Group therapy

Definition

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

Purpose

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

Description

Group therapy encompasses many different kinds of groups with varying theoretical orientations that exist for varying purposes. All therapy groups exist to help individuals grow emotionally and solve personal problems. All utilize the power of the group, as well as the therapist who leads it, in this process.

Unlike the simple two-person relationship between patient and therapist in individual therapy, group therapy offers multiple relationships to assist the individual in growth and problem solving. 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.

Instillation 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. New members or those in despair may be particularly encouraged by others' positive outcomes.

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.

Information giving

An essential component of many therapy groups is increasing members' knowledge and understanding of a common problem. Explicit instruction about 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.

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.

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 coleaders), 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.

Improved social 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.

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.

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.

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.

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.

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

Group therapy in the United States can be traced back to the late nineteenth and early twentieth centuries, when millions of immigrants moved to American shores. Most of these immigrants settled in large cities, and organizations such as Hull House in Chicago were founded to assist them adjust to life in the United States. Known as settlement houses, these agencies helped immigrant groups lobby for better housing, working conditions, and recreational facilities. These early social work groups valued group participation, the democratic process, and personal growth.

In 1905, a Boston physician named Joseph Pratt formed groups of impoverished patients suffering from a common illness—tuberculosis. Pratt believed that these patients could provide mutual support and assistance. Like settlement houses, his early groups were another forerunner of group therapy.

Some early psychoanalysts, especially Alfred Adler, a student of Sigmund Freud, believed that many individual problems were social in origin. In the 1930s Adler encouraged his patients to meet in groups to provide mutual support. At around the same time, social work groups began forming in mental hospitals, child guidance clinics, prisons, and public assistance agencies. A contemporary descendant of these groups is today's support group, in which people with a common problem come together, without a leader or therapist, to help each other solve a common problem. Groups such as Alcoholics Anonymous, Narcotics Anonymous, and Survivors of Incest all have their roots in this early social work movement.

Types of therapy groups

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 THERAPIES. 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.
• Gestalt 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.

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 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.

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 sociopathic 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 groups work?

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 determines 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 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 group therapy?

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.

How 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 group therapy?

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.

See also Abuse; Addiction; Alcohol and related disorders; Amphetamines and related disorders; Anxiety and anxiety disorders; Bulimia nervosa; Cannabis and related disorders; Cocaine and related disorders; Cognitive-behavioral therapy; Grief counseling and therapy; Modeling; Nicotine and related disorders; Obesity; Opioids and related disorders; Peer groups; Psychodynamic therapy; Rational emotive therapy; Reinforcement; Self-help groups; Social skills training; Substance abuse and related disorders; Support groups

Resources

BOOKS

Hales, Dianne and Robert E. Hales. Caring for the Mind: A Comprehensive Guide to Mental Health. New York: Bantam Books, 1995.

Kaplan, Harold I. and Benjamin J. Sadock. Synopsis of Psychiatry. 8th edition. Baltimore: Lippincott Williams and Wilkins, 1998.

Panman, Richard and Sandra Panman. "Group Counseling and Therapy." In The Counseling Sourcebook: A Practical Reference on Contemporary Issues, edited by Judah L. Ronch, William Van Ornum, and Nicholas C Stilwell. New York: Crossroad, 2001.

Yalom, Irvin D. The Theory and Practice of Group Psychotherapy. 4th edition. Basic Books, New York, NY, 1995.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. <http://www.psych.org>.

American Psychological Association (APA). 750 First Street NE, Washington, DC 20002-4242. (202) 336-5700. <//www.apa.org>.

National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <http://www.nimh.nih.gov>.

Barbara S. Sternberg, Ph.D.

Group Therapy

Definition

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

Purpose

Group therapy attempts to give individuals a safe and comfortable place where they can work out problems and emotional issues. Patients gain insight into their own thoughts and behavior, and offer suggestions and support to others. In addition, patients who have a difficult time with interpersonal relationships can benefit from the social interactions that are a basic part of the group therapy experience.

Precautions

Patients who are suicidal, homicidal, psychotic, or in the midst of a major acute crisis are typically not referred for group therapy until their behavior and emotional state have stabilized. Depending on their level of functioning, cognitively impaired patients (like patients with organic brain disease or a traumatic brain injury) may also be unsuitable for group therapy intervention. Some patients with sociopathic traits are not suitable for most groups.

Description

A psychologist, psychiatrist, social worker, or other healthcare professional typically arranges and conducts group therapy sessions. In some therapy groups, two co-therapists share the responsibility of group leadership. Patients are selected on the basis of what they might gain from group therapy interaction and what they can contribute to the group as a whole.

Therapy groups may be homogeneous or heterogeneous. Homogeneous groups have members with similar diagnostic backgrounds (for example, they may all suffer from depression). Heterogeneous groups have a mix of individuals with different emotional issues. The number of group members varies widely, but is typically no more than 12. Groups may be time limited (with a predetermined number of sessions) or indefinite (where the group determines when therapy ends). Membership may be closed or open to new members once sessions begin.

The number of sessions in group therapy depends on the makeup, goals, and setting of the group. For example, a therapy group that is part of a substance abuse program to rehabilitate inpatients would be called short-term group therapy. This term is used because, as patients, the group members will only be in the hospital for a relatively short period of time. Long-term therapy groups may meet for six months, a year, or longer. The therapeutic approach used in therapy depends on the focus of the group and the psychological training of the therapist. Some common techniques include psychodynamic, cognitive-behavioral, and Gestalt therapy.

In a group therapy session, group members are encouraged to openly and honestly discuss the issues that brought them to therapy. They try to help other group members by offering their own suggestions, insights, and empathy regarding their problems. There are no definite rules for group therapy, only that members participate to the best of their ability. However, most therapy groups do have some basic ground rules that are usually discussed during the first session. Patients are asked not to share what goes on in therapy sessions with anyone outside of the group. This protects the confidentiality of the other members. They may also be asked not to see other group members socially outside of therapy because of the harmful effect it might have on the dynamics of the group.

The therapist's main task is to guide the group in self-discovery. Depending on the goals of the group and the training and style of the therapist, he or she may lead the group interaction or allow the group to take their own direction. Typically, the group leader does some of both, providing direction when the group gets off track while letting them set their own agenda. The therapist may guide the group by simply reinforcing the positive behaviors they engage in. For example, if a group member shows empathy to another member, or offers a constructive suggestion, the therapist will point this out and explain the value of these actions to the group. In almost all group therapy situations, the therapist will attempt to emphasize the common traits among group members so that members can gain a sense of group identity. Group members realize that others share the same issues they do.

The main benefit group therapy may have over individual psychotherapy is that some patients behave and react more like themselves in a group setting than they would one-on-one with a therapist. The group therapy patient gains a certain sense of identity and social acceptance from their membership in the group. Suddenly, they are not alone. They are surrounded by others who have the same anxieties and emotional issues that they have. Seeing how others deal with these issues may give them new solutions to their problems. Feedback from group members also offers them a unique insight into their own behavior, and the group provides a safe forum in which to practice new behaviors. Lastly, by helping others in the group work through their problems, group therapy members can gain more self-esteem. Group therapy may also simulate family experiences of patients and will allow family dynamic issues to emerge.

Self-help groups like Alcoholics Anonymous and Weight Watchers fall outside of the psychotherapy realm. These self-help groups do offer many of the same benefits of social support, identity, and belonging that make group therapy effective for many. Self-help group members meet to discuss a common area of concern (like alcoholism, eating disorders, bereavement, parenting). Group sessions are not run by a therapist, but by a nonprofessional leader, group member, or the group as a whole. Self-help groups are sometimes used in addition to psychotherapy or regular group therapy.

Preparation

Patients are typically referred for group therapy by a psychologist or psychiatrist. Some patients may need individual therapy first. Before group sessions begin, the therapist leading the session may conduct a short intake interview with the patient to determine if the group is right for the patient. This interview will also allow the therapist to determine if the addition of the patient will benefit the group. The patient may be given some preliminary information on the group before sessions begin. This may include guidelines for success (like being open, listening to others, taking risks), rules of the group (like maintaining confidentiality), and educational information on what group therapy is about.

Aftercare

The end of long-term group therapy may cause feelings of grief, loss, abandonment, anger, or rejection in some members. The group therapist will attempt to foster a sense of closure by encouraging members to explore their feelings and use newly acquired coping techniques to deal with them. Working through this termination phase of group therapy is an important part of the treatment process.

Risks

Some very fragile patients may not be able to tolerate aggressive or hostile comments from group members. Patients who have trouble communicating in group situations may be at risk for dropping out of group therapy. If no one comments on their silence or makes an attempt to interact with them, they may begin to feel even more isolated and alone instead of identifying with the group. Therefore, the therapist usually attempts to encourage silent members to participate early on in treatment.

Normal results

Studies have shown that both group and individual psychotherapy benefit about 85% of the patients that participate in them. Optimally, patients gain a better understanding of themselves, and perhaps a stronger set of interpersonal and coping skills through the group therapy process. Some patients may continue therapy after group therapy ends, either individually or in another group setting.

Resources

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. 〈http://www.psych.org〉.

American Psychological Association (APA). 750 First St. NE, Washington, DC 20002-4242. (202) 336-5700. 〈ttp://www.apa.org〉.

KEY TERMS

Cognitive-behavioral— A therapy technique that focuses on changing beliefs, images, and thoughts in order to change maladjusted behaviors.

Gestalt— A humanistic therapy technique that focuses on gaining an awareness of emotions and behaviors in the present rather than in the past.

Psychodynamic— A therapy technique that assumes improper or unwanted behavior is caused by unconscious, internal conflicts and focuses on gaining insight into these motivations.

group psychotherapy a means of changing behavior and emotional patterns, based on the premise that much of human behavior and feeling involves the individual's adaptation and response to other people. It is a process carried out in formally organized groups of three or more individuals who seek change, whether their problem is alcoholism, overeating, or poor social skills. The composition of a group may be heterogenous or homogeneous with reference to the age of the members or the type of problem. The therapist may be directive or nondirective, allowing the group to set their own agenda for discussion. The group becomes a "sample" of the outside world, reproducing conditions of interpersonal relationships; its members jointly participate in observing personal motivation and styles of interaction. They also participate in attempting new behaviors and dealing with the consequences of such behaviors, with the intended result that they will eventually be able to employ these behavior patterns outside the group. In observing the totality of the events that take place in group therapy, the process by which elements of personality are developed in each member is also studied.

Origins of Group Therapy

The technique of formally organized group therapy is said to have been devised by J. H. Pratt in 1905. Pratt was holding general-care instruction classes for recently discharged tuberculosis patients when he noticed the impact of this experience on their emotional states. In 1925 psychoanalyst Trigant Burrow became dissatisfied with individual psychoanalysis, and began experimenting with group techniques. Burrow hoped to decrease the authoritarian position of the therapist, and to more thoroughly examine interpersonal interactions. The application of group therapy methods to prison inmates and discharged mental hospital patients was pioneered by Paul Schilder and Louis Wender in the 1930s. At that time group therapy was found to be particularly useful in the treatment of children and adolescents. The development of group therapy was given impetus during World War II, as a result of the large number of soldiers requiring treatment.

Types of Group Therapy

There are various types of group therapy; approaches include behavior therapy, psychoanalytic therapy, sensitivity training, or Gestalt psychology (see psychotherapy ). The composition of groups varies as well, with family therapy and marriage counseling common forms in recent years. Peer group therapy usually consists of a group of individuals who have similar problems, and can be mediated by a psychoanalyst or by the members themselves. Many people seeking help prefer this sort of group therapy over individual therapy, largely because of the comfort derived from knowing that others share their problems. The approach is nondirective, and in some cases, the individual can continue attending sessions whenever they are needed. Alcoholics Anonymous (AA) is a well-known peer support group, run entirely by members. AA has been influential in the formation of similar groups, particularly support groups centered on addictions.

Bibliography

See S. Hearon, Group Therapy (1984); S. Bloch and E. Crouch, Therapeutic Factors in Group Psychotherapy (1987).

group therapy n.
1. (group psychotherapy) psychotherapy involving at least two patients and a therapist. The patients are encouraged to understand and analyse their own and one another's problems. See also encounter group, psychodrama.

2. therapy in which people with the same problem, such as alcoholism or phobias, meet and discuss together their difficulties and possible ways of overcoming them.

group therapy A psychotherapeutic technique usually involving six to eight subjects in the presence of one or two psychotherapists. There are many different types, although as Mark Aveline points out (‘The Group Therapies in Perspective’, Free Association, 1990)
, most assume that the origin of psychological difficulties lies in patterns of poor social relationships.

group ther·a·py • n. a form of psychotherapy in which a group of patients meet to describe and discuss their problems together under the supervision of a therapist.