Behavioural and Cognitive Psychotherapy, 1998, 26, 219–235 Cambridge University Press.

Printed in the United Kingdom

June S. L. Brown
Institute of Psychiatry, London, U.K.

Ray Cochrane
University of Birmingham, U.K.

Carol F. Mack, Newman Leung and Teresa Hancox
South Birmingham Mental Health Trust, Birmingham, U.K. Abstract. This study investigates whether large-scale, day-long stress management workshops open to the general public can work as well as small, weekly groups run for referred clients. It is suggested that the self-referral route may enable some people who might otherwise have been ‘‘filtered out’’ from the traditional health services to get help for their stress-related problems. Analysis showed that the large-scale format was just as effective with a more distressed subgroup as was the small weekly format for formally referred clients, which suggests that the effectiveness of this approach is not only related to a restricted client group. It would appear that the low drop-out rate, the effectiveness of the workshops and the severity of problem handled within this format indicates potential value in this type of approach. Keywords: Large scale, day, workshops, small, anxiety management, groups.

Introduction Group-based stress and anxiety management training has traditionally taken place in small weekly sessions. Whilst these have been found to have had some effect, evaluations have often not been controlled (Campbell, Blake, & Rankin, 1993; Powell, 1987) and͞or shown a clear superiority over a control group (Eayrs, Rowan, & Harvey, 1984). Smith, Wood and Smale (1980) make the point, that ‘‘control groups . . . often
Reprint requests to Dr June S. L. Brown, Psychology Department, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, U.K. © 1998 British Association for Behavioural and Cognitive Psychotherapies

those outside the specific therapeutic interventions. 1985. White. White et al. Keenan. such as a workshop. have been seen as potentially helpful (Butcher & de Clive-Lowe. Yalom (1975) has postulated several non-specific curative factors in all group therapy including ‘‘finding out you are not alone’’ as well as gaining hope. and clients having opportunities to talk to others in a similar position about their problems. albeit of varying degrees of severity. Much of the literature has concentrated on small groupwork (Sank & Shaffer. and stress and anxiety management training in particular.5% of the population..220 J. where psychological skills are taught rather than used therapeutically. Examples of nonspecific factors. These authors have conceptualized a ‘‘filter model’’ which selectively limits the people likely to be referred to the specialist services. include giving clients the belief they could control their own lives. 1984. Within this model are suggested to be such processes as the willingness of an individual to consult a GP for mental health problems. 1984. 1992). 1994). & Brooks. 1993). Size of group is one consideration.e. They suggest that 25% of the population are likely to experience mental health problems. at sometime in their lives but that only 5% to 7% of this 25%. the mental health services are already struggling to cope. 1975) or large educational groups (Andresen. there are two major factors that may influence the effectiveness of intervention generally. Indeed. the other is whether the sessions are ‘‘spaced’’ (usually weekly) or ‘‘massed’’ (longer and͞or more frequent than once a week).. Several investigators (Eayrs et al. 1992). smoking cessation groups can reduce the rate of physical problems like lung cancer and heart disease (Carroll. so that caution is necessary in ensuring that those in groups not only change but that they change more than do the controls’’ (p. as at present. For example. 1992) have also mentioned that ‘‘non-specific’’ factors may have affected the results when no clear differences have been found between different group interventions. Finally.. Recent interest in ‘‘larger-scale’’ interventions has been stimulated by a number of different factors. the GP’s ability to detect mental health problems. i. 117). larger-scale interventions might also be seen as being relevant to those health promotion activities that aim to prevent problems developing in the first place (Drummond. Those few books and articles available on this subject have either looked at large psychotherapeutic groups of over 40 members (Kreeger. Yalom. A large-scale format. as cost-effective prevention strategies often involve reaching large numbers of people. Secondly. . are likely to use the specialist mental health services. It has also been suggested that the cognitive-behavioural approach might be well suited to this style of working as it concentrates on information-giving and on skills teaching. L. 1975) with relatively little written about working with large groups. A potentially large ‘‘unmet need’’ for mental health services has been identified by Goldberg and Huxley (1980. and the GP’s decisionmaking regarding whether to refer someone to the specialist services or not. that is approximately 1. can be seen as particularly appropriate. However. attempting to meet this ‘‘unmet need’’ with the existing configuration of services would put an impossible strain on them. 1992). also show substantial improvement. Brown et al. S. larger-scale ‘‘psychoeducational formats’’. in trying to reach more people with mental health problems. In deciding the kind of large-scale format to use.

Further changes were also found to have occurred between the end of treatment and . The overall picture remains confused. the principles of systematic desensitization (Wolpe. that suggests that massed learning might be more effective is that by Stern and Marks (1973) who found that two hours of prolonged sessions of flooding was more effective with chronic agoraphobics than four half-hour ‘‘spaced’’ sessions of the same procedure. each workshop consisted of 16 to 20 people with diagnosed Generalized Anxiety Disorder. Alternatively. White et al. leadership is much clearer. the conditioned avoidance response may be blocked by challenge. On the other hand. ranging from half a day to several days at a time. leadership roles become more structured. (1992) ran six evening class workshops for 110 anxious patients. and sub-groups start to emerge. Experimental groups consisted of a cognitive. ‘‘blocks’’ of teaching. Beck Depression Inventory and Modified Somatic Perception Questionnaire) when assessed immediately after treatment. Adams and Reynolds (1954) found no differences between the effects of massed learning and spaced learning after the initial stages of the task. behavioural and a cognitive-behavioural group. Kimble’s (1949) study also supports the advantage of spaced learning by showing that learning a complex task was best achieved using relatively short training periods. Classical learning theory would suggest that massed learning is most effective in establishing new behaviours but that. In contrast. and quite fluid leadership arrangements. There has been only one study that has used a large-scale weekly (or spaced) format for a therapeutic group intervention. compared to a waiting list control group. spaced practice or intermittent reinforcement is more powerful in maintaining new behaviours (Gambrill. The authors suggest that ‘‘prolonging sessions increases the chances of some critical but unknown process occurring which facilitates improvement’’ (p. 1971). 1977). all patients in the experimental groups had improved significantly on four of the six main measures of anxiety (Spielberger State scores. rather than concentrated (Freeman. 1958) would suggest that a spaced gradual approach might be most effective. Some studies support the educationalists’ view. They suggest that the intervals between exposure might facilitate incubation of the original fear which had been aroused during the therapeutic session and which may also be increased by cognitive rehearsal. Fear Survey Schedule.Comparison of large and small stress management 221 Various changes that can occur as the size of the group increases have been described (Schiff & Glassman. Some of the relevant differences are that groups with less than six members have a greater degree of intimacy. more face-to-face interactions. 1972). However. When groups get larger than 25. although not on stress. For example. 1969. or longer. ‘‘Massed learning’’ formats tend to consist of either more frequent. with further development of sub-groups as face-to-face interactions continue to decrease. A study. with longer rest periods. There was also a placebo control group. changing cognitions or all of these. They found that. Rice. as size increases and faceto-face interactions decrease. Baddeley and Longman (1978) found that postal workers learned to type postal codes more effectively when learning was spaced (1 hour per day) rather than massed (2 hour sessions twice per day). ‘‘Spaced learning’’ teaching formats have tended to be one-and-a-half-hour to two-hour weekly sessions spread over a number of weeks. 275). The second consideration is of the timing of the sessions. once established. some educationalists argue that studying is more effective when learning is spread over a longer period of time. Clinical studies do not clarify the picture. However.

Carson. Interestingly. In an initial 12 week pilot period. Beck Depression Inventory and Modified Somatic Perception Questionnaire). 4 and 5. 9% for the first session.6%) with an average age of 30. Numbers of people who were in contact at six months were not given. 1986). A comparison is made of . ‘‘walk-in’’ clinics have been described where clients have been able to self-refer (Cheston & Schmidt. but psychologists have made several attempts to reach people who might otherwise not get help from specialist services. She found that attenders were mainly female and from social classes 3. Much of the work reviewed above has related to people referred through the traditional services. 1994. White et al. Cowan. Butcher and de Clive-Lowe (1985) offered members of the public twelve. Heller. follow-up at six months. Gill and Titman (1988) ran a two-day workshop for 31 participants covering self-awareness and coping methods for anxiety and depression.222 J. S. as measured by the Personal Causality Scale.4%).5 years. reduced in the six-month period after treatment in the experimental groups. participants in the placebo group also improved on three of the six measures (Spielberger State scores. as well as medication prescriptions. For example. 1986). has found that self-referrals are often in more need of psychological assistance than referrals coming through traditional channels. L. The 23 participants were largely female (69. In terms of severity of problem presented at such clinics. massed format and there has been only one study that has used a large. she does not report their ‘‘distress levels’’. half of all clients have dropped out by the eighth session (Garfield. although there were no data for the waiting list control group. Again. which seemed to be effective. On the whole. but it was stated that the dropout rate between the final session and the six-month follow-up ranged from 10% to 19% for the different interventions. two large-scale day-long ‘‘massed’’ stress workshops were run and members of the general public were invited to self-refer. 1994). in American studies at least. The programme covered a number of different areas. compared to clinical groups. it was found that consultations with GPs. she found that the most common problem was anxiety (18. On the other hand. Butcher and de Clive-Lowe (1985) reported that the attrition rate with their 23 initial group members was 39% by the end of the course. One common problem with any psychological intervention is a high dropout rate (Garfield. these few studies would suggest that attrition rates may be lower than those reported with individual clients in ordinary clinic situations where.5%) and depression (14. on average. no initial ‘‘distress levels’’ are reported. and then a further 8% over the period from the second session to the final sixth session. quoted in Cheston and Schmidt (1994). Powell (1987) reported a dropout rate of 17% at three-month follow-up. Unfortunately. In addition.5%). Mattsson (1992). weekly. massed format. The workshop was well appreciated by the attenders but was not formally evaluated. Heller (1994) described an evening ‘‘walk-in’’ clinic in South Tees that ran for 8. Few studies have used the massed format for group intervention. In the present study. followed by relationship problems (16. two-hour long evening class sessions. which then went up to 57% at the three month follow-up. Brown et al. No studies have investigated the small. (1992) reported lower attrition rates: this was 10% at initial assessment.5 years.

Several predictions were made. By implication. Second. gender. Four workshops were run: two initial full-day workshops and two more for the waiting list control group at the end of the three-month waiting list period. the range of people attending the workshops can be quite wide. social class and marital status. it was predicted that clients using the different referral routes would have different distress and stress levels. Spaced and Referred) group.Comparison of large and small stress management 223 the characteristics of these clients. This was based on the findings of Goldberg and Huxley (1980. as well as the effectiveness of these large-scale fullday workshops with small. 1992) that some people might not receive help for their mental health problems because they might be ‘‘filtered out’’ for a number of background characteristics such as age. it was predicted that the dropout rate of the LMS group would be less than that for the SSR group during the intervention. These data are compared with those obtained from a waiting list control group. Stress workshop attenders (LMS) and the waiting list control group (WLS) would be more likely to be female. employed and married compared to the small clinical (SSR) group. 1981). Sturt. Third. employment status. regardless of background. it was hypothesized that the three sets of attenders would differ in background characteristics. this would mean that. First. 1992). no predictions are made about the relative effectiveness of the LMS format and the SSR format. it was hypothesized that both the LMS and SSR groups would show more improvement than the WLS group. On the other hand. weekly ‘‘spaced’’ anxiety management groups run by the Psychology Service. The waiting list control group will be known as the WLS (Waiting List Self-referred) group. Massed and Self-referred) group and those attending the weekly anxiety management groups will be known as the SSR (Small. Hurry. Method Design The large-scale stress workshops were run in the context of a city-wide ‘‘Healthy Birmingham 2000’’ campaign that aimed to change the lifestyles of participants. given the opportunity to self-refer. & Wing. This hypothesis was based on there being more opportunities for participants to ‘‘drop out’’ of weekly sessions whereas the day-long workshop offers fewer decision-making points for this to occur. Tennant. This was based on the finding in some psychiatric studies (Goldberg & Huxley. people referred to the psychology service (and then to SSR group) would be more ‘‘distressed’’ than those who referred themselves in the LMS group and the WLS group. such that those with psychotic problems would be virtually certain to be referred to the specialist mental health services. Follow-up meetings . Fourth. many of the mental health problems identified through community surveys are neurotic problems that vary in their severity (Bebbington. The participants attending the large-scale day-long stress workshops will be known as the LMS (Large. 1980. Given the contradictory findings in the literature about the effectiveness of spaced and massed learning and the newness of the largescale workshop approach. that severity of problem is higher among those formally referred to the mental health services.

libraries. Subjects Publicity for the workshops started three months before the specific campaign month. It consists of 40 items. & Lushens. Gorsuch. Brown et al. Intervention The stress workshop programme was designed to run over the course of one day from 9. a psychiatrist or another mental health professional as part of a routine clinical service. run on either a Saturday or a Sunday. However. 1998b). The SSR group consisted of 36 people who had been referred to South Birmingham Psychology Service and been assessed by interview as being suitable for attendance at an anxiety management group. were arranged three months after the workshops. in a leisure centre and led by a team of four psychologists. leisure centres and community centres: letters were also sent to GPs and Practice managers. The local radio station and the Health Authority newspaper also publicized the workshops. A telephone number was given. 1970) was used to measure changes in stable ‘‘trait’’ anxiety as well as ‘‘state’’ anxiety. – A shortened version of the Symptom Checklist 90 (SCL-90) (Derogatis. either by their GP. Posters and information sheets were sent to GP surgeries. Instruments The assessment measures were: – Spielberger State-Trait Anxiety Inventory (Spielberger. Fifty-two subjects were allocated to the LMS group and 74 subjects to the WLS group. All participants were aged between 16 and 65 years. The small. but these will be reported on separately (see Brown & Cochrane. One hundred and twenty-six people indicated they wished to take part in the programme.224 J. weekly stress and anxiety management groups were only made available to those who had been referred to the local Psychology Service. There were 20–24 participants in each of the four workshops (including those who lived outside the District and those over 65 years of age). . and those who were over 65 years old are not reported. as there were no restrictions on age or place of residence because of the citywide campaign. results for those who lived outside of the catchment area of the Psychology Service running the small anxiety groups. They were randomly allocated to the LMS group and to the WLS group.30 am to 5 pm. and 20 items measuring Trait (or stable) Anxiety. 1983) was used to measure distress at inception to the study These two instruments were thought to give a measure of overall distress as well as measures of anxiety. Data are therefore reported for 36 subjects in the LMS group and 52 subjects in the WLS group. The workshops were free. Two other groups were also involved: the half-day group and a placebo control group. for the purposes of this comparison study. S. which members of the public could ring to book a place. L. with 20 measuring State (or transitory) Anxiety.

participants in the SSR group were more anxious on the Spielberger State . As well as the assessments previously mentioned. Procedure Subjects for the stress workshops (LMS and WLS groups) were invited to self-refer.17.Comparison of large and small stress management 225 The SSR groups were run over either six or eight weeks. Each session typically lasted between 1. Results Characteristics at inception into study The three groups did not differ on age. Subjects in the WLS group were offered a place on a similar workshop three months later. five small groups were run. lunchtime arrangements etc. on average. All subjects referred fitted the criteria and were invited to join the group. The model of anxiety was cognitive-behavioural and used Lang’s (1968) tripartite model of physical. cognitive methods. dfG2. Physical relaxation exercises. In all.05) and in employment status (ChiG6. active behavioural methods were also taught. including practical details such as car parking. dfG2. However. they were also asked to complete other pre-assessments for the later evaluation of the workshops. SSR group subjects were referred to the Psychology Service by their GP. Following the full-day workshop. marital status or social class. Further details of the programme are available in Brown and Cochrane (1998c). pF.25 and 1. Attenders were asked to complete the evaluation forms after three months and invited to attend a follow-up meeting. They were then assessed by a psychologist and invited to join the group if they were suitable. immediately before which they again completed the evaluation forms. cognitive and behavioural aspects of anxiety. All who rang to book a place were invited to attend an introductory talk at which they were given more information about the workshops. Incomplete details given by subjects has led to lower data sets for social class and marital status. There were differences on gender (ChiG 6. which were run in Community Mental Health Centres. There were. At this time.5 hours. The normality of anxiety was emphasized. two of the three relevant hypotheses were supported. they did not differ on initial Spielberger Trait scores. pF.05) with more women and͞or employed people in the LMS and WLS Groups compared to the SSR group (see Table 1).60. All those invited were asked to complete the assessment forms before the start of the group. six participants in each of the groups. When the referred (SSR) group participants were compared with the self-referred (LMS and WLS) group members. there was a follow-up meeting. The main selection criteria were that they had anxiety as their major problem and did not have psychotic symptoms. each by a psychologist and a non-psychologist colleague. Information was given about the relationship between stress and anxiety as well as on healthy lifestyles. The content of the programmes was similar. at which difficulties and achievements were discussed. LMS attenders were asked to complete the evaluation forms again after three months. However. psychiatrist or other mental health professional.

4%) 18 (34. Means for these groups are also given in Table 1.5). The non-contact rate at three months was 6 (16.7%) 1 (6. 28 (78%).7%) 10 (32.5%) 11 (34. Thus.3%) 11 (30.2%) 0 (0%) 20 (67.4%) 2 (6. therefore. dfG2.7%) 1.30 SSR group (NG36) 17 (47.92. The dropout rate over the course for the groups was 19.7%) 1 (6. Our prediction that SSR participants would be more distressed was supported.94.3%) 12 (37. With the SSR groups.96.6%) 4 (11.1%) 0 (0%) 21 (58.3%) 1 (3.4%.86 55. pF.4%) 11 (30. Sociodemographic and psychological details of groups Variable Gender male female ¯ Age (x) Employment status employed not employed Social Class 1 2 3 4 5 Marital status single divorced widowed married Psychological distress ¯ SCL-18 (x) Anxiety Spielberger ¯ State (x) ¯ Trait (x) LMS group (NG36) 9 (25%) 27 (75%) 44. Brown et al. Thus.12 34 (65.6%) 4 (12. pF0. five (13.6%) 7 (15.3%) 17 (66. There were no further dropouts from these workshops. the number who did not attend the groups at all was 6 (16. the number of people still in touch was 17 (47.5%) 3 (6.8%) 2 (4.20 54.7%) 9 (60%) 3 (20%) 1 (6.2%) 19 (52.9%) 1 (2%) 33 (64.3%) 20 (45. L.01) and more distressed as measured by the SCL (FG 6.59.9%) 12 (27. . 31 participants attended the two full-day workshops that were run.13 44.76 WLS group (NG52) 12 (23%) 40 (76.7%). with seven participants not finishing the programme. Attendance rate for interventions Of the 36 LMS group participants invited to attend the initial stress workshops.9%) 43.8%) did not attend at all.31 12 (33. All but three of the participants either came to the follow-up or sent their forms in at the three-month follow-up point.92 25 (69.50 51.41 42.2%).5%) 3 (9.8%) 41.4%) 2 (3.3%) 1. The number of people still in touch at three months was.5%) 15 (29.7%). S.7%) 1. Table 1.226 J.72 51.28 measure (FG10. dfG2.

53 0.86 36 1. Means and standard deviations of LMS.05 pF.75 17 1.74 0. Our hypothesis . dfG45. Our hypothesis was therefore supported. dfG62.80 1.47 17 1. A main group effect was found on the Spielberger State measure.Comparison of large and small stress management Table 2.01. the time effect was significant. dfG53.43.65 F 2.89 36 0. Analysis of SCL scores using two way Analysis of Variance with repeated measures Source of variation Group Time GroupBtime Sum of squares 2. Analysis of SCL scores (GSI av) A.10 42. but the group-by-time interaction just missed significance. LMS v SSR tG0.63 227 B.31 df 2.80 2. pF.256 0.98 7.57. NS pF. Effectiveness of formats Results from both types of intervention were compared with those from the waiting list control group using a two-way Analysis of Variance with repeated measures (see Tables 2–4).05 NS A Chi Square analysis comparing the number of subjects who attended and those who dropped out showed that the two formats differed significantly (ChiG9.93 0. Those in the SSR group were more likely to drop out of the group.03 0. SSR v WLS tG2. On both the SCL and the Spielberger Trait measure. 1.49 7.80 Var est.53 1.001 pF.64 0. there were no group differences but the group-by-time interactions were significant. pF. SSR and WLS groups LMS v WLS tG2.05 C.13 0. On all measures. dfG 1.24 3.48. SSR and WLS groups Time 1 LMS group N Mean SD SSR group N Mean SD WLS group N Mean SD 28 1. Change scores on SCL for LMS.49 Time 2 28 0.67 Sig.01).

Changes on the Spielberger Trait measure are shown in Figure 1. pF.00 10.74 df 2. SSR and WLS groups LMS v WLS SSR v WLS LMS v SSR tG1. Table 3.64 17 44. tG2.34 B. Analysis of Spielberger State scores using two way Analysis of Variance with repeated measures Source of variation Group Time GroupBtime Sum of squares 1872. dfG62. NS that the two interventions would be more effective than the waiting list was therefore supported. .34 Time 2 28 37.86 10.32 13. When change scores were compared.79 1.93.08 Sig.33 1617. NS dfG21.47 36 42.67 10.66 1617.92 516. Analysis of change scores on Spielberger State scores for LMS. Analysis of Spielberger State scores A.11 16.05 pF. S.26 3.55 17 54.05 dfG45.79 2. tG1. participants might experience less trait anxiety but increased state anxiety.37 F 4. SSR and WLS groups Time 1 LMS group N Mean SD SSR group N Mean SD WLS group N Mean SD 28 44.79 Var est. Brown et al.90. the full-day workshops appeared to be as effective as the weekly groups.92 258.001 NS C. 936.74 36 40. Means and standard deviations of Spielberger State scores of LMS. Change score analyses were used to allow for scores on the different assessments to go in different directions.228 J.80 19.61 10. L. pF.22.29. the differences on the t-test were each significant on two of the three comparisons made.

pF.87 380. tG1.67 36 50.25 10.51. SSR and WLS groups Time 1 LMS group N Mean SD SSR group N Mean SD WLS group N Mean SD 28 51.05 NS NS Analysis of more distressed and less distressed subgroups of LMS groups A more distressed subgroup of the LMS group was obtained by separating the top half (nG14) of the LMS on the initial Spielberger State measure for those participants for whom follow-up data were available. the latter was chosen because it better differentiated the two groups. dfG62. Means and standard deviations of Spielberger Trait scores for LMS.44 13.13 17 48.06 F 0.86.67 16. dfG20.72 10.86 17. which was almost identical to that for the total SSR group which was 54. SSR and WLS groups LMS v WLS SSR v WLS LMS v SSR tG2.68 807.61. NS pF.01.86. The mean Spielberger State score of this group (to be known as LMS 1) was 54.Comparison of large and small stress management Table 4. The State score was used for this analysis as the SSR and workshop groups only differed on the SCL and the State scores (Table 1). A less distressed subgroup was obtained from those in the lower half (nG14) on the initial State measure.11 9.52 4. The .87 190. Analysis of Spielberger Trait scores A. dfG22.88 17 54.79 1.11 229 B.29 10. tG0.001 pF.79 2. 184.37 Time 2 28 44.90 36 50.20.13 df 2.79 Var est.12 Sig.35 807.05 C.3. Analysis of Spielberger Trait scores using two way Analysis of Variance with repeated measures Source of variation Group Time GroupBtime Sum of squares 369. Analysis of change scores on Spielberger Trait for LMS.

79. Comparison of three groups on Spielberger Trait measure mean score of this group (to be known as LMS 2) was 33.33 Spielberger State scores ¯ n x SD 14 14 14 14 54.001).05).79 34. dfG3. all three measures showed a main time effect ( pF.93 7.6 40.05).0 48. dfG3.9 39.09. L.7 9.001) and the Spielberger Trait measure (FG2. S.5 11.08.5 Spielberger Trait scores ¯ n x SD 14 14 14 14 0. pF. pF.57 0. pG.78.053). The interaction for the SCL just missed significance (FG2.94 0. Brown et al. dfG3.97 0.52 0.001) and a main group effect: the SCL (FG3.34. Means and standard deviations of scores of LMS ‘‘high stress’’ and ‘‘low stress’’ sub-groups SCL scores ¯ n x SD LMS 1 LMS 2 (pre) (fu) (pre) (fu) 14 14 14 14 1.4 7. dfG3.02.11 6.8 . the Spielberger State measure (FG1556. dfG3.75. There were also two significant group-by-time interactions on the Spielberger State measure (FG7.1 33.001) and the Spielberger Trait measure (FG3. pF. Means for all variables are shown in Table 5.55 0.79. pF. dfG3.78.72 0.51 10.67.1 11.78. Table 5.230 J.20 10. pF.1 45. Using a two-way Analysis of Variance with repeated measures to compare the more distressed (LMS 1) and less distressed (LMS 2) groups with the SSR and WLS groups. Figure 1.

NS * NS NS NS Spielberger State difference t 1. Sashidharan. the LMS 1 (high distress) group and WLS group differed significantly on all three measures and the LMS 2 (low distress) group differed on only one measure. 1979) although the contribution of unemployment to the decision to refer is not entirely clear. and contrary to findings in some other studies (e. 1983) as more working people attended the workshops than the SSR group sessions. more working people were able to attend. Hallam.19 1.02 2.01.14 df 30 48 48 30 26 Sig. Surprisingly. Ingham and Miller (1988).001. However.g. the Spielberger State and the SCL scores of the LMS . 1980.59 3. NS *** NS * *** 231 Spielberger Trait difference t 0. found that single women were more likely to use the specialist psychiatric services than married women under the age of 35 years. 1994). it is likely that the result from this study may be an artefact of the selection procedure for the small group as the results from a larger study (Brown & Cochrane.05. 1982. 1980). Discussion Given an opportunity to refer themselves for psychological intervention in this study. a finding congruent with other studies (Butcher & de Clive-Lowe.05 0. 1985.Comparison of large and small stress management Table 6. Marks.54 df 30 48 48 30 26 Sig. & Philpott. When the distress levels of participants in the LMS. Heller. 1998a) do show marital differences between self-referrals for the workshop and all clients treated by the Psychology Service.45 −0. NS *** * NS NS * pGF. Goldberg & Huxley. tends to favour the unemployed being referred to the specialist services: there is evidence to show that unemployment may prompt GPs to recognize mental health problems (Goldberg & Huxley.88 0. Kreitman. An alternative perspective is that the ‘‘filter system’’. It is possible that the self-referral system offered in this study may have provided an alternative route for people who might otherwise have been ‘‘filtered out’’. *** pF. In the comparisons of the change scores of the intervention groups with the WLS group.. which has commonly been associated with mental health (Banks & Jackson.78 df 31 48 48 31 26 Sig. Cochrane.9 2.04 4. SSR and WLS groups were compared before intervention. Connolly. more women were willing to do so than men. ** pGF.45 2. The results of the change score analysis are shown in Table 6. The other key finding was that the amount of change exhibited by the LMS 1 group and SSR group did not differ.22 4. An analysis of the change scores using the t-test was again also carried out.09 0. t-values and significance levels from comparison of change scores between the LMS sub-groups with SSR and WLS groups SCL difference t LMS 1 v SSR LMS 1 v WLS LMS 2 v WLS LMS 2 v SSR LMS 1 v LMS 2 −0. marital status was not a variable which differentiated the composition of the two groups. Another clearly significant differentiator was employment status. for example. Surtees.25 1. It may be that because the workshops were held at weekends. which operates to select people out of formal mental health care.

These include convenience and time for the client. Nor was the idea that only the least distressed would be capable of benefiting from such an intervention supported. These data do not support a commonly held idea that it is only the ‘‘worried well’’ who enrol in large-scale public workshops. Such a format might also reduce the travel time involved. Brown et al. However. a number of practical considerations will affect which format is chosen. the range of distress of those enrolling for the stress workshops was quite wide so that those with minimal problems enrolled alongside those with really quite severe problems. transport. S. A reasonable conclusion from this study is that the LMS group format and the SSR group format appear to be equally effective. childcare) that may need to be made. It may be that deciding to come for a day involved quite a degree of commitment. with limited opportunities for one-to-one interactions and with limited weekly monitoring of homework assignments. they stayed for the full day. Another factor may be that because the stress workshops were held at the weekend and in a leisure centre. The analysis comparing the more distressed subgroup of the LMS group with the SSR group showed the full-day workshop was just as effective even with this more distressed group as was the weekly format for SSR participants. On the other hand. and the third measure just missed significance. showing that the underlying pattern of worry for the three groups were more similar. the average Spielberger Trait scores of the groups were not significantly different. however. Perls. so that once people had made the decision to come. it could be that SSR group participants had more points at which to make a decision about whether or not to continue to come to sessions. This set of results suggests that a full-day workshop format can be seen as a realistic alternative to the traditional small weekly group. .g. The drop-out rate for the small (SSR) groups was clearly higher than for the largescale day-long (LMS) workshops. It may also be that a full day tends to reduce the amount of ambivalence that may be experienced when change is required (Clarkson. but may have needed to have been more assertive to opt out at these stages. This would suggest that a large-scale workshop. it may have been a more convenient setting and time for people to participate than a more traditional mental health centre on a weekday. 1989. participants in the day-long group could have decided not to return after any of the three breaks in the day.232 J. and WLS groups were different from those of the SSR group.. Alternatively. two of the three measures indicated significant group-by-time interactions in the expected direction. Apart from effectiveness and drop-out rate. L. the two treatment groups did not differ when the change scores were compared. Both LMS and SSR groups showed significant changes compared to the WLS group as a result of the intervention. These indicate that those who had been referred to the specialist services in the traditional way were more overtly anxious and distressed at inception into the study than were the self-referrers. 1976). It was. possible to identify a sub-group of workshop attenders whose initial distress levels were equivalent to that of those in the SSR group. This would indicate that when a self-referral route was opened. It might be easier to come for a full day rather than come to a series of weekly sessions. Further. reducing the re-arrangements (e. can be very effective even with quite severely stressed clients.

Effect of shift in distribution of practice conditions following interpolated rest. weekly groups run for referred clients. In considering these results. 1988) indicate a need for caution in coming to such a conclusion. The range of measures used was limited to self-report symptomatic questionnaires as behavioural measures were difficult to obtain in the large-scale context of this study. For group leaders too..25) or 12 hours (8B1. demonstrating that the effectiveness of this approach is not restricted to a less distressed client group. (1954). . especially when large groups of people have to be reached. A check on the interventions was not attempted. There is a continuing debate concerning what the ‘‘curative’’ factors in group treatment might be. reported by Powell (1987) and repeated again by White et al. such as excessive dependence on the group as well as limited effectiveness (Maton. In addition. The suggestion that ‘‘non-specific factors’’.5 hours (6B1.Comparison of large and small stress management 233 Another issue is that of overall time involved in each format. run by different group leaders and for different periods of time. have encountered. A randomized control design whereby self-referrals were randomly allocated to a small weekly group or to a large day-long workshop may be used to make the groups more comparable. such as the opportunity to talk to other people with similar problems. J. the difficulties that some self-help groups. an additional analysis showed that the large-scale format was just as effective with a more distressed subgroup as the small weekly format for formally referred clients. the effectiveness of the workshops. Many thanks also to South Birmingham Psychology Service for supporting the project. and the severity of problem handled within this format indicates potential value in this kind of approach. The workshops lasted six hours. may lead to the hypothesis that the kinds of coping skills taught may be less important factors than group leaders believe. (1992) are important elements. no attempts were made to match the two interventions so that the two groups were seen in different settings. 32–36. there are also time considerations with travel and preparation time as well as ‘‘re-orienting time’’ at the beginning of each session. day-long workshops open to the general public can be as effective as small. References ADAMS. dissatisfaction reported from an information-giving and ‘‘physical exercise’’ group run to help manage stress (see Brown. Nevertheless. Whilst there were some differences in client psychological characteristics because of the different referral processes. which indeed have offered opportunities to share problems with each other. & Hancox 1998b) would suggest that the solutions are not necessarily simple. Journal of Experimental Psychology. It would appear that the low drop-out rate. The weekly sessions lasted either 7. Cochrane. B. Future studies might include self-reports of behavioural changes such as frequency of going to the GP and medication taken. In addition. This study has shown that large-scale. it is important to acknowledge that there were some methodological weaknesses. Acknowledgements Many thanks are due to the people who participated in the workshops and small groups.5). Yet the extra time of engagement did not lead to detectably superior outcomes. 47. & REYNOLDS. A.

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