- Group psychotherapy
Group psychotherapy is a form of
psychotherapyin which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, including Cognitive behavioural therapyor Interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process is explicitly utilised as a mechanism of change by developing, exploring and examining interpersonal relationships within the group.The broader concept of "group therapy" can be taken to include any helping process that takes place in a group, including support groups, skills training groups (such as anger management, mindfulness, relaxation training or social skills training), and psycho-education groups. The differences between psychodynamic groups, activity groups, support groups, problem-solving and psycoeducational groups are discussed by Montgomery (2002). [Montgomery C (2002) Role of dynamic group therapy in psychiatry Advances in Psychiatric Treatment, 8(1): 34-41] . Other, more specialised forms of group therapy would include non-verbal expressive therapies such as dance therapy, music therapyor the TaKeTiNa Rhythm Process.
History of group psychotherapy
The founders of group psychotherapy in the USA were Joseph H. Pratt,
Trigant Burrowand Paul Schilder. All three of them were active and working at the East Coast in first half of the 20th century. After World War II group psychotherapy was further developed by Jacob L. Moreno, Samuel Slavson, Hyman Spotnitz, Irvin Yalom,and Lou Ormont. Yalom's approach to group therapy has been very influential not only in the USA but across the world, through his classic text "The Theory and Practice of Group Psychotherapy". [Yalom and Leszcz (2005) The Theory and Practice of Group Psychotherapy, 5th edition, Basic Books] Moreno developed a specific and highly structured form of group therapy known as Psychodrama.
In the United Kingdom group psychotherapy initially developed independently, with pioneers
S. H. Foulkesand Wilfred Bionusing group therapy as an approach to treating combat fatigue in the Second World War. [T Harrison and D Clarke (1992)The Northfield experiments.British Journal of Psychiatry 160: 698-708 (http://bjp.rcpsych.org/cgi/content/abstract/160/5/698)] Foulkes and Bion were psychoanalysts and incorporated psychoanalysis into group therapy by recognising that transference can arise not only between group members and the therapist but also among group members. Furthermore the psychoanalytic concept of the unconscious was extended with a recognition of a group unconscious, in which the unconscious processes of group members could be acted out in the form of irrational processes in group sessions. Foulkes developed the model known as Group Analysisand the Institute of Group Analysis, while Bion was influential in the development of group therapy at the Tavistock Clinic. Bion has been criticised, for example by Yalom, [ ^ Yalom and Leszcz (2005) The Theory and Practice of Group Psychotherapy, 5th edition, Basic Books, p.193] for his technical approach which had an exclusive focus on analysis of whole-group processes to the exclusion of any exploration of individual group members' issues. Despite this, his recognition of group defences in the "Basic Assumption Group", has been highly influential. [ Bion (1962) Experiences in groups and other papers http://www.pep-web.org/document.php?id=PAQ.033.0441A] [Billow R (2005). Bion Today. International Journal of Group Psychotherapy 55 (4) 613-23]
Bion's approach is comparable to
Social Therapy, first developed in the United States in the late 1970s by Lois Holzmanand Fred Newman, which is a group therapy in which practitioners relate to the group, not its individuals, as the fundamental unit of development. The task of the group is to "build the group" rather than focus on problem solving or "fixing" individuals.
Yalom's therapeutic factors (originally termed "curative factors" but re-named "therapeutic" factors in the 5th edition of 'The Theory and Practice of Group Psychotherapy' [Yalom and Leszcz (2005) The Theory and Practice of Group Psychotherapy, 5th edition, Basic Books, Preface p. xii] are derived from extensive self-report research with users of group therapy [Butler T and Fuhriman A(1983) Curative Factors in Group Therapy: A Review of the Recent Literature. Small Group Research, 14: 131-142] [See also the American Group Psychotherapy Association http://www.agpa.org/guidelines/factorsandmechanisms.html]
*Universality:The recognition of shared experiences and feelings among group members and that these may be widespread or universal human concerns, serves to remove a group member's sense of isolation, validate their experiences and raise self-esteem
*Altruism:The group is a place where members can help each other, and the experience of being able to give something to another person can lift the member's self esteem and help develop more adaptive coping styles and interpersonal skills.
*Instillation of hope:In a mixed group which has members at various stages of development or recovery, a member can be inspired and encouraged by another member who has overcome the problems that they are still struggling with.
*Imparting information:While this is not strictly speaking a psychotherapeutic process, members often report that it has been very helpful to learn factual information from other members in the group, for example about their treatment or about access to services.
*Corrective recapitulation of the primary family experience:Members often unconsciously identify the group therapist and other group members with their own parents and siblings in a process which is a form of
transferencespecific to group psychotherapy. The therapist's interpretations can help group members gain understanding of the impact of childhood experiences on their :personality, and they may learn to avoid unconsciously repeating unhelpful past interactive patterns in present day relationships.
*Development of socialising techniques:The group setting provides a safe and supportive environment for members to take risks by extending their repertoire of interpersonal behaviour and improving their social skills
*Imitative behaviour:One way in which group members can develop social skills is through a modelling process, observing and imitating the therapist and other group members, for example sharing personal feelings, showing concern and supporting others.
*Cohesiveness:It has been suggested [Joyce A, Piper W, Ogrodniczuk J (2007). Therapeutic Alliance and Cohesion Variables as Predictors of Outcome in Short-Term Group Psychotherapy. International Journal of Group Psychotherapy 57 (3),269-97] that this is the primary therapeutic factor from which all others flow. Humans are herd animals with an instinctive need to belong to groups, and personal development can only take place in an interpersonal context. A cohesive group is one in which all members feel a sense of belonging, acceptance and validation.
*Existential factors:Learning that one has to take responsibility for one's own life and the consequences of one's decisions.
Catharsisis the experience of relief from emotional distress through the free and uninhibited expression of emotion. When members tell their story to a supportive audience, they can obtain relief from chronic feelings of shame and guilt.
*Interpersonal learning:Group members achieve a greater level of self-awareness through the process of interacting with others in the group, who give feedback on the member's behaviour and impact on others.
*Self-understanding:This factor overlaps with interpersonal learning but refers to the achievement of greater levels of insight into the genesis of one's problems and the unconscious motivations which underlie one's behaviour.
Group therapy can form part of the therapeutic milieu of a psychiatric in-patient unit [Yalom (1983) Inpatient Group Psychotherapy] [see for example http://psychiatry.stanford.edu/medservices/in.html] or ambulatory psychiatric
Partial hospitalization(also known as Day Hospital treatment). [Ogrodniczuk J & Steinberg P (2005) A Renewed Interest in Day Treatment. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 50(1)] In addition to classical "talking" therapy, group therapy in an institutional setting can also include group-based expressive therapies such as drama therapy, psychodrama, art therapy, and non-verbal types of therapy such as music therapy. Group psychotherapy is a key component of Milieu Therapyin a Therapeutic Community. The total environment or milieu is regarded as the medium of therapy, all interactions and activities regarded as potentially therapeutic and are subject to exploration and interpretation, and are explored in daily or weekly community meetings [See for example Campling & Haigh (1988) Therapeutic Communities: Past present and future. Jessica Kingsley,Publishers, London; De Leon (2000) The Therapeutic Community, Springer]
A form of group therapy has been reported to be effective in psychotic adolescents and recovering addicts. [ AJ Giannini. Use of fiction in therapy. Psychiatric Times.18(12)33-34,2001. ] Projective group therapy uses an outside text such as a novel or motion picture to provide a "stable delusion" for the former cohort and a safe focus for repressed and suppressed emotions or thoughts in the latter. Patient groups read a novel or collectively view a film. They then participate collectively in the discussion of plot, character motivation and author motivation. In the case of films, sound track,cinematography and background are also discussed and processed. Under the guidance of the therapist, defense mechanisms are bypassed by the use of signifiers and semiotic processes. The focus remains on the text rather than on personal issues. [ AJ Giannini. Tangential symbols. Journal of Clinical Pharmacology.33:1134-1139,1993.]
Research on effectiveness
There is clear evidence for the effectiveness of group psychotherapy for depression: a
meta-analysisof 48 studies showed an overall effect sizeof 1.03, which is clinically highly significant. [McDermut W et al (2001) The Efficacy of Group Psychotherapy for Depression: A Meta-analysis and Review of the Empirical Research. Clinical Psychology: Science and Practice, 8, 98-116] Similarly, a meta-analysis of five studies of group psychotherapy for adult sexual abuse survivors showed moderate to strong effect sizes [Callahan, K (2004) A review of interpersonal-psychodynamic group psychotherapy outcomes for adult survivors of childhood sexual abuse. International Journal of Group Psychotherapy, 54 (4): 491-519] , and there is also good evidence for effectiveness with chronic traumatic stress in war veterans. [Kanas, N (2005) Group Therapy for Patients with Chronic Trauma-Related Stress Disorders. International Journal of Group Psychotherapy, 55 (1), 161-6] There is less robust evidence of good outcomes for patients with borderline personality disorder, with some studies showing only small to moderate effect sizes. [Kanas, N (2006) Long-Term Psychodynamic Group Therapy for Patients with Personality Disorders. International Journal of Group Psychotherapy 56 (2), 245-51] The authors comment that these poor outcomes might reflect a need for additional support for some patients, in addition to the group therapy. This is borne out by the impressive results obtained using Mentalization based treatment, a model which combines dynamic group psychotherapy with individual psychotherapy and case management. [Bateman A (2008) 8-Year Follow-Up of Patients Treated for Borderline Personality Disorder. American Journal of Psychiatry, 165 (5)] Most outcome research is carried out using time-limited therapy with diagnostically homogenous groups, however long-term intensive interactional group psychotherapy [Yalom and Leszcz (2005) The Theory and Practice of Group Psychotherapy, 5th edition, Basic Books p. 272] assumes diverse and diagnostically heterogeneous group membership, and an open-ended time scale for therapy. Good outcomes have also been demonstrated for this form of group therapy. [Lorentzen S, Bogwald K, Hoglend P. (2002) Change during and after long-term analytic group psychotherapy. International Journal of Group Psychotherapy. 52 (3), 419-30]
* Self Help Groups
* [http://www.ukselfhelp.info/ Useful directory site for UK groups -for specific needs]
* [http://www.birchmore.org/index.html Useful site about group psychotherapy and shame, with extensive links to other group therapy sites]
* [http://www.eastsideinstitute.org/ East Side Institute for Group and Short Term Psychotherapy]
* [http://www.agpa.org/ American Group Psychotherapy Association]
* [http://www.ormont.org/ Useful information about Lou Ormont's Method of Modern Group Analysis]
* [http://tabirchmore.netfirms.com/ Contents of International Journal of Group Psychotherapy 1969-Present]
* [http://www.group-psychotherapy.com/bibliography.htm A good bibliography of ther group therapy literature]
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