OVERVIEW

The world of group psychotherapy has grown alongside the entire field of the many “talking therapies” during the last 75 years. 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 make 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, 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, and a therapy group will be distinguished from a therapeutic group enterprise. Group therapy rests on some common assumptions that apply to the entire panoply of therapeutic groups. Since the time that the field of psychoanalysis moved from an exploration of one’s inner psyche to an understanding of the importance of the intimate relationship between infant and child, and later between adults, we have been aware that the need for other people resides in all human beings. 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 stay with the anxious new moments in 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. Adages such as “birds of a feather fly together” emphasize that we tend to mimic the people around us in order to belong. 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. Knowledge is power, and the power to change requires a deeper knowledge of one’s blind spots. There is an inevitable pull (based on the contagion and amplification that often overrides the normal shyness of anyone 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. While some group theorists have relied on a cluster of factors relevant to their models of the mind and of pathology, all have used some of the whole group of 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 and in the context of support). Another healing factor is expanding one’s sublimatory options. The impulses that flourished in the context of childhood-limited defenses can now be checked by 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 marvelous source of concern and problem solving. Last, 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.

Table 14-2 Yalom’s Therapeutic Factors in Group Psychotherapy

Adapted from Yalom ID: Theory and practice of group psychotherapy, ed 5, New York, 2005, Basic Books.

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 reestablishment 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. These groups have as their primary focus the restructuring of the patient’s sensorium, the management of acute distress, and the planning for a return to the community. These patients also need help in dealing with the shameful consequences of hospitalization and with the sometimes elusive process of establishing outpatient treatment that will support them after hospital discharge. A benevolent inpatient or partial hospital group experience will be of special value with the latter problem, since group therapy will remain an affordable treatment for the foreseeable future. Many patients who have been hospitalized after an acute medical illness may also need to regain equilibrium, to deal with the shame inherent in losing the ability to live independently, and to prepare to reenter 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, and 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). Increasingly, research data have shown that involvement in these groups can extend the survival and the quality of life of the severely ill (e.g., women with end-stage breast cancer).

Psychotherapy groups provide relief for a certain sector of symptoms. This approach to psychopathology is congruent with categorical nosological systems, such as the Diagnostic and Statistical Manual—Fourth Edition (DSM-IV). Diagnosis in this system is seen as symptomatic rather than developmental; treatment goals include alleviation of symptoms and a change in behavior. For example, patients with eating disorders 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, which is not the primary focus of the group. At the same time, some people who work successfully in these groups may want to continue the work of personality change in open-ended dynamic groups when their symptoms are relieved. Usually, they do well to terminate from one kind of group before engaging in another.

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. Character difficulties are tenacious for all human beings, from the healthiest neurotic to the most regressed patient. Characterological problems often occur outside of the patient’s awareness (often to the disbelief and the alarm of others who see the problems clearly). Such problems 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 for reasons having to do with 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. Whether a member who is difficult in the group stays or leaves or whether a new member enters must not be left to a vote, just as such decisions are not made within a family. The privilege and burden of administrative and inclusion/exclusion matters is a serious responsibility of the group leader, as is the question of single or co-therapy leadership. It is important to remember that the leader is not a member of the group, despite the ambivalent entreaties of the members to bring the leader into 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 nonjudgmental listening and responding to the patients’ struggles. By remaining warm and neutral, the leader is in a position to listen nonjudgmentally to all aspects of the whole 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 bringing to light this unconscious material, patients can learn something new and try to use this new information in their process of change. By working in the here and now, material is fresh and the experience is shared between the therapist and other group members, which creates an opportunity for all to participate in the change process. One advantage of group therapy is that there are multiple people in the room with whom a patient interacts (providing multiple scenarios with which to work).

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 issues for each patient (using material from their intrapsychic process and from interpersonal relations), as part of the group as a whole. Some patients need help sorting through their individual conflicts (including their ambivalence about change, their willingness to share, and to what degree they can trust and feel secure in the group). For others, interactions in relationships are challenging and other group members might have qualities that make it difficult for a patient to feel comfortable. The group leader might choose to mediate or to bring light to an interpersonal conflict that arises (which could help the patient gain insight into his or her interpersonal style and into the barriers to forming healthy relationships with others). 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. An example of this is a low-functioning group for psychotic patients (who live a marginalized life and have trouble feeling comfortable outside of isolation). In this type of group, a leader can help the members see the ways that the “cocoon” in which they live can inhibit the process of making connections with others in the group. By helping the group slowly feel more comfortable outside of their “cocoons” (by reaching out to others in the group), they may be able to venture out of their isolation in the outside world and decrease their loneliness and isolation.

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 the opportunity for the group to 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 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 consists of the following agreements, 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. Beyond the obvious focus on the kind, duration, and theoretical underpinnings, the leader must then decide on several matters: on membership; on logistics (e.g., place, time, and fees); on whether to work alone or with a co-therapist; on 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 restructuring (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 and to collect the history of the patient’s participation in all kinds of groups (e.g., family, school, sports, work, and friendships). This is the time to discuss the group’s agreements and the rationale that underlies them; it is crucial to elicit the patient’s collaboration in the enterprise by making as much information available as possible. 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.

CLINICAL VIGNETTE

WHO SHOULD BE TREATED IN GROUP THERAPY?

Most people who are appropriate for individual psychotherapy are also appropriate for group therapy; the questions are what kind of group and under which circumstances. In a psychodynamically oriented group, where early developmental conflicts and relationships are assumed to interfere with the here and now of the patient’s life, it will be important to organize a group that is reasonably homogeneous for the level of ego development and heterogeneous in every other regard. Mixing people of differing gender, cultures, or ages can be extremely useful so long as these patients emerge from a similar developmental spectrum. The differences among them can then be addressed and exploited to the advantage of the members in the group. However, when patients diverge sharply in levels of ego development, group cohesion and universality will be compromised. For example, a group of patients who experience severe anxiety around loss (consequent to serious abandonment throughout their lives) will do well to work together in a group. On the other hand, to mix two or three such patients in a group of people who are conflicted around intimacy and sustained relationships may well result in two subgroups, neither of which has an easy empathic rapport with the other’s internal dilemmas. The specific symptom or population designation of other groups points the way by definition to patient selection. The rule of thumb is to put together a group of people with the maximal capacity for empathy among the members; homogeneity of ego development tends to maximum empathy.

Although one cannot be certain who will benefit from a group and who will not, there are several factors that might mitigate against a group referral (at least for the present moment in the patient’s life). Some patients are unable to make good use of group therapy without other clinical interventions. For example, the actively manic patient may be more overstimulated than helped in a group. Another category of patient frequently referred to a group includes those who are severely schizoidal and who have really never developed sustained human relationships. To place these patients in a group overrides their capacity and sets them up for early failure. On the other hand, group treatment may be helpful if the patient can receive occasional individual treatment to help him or her deal with the contact with others. Acutely disturbed patients may need and deserve individual attention before their entry into an ongoing therapy group. In all of these cases, prior treatment, either psychopharmacological or individual supportive therapy (or both), may increase the likelihood of the patient succeeding in the therapy group down the road.

COMBINED THERAPIES

Occasionally, patients are treated in both individual and group therapy, either by the same therapist or by two different ones. This option is useful for a variety of patients (including the overintellectualized patient). For some patients, insight becomes a way to avoid feeling. The amplified affect in a group can be very helpful in penetrating the isolation of affect of such patients. This may also work well for the patient who cannot tolerate the dyadic transference of individual treatment. Dyadic treatment can threaten the fragile ego boundaries of a patient who is either very needy, or who is overstimulated by the apparent promises of the individual work. Often these are the patients who are suffering from borderline spectrum problems. These patients often flee treatment, or regress to terrifying actions (that can be life threatening). Adding group therapy can distribute the transferences across the members of the group and the group leader, and may enable the individual and the group treatment to proceed more safely and more productively.

It is crucial that the two therapists collaborate (by frequent phone calls, and by avoiding the patients’ attempts to split them). In the case where the two therapists do not agree, or do not respect the other’s work, the patient is potentially at great risk of harm, or at least in a stalemate that is iatrogenic in origin. It is impossible to overstate the importance of using supervisors and consultants when such a mismatch occurs.

Patients will at times be seen in both individual and group therapy with the same therapist. There are many advantages and, as always, some costs to this treatment plan. It is frequently a surprise to see one’s individual patient when he or she joins a group. It is illuminating to move from working with the intrapsychic dimensions of the patient that have been the concern of the individual hour, and then observe the same patient express those very problems in the interactions with members of the group. For example, a mild and extremely gentle individual patient might startle his or her therapist by launching an aggressive attack on one or more members of the group when the shy facade is challenged. For some patients, however, sharing the therapist’s attention can be so distressing that the work of therapy is stalled. It may be far better for that patient to be referred to another leader’s group, or to defer group treatment to a more secure time.

Clinicians struggle with how much to preserve the privacy of what they know about the patient from the dyadic hour when the patient enters the group, and how much to disclose. While there are no hard and fast rules, what matters is consistency, and the prior agreement with the patient about this matter. Many clinicians opt to protect the information while urging the patient to bring the problems into the group. One major exception is the case where the group or one of its members is at risk; as usual, the rules of confidentiality are suspended when there is any threat to safety of any of the participants. It is very useful to agree that all treaters will be in regular contact with one another in order to work toward the patient’s advantage.

Many of these questions belie an old model that separates body from psyche from social context. As in most treatments that adhere to the bio-psycho-social model, psychosocial treatment has an impact on the biology of the patient, as well as on the psychology and the social adjustment of that person. In cases of more severe distress, a combination of group treatment, psychopharmacological treatment, and, occasionally, individual treatment may be ideal. However, given the cost constraints that delimit most mental health care, group therapy remains a very impressive primary treatment for a whole host of patient situations and needs.

LEGAL AND ETHICAL CONSIDERATIONS IN GROUP THERAPY

The group leader is bound by the usual rules of confidentiality in the group as in any other clinical encounter with a patient. With the exception of a threat to a person or persons, this confidentiality holds and is usually elaborated on in the code of ethics of the therapist’s professional organization. The same pertains to any conduct of the therapist that violates the code of ethics relative to sexual or other extraprofessional contact with a patient. Even in the most mature groups, members may inadvertently be tempted to speak to their spouses or others about an exciting moment in a therapy group. The bigger challenge is how to do this while respecting the confidentiality that is agreed on by and among members. Aside from stressing the importance of protecting the identities of patients in the group, there is little that the leader can do to ensure compliance, nor is it against the law for members to break confidentiality. Group therapists worry about whether the group can become a pool of witnesses in the case of a subpoena. Some states extend the same protection to the members that they do to the leader, namely the patient-therapist privilege, but this has not been tested and may not apply with all professionals across the disciplines.

RESEARCH, OUTCOME, AND EVALUATION

Research on group therapy has focused mostly on outcomes. More recently, measures have been developed that seek to relate the patient’s sense of belonging and of feeling valued in the group with the effectiveness of the treatment. Studies continue to support the importance of group cohesion on group effectiveness; feeling valued is seen as a statement of cohesion. Research also indicates greater confidence in the efficacy of group treatment, and shows no appreciable differences between individual or group therapy and pharmacotherapy. However, these studies remain problematic, given the problems that bedevil most social science research: it is difficult to control for therapist differences, and attempts to do so by providing manuals for intervention become different models than what happens in real life. Nonspecific factors are elusive, but seem to indicate that patients progress when they feel cared about, when the leader is warm and somewhat structured, when the match with colleagues in the group is appropriate, and when the goal and direction of the group are clear and consistent.

Researchers have moved beyond the question of whether groups work to a finer look at how they work, in what circumstances, and for whom. Proper and careful screening and otherwise preparing a patient to enter a group results in a greater chance of success in entering and staying. Members who are at about the same level of ego development do better in open-ended groups than they do in groups with a large disparity of ego levels of development. Short-term, focused groups are more successful if leaders are structured as to agenda and time boundaries, and if the patients are more homogeneous with regard to the problem being addressed.

Research instruments are useful for measuring patient satisfaction and self-reports of increased well-being. The Clinical Outcome Results battery developed by the American Group Psychotherapy Association is one example; it uses such measures as the Symptom Checklist 90—Revised (SCL-90R), the Social Adjustment Scale Self Report (SAS-SR), the Multiple Affect Adjective Check List—Revised (MAACL-R), and the Global Assessment Scale (GAS). More recently, measures such as the Structured Analysis of Social Behavior and the Group Climate Questionnaire (GCQ) have been used extensively by MacKenzie and others who work with patients in structured time-limited groups.

A major shortcoming in group therapy research stems from the pragmatics of conducting research over a long time, and with more amorphous goals. Thus, most of the data emerges from research on time-limited groups, usually within the cognitive-behavioral or interpersonal model. While those findings are very important to secure, they have limited applicability for the more open-ended dynamic models of group treatment. That research remains to be enlarged on. Of particular interest is the emerging research on recovery from severe physical illness (e.g., women with metastatic breast cancer). Women from that population were found to double their survival time, and to decrease their need for pain medication, if they also participated in group therapy along with their usual oncologic treatments.

CONSULTATION AND SUPERVISION FOR GROUP THERAPY

The leader of a group may be less constrained about asking for consultation since all the work is observed by all members in either case. Still, it can be difficult for group leaders to ask for help, as it is difficult for most professional helpers, once they have gone beyond their years of formal training. However, failure to find help in conducting a group can increase exponentially the strain on the leader given the number of people in the consultation room and the multiplicity of countertransference vectors. A well-running group can look deceptively autonomous of the leader’s impact, but the truth is that the leader’s attention and calm form the platform on which the group grows. Occasional consultations or ongoing peer supervision is a safe, judicious practice. In the case of Dr. B. (from our clinical vignette), he was caught in a blind spot of considerable proportion having to do with his vulnerability to the contagion of affect from the members. His supervisor helped him to recognize the problem, to work out the more personal aspects of his psychological stress in his own treatment, and to learn some ways of capitalizing on the moment to his patients’ advantage.

Supervision is also a way for the leader to take advantage of his or her affiliative needs and to avoid using the patient group for dealing with the loneliness of the well-functioning group leader. In addition to departmental faculty with group therapy expertise, there are professional organizations that offer ongoing training and supervision for group leaders at all levels of experience.