Group Psychotherapy

Introduction:
It often has been defined in the broadest terms, encompassing many kinds of groups with goals
that range from behavioural change to educational exchange. Group psychotherapy is
considered here as a field of clinical practice and a specific approach within the realm of
psychotherapy. All group therapy is aimed at alleviating illness or distress with the help of a
trained leader. What distinguishes group treatment from other methods is the use of group
interaction as the agent for change.

Group therapy is a shared therapeutic experience that involves the presence of a trained
professional and others who are working through similar issues. This collaborative form of
healing can focus on interpersonal relationships or on particular concerns shared by group
members. There are numerous psychological and emotional issues that are treated in group
therapy, ranging from addiction and abuse to anxiety and depression.

Group therapy is offered to help you address a variety of issues and reach a range of
therapeutic goals. Some of the topics addressed include substance abuse and other addictions,
domestic violence, divorce, childhood abuse, depression, anxiety, PTSD, and issues surrounding
eating and body image.

Some people choose to join group therapy to supplement primary therapy, to access additional
support, or to serve as the sole component of healing work. Participants in group sessions find
discussing their problems with those who can offer genuine empathy gives them a sense of
belonging and encouragement. Additionally, group therapy members provide support and
direction for others struggling with the same issues they have faced in the past.

What actually happens in the group depends largely on who attends, what is being discussed,
and any specific modalities the therapist uses in group. No matter the focus of the group,
change occurs as you move through various stages of development. As you get to know
yourself and the other members on a deeper level, perhaps working through conflicts as they
come up, your experiences in the group become increasingly restorative.
History and Background:
In 1905, Dr. Joseph Pratt, a Boston physician, brought his tuberculosis patients together for
weekly discussion groups and found that these meetings seemed to improve mutual support,
alleviate depression, and decrease isolation. Moreno, who is best known for developing
psychodrama, first used the term “group therapy” in the 1920s. Group treatment largely was
considered ineffective until World War 11. The many neuropsychiatric casualties returning from
the war compelled the governments of the United States and England to find ways to treat
these veterans more efficiently and economically. Since then, the group therapy field has
mushroomed and is now applied in many different clinical settings for many different types of
problems.

The founders of group psychotherapy in the USA were Joseph H. Pratt, Trigant Burrow, and Paul
Schilder on the East Coast in the first half of the 20th century. After World War II, group
psychotherapy was further developed by many therapists. In particular, Irvin Yalom's approach
to group therapy has been influential not only in the United States but across the world.

An early development in group therapy was the T-group or training group (sometimes also
referred to as sensitivity-training group, human-relations-training group or encounter group).
This is a form of group psychotherapy where participants (typically, between eight and 15
people) learn about themselves and about small-group processes in general through their
interaction with each other. They use feedback, problem solving, and role play to gain insights
into themselves, others, and groups. It was pioneered in the mid-1940s by Kurt Lewin and Carl
Rogers and his colleagues as a method of learning about human behavior in what became the
National Training Laboratories (now NTL Institute) in 1947.

Advantages:
 The patient recreates characteristic difficulties in the group. Interactions in the group
quickly expose patterns of behaviour.
 The “hall of mirrors” concept refers to the group’s ability to confront an individual with
behaviour he or she had been unable to recognize. Individual members are more likely
to accept feed- back about their behaviour if it comes from multiple observers.
 Multiple supporters who empathize with the patient’s struggle can make confrontation
more tolerable and dealing with intense affect more possible.
 The revelation of shameful secrets can lead to immense relief.
 Group interactions pull for socially acceptable responses and interchanges.
  The group offers alternative models for behaviour.
 Group therapy often is experienced as less regressive than individual therapy.

Disadvantages:
 Patients get less exclusive time and attention than in individual therapy.
 Groups can create a feeling of being lost in the crowd, and of not being appreciated for
one’s uniqueness.
 Confidentiality has limitations. The group leader cannot guarantee that members will
maintain confidences.
 Termination is more complicated (less flexible, more final) than in individual therapy.

Therapeutic Factors:
Irvin D. Yalom outlines the key therapeutic principles that have been derived from self-reports
from individuals who have been involved in the group therapy process:

1. The instillation of hope:

The group contains members at different stages of the treatment process. Seeing
people who are coping or recovering gives hope to those at the beginning of the
process. 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 instils hope and inspiration. New members or
those in despair may be particularly encouraged by others' positive outcomes.

2. Universality:
Being part of a group of people who have the same experiences helps people see that
what they are going through is universal and that they are not alone. 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. Imparting information:
Group members can help each other by sharing information.
4. Altruism:
Group members can share their strengths and help others in the group, which can boost
self-esteem and confidence.
5. The corrective recapitulation of the primary family group:
The therapy group is much like a family in some ways. Within the group, each member
can explore how childhood experiences contributed to personality and behaviours. They
can also learn to avoid behaviours that are destructive or unhelpful in real life.
6. Development of socialization techniques:
The group setting is a great place to practice new behaviours. The setting is safe and
supportive, allowing group members to experiment without the fear of failure.
7. Imitative behaviour:
Individuals can model the behaviour of other members of the group or observe and
imitate the behaviour of the therapist.
8. Interpersonal learning:
By interacting with other people and receiving feedback from the group and the
therapist, members of the group can gain a greater understanding of themselves.
9. Group cohesiveness:
Because the group is united in a common goal, members gain a sense of belonging and
acceptance.
10. Catharsis:
Sharing feelings and experiences with a group of people can help relieve pain, guilt, or
stress.
11. Existential factors:
While working within a group offers support and guidance, group therapy helps member
realize that they are responsible for their own lives, actions, and choices.

Techniques:
A successful group requires thoughtful planning:

Clarify your own values about why group treatment is valuable.

Assess the institution in which you work and whether it values group treatment. Will the
institution and your colleagues be friend or foe in your attempts to start a group? Who values
or devalues groups? Who has the authority to help you start a group? What kinds of groups are
already in existence? What kinds of patients need a group? How will you get your group
members? How much competition is there between professionals for these patients?
Consider the type of group you are offering. Groups range from discussion and theme-centered
or supportive/educational to process-oriented therapy. It is essential to be clear about the type
of group so that you can explain the purpose of the group to potential patients and referral
sources and define your role as leader. For example, in a social skills training group, the leader’s
primary role is teacher, whereas in a psychodynamic group, the leader’s role is interpreter of
unconscious phenomena.

Selecting Patients for Group Therapy:

Many different criteria have been proposed for selecting patients. In general, most patients can
work effectively in some type of group therapy. If patients are willing to listen to others and talk
about themselves, then they are group therapy candidates. Exclusionary criteria are: refusal to
enter a group or abide by group agreements and serious problems with interpersonal
relatedness. Contrary to popular opinion, people who do not do well in groups are not the
prime candidates for groups. Caution also needs to be exercised in including patients who are
highly impulsive, acutely suicidal, homicidal, or psychotic.

Basics of Group Therapy:

Most groups meet weekly, although some groups meet twice weekly, and others meet twice
monthly. The important point for therapeutic benefit is that patients do not lose contact with
the affect and process of the previous meeting. The usual time period is 90 minutes, with the
range 75-120 minutes. Less than 75 minutes is not enough time for members to get their fair
share, and meetings longer than 120 minutes can be exhausting for members and leaders.

Group size is four to ten members. Fewer than four members provide a temptation to focus on
individuals, not group processes; more than ten seems to become unmanageable and less
productive. Most group experts recommend seven as the ideal number with higher-functioning
patients, and starting with at least that many patients to compensate for potential early drop-
outs.

It is the group leader’s responsibility to arrange for a comfortable, private room with enough
chairs for everyone. Most group leaders prefer chairs in a circle so that members are not
physically hidden from one another by tables or other furniture.
Group Drop-outs:
Therapy groups end in a variety of ways. Some, such as those in drug rehabilitation programs
and psychiatric hospitals, may be on going, 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.

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.

Role of the Therapist:

1. Constancy:
An environment with small, infrequent changes is helpful to clients living in the
emotionally turbulent world of recovery. Group facilitators can emphasize the reality of
constancy and security through a variety of specific behaviours. For example, group
leaders always should sit in the same place in the group. Leaders also need to respond
consistently to particular behaviours. They should maintain clear and consistent
boundaries, such as specific start and end times, standards for comportment, and
ground rules for speaking. Even dress matters. The setting and type of group will help
determine appropriate dress, but whatever the group leader chooses to wear, some
predictability is desirable throughout the group experience. The group leader should not
come dressed in a suit and tie one day and in blue jeans the next.
2. Active listening
Excellent listening skills are the keystone of any effective therapy. Therapeutic
interventions require the clinician to perceive and to understand both verbal and
nonverbal cues to meaning and metaphorical levels of meaning. In addition, leaders
need to pay attention to the context from which meanings come. Does it pertain to the
here‐and‐now of what is occurring in the group or the then‐and‐there history of the
specific client?

3. Firm identity
A firm sense of their own identities, together with clear reflection on experiences in
group, enables leaders to understand and manage their own emotional lives. For
example, therapists who are aware of their own capacities and tendencies can recognize
their own defences as they come into play in the group. They might need to ask
questions such as: “Am I cutting off discussions that could lead to verbal expression of
anger because I am uncomfortable with anger? Have I blamed clients for the group’s
failure to make progress?”
Group work can be extremely intense emotionally. Leaders who are not in control of
their own emotional reactions can do significant harm—particularly if they are unable to
admit a mistake and apologize for it. The leader also should monitor the process and
avoid being seduced by content issues that arouse anger and could result in a loss of the
required professional stance or distance. A group leader also should be emotionally
healthy and keenly aware of personal emotional problems, lest they become confused
with the urgent issues faced by the group as a whole. The leader should be aware of the
boundary between personal and group issues

4. Confidence
Effective group leaders operate between the certain and the uncertain. In that zone,
they cannot rely on formulas or supply easy answers to clients’ complex problems.
Instead, leaders have to model the consistency that comes from self‐knowledge and
clarity of intent, while remaining attentive to each client’s experience and the
unpredictable unfolding of each session’s work. This secure grounding enables the
leader to model stability for the group.

5. Spontaneity
 Good leaders are creative and flexible. For instance, they know when and how to admit
a mistake, instead of trying to preserve an image of perfection. When a leader admits
error appropriately, group members learn that no one has to be perfect, that they—and
others—can make and admit mistakes, yet retain positive relationships with others.

6. Integrity
Largely due to the nature of the material group members are sharing in process groups,
it is all but inevitable that ethical issues will arise. Leaders should be familiar with their
institution’s policies and with pertinent laws and regulations. Leaders also need to be
anchored by clear internalized standards of conduct and able to maintain the ethical
parameters of their profession.

7. Trust
Group leaders should be able to trust others. Without this capacity, it is difficult to
accomplish a key aim of the group: restoration of group members’ faith and trust in
themselves and their fellow human beings (Flores 1997).

8. Empathy
Empathy, one of the cornerstones of successful group treatment for substance abuse, is
the ability to identify someone else’s feelings while remaining aware that the feelings of
others are distinct from one’s own.

9. Communicates respect for and acceptance of clients and their feelings

10. Encourages a nonjudgmental, collaborative relationship
11. Is supportive and knowledgeable
12. Sincerely compliments rather than denigrates or diminishes another person
13. Tells less and listens more
14. Gently persuades, while understanding that the decision to change is the client’s
15. Provides support throughout the recovery process

Stages of Group Development:

Groups tend to develop in stages. As you work with a support group, or with almost any group
of people who are working together toward a common cause, you'll be able to see the
progression. As a facilitator, knowing what to look for and how to manage the challenges can
have a big impact on how your group progresses.

As with many things, the progress of a group isn’t always neat and tidy. Sometimes groups will
regress to an earlier stage if there’s a major change, if a group member leaves or another is
added, or for various other reasons. Having said that, here’s an overview of how groups
typically develop and progress.

Stage 1 -- Orientation (Forming):

The first stage of group development is known as the forming stage. The forming stage
represents a time where the group is just starting to come together and is characterized with
anxiety and uncertainty. Members are cautious with their behaviour, which is driven by the
desire to be accepted by all members of the group. Conflict, controversy and personal opinions
are avoided even though members are beginning to form impressions of each other and gain an
understanding of what the group will do together. Some believe this cautious behaviour
prevents the group from getting any real work done. However, the focus for group members
during the forming stage is to become familiar with each other and their purpose, not on work.

Typical outcomes of the forming stage include things like gaining an understanding of the
group's purpose, determining how the team will be organized and who will be responsible for
what, discussion of major milestones or phases of the group's goal (including a rough project
schedule), outlining general group rules (including when they will meet) and discovery of what
resources will be available for the group to use.

Stage 2 -- Power Struggle (Storming):

The second stage of group development is known as the storming stage. The storming stage is
where conflict and competition are at its greatest. This is because now that group members
have an understanding of the task and a general feel for who they are as a group and who
group members are, they feel confident and begin to address some of the more important
issues surrounding the group. Such issues can relate to things like the group's tasks, individual
roles and responsibilities or even with the group members themselves.

The storming stage is where the more dominant of the group members emerge, while other,
less confrontational members stay in the comfort and security of suppressing their feelings just
as they did in the previous stage. Even though these individuals stay quiet, issues may still exist.
All members have an increased need for clarification. Questions surrounding leadership,
authority, rules, responsibilities, structure, evaluation criteria and reward systems tend to arise
during the storming stage. Such questions must be answered so that the group can move on to
the next stage. Consequently, not all groups are able to move past the storming stage.

Stage 3 – Cooperation and Integration (Norming):

Once a group receives the clarity that it so desperately needs, it can move on to the third stage
of group development, known as the norming stage. The norming stage is the time where the
group becomes a cohesive unit. Morale is high as group members actively acknowledge the
talents, skills and experience that each member brings to the group. A sense of community is
established and the group remains focused on the group's purpose and goal. Members are
flexible, interdependent and trust each other. Leadership is shared, and members are willing to
adapt to the needs of the group. Information flows seamlessly and is uninhibited due to the
sense of security members feel in the norming stage.

Stage 4 – Synergy (Performing):

This is the ultimate stage. The performing stage is where goals are met and tasks are
accomplished. Here, the group members are comfortable and knowledgeable enough to find
patterns or tactics that contribute to the success of the group.

Sometimes this stage is positive and constructive, at other times it’s tense and uncomfortable.
However, if discomfort does occur, the members have usually determined ways to either work
through or around the distress.

Stage 5 – Closure (Adjourning):

Although not part of the original Tuckman Model, the adjourning stage was added in 1977. This
phase involves dismantling and breaking up the group once all the tasks and goals have been
accomplished.

The adjourning phase actually has a heavy post-training significance. As facilitators, we want to
encourage the group members to network and keep in touch with each other once they return
to their respective jobs. Often, group members can serve as resources and allies to each other
once they get back to the workplace.