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The course
takes place on the telephone using a teleconference
facility. This system enables a group of people to talk to each other, as though
sitting around a table. Each group has a trained group leader who will guide the
group through the course. The first week will normally be an ‘introductory’
session and this enables people to get used to the ‘teleconference’ concept,
to get to know the other members of the group, to ask any relevant questions and
to fully understand what is expected of them.
During the
course, members of the group will be offered the chance to continue as a
self-facilitating befriending group for as long as the group so wishes and your
group leader will explain how this works. If only a few members of a group
wish to continue then it is possible to amalgamate groups together into one
viable group. Members of the group will decide the frequency of meetings
of their befriending group. If you have any questions about this concept
please ask your group leader.
Anyone
about to undertake exposure therapy who may have other health problems is
advised to check things out with their G.P. in order to ensure that the anxiety
experienced during exposure therapy is not detrimental to their health.
If
you would like more information about these courses please ring Colin,
our Telephone Groups Co-ordinator, on (+44)
01952 590005
Written by Colin Hammond, Founder No Panic.
Independent Research into the Benefits of
Telephone Recovery Groups
1. Introduction
This research explores the impact of a telephone recovery
group for people with anxiety difficulties. It was funded by the Department of
Health and carried out during 2004-2006 by Rethink, the National Charity for
Mental health matters.
No Panic provided an opportunity for this research. The
organisation was set up 13 years ago by two service users and a carer who wanted
to share their experiences to help others. It has now become a national charity
with over 3,000 members and supports people living with panic attacks, phobias,
obsessive compulsive disorders and other related anxiety disorders.
No Panic has a strong user-led focus with 95% of both the
governance and management of the charity being user-led, and is staffed entirely
by volunteers.
The telephone recovery group is a 12 week course is designed
to help people who suffer with phobias, panic attacks, OCD and general anxiety
disorders make steps along the road to recovery.
Each weekly one hour session takes place using a
teleconference facility during cheap rate telephone times, usually in the
evenings. This system enables a group of people to talk to each other as though
sitting around a table. Each recovery group has a trained volunteer group leader
who guides participants through the course. The recovery programme is based on a
CBT approach supporting by information and exercises from the accompanying
manual.
Participants are offered the chance to continue as a
self-facilitating befriending group once the course has finished.
2. Background
The scale of anxiety disorders
Severe anxiety and phobic disorders are a widespread problem.
The Office for National Statistics psychiatric morbidity survey (2000) estimates
that around one in six adults aged 16 to 74 years in Great Britain has a
neurotic disorder such as depression, anxiety or phobias. This finding is
supported by No Panic which reports that in the UK there are up to 5 million
people living with agoraphobia; up to 1 million with social phobias; up to 4
million with specific phobias; up to 2 million with obsessive/compulsive
disorders and up to 2 million on tranquillisers.
CBT as a treatment
Psychotherapy is recognised by the Royal College of
Psychiatrists as one of the key treatments for anxiety and phobia, along with
talking about the problem, self-help groups, learning to relax and medication.
CBT (Cognitive Behavioural Therapy) has become one of the most well-used
psychotherapy treatments for anxiety disorder. It developed from cognitive and
behavioural psychological models of human behaviour. Put simply, it is founded
on the idea that if we can change the way we think about situations we can
change the way we respond to them. It involves recognising unhelpful patterns of
thinking and reacting, and modifying or replacing these with more realistic or
helpful ones. In essence CBT involves education about: panic attacks, relaxation
exercises, techniques to tackle the fear of the physical sensations of panic and
on how to challenge inaccurate thoughts, together with approaches to desensitise
the situations that trigger attacks and training in controlled abdominal
breathing.
Research context
There is now a body of evidence supporting the effectiveness
of CBT for treating anxiety disorders, particularly in reducing the frequency
and intensity of panic symptoms as well as treating non–panic anxiety symptoms,
and in addressing generalised anxiety disorders (GAD). Studies have also shown
the success of CBT in group as well as individual settings. NICE recognised the
effectiveness of CBT in 2004 when, following a review of studies comparing CBT
approaches with other psychological interventions, it recommended that ‘if a
psychological intervention is to be offered then it should be CBT’.
The past two decades have seen a rapid growth in the number
of self-help groups to help people cope and educate them about their illness.
Research has shown how the self help approach is effective in self-managing
anxiety, phobia and OCD and for people with anxiety disorders in primary care.
Research also points to the success of self-help approaches to anxiety using
different media, including video-conferences and CBT based software packages.
Apart from just one small scale study (Swinson et al, 1995)
who concluded that ‘telephone behaviour therapy appears to be a cost-effective
and efficacious treatment for agoraphobics living in remote regions where
specialised anxiety disorder services are not readily available’, there has been
very little research on the use of telephone based therapy for people with
anxiety disorders. Most studies of telephone based therapy for people with
common mental health problems have been concerned with diagnosis or treatment
for depression.
No Panic telephone recovery groups have operated for
around 13 years. They have never been systematically evaluated, though they have
received widespread acclaim for the innovative support they provide, including
for example: Queens Award for Voluntary Service, 2004;
National Institute for
Mental Health in England, Positive Practice Award - User Involvement, 2004;
Guardian Charity of the Year Award, 2003; Community Care Awards, Mental Health,
2003 and Overall Winner of the Community Care Awards, 2003.
This research was therefore commissioned to provide an
evaluation of the No Panic telephone recovery groups to review their
effectiveness and contribute to the wider evidence base in this important field.
3. Method
Three main approaches were used in the evaluation. The first
stage was a retrospective survey of participants in recovery groups during 2004.
The aims were to gain feedback from recent participants on their experiences and
self reported benefits and to inform the design of the next stage of the study,
(e.g., to include a question on quality of life changes)
The second stage comprised a ‘case-control’ study which
compared the experiences of people as they went through the telephone recovery
groups against people with anxiety disorders who had not taken part in a
recovery group and had no plans to do so.
The impact of the telephone recovery groups was measured
through bespoke questionnaires and standardised measures of anxiety, overall
well-being and worry. The questionnaires addressed self-rated measures of
anxiety and quality of life. The standardised measures used were:
- General Health Questionnaires (GHQ-30) which measures the general health
of participants and assesses the presence of distress
- State-Trait Anxiety Inventory (STAI) which objectively analyses anxiety
on two levels: how people feel ‘right now at this moment’ and how they
generally feel
- Penn-State Worry Questionnaire (PSWQ) which assesses anxiety levels
through measuring how much people worry.
Data was collected from participants in the No Panic group
and control group at time 1 (baseline), time 2 (immediately after the
intervention - after 12 weeks) and time 3 (long-term follow-up – after 22
weeks). Each participant was given a pack of assessments to complete at each
time point. In addition an exit questionnaire was sent to all telephone recovery
group participants who left the course early.
Stage three involved semi-structured telephone interviews
with 12 group leaders. Information was gathered on their views on the strengths
and weaknesses of the telephone conferencing approach for people with anxiety
difficulties.
4. Profile of research respondents
The survey
- Of the 300 questionnaires sent out, 125 were returned providing a
response rate of 42%.
- Most (80%) respondents were female and White British (90%)
- Most (84%) were aged between 26-65, the average age was 42 years
- Almost all (91%) had been living with an anxiety disorder for at least 2
years, mainly with a generalised anxiety disorder (GAD) or a mixture of
anxiety and depression.
The ‘case-control’ study
- One hundred and seventy-two people took part at the beginning of the
project: 121 in the telephone recovery groups and 51 in the control group.
Forty two telephone recovery group participants provided a full data set for
times 1, 2 and 3 (35%) as did 43 people from the control group (84%)
- There were no significant differences between the groups at time 1
(baseline) on: sex (81% in both the telephone recovery and control groups
were female), age (average 45 and 46 years), ethnicity (White British 88%
and 85%) or how long they had been living with anxiety (average of 158 and
184 months), or diagnoses (the majority of people in both the groups were
diagnosed with GAD/ anxiety)
- At time 1 twice as many of the telephone recovery participants were not
working due to illness or disability (43% and 21%)
- Although there was no significant difference between the groups in terms
of their self-reported quality of life, the standardised measure of general
health using the GHQ-30 showed that those in the telephone recovery groups
were significantly more distressed than in the control group at time 1
- The two groups had similar results from the standardised assessment of
their anxiety and worry levels at time 1, but those in the telephone
recovery groups were significantly more likely to self-report higher levels
of anxiety
- There was no significant difference on any descriptive statistics,
self-report quality of life or anxiety measures and standardised measures of
distress, anxiety or worry for those who dropped out of a telephone recovery
group and those who stayed
- However there were differences between those who remained on the course
but did not return questionnaires Significantly more ‘non-returners’ were
younger, less likely to be distressed at the outset according to their
GHQ-30 scores and had lower levels of self-rated anxiety. This introduces a
potential bias into our sample, which must be considered when drawing
conclusions.
Interviews with group leaders
- Twelve group leaders took part in the interviews out of a possible 13
(80%)
- The average length of time working as a group leader was 3½ years
5. Benefits
The research looked at various areas that the recovery groups
were targeting throughout the course including: access to information; peer
support and friendship; use of other services and supports; changes in quality
of life, anxiety and distress. We look below at each of these domains and any
reported benefits across the three types of data collection: the survey,
case-control study and interviews with group leaders.
- Access to information
Providing information on self help techniques and on
anxiety disorders was identified by group leaders as a key component of the
telephone recovery groups:
"To educate people so that they know what to do when they
suffer from panic attacks and to understand the symptoms, people are less
frightened when they understand what is happening to them and they begin to
put the tools in place".
Information about coping strategies also emerged as a key
benefit for 74% of participants in the case control study. Also over 80% of
people in the survey and the case control study found the suggestions on the
course useful. People described learning about relaxation techniques, such
as breathing exercises to control their anxiety, and about setting goals to
help them overcome the day-to-day obstacles caused by their anxiety
difficulties .
"Increased knowledge about panic and anxiety, learning
that I have all the tools I need in order to help myself and feel better"
"I can control panic better by breathing properly and
telling myself to relax"
An associated commonly mentioned benefit was the ability
to gain further information on anxiety disorders (68%):
"I am more relaxed and I understand my anxieties better"
Peer support and friendship
Peer support is a another core component of the recovery
groups, enabling people to benefit from sharing their experiences and
supporting each other through the course, as one group leader explained:
"People are able to hear other people talk about their
problems and realise that they are not alone, sometimes people hear things
and realise that this is part of their OCD which they hadn’t realised
before. It is good to hear that they are not the only ones who have these
problems".
The research highlighted the success of this approach.
Almost all (90% and 86% in the retrospective and case control study) felt
that it did help to be with others who had similar anxiety problems.
The opportunity to be with, and to discuss difficulties
openly with, people with personal experiences of anxiety was identified as
the major benefit of the recovery group for 89% of those taking part in the
case control study. When asked what they liked most about the course,
everyone highlighted the ability to share problems with others.
"Meeting people with the same problems and discussing
these together – brilliant!"
"I liked the fact that everyone understood and I didn’t
need to feel embarrassed about being scared or anxious about things"
The support is accessible
The biggest strength identified by group leaders was that
the course was run on the telephone and this provided a great way for people
to access support (e.g. those with agoraphobia or social phobia). This
result was mirrored by participants – 80% of those taking part in the
retrospective study did not feel that it was difficult to communicate with
others in this way. There are very few services where people can access
support in their own homes.
"A lot of people find it difficult to go out and
socialise or they are worried that they will show themselves up, using the
telephone is good as people don’t have to go anywhere, if it is too much
people can simply leave".
Quality of life
Following the findings from the survey we included an
additional question on quality of life for people taking part in the case
control study. Here we asked people to rate their satisfaction levels.
Eighty-one percent of No Panic participants rated their quality of life as
unsatisfactory compared to 67% of the control group at time 1. We found no
significant differences, either immediately after or at longer term
follow-up, in the quality of life for people taking part in the No Panic
groups as compared to those in the control group using this scale.
Improvement in anxiety levels
The anxiety level of participants was measured using a
self-report 10-point likert scale (survey and case-control study) and the
standardised measure of anxiety, the STAI (case-control study). Scores on
the STAI did not significantly change for the two groups, however both the
survey and case control study did find that participants self-reported
significantly lower levels of anxiety in the weeks following their time in
the telephone recovery groups. Thus the survey showed that when people were
asked about their anxiety levels up to one year after taking part, they were
more likely to retrospectively report lower levels of anxiety after the
group as compared to before (an average score of 4.86 as compared with 7.79
before).
The cohort study illustrated that those in the No Panic
groups were more likely to report themselves as having higher anxiety at
time 1 (before taking part) compared to people in the control group, however
in the weeks following the course participants in the No Panic group made
greater reductions in their anxiety compared to those not taking part
(control group), so that at 22 weeks both groups were functioning at the
same level. This is represented in figure one. Figure one shows that person
A felt more anxious at time 1 than Person B. Both will experience lower
anxiety levels at time 3 (22 weeks or more weeks later), but Person A
achieved a greater lowering of their anxiety so that they are reporting a
similar level of anxiety as Person B. This shows that Person A has recovered
to a greater extent than Person B.
Figure one. Improvement in anxiety levels
Consequently people described feeling more relaxed and
calmer, and to have fewer panic attacks, as a result of attending the
telephone recovery groups.
"I haven’t had more than two panic attacks in the last
few months"
"I can stand in a queue now and don’t shake or feel like
I am choking now which is a real bonus for me"
"I am not as anxious. I don’t let the anxiety get the
better of me. I can live my life again"
Improvements in overall levels of distress
We measured distress in the cohort study using the GHQ and
PSWQ. There was no difference in scores on the PSWQ immediately after, or 22
weeks following, the No Panic telephone recovery group. However a comparison of
gain scores (differences of time 1 and time 2 scores) on the GHQ illustrated
that people taking part in the No Panic groups had a significantly larger
reduction in distress at time 2 compared to those without this type of
intervention (control group). Unfortunately longer term follow up showed that
this greater reduction in distress was not sustained 10 weeks after taking part.
Figure two
illustrates this finding for
two people, person A taking part in the No Panic groups and Person B, a member
of the control group. It shows that at baseline Person A was more distressed
than Person B, however immediately after the group there was no significant
difference in distress for the two people. Thus the distress levels of person A
reduced significantly more than Person B in this time.
Figure two. Changes in distress, according to the General
Health Questionnaire (GHQ)
6. Conclusions
This report looked at an innovative model of support for
people with anxiety disorders. People are able to access group cognitive
behaviour therapy via the telephone. It was shown that this type of support can
be beneficial for people with anxiety disorders, particularly for hard to reach
groups, e.g. people with agoraphobia or social phobia.
Telephone recovery groups can help reduce participants’
distress and perception of their anxiety levels, and provide them with mutual
support, the opportunity to learn about coping strategies and gain more
information about anxiety disorders.
The impact on anxiety and overall levels of distress was
interesting. In the beginning, participants taking part in this type of
intervention were more distressed and more likely to rate their anxiety as
higher than those who do not decide to take part. Immediately after the groups,
the No Panic group members report a significantly larger reduction in their
distress levels so that they are able to function as other members of the
charity (a control group person). The challenge for models such as the No panic
telephone recovery groups, is to ensure that these reductions in distress
continue following the end of the course.
Similarly, in the weeks following the groups people report
larger reductions in their anxiety levels, so that having reduced their anxiety
significantly more they are now at a similar level of anxiety as people who did
not take part. This data shows that the 12 week course is able to bring people
back to a similar level of distress and anxiety as people who do not feel that
they would benefit from this type of intervention.
This project has collected a large amount of information to
explore the impact of the telephone recovery groups for people living with
anxiety, social phobia, OCD and other anxiety related disorders. We have found
that a number of people have benefited and enjoyed the short courses but as with
all interventions in mental health, no one model is suitable for all and thus
there are some people who found the groups were not suitable for them. It is
important to stress that there is limited research on the use of telephone
recovery groups for managing mental health problems. This study provides a
useful contribution to the evidence base though a larger study using a control
group recruited from the general population rather than No Panic members and a
longer follow-up period would be useful.
Acknowledgements
We would like to express our sincerest thanks to the
following people for their contribution to the project: Department of Health
programme leads, Carolyn Steele (Director) and George Askoorum (Associate
Director); Mo Hutchinson for her involvement in the survey; Professor Kevin
Gournay and Dr Roz Shafran for their contribution to the design of the study;
and No Panic management group; Lillian Owens and Jackie Hammond. Finally we
would like to extend a special thanks to members of No Panic who took part in
this project including group leaders, survey participants and those people
taking part in our case-control study.
Last updated 30th November 2007
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