Group Psychotherapy

Overview

The world of group psychotherapy has grown alongside the entire field of the many “talking therapies” during the last 75 years. Starting with Joseph Pratt in 1906 and his groups for tuberculosis (TB) patients in the early 1900s, the therapeutic use of groups expanded to specific populations, such as those with alcoholism or schizophrenia, until the 1950s saw the development of various group theories and continued expansion of its applications.

Put simply, group psychotherapy rests on the assumption that people need to move from a state of isolation (that so often accompanies mental distress) and towards making contact with others who share common interests (in order to heal and to grow). The presence of committed others who come together with an expert leader to explore the inner and outer workings of each member's personal dilemmas drives the process. Whether an individual suffers from serious mental illness, from conflicted life dilemmas, from medical illness, or from existential trauma, where otherwise normal people are crushed by abnormal situations (e.g., the terrorist attacks of Sept. 11, 2001; war; or natural disasters, such as Hurricane Katrina), a well-organized and well-led group can have a beneficial influence on the bio-psycho-social spectrum of the human organism.

A therapy group is a collection of patients who are selected and brought together by the leader for a shared therapeutic goal ( Table 14-1 ). In this chapter some of the goals of a therapy group will be described. Group therapy rests on some common assumptions that apply to the entire panoply of therapeutic groups. Recent psychoanalytic thinking recognizes the importance of intimate relationships at all ages and the need for others resides in all humans. The need for attachment is seen as primary by a whole host of group theorists; the press for belonging is that which yields a sense of cohesion that can help the individual tolerate the anxious moments when faced with a group of strangers. For better and for worse, people who wish to belong to a cohesive community are apt to mimic and to identify with the feelings and beliefs of other members in that community. At its best, this process allows for new interpersonal learning; at its worst, it raises the specter of dangerous mobs. People in distress tend to downplay and to mute their concerns to avoid facing their problems. In a group, each member is exposed to feelings, to needs, and to drives that increase the individual's awareness of his or her own passions and blind spots. There is an inevitable pull (based on the contagion and amplification that often overrides the normal shyness of individuals in a crowd of strangers) to get to know others more intimately in a group. As the members of a cohesive group move away from being strangers and get to know each other more deeply, they experience their own approaches to intimacy with others and with the self; in exchange, they receive immediate feedback on the impact they have on important others in their surroundings.

Many efforts have been made to describe the curative factors in a therapy group. Summed up into the essential elements, groups help people change and grow by allowing the individual within the group to grow and develop beyond the constrictions in life that brought that person into treatment. All group theorists have used some of the therapeutic factors identified in Table 14-2 . The more common healing factors are those that act by reducing each individual's isolation, by diminishing shame (which we have come to recognize as a major pathogenic factor in mental illness), and by evoking memories of early familial attitudes and interactions (that now can be approached differently with a new set of options in the context of support). Another healing factor is expanding one's behavioral options. The problematic interpersonal behavior patterns that developed in childhood can be reshaped into a broader emotional and behavioral repertoire that can be practiced among group members in the here and now. Provision of support and empathic confrontation can be curative as well. People often fear groups because they imagine they will be the target of harsh confrontation; they are unaware that the cohesive group is a marvellous source of concern and problem-solving. Lastly, unmourned losses are often at the root of a melancholic and depressive stance. Listening to others grieve and responding to others' awareness of our own losses can free an individual to move on.

Psychotherapy groups are as good as their clarity of purpose; the group contract ensues from that clarity. Therapists form groups for a wide variety of therapeutic purposes. Many groups provide support for patients with major illnesses. People in acute and immediate distress often find support in groups that have as their main goal a re-establishment of a person's equilibrium. Patients who have suffered a breakdown of their lives and who have needed hospitalization can use groups on inpatient units or in partial hospital settings to focus on the patient's sensorium, to manage acute distress, to plan for a return to the community, to help in dealing with the shameful consequences of hospitalization and to establish outpatient treatment. Many patients who have experienced an acute medical illness find groups helpful to re-gain equilibrium, to deal with the shame inherent in losing the ability to live independently, and to prepare to re-enter the world outside of the medical environment.

Since Dr. Pratt first offered his “classes” for tubercular patients at the Massachusetts General Hospital in 1905, people have come together to commiserate with one another around common problems, to share information, and to learn how to deal with the impact of those problems on their lives. These groups are often referred to as “symptom specific” or “population specific.” Groups have been organized around medical illnesses (e.g., cancer, diabetes, acquired immunodeficiency syndrome [AIDS]), around psychological problems (e.g., bereavement), and around psychosocial sequelae of trauma (e.g., war or natural disasters). The goals of such groups are to provide support and information that are embedded in a socially-accepting environment with people who are in a position to understand what the others are going through. The treatment may emerge from cognitive-behavioral principles, from psychodynamic principles, or from psycho­educational ones. Frequently, these groups tend to be time-limited; members often join at the same time and terminate together. The problems addressed in these groups are found in a broad variety of patients, from the very healthy to the more distressed, and they cut across other demographic variables (e.g., age and culture).

Some psychotherapy groups seek to provide relief based on symptomatic rather than developmental diagnoses. Treatment goals include alleviation of symptoms and a change in behavior. For example, patients with eating disorders, stress, or specific phobias are clustered in groups that can promote skills for self-monitoring and replace an automatic symptom with a more adaptive set of behaviors and cognitions. These groups may include members with a broad range of intrapsychic development.

Group therapy is the treatment of choice for people with chronic and habitual ways of dealing with life, even when those ways run counter to the patients' best interest. Characterological problems often occur outside of the patient's awareness (often to the disbelief and the alarm of others who see the problems clearly), and are syntonic and perceived as “Who I am” when brought into awareness. Like all bad habits, such ingrained behaviors are resistant to change, even when the patient wants to make such a change. When these characterological stances occur in the group, they are often repeated and come to the attention of the other members, who respond by confrontation and with offers of alternative strategies. In current parlance the term neurotic implies a relatively healthy individual who contains conflict, who owns some of the responsibility, and who may be nonetheless conflicted and guilty about his or her own life related to early developmental realities. In a psychodynamic open-ended group therapy, the neurotic patient observes resistance to intimacy and ambition, and works within the multiple transferences to develop a freer access to life's options.

A group leader must exercise authority over each of the aforementioned factors if the group is to be safe and containing for its members. The privilege and burden of administrative and inclusion/exclusion matters is a serious responsibility of the group leader. It is important to remember that the leader is not a member of the group. The clearer the leader is about the boundaries, the safer are the members to indulge their fantasies of wanting to corrupt the process, or to overcome the leader's authority.

The leader bears clear fiduciary responsibilities for the working of the group and the members within it. The burden is on the leader to exercise restraint and relative neutrality in the sense of non-judgmental listening and responding to the patients' struggles. By remaining warm and neutral, the leader is in a position to listen non-judgmentally to all aspects of the group's impulses and resistances, without taking sides or carrying the burden of policing the group, and deciding which are good feelings and interactions and which are not.

Group therapy offers multiple ways for patients to grow. As in individual therapy, interpretations given by a therapist can facilitate the move of unconscious material into one's consciousness by way of using material that arises during a psychotherapy session: that is, the here-and-now. By working in the here and now, material is fresh and the experience is shared between the therapist and other group members.

In psychodynamic groups, there are opportunities for several relationships to form. First, patients come to a group with their own history and unique perspective on the way the world and relationships work; their own intrapsychic process becomes an integral part of the group. The patient then becomes part of a dyadic relationship with every other group member and the group leader. The patient also becomes part of the larger group, known as “the group as a whole,” which becomes an entity in and of itself from which powerful thoughts and feelings emerge.

A group leader has an abundance of material with which to work, and he or she makes skillful choices as to where to spend time exploring either intrapsychic and interpersonal issues for each patient or patterns of the group as a whole. Many experts agree that the most powerful interpretation is a “group as a whole” interpretation, which sums up the thoughts and feelings of the group using the general process material. A “collective unconscious” forms within the group, and it is useful to highlight feelings of safety, trust, resistance, and intimacy.

One of the more practical theories with which a group can work is that the group becomes a microcosm of the external worlds of each patient. The patient will eventually experience thoughts and feelings that are triggered in his or her daily life in the group. Interactions in the group will remind patients of interactions they have with family, friends, colleagues, and authority figures. The group provides a safe arena to explore these thoughts and feelings, which will then give them insight and strength to experiment with new ways of being in the outside world. Ideally, as they try on “new hats” in the outside world, they can return to the group to check in with how it is going for them.

Creating a Group

Before approaching the concrete work of planning and organizing a psychotherapy group, the goals of the group must be clearly understood and be developed by the leader. These goals in turn will be dependent on the setting, the population, the time available for treatment, and the training and capacity of the leader(s). The group agreements, or contract, will be dictated by the goals.

Great care taken in the design of the group will allow for a more successful group; the more haphazard the planning, the more likely it is that the group will flounder around the members' resistances. The job of the therapist is to provide a safe context and meaning for the therapy group. This is done by designing a contract around the group's goal(s) and by carefully selecting members that are suitable for that group. For example, in a symptom-specific group, members should have similar symptoms and concerns; in a more psychodynamically-oriented group, members should be selected from a fairly homogeneous level of ego development, although their symptoms and character styles may differ along a wide spectrum. The latter group is focused on changing and on expanding internal defenses to promote a greater capacity to love and to work. A sample of the contract for an open-ended group is shown in Box 14-1 , which are explained and agreed to before beginning.

Although there are variations, most group leaders adhere to some form of this contract. Of course, the contract will be tailored to the population and to the goals of the group.

Before the group begins, the leader must make several decisions that will have major implications for the whole enterprise, such as: the duration, theoretical underpinnings, membership, logistics (e.g., place, time, and fees); whether to work alone or with a co-therapist; whether patients will be treated in group therapy alone or in some combination of group therapy, individual therapy, pharmacotherapy, or self-help group; on managing records; and on protecting confidentiality.

In addition to these logistical decisions, the leader's stance in the group needs to be consistent with the goals of the group. A psychodynamic leader of an open-ended group will probably be more likely to sit back and to allow the group's associations to lead the way for the group's work while he or she comments, like a critic at a concert. On the other hand, such a stance makes little sense for the leader of a cognitive-behavioral group, who is engaged in conducting desensitization exercises, and who provides cognitive re-structuring (including homework exercises to meet the goals of that therapeutic endeavor). The more open-ended and exploratory the group, the more the leader is placed in a role of group consultant/critic; the more cognitive and structured the group is, the more the leader is placed in the role of the group conductor.

Both anecdotal evidence and empirical evidence show that investment of significant amounts of time in the preparation of a patient for group therapy will improve the chances of a successful entry and retention into a group. In addition to the usual history-taking, it is very helpful to examine the patient's fantasies and biases about groups, to collect the history of the patient's participation in all kinds of groups (e.g., family, school, sports, work, friendships), to discuss the group's agreements, and their underlying rationale, as well as to obtain the patient's collaboration in the enterprise. Patients are helped by knowing how the group works, by knowing what the leader's role might be, and by knowing what they might expect for themselves.

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