GROUP THERAPY: METHODS AND PROCEDURES:CURATIVE FACTORS

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Clinical Psychology (PSY401)

Lecture 35

GROUP THERAPY: METHODS AND PROCEDURES

Group therapy is a form of psychotherapy in which a small, carefully selected group of individuals meets

regularly with a therapist.

The purpose of group therapy is to assist each individual in emotional growth and personal problem

solving. People may choose group therapy for several reasons. First, group therapy is usually less expensive

than individual therapy, because group members share the cost. Group therapy also allows a therapist to

provide treatment to more people than would be possible otherwise. Aside from cost and efficiency

advantages, group therapy allows people to hear and see how others deal with their problems. In addition,

group members receive vital support and encouragement from others in the group. They can try out new

ways of behaving in a safe, supportive environment and learn how others perceive them.

Groups also have disadvantages. Individuals spend less time talking about their own problems than they

would in one-on-one therapy. Also, certain group members may interact with other group members in

hurtful ways, such as by yelling at them or criticizing them harshly. Generally, therapists try to intercede

when group members act in destructive ways. Another disadvantage of group therapy involves

confidentiality. Although group members usually promise to treat all therapy discussions as confidential,

some group members may worry that other members will share their secrets outside of the group. Group

members who believe this may be less willing to disclose all of their problems, lessening the effectiveness

of therapy for them.

CURATIVE FACTORS:

The noted psychiatrist Dr. Irvin D. Yalom in his book The Theory and Practice of Group Therapy

identified 11 "curative factors" that are the "primary agents of change" in group therapy.

1. nstillation Of Hope: All patients come into therapy hoping to decrease their suffering and improve

their lives. Because each member in a therapy group is inevitably at a different point on the coping

continuum and grows at a different rate, watching others cope with and overcome similar problems

successfully instills hope and inspiration.

2. Universality: A common feeling among group therapy members, especially when a group is just

starting, is that of being isolated, unique, and apart from others. Many who enter group therapy

have great difficulty sustaining interpersonal relationships, and feel unlikable and unlovable. Group

therapy provides a powerful antidote to these feelings. For many, it may be the first time they feel

understood and similar to others. Enormous relief often accompanies the recognition that they are

not alone; this is a special benefit of group therapy.

3. Universality: A common feeling among group therapy members, especially when a group is just

starting, is that of being isolated, unique, and apart from others. Many who enter group therapy

have great difficulty sustaining interpersonal relationships, and feel unlikable and unlovable. Group

therapy provides a powerful antidote to these feelings. For many, it may be the first time they feel

understood and similar to others. Enormous relief often accompanies the recognition that they are

not alone; this is a special benefit of group therapy.

4. Information Giving: An essential component of many therapy groups is increasing members'

knowledge and understanding of a common problem. Explicit instruction about

6. the nature of their shared illness, such as bipolar disorders, depression, panic disorders, or bulimia,

is often a key part of the therapy. Most patients leave the group far more knowledgeable about their

specific condition than when they entered. This makes them increasingly able to help others with

the same or similar problems.

7. Altruism: Group therapy offers its members a unique opportunity: the chance to help others. Often

patients with psychiatric problems believe they have very little to offer others because they have

needed so much help themselves; this can make them feel inadequate. The process of helping

others is a powerful therapeutic tool that greatly enhances members' self-esteem and feeling of self-

worth.

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8. Corrective Recapitulation Of The Primary Family: Many people who enter group therapy had

troubled family lives during their formative years. The group becomes a substitute family that

resembles--and improves upon--the family of origin in significant ways. Like a family, a therapy

group consists of a leader (or co leaders), an authority figure that evokes feelings similar to those

felt toward parents. Other group members substitute for siblings, vying for attention and affection

from the leader/parent, and forming subgroups and coalitions with other members. This recasting

of the family of origin gives members a chance to correct dysfunctional interpersonal relationships

in a way that can have a powerful therapeutic impact.

9. Improved Social Learning Skills: According to Yalom, social learning, or the development of

basic social skills, is a therapeutic factor that occurs in all therapy groups. Some groups place

considerable emphasis on improving social skills, for example, with adolescents preparing to leave

a psychiatric hospital, or among bereaved or divorced members seeking to date again. Group

members offer feedback to one another about the appropriateness of the others' behavior. While

this may be painful, the directness and honesty with which it is offered can provide much-needed

behavioral correction and thus improve relationships both within and outside the group.

10. Imitative Behavior: Research shows that therapists exert a powerful influence on the

communication patterns of group members by modeling certain behaviors. For example, therapists

model active listening, giving nonjudgmental feedback, and offering support. Over time, members

pick up these behaviors and incorporate them. This earns them increasingly positive feedback from

others, enhancing their self-esteem and emotional growth.

11. Interpersonal Learning: Human beings are social animals, born ready to connect. Our lives are

characterized by intense and persistent relationships, and much of our self-esteem is developed via

feedback and reflection from important others. Yet we all develop distortions in the way we see

others, and these distortions can damage even our most important relationships. Therapy groups

provide an opportunity for members to improve their ability to relate to others and live far more

satisfying lives because of it.

12. Group Cohesiveness: Belonging, acceptance, and approval are among the most important and

universal of human needs. Fitting in with our peers as children and adolescents, pledging a sorority

or fraternity as young adults, and joining a church or other social group as adults all fulfill these

basic human needs. Many people with emotional problems, however, have not experienced success

as group members. For them, group therapy may make them feel truly accepted and valued for the

first time. This can be a powerful healing factor as individuals replace their feelings of isolation and

separateness with a sense of belonging.

13. Catharsis: Catharsis is a powerful emotional experience--the release of conscious or unconscious

feelings--followed by a feeling of great relief. Catharsis is a factor in most therapies, including

group therapy. It is a type of emotional learning, as opposed to intellectual understanding, that can

lead to immediate and long-lasting change. While catharsis cannot be forced, a group environment

provides ample opportunity for members to have these powerful experiences.

14. Existential Factors: Existential factors are certain realities of life including death, isolation,

freedom, and meaninglessness. Becoming aware of these realities can lead to anxiety. The trust and

openness that develops among members of a therapy group, however, permits exploration of these

fundamental issues, and can help members develop an acceptance of difficult realities.

HISTORY OF GROUP THERAPY:

For many years, group therapy was practiced as a method of choice by only a handful of dedicated

therapists. Others used it primarily because their caseload was so heavy that group therapy was the only

means by which they could deal with the overload. Still other therapists used group therapy as a

supplementary technique. During individual therapy, for example, a therapist might work toward getting a

patient to achieve insight into his pathological need to derogate women; then, during a group session, other

members of the group might reinforce the therapist's interpretation through their reactions to the patient.

Instead of being seen as a second choice or supplementary form of treatment, however, group methods have

now achieved considerably more visibility and respectability.

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One of the earliest formal uses of group methods was Joseph H. Pratt's work with tubercular patients in

1905. This was an inspirational approach that used lectures and group discussion to help lift the spirits of

depressed patients and promote their cooperation with the medical regimen. A major figure in the group

movement was J. L. Moreno, who began to develop some group methods in Vienna in the early 1900s and,

in 1925, introduced his psychodrama to the United States. Moreno also used the term group therapy

In the 1930s, Slavson encouraged adolescent patients to work through their problems with controlled play.

His procedures were based on psychoanalytic concepts. These and other figures have been identified as

pioneers of the group movement (American Group Psychotherapy Association, 1971; Lubin, 1976).

As was true for clinical psychology generally, it was the aftermath of World War II that really brought

group methods to center stage. The large number of war veterans sharply increased the demand for coun-

seling and therapy. The limitations of the existing agency and hospital facilities made it necessary to use

group methods to cope with the immediate demand. Once these methods had gained a foothold in the

terrain of pragmatism, respectability was but a short distance away. As a result, nearly every school or

approach to individual psychotherapy now has its group counterpart. There are group therapies based on

psychoanalytic principles, Gestalt therapy principles, behavior therapy principles, and many other types as

well.

APPROACHES TO GROUP THERAPY:

PSYCHODYNAMIC THERAPIES:

Psychodynamic theory was conceived by Sigmund Freud, the father of psychoanalysis. Freud believed that

unconscious psychological forces determine thoughts, feelings, and behaviors. By analyzing the interactions

among group members, psychodynamic therapies focus on helping individuals become aware of their

unconscious needs and motivations as well as the concerns common to all group members. Issues of

authority (the relationship to the therapist) and affection (the relationships among group members) provide

rich sources of material that the therapist can use to help group members understand their relationships and

themselves.

PHENOMENOLOGICAL APPROACH:

Until the 1940s virtually all psychotherapy was based on psychoanalytic principles. Several group therapy

approaches were developed by psychoanalytically trained therapists looking to expand their focus beyond

the unconscious to the interpretations individuals place on their experiences. Underlying this focus is the

belief that human beings are capable of consciously controlling their behavior and taking responsibility for

their decisions. Some phenomenological therapies include:

· Psychodrama--developed by Jacob Moreno, an Austrian psychiatrist, this technique encourages

members to play the parts of significant individuals in their lives to help them solve interpersonal

conflicts. Psychodrama brings the conflict into the present, emphasizing dramatic action as a way

of helping group members solve their problems. Catharsis, the therapeutic release of emotions

followed by relief, plays a prominent role. This approach is particularly useful for people who find

it difficult to express their feelings in words.

Person-centered therapy--a therapeutic approach developed by the psychologist Carl Rogers.

Rather than viewing the therapist as expert, Rogers believed that the client's own drive toward

growth and development is the most important healing factor. The therapist empathizes with the

client's feelings and perceptions, helping him or her gain insight and plan constructive action.

Rogers's person-centered therapy became the basis for the intensive group experience known as

the encounter group, in which the leader helps members discuss their feelings about one another

and, through the group process, grow as individuals. Rogers emphasized honest feedback and the

awareness, expression, and acceptance of feelings. He believed that a trusting and cohesive

atmosphere is fundamental to the therapeutic effect of the group.

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Gestalt Group therapy--in the 1940s Fritz Perls challenged psychoanalytic theory and practice

with this approach. Members take turns being in the "hot seat," an empty chair used to represent

people with whom the person is experiencing conflicts. The therapist encourages the client to

become aware of feelings and impulses previously denied.

· Transactional Analysis:

Eric Berne (1961) was the developer of and the dynamic force behind transactional analysis (TA). TA is

essentially a process in which the interactions among the various aspects of the people in the group are

analyzed. Analyses often focus on three chief:'ego states" within each person: the Child ego state, the Parent

ego state, and the: adult ego state. Each state is composed of positive and negative features. The positive_

Child is spontaneous, uninhibited, and creative. The negative Child is fearful, overly emotional, or full of

guilt. On the positive side, the Parent state may be characterized as supportive, loving, or understanding.

The negative Parent is punishing and quick to condemn. The Adult ego state is less oriented toward feelings

and emotions and is more involved with logic, planning, or information gathering. But the Adult can be

reasonable (positive) or non-spontaneous (negative).

Depending on how a person was raised, he or she will manifest various aspects of these positive and

negative characteristics. A child who was over supervised or overregulated by the parents might develop an

inhibited or guilt-ridden ego state. As a result, if a person in the TA group setting discusses sex in a

pompous, authoritative way, and the inhibited person is then asked to respond, she or he may be unable to

do so or may respond under great tension. The therapist might then point out how each person is playing

negative roles (Child, Adult, or Parent). One person is playing a negative Parent role by being pompous and

authoritative. The other person is responding in a negative Child fashion by being inhibited and tense.

Repeated analyses of the interactions among group members reveal the ego states that they typically

employ. These analyses lead the patients toward more rational, appropriate ways of thinking that are closer

to the Adult ego state (positive).

The units that are analyzed are transactions the stimuli and responses that are active between ego states in

two or more people at any given moment. A transactional analysis involves the determination of which ego

states are operative in a given transaction between people.

Another aspect of TA is the emphasis on games (Berne, 1964). Games are behaviors that people frequently

use to avoid getting too close to other people. TA tends to be a swift-moving, action-oriented approach.

There is an emphasis on the present, a sense of grappling with immediate problems that makes it attractive

to many patients and therapists. TA has an aura of responsibility, of learning how to choose between op-

tions and this can be a desirable alternative to more traditional forms of group therapy that often appear to

lumber along at an agonizingly slow pace. There is also a conceptual simplicity to the whole scheme that

seems to make it understandable and perhaps more acceptable to patient and professional alike.

Yet this very simplicity, coupled with the zeal and entrepreneurship of some TA practitioners, has led to a

popularization that can be dangerous. Critics argue that human problems are complex events that cannot

easily be translated into games and that any gains from such procedures are therefore likely to be short-

lived. Certainly there is little in the research literature to calm such fears, since TA therapists rarely produce

research.

· BEHAVIOR THERAPIES:-Behavior therapies comprise a number of techniques based upon a

common theoretical belief: maladaptive behaviors develop according to the same principles that

govern all learning. As a result, they can be unlearned, and new, more adaptive behaviors learned

in their place. The emergence of behavior therapies in the 1950s represented a radical departure

from psychoanalysis.

Behavior therapies focus on how a problem behavior originated, and on the environmental factors that

maintain it. Individuals are encouraged to become self-analytical, looking at events occurring before,

during, and after the problem behavior takes place. Strategies are then developed and employed to replace

the problem behavior with new, more adaptive behaviors.

An important offshoot of behavior therapy is cognitive-behavioral therapy, developed in the 1960s and

1970s, which is the predominant behavioral approach used today. It emphasizes the examination of

thoughts with the goal of changing them to more rational and less inflammatory ones. Albert Ellis, a

psychologist who believed that we cause our own unhappiness by our interpretations of events, rather than

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by the events themselves, is a major figure in cognitive-behavior therapy. By changing what we tell

ourselves, Ellis believes we can reduce the strength of our emotional reactions, as well.

TIME LIMITED GROUP THERAPY:-. The final example of a group approach that we will

discuss is time-limited group therapy (Budman & Gurman, 1988). This contemporary model is

appealing because of its efficiency, _ and it is likely to guide group interventions in the age of

managed care. These groups typically meet on a weekly basis for a predetermined number of

sessions (for example, eight sessions for a group consisting of members who are dealing with a life

crisis). As described by Budman and Gurman (1988), time limited groups are characterized by four

central features:

1. Pregroup preparation and screening. A 1-hour pregroup workshop is used to evaluate and screen

potential group members.

2. Establishing and maintaining a working focus in the group. The working focus is defined as a

particular concern, problem, or issue that is shared by all group members (for example, problems

with intimacy).

3. Group cohesion. Theorists and researchers are convinced that group cohesion (the degree to which

group members are involved in the process, trust each other, cooperate, focus, and express

compassion) is an important determinant of outcome.

4. Reactions to time limits. Because these groups are time limited, group members may experience

feelings related to life stage, to prior losses, and to frustration that more has not been accomplished

in the group.

Budman and Gurman (1988) also analyze the different stages of the group (starting the group, early group

development, termination, follow-up), because each stage presents the therapist with different challenges.

METHODS AND PROCEDURES OF GROUP THERAPY:

Who Belongs In A Therapy Group?

Individuals that share a common problem or concern are often placed in therapy groups where they can

share their mutual struggles and feelings. Groups for bulimic individuals, victims of sexual abuse, adult

children of alcoholics, and recovering drug addicts are some types of common therapy groups.

Individuals that are suicidal, homicidal, psychotic, or in the midst of a major life crisis are not typically

placed in group therapy until their behavior and emotional states have stabilized. People with organic brain

injury and other cognitive impairments may also be poor candidates for group therapy, as are patients with

sociopath traits, who show little ability to empathize with others.

How Are Therapy Groups Constructed?

Therapy groups may be homogeneous or heterogeneous. Homogeneous groups, described above, have

members with similar diagnostic backgrounds (for example, they may all suffer from depression).

Heterogeneous groups contain a mix of individuals with different emotional problems. The number of

group members typically ranges from five to 12.

How Do Therapy Group Works?

The number of sessions in group therapy depends upon the group's makeup, goals, and setting. Some are

time limited, with a predetermined number of sessions known to all members at the beginning. Others are

indeterminate, and the group and/or therapist determine when the group is ready to disband. Membership

may be closed or open to new members. The therapeutic approach used depends on both the focus of the

group and the therapist's orientation.

In group therapy sessions, members are encouraged to discuss the issues that brought them into therapy

openly and honestly. The therapist works to create an atmosphere of trust and acceptance that encourages

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members to support one another. Ground rules may be set at the beginning, such as maintaining

confidentiality of group discussions, and restricting social contact among members outside the group.

The therapist facilitates the group process, that is, the effective functioning of the group, and guides

individuals in self-discovery. Depending upon the group's goals and the therapist's orientation, sessions may

be either highly structured or fluid and relatively undirected. Typically, the leader steers a middle course,

providing direction when the group gets off track, yet letting members set their own agenda. The therapist

may guide the group by reinforcing the positive behaviors they engage in. For example, if one member

shows empathy and supportive listening to another, the therapist might compliment that member and

explain the value of that behavior to the group. In almost all group therapy situations, the therapist will

emphasize the commonalities among members to instill a sense of group identity.

Self-help or support groups like Alcoholics Anonymous and Weight Watchers fall outside of the

psychotherapy realm. These groups offer many of the same benefits, including social support, the

opportunity to identify with others, and the sense of belonging that makes group therapy effective for many.

Self-help groups also meet to share their common concern and help one another cope. These groups,

however, are typically leaderless or run by a member who takes on the leader role for one or more meetings.

Sometimes self-help groups can be an adjunct to psychotherapy groups.

How Are Patients Referred For Therapy Group?

Individuals are typically referred for group therapy by a psychologist or psychiatrist. Some may participate

in both individual and group therapy. Before a person begins in a therapy group, the leader interviews the

individual to ensure a good fit between their needs and the group's. The individual may be given some

preliminary information before sessions begin, such as guidelines and ground rules, and information about

the problem on which the group is focused.

When Do Therapy Groups End?

Therapy groups end in a variety of ways. Some, such as those in drug rehabilitation programs and

psychiatric hospitals, may be ongoing, with patients coming and going as they leave the facility. Others may

have an end date set from the outset. Still others may continue until the group and/or the therapist believe

the group goals have been met.

The termination of a long-term therapy group may cause feelings of grief, loss, abandonment, anger, or

rejection in some members. The therapist attempts to deal with these feelings and foster a sense of closure

by encouraging exploration of feelings and use of newly acquired coping techniques for handling them.

Working through this termination phase is an important part of the treatment process.

Who Drops Out Of Therapy Groups?

Individuals who are emotionally fragile or unable to tolerate aggressive or hostile comments from other

members are at risk of dropping out, as are those who have trouble communicating in a group setting. If the

therapist does not support them and help reduce their sense of isolation and aloneness, they may drop out

and feel like failures. The group can be injured by the premature departure of any of its members, and it is

up to the therapist to minimize the likelihood of this occurrence by careful selection and management of the

group process.

Results:-

Studies have shown that both group and individual psychotherapy benefit about 85% of the patients who

participate in them. Ideally, patients leave with a better understanding and acceptance of themselves, and

stronger interpersonal and coping skills. Some individuals continue in therapy after the group disbands,

either individually or in another group setting.

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THE FUTURE OF GROUP THERAPY:-

Despite the economy and efficiency of group treatments, they appear to be underutilized. One major reason

is that clients and therapists alike tend to view group therapy as a second-choice form of treatment. Fewer

clients are referred for group therapy as compared with other forms of treatment, and even those who are

referred may not follow through and join a group.

Managed behavioral health care is likely to make group therapy a more viable option in the future. Group

therapy is attractive to therapists and managed care organizations because it can save staff time (and

ultimately money) in the care of less severely disturbed patients, and it offers an alternative to inpatient

treatment in some cases. However, to take advantage of these opportunities, group therapists need to better

educate the public and health care professionals about this mode of treatment, aggressively lobby

governments and managed behavioral health care companies to financially support group therapy as a

service, and better educate themselves about managed care and the health care needs that remain unfulfilled.

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