14: Group Psychotherapy

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CHAPTER 14 Group Psychotherapy


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

There are many attempts to categorize what is effective in group therapy. Some factors will be more or less active depending on the kind of group. For example, corrective familial experience will figure prominently in psychodynamic groups, whereas cognitive-behavioral groups will emphasize learning and reality testing. Some are universal to all groups, such as the following:
Factor Definition
Acceptance The feeling of being accepted by other members of the group. Differences of opinion are tolerated, and there is an absence of censure.
Altruism The act of one member helping another; putting another person’s need before one’s own and learning that there is value in giving to others. The term was originated by Auguste Comte (1798–1857), and Freud believed it was a major factor in establishing group cohesion and community feeling.
Cohesion The sense that the group is working together toward a common goal; also referred to as a sense of “weness.” It is believed to be the most important factor related to positive therapeutic effects.
Contagion The process in which the expression of emotion by one member stimulates the awareness of a similar emotion in another member.
Corrective familial experience The group re-creates the family of origin for some members who can work through original conflicts psychologically through group interaction (e.g., sibling rivalry, or anger toward parents).
Empathy A capacity of a group member to put himself or herself into the psychological frame of reference of another group member and thereby understand his or her thinking, feeling, or behavior.
Imitation The conclusion of emulation or modeling of one’s behavior after that of another (also called role modeling); it is also known as spectator therapy, as one patient learns from another.
Insight Conscious awareness and understanding of one’s own psychodynamics and symptoms of maladaptive behavior. Most therapists distinguish two types: (1) intellectual insight—knowledge and awareness without any changes in maladaptive behavior; (2) emotional insight—awareness and understanding leading to positive changes in personality and behavior.
Inspiration The process of imparting a sense of optimism to group members; the ability to recognize that one has the capacity to overcome problems; it is also known as instillation of hope.
Interpretation The process during which the group leader formulates the meaning or significance of a patient’s resistance, defenses, and symbols; the result is that the patient develops a cognitive framework within which to understand his or her behavior.
Learning Patients acquire knowledge about new areas, such as social skills and sexual behavior; they receive advice, obtain guidance, attempt to influence, and are influenced by other group members.
Reality testing Ability of the person to evaluate objectively the world outside the self; this includes the capacity to perceive oneself and other group members accurately.
Ventilation The expression of suppressed feelings, ideas, or events to other group members; sharing of personal secrets ameliorates a sense of sin or guilt (also referred to as self-disclosure).

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).

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