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    Brabender IntroductionToGroupTherapy pp3-77 PDF

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    Introduction to Group Therapy Virginia Brabender ® JOHN WILEY & SONS, INC. vertently fully ren- slarship. 1 ity and ofessions, 1ld like to sychology environ were not ind to my aily. vB Section One Group Therapy 1 Chapter 1 Introduction 3 Effectiveness of Group Therapy 7 Efficiency of Group Therapy ° ‘Yalue of Group Therapy: Perceived and Actual 10 Summary B Chapter 2 _____$_____ Goals of Group Therapy 1B Target Areas of Change 16 Interpersonal Change 17 Intrapsychic Change 18 Skill Acquisition 20 Symptom Relief 21 Beyond the Four Target Areas of Change 23 Summary 24 Selection of Appropriate Goals for a Therapy Group 24 Member Variables 27 Temporal Factors 34 ‘The Therapist 36 Broader Therapeutic Context. 37 Summary 37 Section Two Change Processes 39 Chapter 3. Development of the Group 41 Basic Developmental Concepts 41 Boundaries of the Group 43 Concept of Subgrouping 44 Movement toward Integration 45 Importance of Considering Group Development 46 Stages of Group Development 50 StageI 51 Stage 57 Stage 61 StageIV 64 StageV 66 Final Considerations on Developmental Stages B Summary 4 Chapter 4. Mechanisms of Change 7 ‘Types of Mechanisms 719 Interpersonal Mechanisms 79 Group-Level Mechanisms 93 Intrapersonal Factors. 103 ‘Use of the Mechanisms of Change m2 Group Goals and the Group Model 112 Tenure and Developmental Status of the Group 113, Characteristics of Members 113 Summary Group THERAPY Renata was rather surprised when her therapist suggested that she join a therapy group. The therapist noted, “T just think that in the long run, you ‘will make more rapid progress if you have an opportunity to get some feed: back from some other people.” She initially put off making a decision, She told the therapist she was having financial problems, However, the truth was she was frightened, But the recommendation of her therapist was diffi- cult o dismiss, particularly given the painful struggles she had with others in her hfe. Eventually, when Renata said she would “try” a group, her therapist referred her to a mixed-gender group in which members remained aan average of 22 years. ‘Renata went through a number of preparatory sessions with the group therapist and began to have a glimmering of enthusiasm about the group. However, this positive feeling was dashed during her first session, The group began with members asking Renata about herself. Several members noted that they did not want Renata to feel “pressured” during her first session. Renata made a few vague comments and was relieved when the group shifted to another topic. One mentber, Maureen, accused two other members of talking about her in her absence. Maureen claimed she sensed she “got on their nerves” during the previous session, When she went to her ear after- ‘wards, she saw the two members standing together. They lowered their voices 4s she passed, The members were adamant in their denial, and Maureen seemed mollified. However, a lengthy discussion was laxnched about the dangers and benefits of parking lot discussion. Renata, who had learned something about avoiding topics from her time in individual therapy, silently concluded that the other members of the group must be avoiding their difficulties by absorbing themselves with this parking lot chatter. She ‘was therefore incredulous when the therapist said the group had hit upon an important issue, Feeling that the group occupied itself with too many triv- ialities, she thought about leaving but remembered she had promised her in- dividual therapist she would give ita-"fair shake.” Chapter 4 Chapter 1 tntroduction [In the next few weeks, Renata observed other members closely. Another relatively new member, Oscar, articulated his suspicion that his coworkers were trying to sabotage him by reporting minor mistakes of histo the boss. He didn’t know what was provoking this mean-spiritedness. Renata felt she knew exactly what his co-workers found so provoking about him, for she had been irritated with his patronizing way of desribing his postion on a topic several times as if members couldn't understand him the first time. Moreover, she no- iced that when he wnderstood or agreed with something another member said, he acted as though what that person said was obvious. When he could not comprehend another's points, he acted as ifthe person were speaking non sense. She decided to express these observations to him, and she did so with all the sensitivity she could muster. Oscar tried to interrupt her several times, but the other members told kim he must give himself a chance to be helped. She summed up her comments by saying, “Oscar, the way you treat others makes them feel stupid, and no one likes that.” When she completed her comment, another member, Emma, who had been in the group for several years, said that when she joined the group, she related to others in much the same way Oscar did, She added that she came to realize that her haughty manner was just a manifestation of her certainty that she could not hold her own with others on a genuine level. She had to use means like Oscar's to avoid that moment when she would feel weak and inferior and be seen that way, too. Other members talked about similar be- haviors they used to bolster themselves but that sometimes backfired. Oscar did not directly respond to Emma's comments or those of the other members, but he listened intently, He seemed, at least to Renata, to derive something ‘rom their input. ‘As the months went by, Renata felt positively about her group involve- iment. She didn't talk as much as many of the other members, but she knew that when she did speak, members valued what she said. Often, she would make an observation and other members would then chime in. Because she liked herself in the group, she looked forward to sessions greatly. In one session, two members had been talking about their difficulties with one another. Cathy had said that she felt that Maureen was overbearing in her demeanor toward her and the other members, She further stated that she resented the blunt and intrusive way Maureen questioned her about sen- sitive matters. Maureen defended herself, saying that she was merely doing her job as a group member. Renata had always felt herself to be very aligned with Cathy, so she decided to speak up. “Bus I bet you have a lot ofthe same difficulties with people out there. Sure, we're expected to ask questions and purse ... things, But it's the way you do it. Did you ever hear the expression ‘bull ina china shop’? Introduction 5 sely. Another Maureen looked at her with astonishment. *....A bull?” she ex- 1s coworkers claimed. Renata responded, "Well, I didn’t literally mean... you just come o the boss. He on so strong." Maureen responded, “You want me to be like you? T can't be felt she knew a like you, I can’t be prim and watch everything I say. Your comments come she had been out like these... perfect little packages. I fel I have no idea who you really i topic several are or what you think about anything.” cover, she Wo ‘Tom broke in, “It may be true Renata is ultracareful, but that doesn't her member ‘mean Maureen couldn't benefit from—" Then he could Renata interrupted, “What do you mean by ‘ultracareful’?* speaking non- ‘Tom hesitated, “Well, I've been really grateful for some of your com- tid so with all ‘ments about me. Yet, in a way, Ithink Maureen hit the nail on the head when ral times, Dut she talked about your weighing everything and net saying anything until you re helped. She can say it with exactly the right words. You're never just... spontaneous in ‘others makes here, and if you're the same way out ther, it’s hard to picture you having any relationships that are more than just surface.” Renata began to tear. The ther- rma, who had apist asked Renata how she felt about Tom's and Maureen's comments, Re- the group, she nnata said somewhat tremulously, “Well, Vm sort of shaken... I just didn’t that she came expect it tonight.” Tom said gently, “I didn't mean to upset you. It's just that I fher certainty $0 YOU as... a bud that is almest, well, too delicate to open.” el. She had t0 Cathy quickly interrupted, “That's okay, we're @ bouguet of closed feel weak and i buds.” The other members, including Renata, laughed. nut similar be- Renata then said, “Tom, what do you think my being careful has to do wkfired. Oscar with my relationships? You are: right: My relationships never seem 10 ther members, amount to t00 much... so maybe it's good we're talking about this.” rive something In the months that followed, Renata engaged in considerable work looking at her interpersonal style and how certain of her behaviors inter- group involve Jered with her ability to achieve an intimate relationship. She also came to , but she knew understand some of the fears about closeness that underpinned these behav. ten, she would iors. For example, she discovered her own hidden expectation that in the con- in, Because she text of at intimate relationship, she would discover hidden parts of herself y. that would elicit shame. In fact, over the course of her group participation, heir difficulties she learned about much within herself that might have evoked shame. How- ras overbearing =| ‘ver, because other members were talking about the same feelings and urges, ther stated that her discoveries were almost tolerable. ‘her about sen- is merely doing | bevery aligned | lot of the same | Ihere are many different approaches to group therapy, four of c questions and =| which will be discussed in this text in some detail. Many of the rthe expression dominant approaches use certain resources for psychological growth that are potentially abundant in groups and less available in other Feedback dé plosievrw out centauita doug we ch toute etrdeuce bievoeillout, Aupsite 2 pve 6 chapter Introduction modalities. The vignette that opens this chapter showcases some of these resources. Renata’s individual therapist identified one major resource pres- ent in group treatment: feedback (or the offering of reactions) from the other group members. Over time, Renata was able to learn from the other group members how they saw her and how they reacted af- fectively to their perceptions. A powerful feature of the group is the presence of a number of viewpoints. The reader may have noticed how Renata was presented with a particularly powerful stimulus when Tom joined with Maureen. She could have easily dismissed Maureen's input as defensiveness on Maureen’s part. A component of it was defensive in that Maureen was fending off the narcissistic hurt of Renata’s observation. However, when it was paired with Tom's comments, it became more of a force to reckon with, Another resource highlighted by this example is the type of re- lationships available for exploration. A major dimension of group ‘work is the availability of both peer relationships and relationships with authority. Furthermore, the diversity of personality character- istics of different members provides a range of stimuli to which each member may respond. In that way, a group provides something of the richness of the world outside the group and the environment achieves ecological validity (Brunswick, 1956). Because of their in- herentsheterogencity, groups provide a context where members can exhibit and address the difficulties that may have motivated their desire for treatment. The reader may have noticed in the vignette that the members. ‘of the group did not merely comment on others but identified with them, That is, they considered how behaviors, or a feeling or impulse giving rise to a behavior, could be found in their own person. ‘Through this discovery of:common-ground, members are able to move toward-ahigher degree:of'acceptance of aspects of themselves. For example, Emma helped Oscar to,accept both the fact of his in- sensitive social behaviors (“haught¥/AfP her words) and the motive sustaining the behavior, self-protection, This knowledge that he was not unique in possessing these qualities made the recognition of these qualities far less of a challenge to his self-regard. In fact, by ac- ‘knowledging their presence, he had the potential comfort, if not the downright pleasure, of joining with another person, Another example is Cathy’s use of Tom’s closed bud metaphor. ‘Through the development of a common set of images ‘\(Bttin, 1994), Effectiveness of Group Therapy 7 cases some of members are able to construct a net in which disturbing experiences can be both contained and further explored. This element of sharing resource pres- ® is far less present in individual therapy. Because the therapist has a actions) from caretaking role, acknowledging commonalities with patients may be to learn from more disturbing than reassuring to them. ley reacted at- The reader may have noticed that the therapist made only a sin- e group is the gle comment. Members proceeded through lengthy exchanges that have noticed the therapist neither initiated nor sustained. The therapist's lack of ful stimulus evident activity does not mean that the therapist’s role is unimpor- sily dismissed tant, In fact, much of this text will be devoted to the activities of the A component therapist in the group and how they differ across models. Nonethe- he narcissistic less, in many contemporary approaches, much of the work that is $ paired with done is member centered. Because this group has undergone con- vith, siderable development (see Chapter 3), it has acquired a mode of he type of re- operation that enables members to be helpful to one another. The ‘ion of group potential in any group of constructive member-to-member inter- relationships action is a feature that is unique to group therapy. ity character- This vignette and the analysis following it are offered to give o which each the reader a glimmering of the distinctiveness of this modality and a something of sense of why Renata’s individual therapist might have believed that environment the group could make a special contribution to her realization of her ie of their in- therapeutic goals, The vignette serves as a foundation for our explo- members can ration of this modality because it generates such critical questions stivated their as: How can the special features of group therapy be amplified? What kinds of patients would be particularly abie to benefit from the members the special features of this modality? Questions such as these will be entified with addressed throughout this text. ag or impulse own person. s are able to themselves. Effectiveness of Group Ther act of his in- Group Therapy d the motive The special features of group therapy are of interest only if they can 2 that he was ~ de shown to produce positive change in group members. The effec- ‘cognition of tiveness of therapy groups relative to no treatment at all, to a n fact, by ac- placebo condition, or to another modality—most typically, individ- mt, not the ual therapy—has been examined in a variety of studies. Fubriman and Burlinghame (1994), in a survey of the outcome literature on id metaphor. ' group therapy, noted that it was not until the 1970s that such stud- Ritin, 1994), ies had sufficient methodological rigor to yield valid and reliable 8 chapter 1 Introduction results. For example, samples had been assigned to groups not ran- domly but on the basis of convenience. ‘By the 1970s, an awareness,of the importance of methodology led to the design of sounder studies. Gradually, a pattern emerged showing the effectiveness of group therapy. For example, Toseland and Siporin. (1986) reviewed all of the studies to date that used group treatment with a symptomatically heterogeneous group of patients and met a set of methodological criteria. All of the studies had to have random assignment of subjects to the groups being com- pared, a control group, and independent and dependent variables measured by one or more standardized instruments. ‘The investigators found that out of the 32 studies that met these criteria, 24 (or-75-percent) showed that group therapy and individ- val therapy did not have differential effectiveness (although both were superior to no treatment or minimal treatment). In eight stud- ies, group treatment was superior to no treatment or individual treatment, The investigators also found that in studies for which at- tendance data was available, the rate of premature termination was lower for group patients than for individual patients, ‘Additional light is shed on the effectiveness of group therapy from reviews based upon the meta-analytic method (Smith, Glass, & Miller, 1980). The meta-analytic method is based upon a standard quantitative index or effect size that represents each measure of an ‘outcome study. The effect sizes are then averaged across measures and studies and compared to those of a control condition. In this way, the effect of a given modality such as group therapy can be compared to that of other modalities or no treatment. Existing re- views based on meta-analyses include investigations in which group and individual treatments were directly compared and those in which they were not, for example, studies in which only individual treatment was administered. "As Fuhriman and Burlingame note, out of seven meta-analytic studies, five found no difference between individual and group ther- apy (Miller & Berman, 1983; Robinson, Berman, & Neimeyer, 1990; Shapiro & Shapiro, 1982; Smith et al., 1980; Tillitski, 1990). (Shapiro and Shapiro report a slight superiority of individual ther- apy over group therapy. However, this is a statistically nonsignificant finding. Both individual and group treatments substantially ex- ceeded couple/family therapy.) However, two meta-analytic studies showed a superiority of individual over group treatment. Fubriman ups not ran- nethodology 2m emerged le, Toseland te that used tus group of f the studies s being com- ent variables rat met these and individ- chough both n eight stud- or individuial for which at- nination was roup therapy nith, Glass, & ma standard jeasure of an oss measures lition. In this erapy can be . Existing re- which group and those in aly individual meta-analytic id group ther- imeyer, 199 litski, 1990). dividual ther- ronsignificant stantially ex- ralytic studies ‘ht. Fubriman Efficiency of Group Therapy 9 and Burlingame wondered what set apart the two studies in which groups fared mote poorly than the others. By reviewing the specific studies included in the two meta-analytic investigations, they found that in the majority of studies representing the group modality, group therapy was used specifically because of its convenience. They write, ‘no attempt was made to incorporate or capitalize upon unique properties deemed therapeutic to the group format. .. . [The studies} can best be described as individual treatment in the pres- ence of others” (p. 16). What this pattern of findings among meta-analytic studies suggests is that group therapy ‘has its: own special elements that should be.deployed in order to maximize its benefits. Furthermore, when these elements are activated, group treatment is effective on a variety of outcome measures relative to no treatment or minimal treatment. It also is at least of comparable-effectiveness to other modalities such as individual therapy. The reader had an opportunity to see sothe of the unique properties of group therapy in the descrip- tion of Renata’s group experience, for example, feedback from peers and the discovery of shared experiences. These properties will be de- scribed more comprehensively and formally in subsequent chapters. Efficiency of Group Therapy From its earliest days, group therapy has been appreciated for its ef- ficiency. One of the earliest group therapists, Edward Lazell at St. Elizabeth's Hospital, Washington, D.C., saw in group therapy a way of treating schizophrenic patients, who were so large in numbers that they could not possibly be seen individually, He convened large groups of patients to hear lectures he would deliver on psychoana- lytic concepts and organized participants into discussion groups. After World War II, group therapy became a celebrated modality again because of its efficiency. Scheidlinger (1993) wrote, “Faced with many psychiatric casualties, a few military psychiatrists were forced to use group treatment methods through sheer necessity” (p. 3) Today, the efficiency of group therapy continues to be one of its appealing attributes. We practice in an era in which treatment is limited by time. Time is restricted by third-party payers such as managed health care organizations that often reimburse only for a | limited number of sessions. The length of treatment is also curtailed Dy patients themselves in search of quick relief, MacKenzie re- t ° viewed utilization patterns of mental health services and found that the majority of individuals receive fewer than eight sessions. More- over, fewer than 15 percent are still in treatment beyond 6 months. One implication of this finding is that to be serviceable to the vast ‘majority of mental health recipients, any modality must be able to produce positive effects within a very brief period of time. In the prior section in which the efficacy of group therapy was established, a number of reviews were cited. These reviews are based primarily ‘on group therapy interventions that are either brief or short-term in nature, These studies overwhelmingly show that therapy groups can produce positive position changes in a relatively brief period. ‘The other respect in which group therapy is efficient is in its ca- pacity to treat multiple patients simultaneously. Group therapy t places less demand on staff resources relative to individual therapy. MacKenzie (1995) estimated that in a given health care system, 15 percent of the patients in the system will require long-term therapy (approximately 50 sessions). If these patients receive individual i therapy, they will utilize 37 percent of staff resources. If these same patients are treated in group therapy, the percentage drops to 25, Frecing up staff time for the much larger group ol patients who re- quire crisis intervention (approximately 8 sessions). Roller (1997) noted, “A group therapist can treat from two to three times as many patients in one-half to one-third of the time” (p. xiii). Because of the savings in staff time, some managed care companies may be willing to increase the number of sessions, enabling the accomplishment of more ambitious goals. ‘Because in group therapy multiple clients are seen at one time, / fees for group therapy are almost always substantially lower than they are for individual therapy. Thus, one consequence of group | therapy’s efficiency is that it is more affordable for poorer persons. 10 chapter 1 introduction Value of Group Therapy: Perceived and Actual Given the findings in the research literature—findings that have been available for nearly two decades—it may seem paradoxical that in many environments, particularly outpatient treatment, group ther- apy is not perceived as the treatment of choice. Ifa given treatment is o curtailed Kenzie re- found that ons, More- 6 months. to the vast be able to ime. In the established, d primarily ort-term in groups can riod. ‘isin up therapy ual therapy. system, 15 sm therapy : individual these same lrops to 25, nts who Te- aller (1997) nes as many cause of the y be willing slishment of at one time, lower than ce of group er persons. at have been xical that in, group ther- treatment is Value of Group Therapy: Perceived and Actual 11 as effective as another and is more efficient (both in terms of the tenure of the person in treatment as well as the number of persons ‘treated by a given therapist in an interval), then why should it not be used in preference to individual therapy? Why should not the train- ing of mental health professionals in group therapy skills occur as early and as extensively as they do in individual therapy skills? The answer is that there is a disparity. between/the actual and perceived yalue of group therapy (MacKenzie, 1994; Steenbarger & Budman, 1996), a disparity for which there are at least several causes, First, for-many years, the uniqueness of group therapy in réla- tion to other modalities was not fully:appreciated, in many cases even by group therapists themselves let alone the community of menial health practitioners or, mote broadly still, the public. The problem was the falsevassumption that the~iti¢chatiism of ‘chatige ‘was.the:samnein the two modalities: If the change-producing cle- ments in both individual therapy and group therapy are identical, then the latter would seem to provide group members with a more diluied exposure to these elements than would individual therapy. Consider these two examples. Suppose a psychodynamic therapist identifies insight as the change-producing factor in any treatment. In individual therapy, it might seem that the patient, being the ther- apist’s exclusive focus, would have greater opportunity to be the re- cipient of the kinds of interpretive comments that Jead to insight. Furthermore, the therapist's more ample exposure to the historical and contemporary details of the patient's life outside of therapy would provide the basis for more finely hewn interpretations, Another example is a therapist providing cognitive behavioral treatment. If the most critical element of the treatment is the identi- fication of individual cognitions, then individual therapy would give the therapist a greater fund of material to formulate more precisely what these cognitions are relative to group therapy, where the time is divided among members. In fact, when the: processes in: group:therapy-that.are empha- sized-are the:same processes available in-individual therapy, the for- mer is-a weaker form of treatment relative to its potential: Individual therapy conducted in a group is less potent individual therapy:Tt 4s only when. the: interactional: processes ‘of group therapy are given center stage that this modality realizes its potential, As the contrasts among the meta-analytic studies show, when these interactional processes are the focus of therapists and members, group therapy is 12 chapter 1 introduction at least as effective as individual therapy. However, as long as mental health professionals do not fully appreciate the distinctiveness of the processes of group therapy, the disparity will exist between the per- ceived and actual value of this modality. ‘Another factor is cultural, Culture may account for why group therapy has failed to be understood in its particularity. Western cul- ture, especially Western Anglo-Saxon culture and particularly since the Enlightenment, has placed high value upon the individual be- yond that of the group, and upon individual fulfilment rather than the commonweal (Skolnick, 2000). In this culture, individual ther- apy is highly valued specifically because it centers upon the individ- nual. That is, it has primacy because it focuses upon the primary social unit of the culture. This is very different from other cultures that place highest priority upon the group. For example, in Eastern cul- ture, the group is highly valued and the individual is understood in terms of his or her connection with, and contribution to, the group. ‘The cost of the Western cultural perspective can be seen in the array of social problems that beset the United States and other West~ em countries, School violence is an example par excellence. While many aspects of this phenomenon are unknown, one common pat- tern is that a youth or subgroup of youths are scapegoated by their peers, The scapegoated persons respond to this psychological aggres- sion with acts of physical violence. This problem is one of group dy- namics. Although certainly the youths who take such action bring difficulties to school, the interactions they have with their peers in school are central to the violence that emerges. As the reader will see, scapegoating is one solution that groups readily use to solve their problems, and one task in a group’s development is to acquire more mature, constructive means of problem solving. ‘Rutan and Stone (1993) identify another example of the cost of this cultural emphasis upon the individual to the neglect of larger social units such as the couple, the family, and the community. An ‘emphasis upon the individual, and in particular, individual gratifica- tion, has led to the erosion of intimate, stable relationships: ‘There has been a strong trend in modern society to vatue happiness now at the expense of deepened relationship and firm foundations (Lasch, 1979; “Marin, 1975). “Doing your own thing” is no longer countereultural eth. It thas become part ofthe value system in all sectors and strata of society. The ready option today is to change the relationship rather than resolve the ig as mental reness of the cen the per- why group Nestern cul- cularly since dividual be- rather than vidual ther- the individ- mary social tures that Eastern cul- nderstood in , the group. 2 seen in the | other West- lence. While ommon pat aied by their ical aggres- of group dy- action bring heir peers in ¢ reader will use to solve is to acquire of the cost of lect of larger nmunity. An’ tual gratifica~ higis: piness now at s (Lasch, 1979; vltural thos. It a of society. The han resolve the Summary 13 conflicts. Thi tendency has become both the cause and the effet of the dra- ‘matic instability of modern marriages and family life (at present the risk of a marriage ending in divorce in the United States is approaching one in two). (Rutan & Storié, 1993, p, 6) As every practitioner knows, one of the most common presenting complaints of individuals entering therapy is the sense of emptiness and meaninglessness that the failure to sustain relationships of sub- stance produces. While the cultural emphasis on individualism may hinder a full appreciation of the value of group therapy, it is also true that group therapy is ideally suited to treating the relationship afflictions that are so prevalent today. Within this modality, the individual is always in focus. However, in focus, too, is the individual's relationship to each other member and to the group as a whole. :As individuals grow in.the group, relationships grow, and the community grows. > In this chapter, a vignette highlighted many of the special features of group therapy. These features distinguish group therapy from indi- vidual therapy and to some extent from modalities such as couple and family therapy. These features include the giving and receiving of feedback about one’s interpersonal style based upon immediate experiences with other members of the group. Other benefits in- ude the multiplicity of perspectives on oneself, the availability of both peer and authority relationships for exploration, and members’ identifications with one another's experience. This list is a partial one, which will be expanded throughout the course of the text. ‘The success of group therapy in effecting positive change in members has been investigated in many studies. Generally, these studies show that group therapy is as effective as individual therapy and in some cases more so. However, an examination of patterns of results across different meta-analytic studies suggests that group therapy is most likely to produce positive results when the features tbat distinguish it from other modalities are emphasized within the treatment. The efficiency of group therapy is inherent given that one or two therapists can simultaneously treat multiple clients. This feature 14 chapter 1 introduction generally makes group therapy more affordable. However, another aspect of its efficiency is that positive outcomes can occur after rela tively brief intervals. Of course,, longer-term involvements provide the opportunity for additional benefits. The efficiency of group ther- apy makes it compatible with the emphasis within contemporary health-care delivery systems on cost containment. ‘There is a disparity between the perceived and actual value of group therapy in the eyes of the public and the mental health com- munity. While the comparable if not superior effectiveness of group therapy in relation to individual therapy has been well established, group therapy continues to be seen as a less desirable alternative. ‘Reasons for this disparity include a failure of the professional mental health community to realize the distinctive processes that are acti- vated in the therapy group, and the emphasis in Western culture upon individualism. Despite this disparity, group therapy is highly tailored to contemporary societal and personal needs. er, another rafter rela- nts provide group ther- uemporary ral value of nealth com- 23s of group established, alternative. onal mental hat are acti- tern culture py is highly GG”. therapy is a tool for effecting change. To employ this ‘ool to its fullest advantage, a professional must know what types of changes it can effect. Consider the following three situations in which such knowledge about what groups can do would be necessary for good clinical decision making: ‘Situation F ‘The director ofa residential treatment center for persons with depres- sive disorders considers introducing a.group. therapy program to help individuals deal more effectively with depressive symptoms. However, the director is not a specialist on groups and is uncertain about what _sroups cant do for depressed people. Situation 2 An intake worker in a community mental health center interviews a 35-year-old man who complains of having difficulty maintaining em- ployment. After inquiry about his succes indifferent types of relation ships, she forms a hypothesis that this person has conflictual feelings foward authority figures that give rise to hostile behaviors toward su- pervisors at work. She wonders whether this man could better resolve this conflict in a therapy group. Situation 3 Two psychology interns were asked to run a therapy group in a crisis unit of a psychiatric hospital. While there had been various activity therapy groups, the unit had not had a therapy group in operation previously. The average group member was likely to remain in the ‘sroup for four sessions, but some could be present for ony a single session. The interns could not imagine that in such limited time, goals such as symptom reduction, conflict resolution, or skill acquisition would be realistic possibilities. They asked their supervisor whether Chapter 15 16 chapter 2. Goals of Group Therapy in such a short interval, there was anything that a group could do for its | members. | . ‘The professionals in all these situations are called upon to make a 1 clinical decision based on their knowledge ‘of what a group can do. i ‘As these examples suggest, it is not only the group therapist ‘who ‘must possess this knowledge. Essentially, any mental health adminis ! trator or clinician can make decisions more effectively by an aware- | ness of the full scope of this modality. | In this chapter, we will discuss four areas of change that can be instigated by group therapy participation. Knowledge of these areas i of change will help practitioners in several ways. First, therapists will { be aided in selecting specific goals for a particular group, goals that will be relevant to the needs of the population the group is intended to serve. The psychology interns in Situation 3 would be able to for- mulate group goals for their inpatients other than those requiring the | members’ long-term involvement in the group. Second, therapists v will better recognize when a group referral is warranted. For exam- ple, the intake worker in Situation 2 would know whether a group Could serve the needs of the man with authority problems, or an- other individual afraid of driving over bridges, or still another who cannot sustain a long-term intimate relationship. Third, practitioners ‘will be helped in identifying the distinctive contribution group ther- apy can make in a given setting. For example, on the unit providing treatment for persons with depression, a number of interventions are designed to relieve symptoms. A program director’s awareness of the multiplicity of possible group goals will allow her to know that the group need not duplicate the contributions of other modalities. Target Areas of Change While the number of goals that can be pursued in a therapy group : is virtually limitless, any given goal will for the most part fall under { one or morc of four target areas of change: interpersonal change, ‘ intrapsychic change, skill acquisition, and symptom relief. With. some approaches to group therapy, change in a given target area ‘will be conceptualized as leading to change in another. According to t some approaches, for example, intrapsychic change is expected to Tead to interpersonal and symptomatic change. In this case, the uld do for its to make a yup can do. srapist who th adminis- y an aware- that can be these areas erapists will », goals that 1s intended able to for- equiring the d, therapists I. For exam- ther a group lems, or an- mother who practitioners (group ther- ait providing nterventions awareness of to know that modalities. herapy group art fall under onal-change, relief. With n target area According to s expected to this case, the Target Areas of Change 17 intrapsychic change is primary in that it is the object of interven- tions. The interpersonal and symptomatic changes-are secondary in that they follow change in another target:area. The distinction be- tween primary and secondary changes is important because clarity about primary targets of change will help the therapist to plan effec- tive interventions. An awareness of secondary targets of change en- ables the therapist to recognize the number of ways in which the effectiveness of an intervention can be measured. Interpersonal Change ‘Through group participation, members can increase their capacities to have fulfilling, successful relationships, Chapter 1 gave an exam- ple of a therapy group whose members exhibited various-behaviors ould be.likely to alienate-them from others. Our protagonist, er) exhibited an excessively cautious style of relating that cre- a sense of distance‘in | ‘her relationships. Over the course of the Cor Renata showed more spontaneity in her relationships with ‘other members, a spontaneity that would be expected to transfer to her relationships outside the group. Another member, Maureen, who showed a high level of initrusiveness in her approach to other mem- bers, might exhibit increased sensitivity to members’ levels of will- ingness to disclose private aspects of themselves. The reader may also remember Oscar, Whose condéscéndinig demeanor created trouble for ‘him. Over the course of his group participation, Oscar might show a manner of interacting that is less peremptory and more respectful. Is there any evidence that group therapy can foster interper- sonal change? The relatively small number of studies addressing this question have generally supported the notion that group therapy participation can lead to healthier, more effective relationships. For example, an early study by Beard and Scott (1975) compared inpa- tients with chronic mental illness who participated in group therapy with those who did not, emphasizing the examination of communi- cations, Relative to the control subjects, participants in the therapy group showed greater flexibility in social bebaviors, a more accurate understanding of social situations, and a greater capacity to obtain fecdback to correct their distorted ideas. Byrnes, Hansen, Malloy, Carter, and Curry (1999) found that adolescents in a group therapy program showed a reduction in rates of criminal charges (reflecting a decrease in antisocial behaviors). Carbonell and Parteleno-Barehmi 18 Chapter 2. Goals of Group Therapy (1999) observed that participation in a 20-week psychodrama grout led to less self-reported withdrawal in middle school girls who had experienced chronic stress or traumatic life events. Shechtman and Ben-David (1999) found that children participating in a 10-week group showed less aggressive activity relative to controls. Kilman fr al. (1999) found that participation in a 3-day weekend group helped women with attachment difficulties report improved inter- personal styles and more secure attachments relative t0 controls. intrapsychic ‘Change ‘A second area of possible change is tntrapsychic. Here the effort is to ‘etiect_ a positive, change in-cognitive/emotional process’ and struc-» fures or in their organization and interrelationships. An axiom of the approaches emphasizing intrapsychic change is that for external Change (sich as in interpersonal behaviors) to.oecur in a way thats Seasonably Tasting, and generalizable 10 circumstances outside the group, such change must take place in tandem with internal change. The nature of the internal change sought is critically dependent upon the particular model a therapist uses. However, for many approaches, part of the change sought is making unconscious aspects of the self Conscious so that they can be integrated into the self. ‘For many approaches that emphasize intrapsychic change,

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