment history, household income, ethnicity, and physical ability.

Two of these factors, physical ability and age, were identified by participants and facilitators as characteristics that altered the needs, interests, and capabilities of the BA group. The flexibility of facilitators to adapt programs in real time to meet the needs of patients proved more successful when it came to physical limitations than with age differences, highlighting the challenges in providing truly patient-centered care in a group format.

The facilitators of the BA group successfully adapted activities to accommodate the physical limitations of group members, which included chronic pain, fibromyalgia, osteoarthritis, herniated discs, chronic obstructive pulmonary disease, carpel tunnel syndrome, and chronic sleep disorder. To accommodate the needs of the participants, the BA facilitators adjusted the planned program of activities including the team building activities, the active problem-solving games, and the two group outings. The initial plan was to incorporate adventure therapy, such as a ropes course and so forth, but it was quickly apparent that this plan would not work for the participants: “You have to be flexible, right? We talked about the ropes [physical activity], we can take certain people out on the ropes course but if there are walkers [assisted walking aids] it’s not happening.” The facilitators were open to the challenge of adapting their planned activities to suit the needs of the group members while still remaining true to the tenets of BA and were gratified by the positive response from participants:
…in the team building part there was a man who has a number of physical limitations and he was actually quite impressed by being able to go out and work with people [the group members] and communicate. The activity wasn’t overly strenuous and it turned out to be a lot of fun for him.
While facilitators were able to make some successful adaptations, they were challenged to accommodate the age differences between participants. One person in the BA group was 28 years old and made several comments to his therapist during individual sessions about not wanting to end up like the rest of the people in the group. He also stated that he didn’t feel a strong connection to the other group members, as he is in a different stage of life. He told the therapist, “I want something different in my life. I don’t want to be sitting here at 50-something talking,” and the therapist stated, “I think that he really felt alienated.” With the support of his therapist in individual sessions, he did continue to set and meet his personal goals, but there was ongoing concern he might drop out of the group. This challenge was also acknowledged by his group peers with comments such as, “Twenty-five year olds would get bored in this group, as they are at a different life stage…I’m 65 and I’ve had hard times they may not understand.”

Feasibility—Logistical Lessons for Future BA Groups

Both groups supported the practicality of frequency, time of day, session length, and length of the group intervention. The twice-weekly 2-hr sessions were held on Mondays and Thursdays from 10 a.m. until noon with a 15-min break in the middle. This timing and frequency was acceptable to participants. Participants reported that a morning group helped them to get up and out of the house, and their commitment to the group, peers, and research study was a motivator to do so. There were no concerns with the burden of twice-weekly attendance, likely because none of the participants were currently working due to their MDD. The BA group also reported that meeting twice weekly, the homework practice, and their relationships with their peers helped keep their focus on treatment and provided accountability in terms of working on and completing their stated goals. Meeting twice-weekly encouraged participants to remain focused on their goals and on making behavioral changes. One participant referred to the BA strategies as “mental calisthenics,” and the group agreed that once per week would be insufficient. Participants in the peer support group shared consistently negative feedback about the format but maintained consistent attendance, attributing their motivation to a commitment to the research study and future patients:
I feel privileged to be a part of the group [research study]. I’m very appreciative and I’m just looking forward to making a difference for myself and for others.
Overall, the BA material appeared to be suitable and applicable to all participants despite varying education levels. During the first focus group, many of the BA participants reported that the pacing of new information or learning needed to be slowed down, as “there is a lot of content and it feels a bit rushed at times.” This feedback was given to the facilitators who identified the challenge of balancing the participants’ desire for information (asking questions) and an opportunity to discuss, review, and process their experiences and progress (supporting group cohesion). The facilitators accepted this feedback and adjusted the pace of sessions, while at the same time keeping the core BA principles (values, goals, setting, and scheduling) to the forefront. The following comment highlighted this dilemma:
Certainly we want to work on understanding better what their goals are, their activity schedules, connections between activities and mood—doing a quick go around [homework review] and getting something from everyone, but it is so time consuming that it would often delay the new learning—and this is so the core of BA that if we don’t get it right early on, then it’s harder to apply the other principles.

Discussion and Applications to Practice

MDD is a global health-care problem and is the leading cause of disability (WHO, 2004, 2012). While effective treatments exist, these options have proven to be expensive and of limited benefit to many individuals. In contrast, BA is professed to be easier to implement, exportable, and cost-effective (Dimidjian et al., 2006; Hopko, Lejuez, LePage, Hopko, & McNeil, 2003). Since the mid-1990s, BA has been suggested as a stand-alone treatment for depression (Jacobson et al., 1996). The evidence for its effectiveness when compared to other treatments has been debated in the literature with a Cochrane review, suggesting larger samples with improved reporting of design are needed (Shinohara et al., 2013). Evidence about the effectiveness of BA so far typically focuses on individual BA, with few studies examining the utility of a group format. This pilot study is part of a larger mixed methods trial addressing this gap in the research literature.

Outcomes from the BA group suggested it is effective and beneficial. This substantiates the promising results of other research into the delivery of BA in a group format (Houghton et al., 2008; Porter et al., 2004; Wesson et al., 2014). Many participants in the BA group described improvement in their mood and functioning, which they attributed to the structure, content, frequency, and social cohesion. Mental health outcomes also included increased social supports (both peer and family), increased humor, and an increase in goal setting and completion of planned activities. The compelling social cohesion that quickly developed among the group is particularly relevant, given that depression usually leads to social isolation and limited social supports, which further produces feelings of depression and loneliness. These withdrawal and avoidance behaviors are thought to exacerbate depressive symptoms (Jacobson et al., 2001). The social cohesion observed in this study supports the suggestion that social interaction in a BA group may serve as a positive reinforcer in its own right (Porter et al., 2004). We would argue that this social cohesion was nurtured in a structured but flexible approach that encouraged the developing and completion of individual goals as group members acted as supportive coaches. In some ways, it might be said to have encouraged a built-in compassionate peer accountability system.

This pragmatic study demonstrated that a flexible and client-centered version of group BA for depression can be successfully delivered to a patient population with high rates of severity, chronicity with lengthy psychiatric histories, physical disabilities, and lower rates of employment. The client-centered approach likely led to greater uptake and acceptability of the BA protocol. Perhaps a rigid adherence to the planned BA protocol would have negatively impacted uptake and acceptability and may even have impacted mood and functioning outcomes. BA, similar to CBT, is a structured protocol-based treatment that uses worksheets (Martell, Dimidjian, & Herman-Dunn, 2013; Soucy & Provencher, 2013). According to Martell, Dimidjian and Herman-Dunn (2013), this structure ensures that the client and therapist stay on track, while at the same time, the therapist’s style is validating, collaborative, and nonjudgmental. Participant and facilitator feedback clearly indicated the value of the structure and content of BA, while also prioritizing flexibility and adaptation of the intervention. Facilitators addressed participant feedback and adapted the content to meet the needs of participants with impaired functioning due to physical impairment and severe MDD but also to accommodate the participants’ desire for group discussion and sharing. The tension between fitting in the planned content, in particular the core of BA, and the conversations generated by the content is a challenge likely experienced in other structured therapy groups and requires facilitator flexibility to address.

Despite a commitment to adaptation and client-centeredness, facilitators were challenged to address age differences in this group format intervention. This difficulty may persist in future RCTs. However, when BA is provided in clinics, it is possible to address this issue by ensuring that there is more than one younger person selected for a group, hopefully allowing the younger members to form a relationship that leads to improved attendance and group cohesion. Given the comments from the younger BA participant and from the older participants who bonded over shared life experience, therapists developing BA groups may wish to select group members based on similar age and life stage.

Implications for future research include the need to consider the type of comparator group selected. The use of a peer-led support group as a comparator confirmed that the frequency, time, or length of the sessions was not the main contributing factor in improving mood and functioning. Interestingly, it was through seeking participant feedback via qualitative data sources that we unexpectedly discovered that the peer support group format was negatively impacting the mood of many of the participants. While this may have been observed when examining quantitative data sources, such as the Beck Depression Inventory II scores, the richness of the qualitative data illustrated the significant problem with unstructured peer-led groups in a population of patients who are chronically and severely depressed. The differences between the two groups were so stark that the clinical and research team has opted to use a wait-list group as the comparator for the main trial. Given the effectiveness of the BA group and requests from the comparator group participants, they were offered a BA group immediately after this pilot study concluded. Recent research has suggested that choosing an appropriate comparator group for behavioral and social science RCTs is critical to provide true intervention effects and most trials fail to provide the rationale for their selection of a comparator group (Wang et al., 2017). The findings of this trial clearly indicated the importance of changing our comparator group, which called our attention to the need for careful selection of a control group in this particular population.

It is important to acknowledge the limitations of our study. First, our sample may be subject to selection bias. Participation in our study was voluntary, and it is likely that volunteers differ significantly from nonvolunteers in clinically relevant factors. As a result, our sample may not be representative of the population of individuals with MDD as a whole. Additionally, our sample consisted of participants seeking treatment and thus is not representative of a nontreatment-seeking population. Finally, our study was conducted in an outpatient tertiary setting at a hospital that often provides services to patients with chronic and severe depression. Therefore, it is possible that our findings may not be applicable to other health-care and non-health-care settings, where client factors may differ. However, despite these limitations, it appears BA in a group format is a promising evidenced-based practice that will be researched further in our main RCT trial of this mixed methods study.

Despite the aforementioned limitations, our study used rigorous methods to explore the effectiveness, acceptability, and feasibility of a BA group intervention for depression. Our iterative approach to soliciting and implementing feedback from participants was appreciated by the participants in both groups, and the logistical lessons learned will be taken into account for the main trial. This approach substantiated the work of other researchers in health care (Lawton et al., 2013; Van Eyk & Baum, 2003) who encourage patient participation. Lastly, we wish to acknowledge the lived experiences of participants and the importance of listening to their voices when shaping our main trial and other future research. The values inherent in the social work profession promote social work practice and research that is inclusive and supports client determination through listening to client voices and expertise. More generally, if we purport to take a patient or client-centered approach in health care, it is important that we do listen to patient voices and address their preferences and concerns when researching and developing treatment interventions.

Age in Years	BA Intervention	Peer Group Control
25–35	1	1
36–45	2	3
46–50	2	3
51–60	4	1
61–70	1	2
Total	10	10

Participant Type	Week 2	Week 4	Week 5	Week 18
BA intervention group	Individual interviews	Focus group		Focus group
Peer support control group	Individual interviews	Focus group		Focus group
Facilitators		Focus group	Feedback session	Feedback session

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The pilot study is supported by the in-kind contribution of resources and personnel from the Mood Disorders Program, St. Joseph’s HealthCare Hamilton.

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Participant Type	Week 2	Week 4	Week 5	Week 18
Participant Type	Session 4	Session 8		Postsession 28
BA intervention group	Individual interviews	Focus group		Focus group
Peer support control group	Individual interviews	Focus group		Focus group
Facilitators		Focus group	Feedback session	Feedback session