Group Therapy

Prepared by: Jincy Jose, MSc.Nursing, Manipal College of Nursing, Manipal

Introduction

Human beings live in a social world in which their ability to gain esteem and self definition significantly follows from their success in their personal relationships. Psychotherapy in a group setting provides a social arena in which the members can learn about their assets and deficits through interactions with peers and authority. Members also have opportunity to experiment with newly learned behaviors in the protected environment of the group in preparation for using them in the external world.

HISTORY

Group psychotherapy began at the turn of the century when Joseph Pratt, a Boston physician, recognized the positive effects of bringing the tuberculosis patients who did not have access to sanatoria.

Their recovery requires strict hygienic regimens in their impoverished homes. Using regular group meetings he educated his patients as to how to combat the diseases.  Other psychiatrists were influenced by this method. Cody Marsh even included dance classes in his hospital, he said that “By the crowd they have been broken; by the crowd they shall be healed”. The role of the charismatic leader and the dynamics of group relationships were recognized by Freud later.

Group therapy received a stimulus during World War II when many therapists were initially exposed to group works during their military experience. Theoreticians from England and US applied psychoanalytic or interpersonal theory to group therapy concepts. Interest in group process, stimulated by the work of Kurt Lewin. The social revolutions in the 1960s resulted in the beginning of sensitivity training experiences (T groups), and a variety of personal growth groups. The emergence of transactional analysis, gestalt theory, bioenergetics, existential models for group therapy and many additional innovative variations have enriched the group therapy fields.

In Britain and  America during the second world war, an appreciation of group psychology lead to a wide range of innovations, the most important are the following- the use of the group approaches for the selection and allocation of work responsibilities, studies of group morale, the integration of psychiatric knowledge in the management of large groups through the role of the command psychiatrist.

Early pioneers – Jocob Moreno was the innovator of group psychodrama. He also introduced sociometry, a scientific method for the study of group affiliation and group conflicts. Slavson was an educationalist of psychoanalytic persuasion that became the central figure in the development of group therapy and group psychodrama. His organizational efforts leads to the formation of American Group Psychotherapy Association. Alexander Wolf and Emanuel Schwarts began to apply psychoanalytic ideas to the group therapy in the late 1930’s in their therapy people underwent psychoanalytic therapy under the group setting.

DEFINITION OF GROUP

A group is a collection of individuals whose association is founded on commonalities of interest, norms and values. Membership in the groups may be by chance, by choice or by circumstances

DEFINITION OF GROUP THERAPY

1)  A type of psychiatric care in which several patients meet with one or more therapists at the same time. The patients form a support group for each other as well as receiving expert care and advice. The group therapy model is particularly appropriate for psychiatric illnesses that are support-intensive, such as anxiety disorders, but is not well suited for treatment of some other psychiatric disorders.

2)  A type of psychoanalysis in which patients analyze each other with the assistance of one or more psychotherapists, as in an "encounter group

3)   A form of psychotherapy that involves sessions guided by a therapist and attended by several clients who confront their personal problems together. The interaction among clients is considered to be an integral part of the therapeutic process

4)  Group therapy is a form of psychosocial treatment where a small group of patients meet regularly to talk, interact, and discuss problems with each other and the group leader (therapist).

Cognitive behaviour group therapy

Definition: A form of group therapy developed according to the principles of cognitive-behavioral therapy (CBT). The two primary techniques used in cognitive-behavioral group therapy (also known as CBGT) are cognitive restructuring (changing negative thinking patterns) and exposure (facing feared situations). Also Known As: CBGT

PRINCIPAL MODELS OF PSYCHODYNAMIC GROUP THERAPY

The therapist

The therapist is responsible to the group and to the institution in which it is set. He should have an appropriate training to perform the task. A formal qualification in psychotherapy is the ideal training. This will have included theory, personal therapy for the therapist and clinical supervision. Mental health professionals from all the disciplines make an active contribution to a rich and diverse service with the training requirement of theory and supervision.

The establishment of a group begins as a management task in the definition of its goals , recruitment of its members , protection of its setting , venue etc. it evolves as a therapeutic task in which the therapist is responsible for maintaining the therapeutic attitude to the individual members and to the group as a whole.

Structure, process and content: the dynamic element of the group.

Structure-Structure describes the more enduring aspects of any group’s make up- the architecture of the interpersonal relationships are conceptualized in terms of setting and its boundaries and then conceptualizes in the bond between each individual , the therapist and the group as a whole.

Process -Process describes the fluid and the dynamics fluctuations of emotions and experiences , the business of relating and communicating the changes of association and the inter member responses

Content-The content of a group’s exchange in its visible and audible events in the narrative line and dramatic content of peoples encounters, the topics raised , discussed and the thematic development.

Structure

Process                              content 

  The dynamic elements of a group

Models of group therapy

A.    INTERPERSONAL GROUP THERAPY

The focus is on interpersonal learning as a primary mechanism of change. The group provides the antidotes to mal adaptive interpersonal beliefs and behaviors through feedback from others and encouragement to experiment with healthier behaviors, first with in the group and the outside. The joint examination of inter group transference reactions allows members to replace processes that have a historical origin in the ‘there and then’ – the dynamic past – with in those more appropriate to the here and now – the dynamic present

The elements of an interpersonal group

The model represents that the interpersonal dynamics are kept at fore front of member’s attention by the therapist. The inter personal approach places the therapist among the other members of the group with out giving him or her distinctive identity or any formal demarcation for the boundaries of the group as a whole.

Yalom suggested 11 curative factors according to this model. They are

• Instillation of hope

• Universality

• Imparting information

• Altruism

• Corrective recapitulation of primary family group

• Development of socializing techniques

• Imitative behaviour

• Interpersonal learning

• Group cohesiveness

• Catharsis

• Existential factors

THE TAVISTOCK MODEL

This model is developed by Bion. According to this model, in a group at any point of time, its culture and climate are governed by primitive unconscious anxieties that impede its capacity for a rational work. This is a therapist centered approach. The two –body psychology used here to enforce a series of interactions and it helps to reduce the complexity and the constraints of the group work.

                                       The element of Tavstock group.

III.  THE GROUP ANALYTIC MODEL

Groups may begin with relatively high level of group activity and leadership activity, referred to as dynamic administration. This approach integrates the important aspects of the other two models. The therapist is encouraged to address the individuals as well as the whole group. This concept is developed by an integrated set of concepts of structure, process and outcome.

The elements of a group analytic group

Indications for group therapy & selection of patients

In group therapy, the interaction of group members offer possibilities for change and growth. But whether patients referred for group psychotherapy are going to benefit from the treatment depends to a large extent on their careful selection and preparation. Group therapy appears to be most useful for patients whose problems are mainly in relationships with other people. The most expected candidates for group therapy define their problem as interpersonal, they are committed to bring change in relationship, are willing to be influenced by the group and engage in appropriate self disclosure.

Patients should be offered a group that is best suited for their problem and it should be ascertained whether the patient is suitable for group therapy or not. For this a therapist needs a great deal of information. A screening interview, psychiatric history and mental status examination can help to select patients for group therapy. There are some inclusion and exclusion criteria for group therapy.

Inclusion criteria

• Ability to perform the group task

• Problem areas are compatible with goals of the group

• Motivation to change

Exclusion criteria

·        Marked incompatibility with group norms for acceptable behaviour

·        Inability to tolerate group setting

·        Severe incompatibility with one or more of the other member

·        Tendency to assume deviant role

COMPOSITION OF GROUPS

Size---Group therapy has been successful with as few as three members and as many as 15 but most therapists consider 8-10 members the optimal size.

Homogeneous versus heterogeneous groups

Many therapists believe that a group should be as heterogeneous as possible to ensure maximum interaction. Patients with different diagnostic categories and behavioural patterns, and patients from different races, social levels, educational and backgrounds should be brought together. Patients between 20 and 65 years of age can be effectively included. Age differences aid in relieving and rectifying interpersonal difficulties.

Homogeneous group is more suitable for children and adolescents. Patients with similar problems like substance abuse, mild to moderate depression etc. can also be benefited in a homogeneous group.

Open versus closed group

The closed groups begin and ends with same membership. The open group permits termination of members at different points and their substitution by new patients

Frequency and length of sessions

Group therapies can be conducted once or twice a week, each session lasting for 1-2 hours

HOW DOES GROUP PSYCHOTHERAPY WORK?

Members of the group share with others personal issues which they are facing. A participant can talk about events s/he was involved in during the week, her/his responses to these events, problems s/he had tackled, etc. The participant can share his/her feelings and thoughts about what happened in previous sessions, and relate to issues raised by other members or to the leader's words. Other participants can react to her/his words, give her/him feedback, encourage, give support or criticism, or share their thoughts and feelings following his/her words. The subjects for discussion are not determined by the leader but rise spontaneously from the group. The member in the group feels that (s) he is not alone with her/his problem and that there are others who feel the same. The group can become a source of support and strength in times of stress for the participant. The feedback (s) he gets from others on her/his behavior in the group can make her/him become aware to maladaptive patterns of behavior, change her/his point of view and help him/her adopt more constructive and effective reactions. It can become a laboratory for practicing new behaviors.

Frequently the people you meet in the group represent others in your past or current life with whom you have difficulty. In group therapy you have the opportunity to work through these situations.

WHO CAN BENEFIT FROM GROUP PSYCHOTHERAPY?
Group psychotherapy is suitable for a large variety of problems and difficulties, beginning with people who would like to develop their interpersonal skills and ending with people with emotional problems like anxiety, depression, etc. There are support groups for people in the same situation or crisis (e.g. groups for bereaved parents, groups for sexually abused women), but usually the recommendation for the therapeutic group is to be as heterogeneous as possible and represent a micro-cosmos. For that reason in building the group, the leader will try to include men and women, young and old people, married and singles, etc. The group is especially effective for people with interpersonal difficulties and problems in relations. Whether these difficulties are in social, working, couple or even sexual relations, the participant can benefit a lot in these areas.

Groups are ideally suited to people who are struggling with relationship issues like intimacy, trust, self-esteem. The group interactions help the participants to identify, get feedback, and change the patterns that are sabotaging the relations. The great advantage of group psychotherapy is working on these patterns in the "here and now" - in a group situation more similar to reality and close to the interpersonal events.

THERAPEUTIC FACTORS IN GROUP THERAPY

Following therapeutic factors in group therapy have been listed by Kaplan & Sadock (1983)

TYPES OF THERAPEUTIC GROUPS

1. Self help groups

2. Medication groups

3. Interpersonal group therapy

4. Encounter groups

5. Psychodrama

Supportive groups

In this approach, therapi