Group Therapy

Professorial Tutorial Sebastian Theilhaber from 20/06/2007 Based on: Professorial Tutorial held by Marita Smith on 11/05/2001

Group Psychotherapy: “A widely accepted treatment modality, which uses forces within the group, constructive interactions between members and the interventions of a trained leader to change the maladaptive behaviour, thoughts and feelings of emotionally ill patients” [1]. Group Dynamics: “The intrinsic nature of groups, the ways in which the group and its individual members affect each other and the relationship of this interaction to issues of group development, structure and goals” [3].

Historical Aspects
Scheidlinger [4] divided the development of group therapy into the following phases: 1. The Precursors 2. The Pioneers 3. Influences of WWII 4. Community Mental Health Centres Movement 5. Vietnam War The Precursors 1905: Joseph Hersey Pratt (1911-1981) [2], a Boston internist, worked with tubercular patients at the Boston Dispensary and observed that patients' emotional reactions, their feelings of shame and discouragement because of their illness, often interfered with their capacity to adhere to self-care regimens. He began with teaching groups (“Thought Control Class Method” [3]) about home care and later included other groups of patients with chronic conditions, to which he also counted homosexuality. 1909: Cody Marsh [2] – a minister at Kings Park State Hospital in New York, who later became a psychiatrist and gave “inspirational group lectures”. He organized social groups to utilized every possible activity to involve patients in the realities of living, encourage them to discuss their problems and to support each other. He pioneered psycho-education group for hospital personnel as well. 1920: Edward W Lazell [2] – a psychiatrist, inspired by J H Pratt, developed groups lecture methods for severely ill psychiatric patients in which he discussed patients' dynamics interpreted along Freudian psychoanalytic lines, a technique he later discontinued. 1921: Alfred Adler (1870 – 1937) was an Austrian medical doctor and psychologist, founder of the school of individual psychology. He used “collective therapy” with families and children in his Viennese child guidance clinics. 1920’s: Trigant Burrow – a psychoanalyst conducted “group analysis” with a focus on social interactions in the group. He was expelled from the American Psychoanalytical Association and lost the support of Freud when he began to concentrate on measuring the physiological reactions of group members.
1 2 3 Kaplan HI, Sadock BJ. Editors, Comprehensive Textbook of Psychiatry, 6th edition, Williams and Wilkins, Baltimore, 1994 A Brief History of the American Group Psychotherapy Association 1943-1968, International Journal of Group Psychotherapy, Volume XXI October, 1971 Number 4 Groups were large, consisting of as many as 80 to 100 patients who sat in rows in classroom fashion facing the speaker on the platform. Patients with the best attendance record were moved toward the front. The "star" patients sat on a bench facing the audience next to the doctor. (From [2])

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The Pioneers 1930: Louis Wender - began to apply Freudian principles such as transference, interpretation and working through to groups at regularly scheduled meetings with the total patient population of a sanitarium in Hastings-onHudson, N Y The Hillside Hospital. 1938: Alexander Wolf – developed a form of group psychotherapy which adhered strictly to Freudian principles and omitted the examination of group dynamic functions. 1942: Jacob L Moreno (1889 - 1974) – Viennese Analyst and founder of psychodrama began his career of using group action methods. Many of his ideas were later adopted by American Gestalt-, existential- and encounter-group therapists. He founded the American Society for Group Psychotherapy and Psychodrama 1943: S R Slavson – a self taught Freudian psychotherapist and Moreno’s life-long adversary founded the American Group Psychotherapy Association. This was only open to trained mental health professionals, unlike Moreno’s group. The Association published its own journal, The International Journal of Group Psychotherapy. Slavson developed the areas of child and adolescent group psychotherapy in addition to his work with adult groups. Influences of WWII Group methods were adopted by military psychiatrists in England during WWII out of necessity due to the large number of psychiatric casualties, the so called Northfield Experiments. This movement produced many important figures in the theory and practice of group psychotherapy including S. Foulkeds, Wilfred Bion, Thomas Main and Harold Bridger. Subsequent to WWII there was an ongoing rapid expansion of group theory and practice. Community Mental Health Centres Movement The huge expansion of community mental health centres in America in the 1960’s had a profound effect on group psychotherapy, with the widespread employment of group methods. Initially many such groups were conducted by staff who were untrained in group methods and had insufficient supervision, at times with disastrous results. This led to a greater emphasis on training and supervision in the field. Vietnam War The youth revolt around the time of the Vietnam War gave rise to many non-traditional group models, including encounter groups and transcendental medication groups. Poor screening measures led to a number of psychiatric casualties among group members, given the regressive emotional atmosphere of some of these groups. Unified protest from mental health professional organizations led to a curtailment of these kinds of group methods.

Theoretical Grounds:
Psychoanalytic theory: Characterized by the use of concepts of: • • • • • • • • • • • • • Transference Counter-transference Free association Resistance The unconscious Conflict theory Sexual and aggressive instincts Dream analysis Infantile sexuality Defense mechanisms Regression Acting out Working through

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Further key elements are: • • • • • Therapist favors such as: object relation theory [4], structural theory, Heinz Kohut [5] (Psychology of self), Harry Stack Sullivan ("interactional" versus the "intrapsychic"). Group members will act as they did in their original families. Superior emphasis on Therapeutic Factors (see related paragraph). Integrates the intrapsychic-, interpersonal-, group-as-a-whole- and social- aspects. Key element is the understanding and regulation of boundaries within the group and of dynamics in the group as a whole.

General System Theory:

Transactional Analysis: Makes prominent use of the structural theory and the concept of regression. Focusing on the ego status. Behavior Therapy: Emphasis on social skills training, cognitive therapy, cognitive restructuring, stress inoculations, problem solving by making heavy use of the therapeutic factors. Often used in in- and outpatient settings, particularly with chronically mentally ill people. Existentialism: Existentialism is a philosophical movement which claims that individual human beings have full responsibility for creating the meanings of their own lives. It is a reaction against more traditional philosophies[6]. Existential psychology as a major offshot of it is predominantly represented by Viktor Frankl (Europe and US), Irvin Yalom (One of the most prolific writers on techniques and theory of Existential Psychology in the USA), Rollo May. The person who has contributed most to the development of a European version of Existential Psychotherapy is the British based Emmy van Deurzen. Wilfred Bion [7]: • • • • A British psychoanalyst who worked at the Tavistock Clinic in 1940-1950 and later in America. With other psychiatrists in the “Northfield Experiments“ ('psychiatric casualties of war') at the Hollymoor Hospital in England, during WWII, developed a number of theories of group dynamics. His central belief was that in every group, 2 groups were present, the “work group” and the “basic assumptions group”, and in every group there are two aspects or ways of behaving. The Work Group: Refers to the aspect of the group functioning which has to do with the real task of the group. It is aware of its purpose and can define its task. Different members of the group have different roles, which help the group achieve the task in a logical manner. This idealized group which rarely exists, was the subject of much of Bion’s work – ie why don’t groups behave in the rational way of the idealised group? The Basic Assumptions Group: “Basic Assumption” refers to the assumption that underlies a behaviour. It is an “as if” term. That is , one behaves “as if” such and such were the case. Bion used the term to refer to the tacit or unconscious assumptions which exist, rather than those which are overtly expressed. In his opinion, these assumptions can be recognized by examining the emotional state of the group. The statement of the basic assumption (in the form of an interpretation) clarifies the behaviour of the group that contributes to it not functioning properly as a work group. Bion described 3 basic assumptions: Dependency basic assumption : Members act as if they know noting and as if the leader is all powerful and all knowing. The aim of this group is to gain security through and to have its members protected by one member of the group. Fight-Flight basic assumption : The group acts as if it has met to preserve itself. This can only be achieved by fighting someone or by running away from someone/something. The leader is seen as someone who can mobilize the group into attack or lead it in flight.
“In psychodynamics, Object relations theory is the idea that the ego-self exists only in relation to external or internal objects. The internal objects are internalized versions of external objects, primarily formed from early interactions with the parents. There are three fundamental "affects" that can exist between the self and the object - attachment, frustration, and rejection. These affects are universal emotional states that are major building blocks of the personality. Object relations theory was pioneered in the 1940s and 50's by British psychologists Ronald Fairbairn, D.W. Winnicott, Harry Guntrip, and others.” * 03/051913 – 08/10/1981, MD, Neurology / Vienna. 1939 emigrated to Chicago. Rejecting Freuds structural theory, he developed the threepart self / Self-Psychology. 1897-1979, trained in psychoanalysis under the influence of Melanie Klein.




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Pairing basic assumption: In this group, the group has met for the pruposes of reproduction, to bring forth the savior that will solve all its problems.

Terapeutic Factors:
There are various systems describing those and some seem to be much more elaborate. Abreaction: Reliving of repressed and usually painful experiences and bringing it to consciousness with the idea to create better insight. Acceptance: Sense of being accepted in the group and experience of tolerance. Risks can be taken without disastrous effects or judgment. Altruism: Putting another person´s needs before one´s own and learning the there is value in giving to others. Catharsis: The state to which abreaction leads. Ventilation of feelings such as anger, anxiety, sadness, guilt and shame lead to an emotional release which makes sense as experiences. Sharing this in a group a reduces isolation and enables trust. Cohesion: Sense of a common goal within the group. Consensual validation: Making a comparison between the own conceptualization and those of others with the chance of correction. Contagion: The process of emotions, expressed by somebody, stimulate the awareness of similar emotions in the observer. Corrective familial experience: The process, in which the group re-creates the family of origin, providing the space for abreaction. Empathy: Heinz Kohut: “[...] the capacity to think and feel oneself into the inner life of another person.” [8] Identification: Incorporation of characteristics of another object in to ones own ego system as defense. Imitation: Conscious emulation of a role model. Insight: Conscious awareness and understanding of ones own ego system, ideally with the capacity to initiate changes. Inspiration: Instillation of hope. Interaction: Free and open exchange of ideas and feelings. Interpretation: The formulation of meaning and significance of members resistance, defenses and symbols to promote the development of a cognitive framework for the understanding of ones behavior. Learning: Acquisition of knowledge by interaction. This requires adequate feedback from the group and also a willingness to relate constructively and adaptively within the group.
8 Kohut, H. (1984). How does analysis cure? (p. 82). Chicago: The University of Chicago Press.

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Vicarious Learning Each member does not need to go through the work to tackle a shared problem, but can benefit from noting how a peer deals with it. There are potential models from which to learn and each patient may have a quality which another wishes to emulate. Reality testing: The capacity of accurate perception and evaluation of self and others. Transference: Projection onto the therapist, who is representing an object from the past. Universalization: Awareness of that other have similar problems. Ventilation: Expression of suppressed material to ameliorate a sense of guilt or sin.

Conceptual models:
1. Freudian: Uses basic psychoanalytic concepts of transference, countertransference, free association, the unconscious, etc. Neo-Freudian: Based on the theories of Sullivan, Horney and Kohut. Yalom: Developed an interpersonal orientation, based on the principles of Harry Stack Sullivan. The primary focus is on the here and now interpersonal relationships. The group therapy session becomes a place for the expression and understanding of problems such as mistrust, anger and dependency. Yalom delineated numerous therapeutic factors operative in group therapy and wrote a classic textbook on the subject “The theory and Practice of Group Psychotherapy”. Object-Relations: Based on Bion’s theories of the “work group” and “basic assumptions” and incorporating Melanie Klein’s theory of the paranoid schizoid position and the depressive position. Redecision Therapy: Developed by Robert and Mary Goulding, American psychoanalysts, it combines elements of newer therapies that came into being in the 1960’s. Group members reclaim responsibility for and poser in their lives. The group’s nurturing environment promotes mature decisions for behavioural change and therapist models ways of living and being. Existential: Combines the concepts of existential philosophy with psychotherapy. The group undergoes a process of self examination in which the meanings of phenomena such as life and death, illness and failure are explored. Patients can then arrive at their own responsible life choices. Cognitive-Behavioral Therapy: Widely used in inpatient and outpatient settings. Individual members and the group contract for mutually agreeable goals. The group setting provides the opportunity for patients to learn and practice new skills, behaviors and cognitions and to provide each other with support. Psychodrama: Devised by Jacob Moreno. Designed to evoke the expression of feelings involved in personal problems in a spontaneous, dramatic role play. Group members role play past, present or anticipated conflict situations to release tension and practice more adaptive behaviour. Supportive: Elements of supportive therapy are applied to the group setting.

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Selection of Patients:
Exclusion criteria: • • • • • • • • • • Disturbed behaviour, Brain damage, paranoia, Extreme narcissism, Hypochondryasis, Suicidality, Current addiction, Acute psychosis, Extreme antisocial [9] . Often not possible in the inpatients setting. There are few conditions cited in the literature as exclusion criteria, for which an opposing opinion or anecdotal report cannot be found. Highly motivated Interested in the same goal as the group Active participation Sufficient trust to share life experiences Psychologically minded Self-reflective individual Willingness to self-disclosure within the group Certain capacity for interpersonal relationship

Consideration [9, 10]:

Desirable Patient Characteristics [ 11]: • • • • • • • •

Composing the group [11]:
• • • • • • • • Who is likely to benefit from group therapy: creating the therapeutic alliance. Clients with manifest interpersonal difficulties. Clients who lack self-awareness in the interpersonal realm Manifest ego-syntonic character pathology; clients who are action-oriented; clients who will benefit from the affective stimulation and interaction clients who need either to dilute an overly intense and dependent therapeutic relationship or to intensify an arid, sterile therapeutic relationship who will benefit from the presence of peers to support and challenge them

Preparation of Patients:
• • •

Establish the beginnings of a therapeutic alliance. Reduce the initial anxiety and misconceptions about joining a therapy group. Provide information and instruction about group therapy to facilitate the client’s ability to provide informed consent.
Irvin D Yalom, “The theory and Practice of group Psychotherapy”, 2nd edition, Basic Books, New York, 1975

10 Irvin D Yalom, “Existentielle Psychotherapie”, 3rd edition, Edition Humanistische Pschologie, 2000 11 Practice Guidelines for Group Psychotherapy, The American GPA, Science to Service Task Force, 2007

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Achieve consensus between group leader and group members on the objectives of the therapy.

Therapist Function:
Executive Function, Boundary management: • • • • • setting up the parameters of the group such as frequency, length of each session, establishing rules and limits, managing time, interceding when the group goes off course in some way. Being concerned with the well-being of the members of the group, and with the effectiveness of the treatment they are receiving. Efforts to uncover and encourage the expression of feelings, values and personal attitudes. Helping members to develop their ability to understand themselves, each other, and people outside the group, as well as what they might do to change things in their lives. Developing “insight” is not an emotionally neutral experience. Helping members to understand how some aspect of one’s past is affecting one in the present and how other people are affected by them and what is it about other people that elicit particular kinds of responses in them. Shaping the dialog. Therapists should not reveal anything that they are uncomfortable sharing about themselves. The only legitimate rationale for the therapist’s personal disclosure is the conviction that it will facilitate the work of the group at that moment in time. The focus has to remain on the client/therapy: “judicious” disclosure.


Emotional Stimulation: • • Meaning-attribution:

Fostering Client Self-Awareness: •

Establishing Group Norms: • • • Therapist Transparency and Use of Self:

Problems typically addressed:
• • • • Interpersonal – eg lacking trust, overly dependent, abrasively assertive Emotional – eg poor emotional control, inability to express emotions such as love or anger Self-concept – eg poor self esteem Symptomatic – eg anxiety, depressive, ineffective coping with stress

Group Development:
• • Setting and Boundary management will have a major impact. Assumptions about group development (MacKenzie, 1994): 1. Development will be in a regular and observable pattern 2. Same developmental features will be evident in all groups that develop in a normative fashion.

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3. 4.

Development will be epigenetic, with later developmental stages being contingent on the successful negotiation of earlier developmental crises. Development will be manifest increasing interactional complexity but may, exhibit regression and reversibility, recycling back to earlier stages of development.

Developmental Stages: 1. Forming / Preaffiliation (anxiety, seek guidance from the group leader) 2. Counter-dependency and flight / Storming (struggles around “power and control”, competition and conflict, anxiety) 3. Norming / Trust and Structure 4. Performing / Differentiation (mature and productive group process and the expression of individual differences) 5. Adjourning / Separation / Termination

• • • The ending phase includes a review and reinforcement of individual change which has occurred in the therapy; The therapist guides the departing client to a resolution of the relationships with the therapist and group members; The individual is helped to face future life demands with the tools provided in the therapy. [ 11]

Types of Group Therapy:
Many types of group therapy exist and as do an equally diverse number of theoretical models: • • • • • • • • • • • • • • Psychoanalytic Existential Cognitive-behavioural Self-help group In-patient setting Out-patient setting Children Adolescents Adults Elderly Psychiatry General Medical Fields (particularly chronic illness) Drug and Alcohol Workplace

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Group Therapy for Specific Populations:

Schizophrenia: • • Often group therapy is in outpatient or rehabilitation setting CBT or skill acquisition groups are common

Mood Disorders: • Helpful after the severe phase of illness

Anxiety Disorders: • • Psychodynamic and CBT therapy types can be used Some anxiety groups lend themselves to homogeneous approach such as phobias, PTSD

Somatoform Disorders: • Supportive type therapy

Eating Disorders: • • CBT in the early phase Psychotherapy in later phase

Personality Disorders: • • Both CBT and Psychodynamic models have been used Generally best if the group is heterogeneous in nature

Group Therapy for PTSD
There is a long tradition of using group psychotherapy for men and women who have been traumatized. Throughout history the need to talk about and process with others experiences of trauma has been central to healing psychic wounds. Group treatment for military veteran survivors of war and sexual trauma aims not to cure PTSD, but to help each individual regain connection to 1. A sense of self that integrates experiences before, during and after the military 2. Personal, familial and societal resources as a member of a safe and supportive community. Group therapy draws on the synergistic power of therapeutic guidance and peer relationships to assist each member in reconstructing a personal narrative that integrates trauma and powerlessness with a new sense of personal control and mutual support [7]. Group work provides opportunities for interaction with not only fellow survivors but also those who have experienced other kinds of trauma and with untouched witnesses. Group therapy for military-related trauma thus frees members and leaders alike to fully recognize the lasting and profound impact of trauma, while exploring the potential for sharing little-by-little the experience of renewal [7].

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Research in the field of Group Therapy:
• • • • Research into the effectiveness of group therapy is difficult because of the large number of confounding variables that are potentially present. The great range of therapies that come under the heading “group therapy” similarly make research in this field particularly difficult. Because of these factors widely varied results have been found in studies. suggesting that group therapy is effective to those which do not. These vary from those

The American Group Psychotherapy Association has devised the “Clinical Outcome Results Battery”, which consists of several outcome instruments, including the Symptom Checklist 90 – Revised, the Social Adjustment Scale Self Report, the Multiple Affect Checklist Revised and the Global Assessment Scale.

Some important Recent Studies:[6]
Piper & Joyce provided a review of the group outcome literature from 1983 to 1994 – this includes a total of 86 studies. • • • Efficacy and applicability was strongly supported in the studies with solid methodology Equivalence of outcome between group and individual approaches was confirmed Advantages such as efficiency and ease of administration are also discussed by the authors.

Brown & Schulberg reported a literature review of the efficacy of psychosocial treatment for patients with depression and anxiety disorders. • • Good evidence for the efficacy of the treatments compared to treatment as usual No difference in the effect between individual and group modalities.

Penn & Mueser reviewed the literature on psycosocial treatment of schizophrenia • Social Skills Training was usually performed in groups & improved outcome.

Take Home Message:
• • • Group therapy is a rich and dynamic field, difficult to overview and systematically challenging. Cost-effectiveness pressures in mental health services mean that group therapy techniques may be utilized more frequently and commonly. Although there is a lot of literature about group therapy, there seems to be a dearth of recent literature regarding theoretical models, particularly for mainstream psychiatry, with technical ideas and knowledge for trainees. Added to this there appears to be a need for the protagonists of group therapy to “catch up” and provide the routine monitoring of clinical service performance in order to provide some sort of measure of the effectiveness of the group treatment programs. Effective time-limited approaches which select appropriate patients for group therapy would seem to be a sensible and fruitful way to utilize group therapy in clinical practice in a variety of settings, particularly in a climate of limited resources.

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1. Kaplan HI, Sadock BJ. Editors, Comprehensive Textbook of Psychiatry, 6th edition, Williams and Wilkins, Baltimore, 1994 Yalom ID. The theory and Practice of group Psychotherapy, 3rd edition, Basic Books, New York, 1985. Rioch MJ. The work of Wilfred Bion on groups. Psychiatry, 1970; 33: 56-66. Scheidlinger S. An overview of nine decades of group psychotherapy. Psychiatry, 1994; 45: 217-225 Hospital and Community

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Bloch S. editor. An Introduction to the Psychotherapies, 3 rd edition, Oxford University Press, Oxford, 1996. MacKenzie KR. Advances in group psychotherapy. Current Opinion in Psychiatry 1997, 10:239-242. Young, Bruce & Blake eds. Group Treatments for PTSD. Brunner, 1999.

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