45.

GROUP THERAPY
John F. Zrebiec, M.S.W.
1. What is group psychotherapy? It often has been defined in the broadest terms, encompassing many kinds of groups with goals that range from behavioral 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.

2. How did group therapy begin?

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 1 1 . 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.

3. What are the advantages of group therapy?

The patient recreates characteristic difficulties in the group. Interactions in the group quickly expose patterns of behavior. The hall of mirrors concept refers to the groups ability to confront an individual with behavior he or she had been unable to recognize. Individual members are more likely to accept feedback about their behavior if it comes from multiple observers. Multiple supporters who empathize with the patients 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 behavior. Group therapy often is experienced as less regressive than individual therapy.
0

4. What are the 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 ones 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. 5. Are there different theoretical viewpoints? Originally, most group therapy was established on psychodynamic principles; now most group therapists use a combination of theories. For example, a common blend of models is psychodynamic (focused on individual group members), interpersonal (focused on interactions between members), and group as a whole (focused on the group processes). This chapter blends those models into some general principles that are broadly applicable to a wide variety of groups, of any length and type, in any clinical setting.
23 1

232

Group Therapy

6. What do I need to do first?

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 leaders primary role is teacher, whereas in a psychodynamic group, the leaders role is interpreter of unconscious phenomena.

7. How do I select patients for groups? 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.

8. Which group for which patient?

Groups are not random collections of strangers thrown together because a clinic has too few therapists and too many patients. It i s important not only to select patients who will benefit from group therapy, but to place them in a group that is particularly appropriate. Beginning groups traditionally comprise members who are similar in terms of ego development but different in terms of interpersonal style. For example, the ability to establish trust or capacity for concern is similar, but degrees of shyness or submissiveness are different. Most important is that no members see themselves as one of a kind in the group because they will be at high risk to drop out. To use a broad example, the only elderly, widowed man in a group with young, new mothers is going to find little common ground with other members and is likely to quickly leave the group. There are three reasons why patients drop out of groups: The right group at the wrong time (the patient is not ready for group). The wrong group at the right time (e.g., the elder widower with the young mothers). The patient i s not suited for group treatment.

9. Should I conduct a screening interview? Ideally, there should be at least one individual interview before a patient is accepted into a group. Some patients may require more if they are unfamiliar with therapy or ambivalent about joining the group. Assessment of a patient, for group therapy in general and for your group in particular, requires face-to-face contact. The interview also helps form an alliance between leader and member, establish goals, provide education about the role of the leader and the members, review the group agreements, answer questions, and address potential problems. Finally, it gives the patient an opportunity to make an informed decision about joining the group.
The Screening Interview: Common Questions

What do you want to get out of this group? Why do you want to joint this group at this time? What is your experience in groups (prior treatment, but also including family, school, job, social groups)?
Tuble continued on following puge

Group Therapy
The Screening Interview: Common Questions (Cont.)
What do you imagine this group will be like? What do you think you will contribute to thiy group? What will be the most difficult aspect of this group for you? May we review group agreements?

233

10. Should I have a group agreement? Yes. All groups need some operational guidelines that provide structure and a baseline for addressing any future behavior that jeopardizes the group. The following guidelines traditionally have been used by psychodynamic group therapists. They can be modified for time-limited groups, and for groups with a variety of patients in different settings. Members agree to: Attend each meeting, be on time, and remain for the entire meeting. Work on the problems which brought them to the group. Realize that communication is verbal and not physical. Protect the names and identities of other group members. Use relationships therapeutically and not socially. Remain in the group until the problems which brought them to the group are resolved. Give appropriate time to themselves and to the group to understand the reasons for leaving, should they decide to leave, and to say good-bye. Give the leader permission to speak with their individual therapist (if they have one) at any time that the leader feels it is in their best interests. Be responsible about payment. 11. What are the basics in terms of time, size, and place? 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 provides 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 leaders 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. 12. What is the role of the leader? To help the group members understand themselves by understanding their behavior in the group. The leader, then, has the challenge of deciding how the group can best be helped. Several decisions are involved: What to say, how much to say, and when to say it. How much attention to give to the present experience versus past events or future hopes. How much attention to give to individuals while still observing interactions between members. How much value to give to feelings and emotional experience without ignoring reason and intellectual understanding. How to integrate dialogue about group members with discussions about people outside the group. How to blend understanding of the content (obvious meaning) with the process (symbolic meaning) How much to respond to group demands or wishes. How much personal information to share.

234

Group Therapy

All of these leadership decisions are influenced by theoretical orientation, personality, and context of the group. Moreover, all are a matter of degree, not all or nothing, and each has consequences for the group. 10 Useful Rules.for the Group Therapist
1. Each meeting is in a context (time, place, purpose). 2. Each group member has a context. Try to keep in mind their history and presenting problems. 3. Pay attention to what is happening in the group at that very moment . . . the here and now focus. Ask yourself What is happening? Why is it happening now? 4. Remember everything that happens in the group has something to do with the group. 5. Each group meeting has a theme or connecting thread. 6. Pay special attention to the beginning words and behaviors that might predict the theme. 7.Think in terms of metaphors or analogies as a clue to the theme of the group. 8. Pay attention to your own emotional response to the group as a barometer of what is happening in the meeting. 9. Do not panic if you do not always know what is happening in the group. This is a common experience. Remember the above points and try to formulate hypotheses that can help you make an educated guess about the theme. 10. Prepare a summary statement whether you actually state it or not, as a way of organizing the group theme.

13. Are there advantages to co-leadership? Co-therapy is a frequently used model, primarily for training. The most important and time-consuming aspect is the need for the co-therapists to maintain their communication and attend to their relationship. Advantages Disadvantages For Patients Increased cost Destructive competition Enhances continuity in case of leader absence Lack of communication May provide a constructive relationship model for imitation Serious disagreement based on each leaders different professional, Replicates a two-parent family clinical, or administrative role Provides more limit-setting capability For Leaders Distancing from the emotional imProvides mutual support and co-supervision pact of the experience One leader overshadowed by more Offers two vantage points on group experienced other Allows leaders to share or change roles from verbal to observational and focus from whole group to individual Helps in dealing with crises and concrete tasks 14. Are there stages in group development? ~It is valuable for the group leader to have a developmental framework for understanding group themes and the myriad interactions of group process. Yalom proposes a useful framework for thinking about these four developmental stages. Stage 1 (in or out)-searching for purpose, getting to know other members, finding siniilarities, and learning the ground rules. Members are primarily concerned with acceptance and nonacceptance. Do the others like me? Are we similar? Communication in this stage often is superficial, polite, focused on giving or seeking advice, and gaining approval from the leader. The leaders primary role is to promote trust and safety, and to help members find common ground. Stage 2 (top or bottom)-jockeying for positions of control, dominance, and power among members, but above all, between members and the leader. The honeymoon comes to an end as safety and trust are established. Now, members want to know how they are different, how much autonomy the group leader will permit, and how much they can challenge one another and the leader. How can

Group Therapy

235

they batter, bend, and break group guidelines? Who are the strong ones? Whereas in the first stage members were primarily concerned with being seen as the same, now they are primarily concerned with being accepted as different. Criticism of one another, hostility toward the leader, and disenchantment with the group are typical. The group has great expectations of the leader so it should come as no surprise that they are disappointed in the leaders failure to fulfill their dreams. It is essential that the group leader tolerate their disappointment, encourage their confrontation, and not respond punitively. Remember that this rebellious, emotionally stormy phase is a sign that the group is moving ahead. Stage 3 (near or far)-the chief concern of the group is intimacy and closeness. How close to get to others? How many secrets to share? Following the previous stage of conflict there is more trust, cooperation, openness in communication, and group spirit. The leader sets the stage for progress by making sure that the group does not suppress all negative affect for the sake of group cohesiveness. The group is now ready to become a mature working group, with focus, flexibility, compassion, a greater tolerance for affect, a realistic appraisal of the leader, and a recognition of the value of other members. Stage 4-termination. It is the leaders job to draw the attention of the group members to the loss. Ordinarily, termination resurrects feelings around three themes: mortality and death, separation, and hope. These stages are present in all groups, but the depth and breadth of expression differ depending on the goals, time, and leadership style. There is overlap, with no clear boundaries between stages or consistency between groups. Groups never ultimately resolve these developmental issues, but periodically cycle through them at progressively deeper levels as stresses and conflicts emerge.

15. How do I handle difficult patients?

The difficult patient, often self-centered or demanding, can create a difficult group and a scapegoated group member. Volumes have been written about managing difficult patients, but it is worth mentioning one particularly constructive approach in groups. It is based on the premise that the difficult patient plays an important role for the group and represents aspects of everyone else in the group. The most therapeutic response is to focus on the reaction of other group members rather than on the pathology of the individual patient. This approach avoids further attack on the individual patient and encourages others to take responsibility for their share of the interaction.

16. What about combining group therapy with pharmacotherapy or individual therapy?
Psychotropic medications are common in groups and essential for psychotic patients. Attitudes about and reasons for medication typically become a topic for group discussion. Many patients receive concurrent individual and group therapy, which can be a powerful combination. There are two variations: combined therapy, in which the same therapist sees the patient in both individual and group therapy, and conjoint therapy, in which the patient is seen in individual and group therapy by two different therapists. Group therapy often is added to individual treatment, but patients can be referred for individual treatment from group, as well. Note that neither mode of treatment should be viewed as better than the other. When considering combined or conjoint therapy, be sure to review repercussions for communication, confidentiality, and countertransference.

17. How do I decide when to terminate? Time-limited groups come to a preordained ending. Other groups end because of the leaders decision to terminate. Patients leave groups because they have successfully completed treatment or leave prematurely for a variety of personal, group, and circumstantial reasons. The leave-taking process is more complicated than in individual therapy because it affects a number of people, not just the therapist. The leader should attempt to prevent premature termination and should draw attention to the feelings surrounding termination. Two helpful questions are: (1) Has the patient leaving gained the most possible from the group? (2) Why is the patient leaving at this particular time? The decision also can be examined on the basis of whether the original goal for joining the group has been accomplished. Interestingly, groups often assess the constructive changes and continuing conflicts exhibited by the terminating member.

236

Relaxation Training

18. Is there a place for brief group therapy? Time-limited treatment is becoming more common because of cost-limited care. Time-limited groups often are formed around specific symptoms, crises, or common issues (for example, medical illness, divorce, or adolescence) with limited goals of symptom relief, crisis management, or support and psychoeducation. Brief-treatment groups also are designed for more aggressive interpersonal intervention and more ambitious therapeutic change. They have in common a careful selection of patients, explicit goals, a well-defined working focus, rapid application of learning, active leaders, the use of interpersonal resources, and the use of time limits to accelerate behavior change. Unlike longer-tenn groups, patients can return for several courses of treatment; in both, success is predicated on careful pregroup preparation. Time-limited groups also can be conceptualized as having developmental stages (see Question 14). Progression through stages may be intensified because of the time limit.

19. Can the leader guarantee confidentiality? The legal and ethical responsibility to protect the patients privacy and confidentiality is uncompromised and uncomplicated for the therapist doing individual treatment. However, although the same standard applies for the group therapist, group therapy poses special problems because patients are expected to respect the identities and protect the information shared by other group members. In actuality, group therapy places limits on confidentiality (when one group member violates the confidentiality of another) because neither the leader nor the other group members have any legal means of enforcement.
BIBLIOGRAPHY
1 . Agazarian YM: System-Centered Therapy for Groups. New York, Guilford Press, 1997. 2. Alonso A, Swiller HI (eds): Group Therapy in Clinical Practice. Washington, DC, American Psychiatric Association Press, 1993. 3. Bernard HS, MacKenzie KR (eds): Basics of Group Psychotherapy. New York, Guilford Press, 1994.. 4. Dies RR: Models of group psychotherapy: Sifting through the confusion. Int J Group Psychother 42: 1-17, 1992. 5. Kaplan HI, Sadock BJ (eds): Comprehensive Group Psychotherapy. Baltimore, Williams &Wilkins, 1993. 6. Klein RH, Bernard HS, Singer DL (eds): Handbook of Contemporary Group Psychotherapy: Contributions From Object Relations, Self-Psychology, and Social Systems Theories. Madison, CT, International Universities Press, 1992. 7. Roth BE, Stone WN, Kibel HD (eds): The Difficult Patient in Group. Madison, CT, International Universities Press, 1990. 8. Rutan JS, Stone WN: Psychodynamic Group Psychotherapy. New York, Guilford Press, 1993. 9. Scheidlinger S: Group dynamics and group psychotherapy revisited: Four decades later. Int J Group Psychother 47:141-159, 1997. 10. Steenbarger BN, Budman SH: Group psychotherapy and managed behavioral health care: Current trends and future challenges. Int J Group Psychother 46:297-309, 1996. 11. Yalom ID: The Theory and Practice of Group Psychotherapy. New York, Basic Books, 1995.

46. RELAXATION TRAINING

1. What are the major forms of relaxation training? Self-guided, passive attention to single object of focus Meditation Progressive muscle relaxation Systematic contraction and relaxation of major muscle groups Hypnosis Verbal and repetitive suggestions, often involving mental imagery, to relax mind and body Autogenic training Structured series of formalized suggestions directed toward promoting body sensations associated with relaxation