Group Therapy

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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.

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 use 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, 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, making them increasingly able to help others with the same or similar problems.

ABRAHAM H. MASLOW (1908-1970)

Abraham H. Maslow, founder of humanistic psychology, was born in Brooklyn, N.Y. Maslow received his M.A. from the University of Wisconsin in 1931, and his Ph.D. in 1934. In his most important work, Motivation and Personality (1954), Maslow did not repudiate classical psychology; rather, he attempted to enlarge upon its conception of personality by stressing man’s higher nature. In contrast to “the analytic-dissecting-atomistic-Newtonian approach” of behaviorism and Freudian psychoanalysis, it emphasized the holistic character of human nature. It defined and explained “the need hierarchy,” “self-actualization,” and “peak experiences,” phrases that have become part of the vocabulary of psychologists.

In 1967, Maslow was named humanist of the year by the American Humanist Association. That same year he was elected president of the American Psychological Association. He also played a major role in organizing both the Journal of Humanistic Psychology and the Journal of Trans-personal Psychology. At the time of his death he was a resident fellow at the Laughlin Foundation in California. Like the early humanists, he emphasized the inherent goodness in people. Maslow viewed humans as exercising a high degree of conscious control over their lives and as having a high resistance to pressures from the environment. He viewed personality development as the process of breaking the chains binding an individual to the animal world and building a more human world.

Maslow’s theories have had a major impact upon practicing psychologists because of his ideas’ direct, personal, and subjective plausibility. Synanon, the drug-addiction rehabilitation center, and the Esalen Institute, one of the best-known centers for practicing group-encounter psychotherapy, make use of Maslow’s ideas, but the need hierarchy and other popular conceptions have had little influence on psychological research. Maslow was a global theorist who tested his ideas imprecisely and nonquantitatively. He believed that his theories could never be tested in an animal laboratory or test tube but that they required “a life situation of the total human being in his social environment.”

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, and thus feel inadequate. The process of helping others is a powerful therapeutic tool that greatly enhances self-esteem and feelings 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 who 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. Although 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

Humans 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. Although 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 develop 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 descendent 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 common problems. 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 clients’ feelings and perceptions, helping them 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 who 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.

People who 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 have 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 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 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

KEY TERMS

Altruism —An unselfish willingness to help others.

Behavior therapies —Numerous techniques all having their roots in principles of learning.

Catharsis —A powerful emotional release followed by a feeling of great relief.

Cognitive-behavior therapy —An approach to psychotherapy that emphasizes the correction of distorted thinking patterns and changing one’s behaviors accordingly.

Existential factors —Realities of life including death, isolation, freedom, and meaninglessness that must be faced by all individuals.

Gestalt therapy —A therapeutic approach that focuses on increasing awareness of feelings and impulses in the present.

Group cohesiveness —The degree to which a group functions well in its assigned task; the importance the group develops to each of its members.

Group psychotherapy —A form of therapy in which a small, carefully selected group of individuals meets regularly with a therapist to assist each individual in emotional growth and personal problem solving.

Imitative behavior —Behaviors of a therapist or group member that are imitated, consciously or unconsciously, by other group members.

Individual psychotherapy —A relationship between therapist and patient designed to foster the patient’s emotional growth and personal problem-solving skills.

Information giving —Imparting of information about a disease or condition as part of the therapeutic process.

Interpersonal learning —Learning that takes place via feedback from others.

Person-centered therapy —A therapeutic approach that believes the client’s own drive toward growth and development is the most important factor in healing.

Phenomenological therapy —A therapeutic approach that focuses on the interpretations individuals place on their experiences.

Psychodrama —A form of group therapy that has group members act out parts of important people in the lives of individual group members.

Psychodynamic groups —Psychotherapy groups that utilize the principles of unconscious needs and motivations developed by Sigmund Freud.

Self-help groups —Groups that fall outside the realm of psychotherapy groups, but that offer help to individuals around a particular problem or concern. These groups typically are not professionally led.

Termination —The process of ending a therapy group; an important part of a group therapy.

Universality —The feeling of being isolated, unique, and separate from others, often experienced by therapy group members.

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 people begin in a therapy group, the leader interviews the individuals to ensure a good fit between their needs and the group’s. The individuals 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 that 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.

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 ed. Baltimore: Lippincott Williams and Wilkins, 1998.

Panman, Richard, and Sandra Panman. “Group Counseling and Therapy.” The Counseling Sourcebook: A Practical Reference on Contemporary Issues, eds. 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 ed. New York: Basic Books, 1995.

ORGANIZATIONS

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

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

American Society of Group Psychotherapy and Psychodrama. 301 N. Harrison Street, Suite 508, Princeton, NJ 08540. Telephone: (609) 452-1339. Website: <http://www.asgpp.org/html/about_us.html.>

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

OTHER

American Academy of Family Physicians. “Cognitive Therapy.” Available online at: <http://familydoctor.org/882.xml>.

Kleber, Herbert D., and others. Practice Guideline for Treatment of Patients with Substance Use Disorders. 2nd ed. 2006. Available online through the American Psychiatric Association at: <http://www.psych.org/psych_pract/treatg/pg/SUD2ePG_04-28-06.pdf>.

National Alliance on Mental Illness. “Cognitive-Behavioral Therapy.” Available online at: <http://www.nami.org/Template.cfm?Section=About_Treatments_and_Supports&template=/ContentManagement/Content Display.cfm&ContentID=7952>.

Barbara S. Sternberg, PhD
Emily Jane Willingham, PhD

The Gale Encyclopedia of Mental Health