45. group therapy

8/12/2019 45. Group Therapy

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45. GROUP THERAPYohn F. Zrebiec, M . S . W .

1 What is group psychotherapy?It often has been defined in the broadest terms, encom passing many kinds of g roups w ith goalsthat range from behavioral change to educational exchange. Group psychotherapy is considered hereas a field of clinical practice and a specific approach within the realm of psychotherapy. All grouptherapy is aimed at alleviating illness or distress with the help of a trained leader. What distinguishesgroup treatment from other methods is the use of group interactionas the agent for change.2 How did group therapy begin?

In 190 5, Dr. Josep h Pratt, a Boston physician, brought his tuberculosis patien ts together f orweekly discussion groups and found that these meetings seemed to improve mutual supp ort, allevi-ate depression, a nd decre ase isolation. M oreno, who is best known f or developing psychodrama,first used the term group therapy in the 1920s. Group treatment largely was considered ineffectiveuntil World War 11 The many neuropsychiatric casualties returning fro m the war com pelled the gov-ernments of the Un ited States and England to find ways to treat these veterans more efficiently andeconomically. Since then, the group therapy field has mushroomed and is now applied in many dif-ferent clinical settings for many different types of problems.3 What are the advantages of group therapy?The patient recreates characteristic difficulties in the group. Interactions in the group quickly

expose patterns of behavior.The h all of mirrors concept refers to the groups ability to confront an individual with be-havior he o r she had been unable to recognize. Individual m emb ers are more likely to accept feed-back about their behavior if it comes from multiple observers.Multiple supporters who empathize with the patients struggle can make confrontation moretolerable and dealing with intense affect more possible.The revelation of sham eful secrets can lead to imm ense relief.Group interactions pull for socially acceptable responses and interchanges.The group o ffers alternative mo dels for behavior.Group therapy often is experienced as less regressive than individual therapy.4 What are the disadvantages?Patients get less exclusive time and attention than in individual therapy.Groups can create a feeling of being lost in the crowd, and of not being appreciated fo r ones

Confidentiality has limitations. The group leader cannot guarantee that members will maintainTermination is more complicated (less flexible, more final) than in individual therapy.

uniqueness.confidences.

5 Are there different theoretical viewpoints?Originally, most group therapy was established on psychodynamic principles; now most grou ptherapists use a combination of theories. For example, a comm on blend of m odels is psychodynamic(focused on individual group mem bers), interpersonal (focused on interactions between mem bers),and group as a w hole (focused on the group processes). This chapter blends those mo dels into somegeneral principles that are broadly applicable to a wide variety of groups, of any length and type, inany clinical setting.23 1


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3 Group Therapy6 What do I need to do first?A successful group requires thoughtful planning:

Clarify your own values about why group treatment is valuable.Assess the institution in which you work and whether it values group treatment. Will the insti-

tution and yo ur colleagues be friend o r foe in your attempts to start a group ? Who values or devaluesgroups ? W ho has the authority to help you start a group? Wh at kinds of groups are already in exis-tence? What kinds of patien ts need a group? How will you get your group members? How muchcompetition is there between professionals for these patients?Consider the type of group you are offering. Groups range from discussion and them e-centeredor supportive/educational to process-oriented therapy . It is essential to be clear about the type of groupso that you can explain the purpose of the group to potential patients and referral sources and defineyour role as leader. For exam ple, in a soc ial skills training grou p, the leaders primary role is teacher,whereas in a psychody namic group , the leaders role is interpreter of unconscious phenomena.

7. How do I select patients for groups?Many different criteria have been proposed for selecting patients. In general, most patients canwork effectively in some type of group therapy. If patients are willing to listen to others and talkabout themselves, then they are group therapy candidates. Exclusionary criteria are: refusal to entera group or abide by group ag reemen ts and serious problems with interpersonal relatedness. Contraryto popular opinion, people wh o do not do well in groups are not the prime candidates fo r groups.Caution also needs to be exercised in including patients who are highly impulsive, acutely suicidal,homicidal, or psychotic.8. Which group for which patient?Groups are not random collections of strangers thrown together because a clinic has too few

therapists an d too many p atients. It i s important no t only to select patients wh o will benefit fromgroup therapy, but to place them in a grou p that is particularly appropriate. B eginning groups tradi-tionally comprise m embers w ho ar e similar in terms of ego development but d ifferent in terms of in-terpersonal style. For example, the ability to establish trust or capacity for concern is similar, butdegrees of shyness o r submissiveness are different. Most im porta nt is that no members see them-selves as one of a kind in the grou p because they w ill be at high risk to drop ou t. To use a broad ex-ample, the only elderly, widowed man in a group w ith youn g, new mo thers is going to find littlecomm on ground w ith other memb ers and is likely to quickly leave the group.There are three reasons why patients drop out of groups:Th e right group at the wrong tim e (the patient is not ready for group).The wrong group at the right time (e.g., the elder widower w ith the young mo thers).The patient i s not suited fo r group treatment.

9. Should I conduct a screening interview?Ideally, there should be at least one individual interview before a patient is accepted into agroup. Som e patients may requ ire more if they are unfamiliar w ith therapy or ambivalent about join -ing the group. Assessment of a patient, for gro up therapy in general and for your gro up in particular,requires face-to-face contact. The interview also helps form an alliance between leader and member,establish goals, provide education about the role of the leader and the members, review the groupagreements, answer questions, and address potential problems. Finally, it gives the patient an oppor-tunity to m ake an informed decision about joining the grou p.

The Screening Interview: ommonQuestionsWhat do you want to get out of this group?Why do you want to joint th is group at this time?What is your experience in groups (prior treatm ent, but also including family, school, job,social groups)?

uble continued on ollowing puge


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Group Therapy 233The Screening In terview: ommon Questions Cont.)

What do you imagine this group will be like?What do you think you will contribute to thiy group?What will be the most difficult aspect of this group for you?May we review group agreements?

10. Should I have a group agreement?Yes. All groups n eed so me operational guide lines that provide structure and a baseline fo r ad-dressing any future behavior that jeopardizes the group. T he following guidelines traditionally havebeen used by psychodynamic group therapists. They can be modified for time-limited groups, andfor groups with a variety of patients in different settings. Members agree to:Attend each m eeting, be on time, and remain for the en tire meeting.Work on the problems which brought them to the group.Realize that communication is verbal and not physical.Protect the names an d identities of other group mem bers.Use relationships therapeutically and not socially.Remain in the gro up until the problems w hich brought them to the group are resolved.Give appropriate time to themselves and to the group to understand the reasons fo r leaving,Give the leader permission to speak with their individual therapist (if they have one) at anyBe responsible about paym ent.

should they decide to leave, and to say good-bye.time that the leader feels it is in their best interests.

11. What are the basics in terms of time size and place?Most gr oup s meet weekly, although som e groups meet twice weekly, and others meet twicemonthly. The im porta nt poin t for therapeutic benefit is that patients do not lose contact with theaffect and pro cess of the previous meeting. The usua l time period is 90 minutes, with the range75-120 minutes. Less than 75 minutes is not enough time f or m embers to get their fair share, andmeetings longer than 120 minutes can be exhausting for m embers and leaders.Group size is four to ten members. Fewer than fou r mem bers provides a temptation to focus onindividuals, not grou p processes; more than ten seems to becom e unm anageable and less productive.Mo st group experts recommend seven as the ideal number with higher-functioning patien ts, andstarting with at least that many patients to compensate for potential early drop-outs.It is the group leaders responsibility to arrange for a comfortable, private room with e nou ghchairs for everyone. Most grou p leaders prefer chairs in a circle so that mem bers are not physicallyhidden from one another by tables or other furniture.12. What is the role of the leader?To help the gro up mem bers understand themselves by understanding their behavior in the group.The leader, then, has the challenge of deciding how the group can best be helped. Several decisionsare involved:What to say, how m uch to say, and when to say it.How m uch attention to give to the present experience versus past events or future hopes.How much attention to give to individuals while still observing interactions between members.

How m uch value to give to feelings and em otional experience without ignoring reason and in-How to integrate dialogue about group memb ers with discussions about people outs ide theHow to blend understanding of the con tent (obviou s me aning ) with the process (symbolicHow much to respond to group dem ands or wishes.How much personal information to share.

tellectual understanding.group.meaning)


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234 Group TherapyAll of these leadership decisions are influenced by theoretical orientation, personality, and con-text of the group. Moreover, all are a matter of degree, not all or nothing, and each has consequencesfor the group.

1 Useful Rule s.for the G rou p Therapist12.3.4.56.78.9.

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Each meeting is in a context time, place, purpose).Each group member has a context. Try to keep in mind their history and presenting problems.Pay attention to what is happening in the group at that very moment . the here and now focus.Ask yourself What is happening? Why is it happening now?Remember everything that happens in the group has something to do with the group.Each group meeting has a theme r connecting thread.Pay special attention to the beginning words and behaviors that might predict the theme.Think in terms of metaphors or analogies as a clue to the theme of the group.Pay attention to your own emotional response to the group as a barometer of what is happening in themeeting.Do not panic if you do not always know what is happening in the group. This is a common experi-ence. Remember the above points and try to formulate hypotheses that can help you make an edu-cated guess about the theme.Prepare a summary statement whether you actually state it or not, as a way of organizing the grouptheme.

13. Are there advantagesto co-leadership?Co-therapy is a frequently used model, primarily for training. The most important and time-con-suming aspect is the need for the co-therapists to maintain their communication and attend to theirrelationship.AdvantagesFor PatientsEnhances continuity in case of leader absenceMay provide a constructive relationship model

Replicates a two-parent familyProvides more limit-setting capabilityProvides mutual support and co-supervisionOffers two vantage points on groupAllows leaders to share or change roles from

for imitation

For Leaders

verbal to observational and focus from wholegroup to individualHelps in dealing with crises and concrete tasks14. Are there stages in group development?

DisadvantagesIncreased costDestructive competitionLack of communicationSerious disagreement based on eachleaders different professional,clinical, or administrative roleDistancing from the emotional im-pact of the experienceOne leader overshadowed by moreexperienced other

~It is valuable for the group leader to have a developmental framework for understanding groupthemes and the myriad interactions of group process. Yalom proposes a useful framework for think-ing about these four developmental stages.Stage 1 in or out)-searching for purpose, getting to know other members, finding siniilari-

ties, and learning the ground rules. Members are primarily concerned with acceptance and nonac-ceptance. Do the others like me? Are we similar? Communication in this stage often is superficial,polite, focused on giving or seeking advice, and gaining approval from the leader. The leaders pri-mary role is to promote trust and safety, and to help members find common ground.Stage 2 top or bottom)-jockeying for positions of control, dominance, and power amongmembers, but above all, between members and the leader. The honeymoon comes to an end as safetyand trust are established. Now, members want to know how they are different, how much autonomythe group leader will permit, and how much they can challenge one another and the leader. How can


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Group Therapy 235they batter, bend, and break g roup guidelines? Wh o are the strong on es? Whereas in the first stagemem bers were primarily c oncerned w ith being seen as the sam e, now they are primarily concernedwith being accepted as different. Criticism of o ne another, hostility toward the leade r, and d isenchant-men t with the group are typical. The group has great expectations of the leader so it should come as nosurprise that they a re disappointed in the leaders failure to fulfill their dreams. It is essential that thegroup leader tolerate their disappointm ent, encourage their confrontation, and not respond punitively.Rem ember that this rebellious, emotionally stormy phase is a sign that the group is moving ahead.Stage 3 (nea r or far)-the chief concern of the group is intimacy and closeness. How close toget to others? How many secrets to sh are? Following the previous stage of conflict there is moretrust, coop eration, openness in co mm unication, and group spirit . The leader sets the stage forprogress by making sure that the group does not suppress all negative affect for the sake of group co-hesiveness. The group is now ready to become a mature working g roup, with focus, flexibility, com-passion, a g reater tolerance for affect, a realistic appraisal of the leader, and a recognition of thevalue of other mem bers.Stage 4-termination. It is the leaders jo b to draw the attention of the group m embers to theloss. Ordinarily, termination resurrects feelings around three themes: mortality and death, separa-tion, and hope.These stages are present in all groups, but the depth and breadth of expression differ dependingon the goals, time, and leadership style. There is overlap, with no clear boundaries betw een stages orconsistency between groups. Groups never ultimately resolve these developmental issu es, but peri-odically cycle through them at progressively deeper levels as stresses and conflicts emerge.15 How do I hand le difficult patients?The difficult patient, often self-centered o r dem anding, can create a difficult group an d a scape-goated g roup m ember. Volumes have been written about m anaging d ifficult patients, but it is worthmentioning one particularly constructive approach in groups. It is based on the premise that the dif-ficult patient plays an im portant role for the g roup and represents aspects of everyone else in thegroup . The most therapeutic response is to focus on the reaction of other group mem bers rather thanon the pathology of the individual patient. This approach avoids further attack on the individual pa-tient and encourages others to take responsibility for their share of the interaction.16. What ab out combining group therapy with pharmacotherapy or individual therapy?Psychotropic m edications are common in groups and essential for psychotic patients. Attitudesabout and reasons f or medication typically become a topic for group d iscussion.Many patients receive concurrent individual and group therapy, which can be a powerful com bi-nation. There are two variations: combined therapy, in which the same therapist sees the patient inboth individual and group therapy, and conjoint therapy, in which the patient is seen in individualand group therapy by two different therapists. Gro up therapy often is added to individual treatment,but patients can be referred fo r individual treatment from group, as well. Note that neither m ode oftreatment sho uld be viewed as better than the other. When considering combined or conjoint therapy,be sure to review repercussions for communication, confidentiality, and countertransference.17. How do I decide when to terminate?Time-limited groups come to a preordained ending. Other groups end because of the leadersdecision to terminate. Patients leave groups because they have successfully completed treatment orleave prematurely for a variety of personal, gro up, and circu ms tantial reaso ns. Th e leave-takingprocess is more complicated than in individual therapy because it affects a number of people, notjust th e therapist. The leader should attempt to prevent premature termination and should draw atten-tion to the feelings surround ing termination. Two helpful questions are: 1 ) Has the patient leavinggained the m ost possible from the group? (2) Why is the patient leaving at this particular time? Thedecision also can be examined on the basis of w hether the original goal for joinin g the group hasbeen accom plished. Interestingly, groups often assess the constructive ch anges and continuing con-flicts exhibited by the terminating member.


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236 Relaxation Training18. Is there a place for brief group therapy?Time-limited treatment is becoming more common because of cost-limited care. Time-limitedgroups often are formed around specific symptoms, crises, or comm on issues (for exam ple, medical ill-ness, divorce, or adolescence) with limited goals of sym ptom relief, crisis managem ent, or support andpsychoeducation. Brief-treatment groups also are designed for more aggressive interpersonal interven-tion and more am bitious therapeutic change. They have in common a careful selection of patients, ex-plicit goals, a well-defined w orking foc us, rapid application of learning, active leaders, the use ofinterpersonal resources, and the use of time limits to accelerate behavior change. Unlike longer-tenngroups, patients can return fo r several courses of treatment; in both, success is predicated on carefulpregroup preparation.Time-limited groups also can be conceptualized as having developmental stages (see Question14 .Progression through stages may be intensified because of the time limit.19. Can the leader guarantee confidentiality?The legal and ethical responsibility to protect the patients privacy and confidentiality is uncom-prom ised and uncomplicated for the therapist doing individual treatment. However, although the samestandard applies for the group therap ist, group therapy poses sp ecial problem s because patients are ex-pected to respect the identities and protect the inform ation shared by other gro up mem bers. In actuality,group therapy places limits on confidentiality (when one grou p m ember violates the confidentiality ofanother) because neither the leader nor the other group mem bers have any legal means of enforcement.

BIBLIOGRAPHY1 Agazarian YM: System-Centered Therapy fo r Groups. New York, Guilford Press, 1997.2 . Alonso A, Sw iller HI (eds): Group Therapy in Clinical Practice. Washington, DC, American Psychiatric3. Bernard HS, MacKenzie KR (eds): Basics of Gro up Psychotherapy. New York, Guilford Press, 1994..4. Dies RR: Models of group psychotherapy: Sifting through the confusion . IntJ Group Psychothe r 42: 1-17, 1992.5 Kaplan HI, Sadock BJ (eds): Comprehensive Group Psychotherapy. Baltimore, Williams Wilkins, 199 3.6. Klein RH, Bernard HS, Singer DL (eds): Handbook of Contemporary Group Psychotherapy: ContributionsFrom Object Relations, Self-Psychology, and Social Systems T heories. Madison, CT, InternationalUniversities Press , 1992.7. Roth BE, Stone WN, Kibel HD (eds): The Difficult Patient in Group. Madison, CT, International Universi-ties Press, 1990.8. Rutan JS, Stone WN: Psychodynamic Group Psychotherapy. New York, Guilford Press, 1993.9. Scheidlinger S: Grou p dynam ics and grou p psychotherapy re visited: Four decades later. Int J Group

10. Steenbarger BN , Budman SH : Gro up psychotherapy and managed behavioral health care: Current trends and11 Yalom ID: T he Theory a nd Practice of Gro up Psychotherapy. New York, Basic Books, 1995.

Association Press, 1993.

Psychother 47:141-159, 1997.future cha llenge s. Int J Group Psychother 46:297-309, 1996.

46. RELAXATION TRAINING

1 What are the major forms of relaxation training?MeditationProgressive muscle relaxationHypnosisAutogenic training

Self-guided, passive attention to sing le object of focusSystem atic contraction and relaxation of m ajor muscle groupsVerbal and repetitive sug gestion s, often involving mentalimagery, to relax mind and bodyStructured series of formalized suggestions directed towardpromoting body sensations associated with relaxation

45. group therapy

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