Unit – VII: Systemic therapies

Group therapy and interpersonal therapy

: Origin, theoretical models, formulation, procedures, techniques, stages, process, outcome,

indications, and research & current status.

Interpersonal therapy

⮚ Interpersonal psychotherapy (IPT) is a brief, manualized, attachment

focused therapy that centers on resolving interpersonal problems and symptomatic
recovery.
⮚ It is an empirically supported treatment (EST) that follows a highly structured and
time-limited approach and is intended to be completed within 12–16 weeks.
⮚ IPT is based on the principle that relationships and life events impact mood and that
the reverse is also true.
❖ Origin

● Developed by Gerald Klerman (1929–1992)

● In developing a brief therapeutic approach to the treatment of depression, Klerman
studied psychological research on depression to determine which factors played a role
in the onset of depression. Several important conclusions from the research that helped
Klerman to determine which aspects of depression to treat.
● Reviewing this research led Klerman to identify four major problem areas that
interpersonal therapy should be able to address and treat: grief, interpersonal disputes,
role transitions, and interpersonal deficits.

❖ Theoretical models
⮚ Specifically, IPT is supported by three theoretical pillars:
1. Attachment theory
- Proposed by John Bowlby, describes the manner in which individuals form, maintain,
and end relationships.
- Human beings, said Bowlby, have an innate tendency to seek attachments; the quest for
them contributes not only to individual satisfaction, but to the survival of the species.
- Attachment forms the basis for the life-long patterns of interpersonal behaviour which
lead an individual to seek care and reassurance in a particular way.
- Attachments lead to reciprocal, personal, social bonds with significant others, and
because they generate experiences of warmth, nurturance, and protection, they also
decrease the need for vigilance and rigid muscle tone (indicating hyper-alertness for
defence).
- Understandably, proponents of attachment theory recognise an individual’s
vulnerability to depression if: (a) attachments do not develop early in life and/or (b)
attachment bonds are disrupted, say through death, divorce, or abandonment.
 - The distress associated with disruptions in attachments may be due to problems within
the specific relationship, but is also heightened when an individual’s social support
network is not able to sustain him or her during the loss, conflict, or transition.
- Insecurely attached individuals are more likely to become distressed than securely
attached people during interpersonal conflicts, after the loss of a relationship, or
following role transitions, both because they are less secure in their primary attachments
and because they have poor social support networks.

2. communication theory
While some psychotherapies may try to change an insecurely attached individual’s
basic attachment style, IPT works with that as a given. IPT focuses, rather, on the ways
the client communicates attachment needs, and on how the person can build a more
supportive social support network. Comparing these two foundational pillars of IPT,
we could say that attachment theory is linked to the broad, or macro-context of a person.
- Communication theory, in its quest to describe how individuals communicate their
attachment needs to significant others, informs individual relationships on a micro-
level.
- Like attachment theory, however, communication theory deals in aspects of
interpersonal relationships that are below the level of conscious awareness, and thus
sometimes difficult to identify.
3. social theory.
The final pillar of IPT’s support foundation focuses on the role that interpersonal factors
have in creating maladaptive responses to life events which then generate depression
and/or anxiety.
- Factors such as loss or disrupted or poor social support create the social milieu in which
a person develops interpersonal relationships, which in turn strongly influences how a
person copes with interpersonal stress.
- Social theory emphasises that it is the current environment which is crucial. Thus, poor
social support is seen to be causal in the generating of psychological distress (Stuart,
2006).

❖ Principle
It is believed that depression was the result of a variety of interpersonal issues and there were
four interpersonal problem areas that, if they could be alleviated, would help an individual deal
with depression: grief, interpersonal disputes, role transitions, and interpersonal deficits.
Grief: Although grief is considered a normal emotion, not a psychiatric disorder, it can provide
difficulties for people in mourning, particularly when the reaction is severe and continues over
a long period of time. Grief may present a particularly difficult problem when individuals
experience the loss of more than one person who is close to them. Furthermore, some
individuals are more prone to becoming depressed after losing a close friend or family member
than are others. This reaction is often referred to as complicated bereavement.
Interpersonal disputes: Often struggles, arguments, or disagreements with others, particularly
on a continuing basis, can lead to depression. Sometimes the dispute is with a family member,
spouse, child, parent, or other relative. At other times, the dispute may be with someone at
work—a boss, a subordinate, or a coworker. Other times disputes are with friends or associates,
or people in community organizations, such as in church groups. When individuals are
depressed, disputes may be with people in many of these groups.
Role transitions:This is a broad category that includes many different types of life changes.
Some are planned for and some are not. Examples of developmental changes are going to
college, getting engaged or married, separating or divorcing, dealing with difficult children, or
having a child leave the home. Sometimes role transitions have to do with work, such as trying
to find a job, dealing with promotion or demotion, or being fired or laid off. Other role
transitions may be accidental or not predictable. An individual may develop a serious illness
or disease, may be injured in an accident while at work or somewhere else, or have to deal with
losing a house to fire or flood. Individuals who are prone to depression may, when faced with
one of these situations, see their situation as hopeless or out of control.
Interpersonal deficits. Some individuals may be socially isolated or have few social skills.
Individuals who have few friends, “loners,” may have difficulty making or sustaining
relationships. This can be a default category for patients who do not fit the other categories
(Markowitz, 1998). When individuals do not report recent events that may have caused
depression, this category is often used. Individuals falling into this category are more likely to
have personality disorders than are those in the others. Because this area implies lack of social
skills and continuing interpersonal problems, it can be a more difficult area to treat than the
other three (Markowitz, 1998).
● The focus of interpersonal therapy is on current problems that deal with relationships.
When assessing patient problems, the therapist finds out which ones of the four
categories fit the patient’s problems. This will have a direct impact on the therapeutic
approach the therapist takes. Additionally, the therapist may use such measures as the
Hamilton Rating Scale for Depression (Hamilton, 1960) or the Beck Depression
Inventory to assess severity of depression.
❖ Goals
Grief. Individuals are helped with the mourning process and to deal with their sadness. They
are helped to reestablish interest in relationships and to become involved in both relationships
and activities.
Interpersonal disputes. Clients are assisted in understanding disputes or arguments as they
relate to depression. They are helped to develop strategies to resolve the dispute or to bring
about a change in an impasse. Sometimes they may change their expectations of their problems
and relationships with others.
Role transition. When individuals move from one role to the other, they often need to mourn
the loss of the old role. Seeing the new role as more positive is one goal. Another is to develop
a sense of mastery of the new role or roles and thus increase self-esteem.
Interpersonal deficits. By reducing isolation from others, changes in this problem area can be
made. Goals are to develop new relationships or improve ones that may be superficial.
Procedure
The typical course of IPT lasts 12 to 20 sessions over a 4- to 5-month period. The initial phase
is dedicated to identifying the problem area that will be the target for treatment. The
intermediate phase is devoted to working on the target problem area(s). The termination phase
is focused on consolidating gains made during treatment and preparing the patients for future
work on their own
Process
IPT has a “phasic” structure in that it is conducted in three distinct phases the initial,
middle, and termination phases.
Initial Phase.
⮚ Sessions one through five typically constitute the initial phase of IPT. After assessing
the patient’s current psychiatric symptoms and obtaining a history of these symptoms,
the therapist explains the rationale of IPT, underscoring that therapy will focus on
identifying and altering dysfunctional interpersonal patterns related to psychiatric
symptomatology.
⮚ To determine the precise focus of treatment the therapist will conduct an interpersonal
inventory with the patient and will develop an interpersonal formulation based on this.
In the interpersonal formulation, the therapist will link the patient’s psychiatric
symptomatology with the therapist’s identification of the problem area(s). The patient’s
concurrence with the therapist’s assessment of the problem and agreement to work on
this area are essential before beginning the intermediate treatment phase.

⮚ Diagnosis and assignment of the sick role: After a thorough psychiatric interview has
been conducted, the therapist gives the patient a formal diagnosis. Assignment of the
sick role during this phase serves the dual function of granting the patient both the
permission and the responsibility to recover. The sick role is not assigned to condescend
to the patient but, rather, is designed temporarily to exempt the individual from the
responsibilities so as to devote full attention to recovery.

⮚ Identify current interpersonal problems: the interpersonal inventory: The

therapist conducts an interpersonal inventory, which includes a review of the patient’s
past and current social functioning and close relationships. A thorough interpersonal
inventory is essential for adequate case formulation and development of an optimal
treatment plan.

- For each individual who is important in the patient’s life, the following information is
assessed: frequency of contact, activities shared, satisfactory and unsatisfactory aspects
of the relationship, and ways in which the patient would like to change the relationship.
- The interpersonal inventory provides a structure for elucidating the social and
interpersonal context of the onset and maintenance of psychiatric symptoms and
delineates the focus of treatment. Of particular importance are changes in relationships
(e.g., the death of a significant other, a change in jobs, an increase in marital discord,
disconnection from a friend).
- The therapist obtains a chronological history of significant life events, fluctuations in
mood and self-esteem, interpersonal relationships, and psychiatric symptoms. From this
review, the therapist can make a connection between certain life experiences and
psychiatric symptoms. As this interrelationship is delineated, patients understand more
clearly the rationale of interpersonal psychotherapy
⮚ Establish the relevant problem areas: On completion of the interpersonal inventory,
the therapist develops an individualized interpersonal formulation, linking the patient’s
symptoms to one of the four interpersonal problem areas—grief, interpersonal deficits,
interpersonal role disputes, or role transitions. Although the therapist explicitly assigns
a problem area, the patient needs to concur with the salience of the problem area
proposed and agree to work on it in treatment.
 ⮚ Collaboratively develop treatment goals: After the major interpersonal problem
area(s) associated with the onset or maintenance of the disorder is identified, the
therapist and patient work together to formulate a treatment plan with specified goals.
- The goals developed at this stage will be referenced at each future session and will
guide the day-to-day work of the treatment. Goals should flow from the identified
problem area and be designed to address it. After identification of a goal, the therapist
and patient collaboratively identify specific steps the patient will take to improve
relationships and socialization.
Before the end of the initial phase, patients may be given a written summary of their goals,
which serves as a treatment contract to guide their work for the remainder of treatment.
Intermediate Phase.
The intermediate phase typically lasts from eight to ten sessions and continues the “work” of
the therapy. Once the patient and therapist have agreed on the primary problem area and have
set treatment goals, the intermediate phase of treatment begins. An essential task throughout
the intermediate phase is to strengthen the connections the patient makes between the changes
he or she is making in his or her interpersonal life and the changes in his or her psychiatric
symptoms. During the intermediate phase, the therapist implements the treatment strategies
specific to the identified problem area.
Problem Area Description Goals Strategies

Grief Complicated *Facilitate the mourning *Reconstruct the patient’s

bereavement after process relationship with the
death of a loved one *Help the patient to deceased
establish interest in *Explore associated feelings
new activities and (Negative and positive)
relationships to substitute for
what has been lost

Interpersonal A history of social *Reduce patient’s social *Consider ways of becoming

deficits impoverishment, isolation reinvolved with others
inadequate or *Enhance quality of any *Review past significant
unsustaining existing relationships relationships, including
interpersonal *Encourage the formation of negative and positive aspects
relationships new relationships Explore repetitive patterns in
relationships
*Note problematic
interpersonal patterns in
the session and relate them
to similar patterns in the
patient’s life
Interpersonal Conflicts with a *Identify the nature of the *Determine the stage of the
role disputes significant other—a dispute dispute: renegotiation (calm
partner, other *Explore options to resolve down participants to
family member, dispute facilitate resolution);
coworker, or close *Modify expectations and impasse (increase
friend faulty communication disharmony to reopen
to bring about a negotiation); dissolution
satisfactory resolution (assist mourning and
If modification is adaptation)
unworkable, encourage
 patient to reassess the *Understand how
expectations for the nonreciprocal
relationship and to role expectations relate to
generate options to the dispute
either resolve it or Identify available resources to
dissolve it and mourn its bring about change in the
loss relationship

Role transitions Economic or family *Mourn and accept the loss *Review positive and
change—the of the old role negative
beginning or end of *Recognize the positive and aspects of old and new roles
a relationship or negative aspects of the *Explore feelings about what
career, a move, new role and assets and is lost
promotion, liabilities of the old role *Encourage development of
retirement, *Restore self-esteem by social support system and
graduation, developing a sense of new skills called for in new
diagnosis of a mastery regarding the role
medical illness demands of the new role

⮚ FACILITATE PATIENT’S WORK ON IDENTIFIED GOALS. In structuring the

intermediate phase, the IPT takes a moderate position between the extremes of being
highly active and merely reactive to the patient’s concerns.
- The need for the patient to change is stressed at regular intervals. It is important to note
that this constitutes a general encouragement to change rather than pressure to take a
specific course of action.
- In sessions, unfocused conversations are redirected to central themes of treatment, and
abstract and vague discussions are minimized to maintain focus. Therapists avoid
asking questions that elicit general or passive responses, such as general inquiries about
the patient’s week. Instead, sessions open with questions such as “What would you like
to work on today?” and “How have things been since we last met?” These questions
keep the patients focused on recent interpersonal events and psychiatric symptoms,
which the therapist attempts to link.
- A critical goal in the intermediate phase is to facilitate and help to strengthen the
patient’s connections between their psychiatric symptoms and the difficulties they have
in their interpersonal lives.
Termination phase
Termination Phase.
⮚ In the termination phase (usually four to five sessions in length), the therapist discusses
termination explicitly with the patient and assists him or her in understanding that the
end of the treatment is a potential time of grief.
⮚ During this phase, patients are encouraged to describe specific changes in their
psychiatric symptoms, especially as they relate to improvements in the identified
problem area(s).The therapist also assists the patient in evaluating and consolidating
gains, detailing plans for maintaining improvements in the identified interpersonal
problem area(s), and outlining remaining work for the patient to continue on his or her
own. Patients are also encouraged to identify early warning signs of symptom
recurrence and identify plans of action.
⮚ Discuss termination explicitly: The therapist systematically raises the issue of
reactions to impending termination in each of the last several sessions. Introducing the
idea that termination is an explicit stage will plant the seed that it is an important topic
to discuss. Therapists always ask patients how they feel about the ending of treatment—
not least because this provides an opportunity to emphasize what has been achieved and
to stress the patient’s competence at dealing with future areas of difficulty.
⮚ Discuss termination as a potential time of grief: Patient reactions to the conclusion
of treatments are often varied. As therapy nears completion, and sometimes well before
that, patients may develop anxiety about saying goodbye and going it alone. Because
termination marks the end of a connection to the therapist, is has a theme of loss, an
analogue of grief. It is important to state this possibility explicitly because
unacknowledged sad feelings may lead to fears of relapse and an increase in symptoms.
⮚ Review progress. An important aspect of the termination phase is encouraging patients
to talk about the progress they have made and giving feedback about the changes that
have been seen. This review helps to consolidate the work that has been done. It is not
uncommon for individuals to attribute changes in treatment to the therapist rather than
to their own hard work. Misplaced credit may erode the patient’s confidence in the
ability for continued success and improvement without treatment. Therefore, the
therapist needs to emphasize how the patient has begun successfully to manage his or
her outside relationships.
⮚ Encourage maintenance of therapeutic gains. Patients are encouraged to maintain
the interpersonal behaviors that have led to changes in their psychiatric symptom
profile, and therapists work to develop a plan for continued work on identified goals.
However, there are always goals that are not accomplished within the time frame of
interpersonal psychotherapy, and patients need to be aware of this. Indeed, future
difficulties can be expected, and the therapist needs to cultivate a discussion of how to
handle them. It is vital to assist patients in thinking about warning signs and symptoms
that suggest a need for intervention.
❖ General Therapeutic Techniques
⮚ Exploratory Questions. The use of general, open-ended questions can facilitate
the free discussion of material. This is particularly true in the initial phases of a
session. For example, the therapist might say, “Tell me about your relationship with
your husband.” Once this has generated discussion, progressively more specific
questioning will ensue.
⮚ Encouraging Affect. Interpersonal psychotherapy focuses on affect evocation and
exploration. Specifically, the therapist helps patients to (1) acknowledge and accept
painful affects—as the feelings are expressed, it is important for the therapist to
validate and help the patient to accept them; (2) use affective experiences to bring
about desired interpersonal changes— the goal is to help the patient to act more
constructively in interpersonal relationships, and this may involve learning when
his or her needs are met by expressing affect and when they are better met by
suppressing affect; and (3) experience suppressed affects—frequently patients are
emotionally constricted in situations in which others would typically experience
strong emotions.
⮚ Communication Analysis. This technique is used to identify any communication
difficulties that the patient may be experiencing and to help the patient change
ineffective communication patterns. Typically, the therapist will ask the patient to
recall in great detail an important recent interaction or argument with a significant
 other. Together, patient and therapist work to identify any communication
difficulties and find more effective communication strategies.
⮚ Use of Therapeutic Relationship. The premise behind this technique is that people
have characteristic patterns of interacting with others. Use of the therapeutic
relationship in IPT is less routine. If appropriate, however, the patient’s thoughts,
feelings, expectations, and behavior in therapeutic relationship are explored and
related to the patient’s characteristic way of behaving or feeling in other
relationships. In IPT it is particularly relevant and useful for patients with
interpersonal deficits (the patient develops a relationship with the therapist as a
model for other relationships) and interpersonal role disputes (the patient receives
feedback on how he or she comes across and thereby has the opportunity to
understand the nature of his or her difficulties in relating with others)
Indications
⮚ IPT is not just for depression.
⮚ It may also help treat:
bipolar disorder (when used along with medication)
borderline personality disorder
depression as a result of disease, such as HIV
depression as a result of caregiving
dysthymia
eating disorders
marital disputes
panic disorder
protracted bereavement
Current status
⮚ Since it was first developed in the 1970s, clinical and research interest in IPT has grown
steadily.
⮚ IPT has been adapted, tested, and shown to be efficacious as a treatment for a variety
of mood and other disorders.
Adaptations for mood disorders include IPT as a maintenance treatment of depression,
⮚ IPT for pregnancy, miscarriage, and postpartum depression, IPT for depression in
adolescents and children, IPT for depression in older adults, IPT for depression in
medical patients, IPT for dysthymic disorder, and IPT for bipolar disorder.
⮚ IPT has also been adapted for eating disorders, substance abuse, anxiety disorders,
borderline personality disorder (BPD), and posttraumatic stress disorder.
The evidence for the efficacy of IPT is strongest for mood disorders (where the most
trials have taken place), varies for other adaptations, and remains untested for some of
the newest ones.
⮚ An abbreviated form of IPT called interpersonal counseling (IPC) has also been
developed and tested (Weissman & Klerman, 1986) to address the practical restraints
of treating patients in certain settings (e.g. patients with depression as a secondary
diagnosis being treated for a medical problem in a general hospital setting).
⮚ A new adaptation, IPT-EST (evaluation, support, and triage), developed by Weissman
and Verdeli, provides a three-session intervention based on the first phase of the
standard IPT (diagnosis, identification of the interpersonal problem area, and
management of depression). IPT-EST is designed to be followed by an assessment of
the need for ongoing treatment. IPT-EST is currently being refined and tested.
 * Group therapy
● A group is a collection of individuals whose association is founded on commonalities
of interest, norms, and values. Membership in the groups may be by chance, by choice,
or by circumstances. (Graffam, 2014)
● Group psychotherapy is a modality that employs a professionally trained leader who
selects, composes, organizes, and leads a collection of members to work together
toward the maximal attainment of the goals for each individual in the group and for the
group itself.
❖ History and evolution of group therapy
⮚ GP originated in America- Joseph H. Pratt in 1905.
Groups composed of patients with tuberculosis. He was holding general care instruction
classes for them and noticed impact of this experience on their emotional state
He referred to these groups as classes.
⮚ Trigant Burrow (1927)
Coined the term group analysis and conducted group therapy for non-institutionalized
patients.
⮚ Louis Wender (1940)
Introduced the notion of the group as a recreated family, applied psychoanalytic
concepts to group therapy, and began the use of combined therapy.
The application of group therapy methods to prison inmates and discharged mental
hospital patients was pioneered by Paul Schilder and Louis Wender in the 1930s.
⮚ Samuel Slavson (1951)
An engineer by profession, founded the American Group Psychotherapy Association in
1948. He is regarded as having had the most influence on the development of American
group psychotherapy.
⮚ During the 1930s and 1940s Wolf and Schwartz (1962) actively applied the principles
of psychoanalysis to groups of adults.
⮚ The development of group therapy was given impetus during World War II, as a result
of the large number of soldiers requiring treatment.
⮚ Group psychotherapy also created interest in Europe.
⮚ A Romanian psychiatrist, Jacob L. Moreno (1898–1974), primarily identified with
psychodrama, borrowed from his experience with GP
He introduced GP in 1910 included role-playing and role-training methods (Moreno,
1947).

❖ Theoretical orientations
⮚ Major theoretical orientations toward group therapy can be broadly subsumed under the
psychodynamic, interpersonal, and cognitive-behavioral schools of thought.
⮚ The psychoanalytic spectrum has evolved to include more than classical Freudian
psychoanalytic theory. Exponents of the British school of object relations based on the
work of Melanie Klein, Ronald Fairbairn, D.W. Winnicott, Harry Guntrip, and other
self-psychologists utilize the unique properties of the therapy group to observe and alter
the behavioral and ideational manifestations that originate in the inner world of the
group member. Group members function as or represent part objects that parallel those
that exist in the mind of an individual and are projected onto and enacted within the
interactions in the group. In this way, the group provides an unparalleled setting for
behavioral information about how group members perceive and misperceive their
relationships to fellow group members and to the group leader. Practitioners with this
 orientation use the group to highlight unresolved issues involving themes of emotional
attachment, acceptance and rejection, managing intense affect, and tolerance of
frustration.
⮚ Ego psychologists also fall within the penumbra of modern psychoanalytic practices in
group therapy. Their theoretical base builds on earlier work by Heinz Hartmann, Ernst
Kris, and David Rapaport who viewed Freud’s structural theory of mental function into
id, ego, and superego components as incomplete. They postulated that a conflict free or
adaptational portion of the ego exists as well. In clinical group work, ego psychologists
rely on an appreciation of the mechanisms of defense that members use to counter their
anxieties, the utilization of the peer and authority transferences in the group, and on the
countertransference reactions of the group therapist.
⮚ Group therapy is an interpersonal form of treatment. Interpersonal theorists, most
notably Irvin Yalom, advocate a group approach that centers on the interaction of group
participants in the “here and now” transactions in the group session. Yalom also added
universal existential dilemmas to a method that calls for active group leadership in
creating an early, cohesive group framework.
⮚ Cognitive and behavioral approaches rely primarily on learning theory and experiential
elements to reach their goals. Structured, often manual- driven protocols are utilized in
a time-limited group composed of members with a shared set of problems. Cognitive
approaches are the most standardized of all group interventions and are, therefore, the
types of groups that are most easily measured in terms of group process and outcome.
⮚ Systems oriented group approaches have found a bona fide place in group therapy as
they have in family therapy. The assumption that the therapy group is an entity larger
than the sum of its parts and that each member plays a role in the success or failure of
the group enterprise is a central core to the systems approach.
⮚ Gestalt, redecision, and transactional analysis group therapies. The first, based on Kurt
Lewin’s field theory and the work of Fritz Perls and Paul Goodman enjoyed great
popularity during the sensitivity and encounter group movement in the late 1960s and
1970s. A central tenet of the Gestalt approach is the emphasis on group process over
group content and efforts to mobilize strong affect that stands in the way of a person
actualizing his or her full potential. The group focuses is on emotional experience in
the present moment and employs a variety of active, noninterpretive exercises designed
to heighten self-awareness and to facilitate change.
⮚ Transactional analysis, commonly known as TA, Its founder, Eric Berne, replaced
Freud’s structural theory of the psyche from id, ego, and superego to what he termed
“ego states” of Parent (“exteropsychic), Adult (“neopsychic”), and Child
(“archaeopsychic”). Berne codified a series of dysfunctional interpersonal patterns into
what he identified as “games” that people engage in repetitively without success. The
goal of the therapy group was to identify transactional states among group members
and to change childhood “life scripts” into more adaptive adult patterns.
❖ Types of groups
Task Groups: A group that comes together to perform a task that has a concrete goal
Guidance/Psycho- educational Group: Preventative and educational groups that help group
members learn information about a particular topic or issue and might also help group members
cope with that same issue
Counseling/Interpersonal Problem-Solving Groups: These groups help participants resolve
problems of living through interpersonal support and problem solving.
Psychotherapy Groups: These groups focus on personality reconstruction or remediation of
deep-seated psychological problems
Support Groups: These deal with special populations and deal with specific issues and offer
support, comfort, and connectedness to others.
Self-help Groups: These have no formal or trained group leader. (e.g. Alcoholics Anonymous
or Gamblers Anonymous)

❖ Group dynamics
⮚ Refers to the interactional patterns within groups. This includes group-level
experiences such as group cohesion based on seeing the group as attractive and helpful
and that provides an important supportive function.
⮚ Group norms evolve from the group interaction with guidance from the leader that give
stability and safety within the group.
⮚ Members will also adopt group roles based on their own outside behaviors that will
provide important learning experiences in the group interaction.
1. Group dynamics also embraces the concept of therapeutic factors. These
provide supportive and motivating experiences that create a powerful change
environment.
2. Supportive factors:
a. Universality by understanding that others have had similar
experiences
b. Feeling acceptance by the group
c. Experiencing altruism by helping each other
 d. Developing a sense of hope that change is possible
Self-revelation factors:
a. Self-disclosure b. Catharsis
4. Learning factors
a. Modeling on others
b. Vicarious learning through watching others
c. Guidance through suggestions from others
d. Education from the experiences of others
Psychological work factors
a. Interpersonal learning from group interaction
b. Insight into one’s own patterns
❖ Group size: Varies from 3-4 members to several hundred depending upon the
group (e.g. psychotherapeutic or task group).

-Group counseling and psychotherapy generally work best with 6-8 members
❖ Length and duration of sessions: Group sessions range from 1-2 hours.

Session duration can be only once or in some cases might last for years (e.g.
open-ended psychotherapy group)

❖ Assessment of therapeutic mechanisms in clinical practice

Clinicians who have an interest in tracking the therapeutic relationship in group
psychotherapy. American Group Psychotherapy Association (Burlingame et al.,
2006) recently released a Core Battery of instruments
-To assist group clinicians in selecting members
-Tracking their individual improvement
-Assessing aspects of the therapeutic relationship.
-Taken together, the measures address three components of the group therapy
experience:
Positive relational bond
Positive working relationship
Negative factors that interfere with the bond or the work of therapy.
STAGES OF GROUP DEVELOPMENT
● Well-designed therapeutic groups go through developmental processes over the course
of their life span. The stages of group development are characterized by observable
individual and group-as-a-whole phenomena.
● The American Group Psychotherapy Association’s Practice Guidelines for Group
Psychotherapy brought a five-stage paradigm of group development:
forming/preaffiliation, storming/power and control, norming/intimacy,
performing/differentiation, and adjourning/separation.
● It is essential that the group leader be aware of the stage of the group’s development
and intervenes with the most stage- specific techniques available. Ill-timed or poorly
sequenced interventions are not only ineffective, they can be damaging to individuals
and to the whole group endeavour. Confronting a fragile member before sound group
cohesion and
Preaffiliation
⮚ Initial concerns around inclusion and exclusion, acceptance by the leader and other
members, the search for similarities, fears of interpersonal aggression, and competitive
themes typify the first stage of a psychotherapy group.
⮚ The group leader’s focus is on knitting the nucleus of the group into a cohesive whole.
⮚ Therapist interventions encourage identification of goal compatibility among members,
modelling and eliciting supportive comments, promoting “here and now” interaction
among members, discouraging excessive dependency on the leader, establishing clear
group norms, and constructing a secure therapeutic frame to contain the group as it goes
forward. A strong educational function also characterizes the therapist’s role in the first
stage.
Power and Control
⮚ Apprehension about the emotional safety of the group, testing the group leader’s
strength and weaknesses, negotiating differences with others in the group and
experimentation with self-disclosure and self-assertiveness are hallmarks of the second
or “storming” stage.
⮚ Among the leadership tasks in this phase are mediating power struggles and conflicts
in the group, demonstrating firm but fair limit setting, being on the alert for issues that
might lead to drop-outs from group, promoting collaboration among members, and
keeping the group on task toward the attainment of its goals.
Performing/Differentiation
⮚ As the group progresses toward a more mature level, intragroup transferences become
more apparent. Both vertical (member-to-leader) and horizontal (member-to member)
transferences are accessible.
⮚ Levels of self-disclosure are higher and deeper interpersonal bonding takes place
among members.
⮚ There is a gradual transition from leader-directed group interplay to members sharing
more responsibility for behaving in concert with the group norms. A cooperative group
climate and greater reciprocity between members typifies the intimacy stage.
⮚ The role of the group therapist during this stage can be less active that in earlier stages;
however, the group therapist still plays a critical role in guiding the group process and
preventing it from getting detoured into unproductive or counter-therapeutic channels.
⮚ The leader aims to keep the group on track and reinforce those behaviors that promote
the acquisition of insight, recognize constructive attempts at problem solving,
encourage the group to keep going forward in a collaborative spirit, and to guard against
the formation of subgroups.
Norming/Intimacy
⮚ Against the backdrop of the secure base of established group cohesion, group members
in this stage are more willing to expose deeper feelings that might have activated real
or imagined risks at an earlier point in time.
⮚ This stage is an active one in which members is less afraid to show individual
differences. The prevailing group climate is one of mutuality and acceptance. This
atmosphere fosters greater understanding of relationships through the experiential
learning that comes by virtue of being in stable relationships with others in the group
over time.
⮚ Leadership focuses on letting the group be more self-sufficient and rewards
spontaneous interaction among participants.
⮚ The leader has to guard against abdicating the leadership role by becoming too passive
during this phase.
⮚ Allowing and urging the group to be proactive and trusting the group are issues for the
therapist during the phase of establishing intimacy.
Adjourning/Separation
⮚ The termination stage of therapy groups is noted for the triad of denial, regression and
recapitulation.
⮚ Ambivalent feelings are evoked as members contemplate the impact of the loss of a
valued member. Feelings of altruism, admiration, and having contributed to a fellow
group member’s success are accompanied by concurrent feelings of loss, competition,
envy, anger, and concerns about each member’s future. Members voice anxieties about
the viability of the group when a known member leaves during this stage.
❖ Therapeutic factors in group therapy
⮚ Abreaction: A process by which repressed material, particularly a painful experience
or conflict, is brought back to consciousness. During the process, the person not only
recalls, but also relives the material, which is accompanied by the appropriate emotional
response; insight usually results from the experience.
⮚ Acceptance: The feeling of being accepted by other members of the group; differences
are tolerated, and there is an absence of censure.
⮚ Altruism: The act of one member’s being of help to 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.
⮚ Catharsis: The expression of ideas, thoughts, and suppressed material that is
accompanied by an emotional response that produces a state of relief in the patient.
⮚ Cohesion: The sense that the group is working together toward a common goal; also
referred to as a sense of we-ness; believed to be the most important factor related to
positive therapeutic effects.
⮚ Consensual validation: Confirmation of reality by comparing one’s own
conceptualizations with those of other group members; interpersonal distortions are
thereby corrected. The term was introduced by Harry Stack Sullivan. Trigant Burrow
had used the phrase consensual observation to refer to the same phenomenon.
⮚ 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 recreates the family of origin for some
members who can work through conflicts psychologically through group interaction
(e.g., sibling rivalry, anger original 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.
⮚ Identification: An unconscious defense mechanism in which the person incorporates
the characteristics and qualities of another person or object into his or her ego system.
⮚ Imitation: The conscious emulation or modeling of one’s behavior after that of another
(also called role modeling); 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 and (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; also known as
installation of hope.
⮚ Interaction: The free and open exchange of ideas and feelings among group members;
effective interaction is emotionally charged.
⮚ 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, and attempt to influence and are
influenced by other group members.
⮚ Reality testing Ability: of the person to evaluate objectively the world outside the self;
includes the capacity to perceive oneself and other group members accurately.
⮚ Transference: Projection of feelings, thoughts, and wishes onto the therapist, who has
come to represent an object from the patient’s past. Such reactions, although perhaps
appropriate for the condition prevailing in the patient’s earlier life, are inappropriate
and anachronistic when applied to the therapist in the present. Patients in group therapy
may also direct such feelings toward one another, a process called multiple
transferences.
⮚ Universalization: The awareness of the patient that he or she is not alone in having
problems; others share similar complaints or difficulties in learning; the patient is not
unique. Ventilation The expression of suppressed feelings, ideas, or events to other
group members; the sharing of personal secrets that ameliorates a sense of sin or guilt
(also referred to as self-disclosure).

Indications
⮚ Addiction: Having a strong support network is key when it comes to overcoming
addiction. For some people, this kind of network isn't available at home and they may
benefit more from the support of others with an addiction. Hearing how others cope,
learning interpersonal skills and uncovering how your behaviours can impact other
people can all help you on your journey to overcoming addiction.
⮚ Anxiety: For people suffering with anxiety, getting out and interacting with those who
understand can be helpful. Knowing you aren't alone in your feelings and hearing how
others manage their anxiety can be invaluable. You are also likely to develop better
social skills, which can help if you suffer from social anxiety.
⮚ Depression: Those dealing with depression may find themselves feeling vulnerable and
isolated. Getting out of the house and talking to others is always useful and in a group
therapy session it can be even more so. Reaching out to others going through similar
issues and discussing coping mechanisms can help you to help yourself. You may also
find that imparting your own advice helps to boost your sense of self-esteem.
⮚ Eating disorders: For some people, the support network created by group therapy can
aid recovery from an eating disorder. For others however, it can be counterproductive.
If you find that you are comparing yourself to others in the group (for example their
weight/size) it may be worth seeking individual therapy instead.
⮚ Obsessive compulsive disorder: Being alone with your own thoughts during times of
anxiety can trigger symptoms when you suffer from obsessive compulsive disorder.
Speaking to others who understand your feelings and behaviours can help you
understand your condition better. Together you can support one another and look to
find ways of coping.
⮚ Relationship difficulties: If you find it difficult to forge and maintain relationships,
attending group therapy could help. Being around other people on a regular basis can
help you to develop interpersonal and social skills that you can go on to practice outside
of your sessions.
⮚ Schizophrenia: Group therapy for those with schizophrenia can be beneficial,
depending on the severity of the condition. It can be helpful to reach out to others who
experience similar symptoms to yourself, and learning more about the disorder can help
you understand your own thoughts better. If you find you are feeling unsafe or paranoid
 during group therapy sessions however, it is important to discuss your feelings with
your therapist.
⮚ Self-harm: Meeting with others who struggle with self-harm can help you feel less
alone. Hearing how others cope with their problems, including practical tips you may
not have thought of, can also be incredibly helpful.

Contraindications
⮚ Acute situational crisis
⮚ Deeply depressed suicidal clients
⮚ Members who are unable to attend regularly
⮚ Clients with Antisocial Personality Disorder (unless the group is specifically designed
for them)
(Burlingame, Fuhriman, & Johnson, 2002; Yalom & Leszcz, 2005)
⮚ Clients with delusions.
⮚ Older age.
⮚ Low intelligence.
⮚ Unwillingness
⮚ Lack of adequately trained staff.
❖ Advantages
⮚ More clients can be treated at once, fostering cost effectiveness.
⮚ Members benefit by hearing others discuss similar problems; feelings of isolation,
alienation, and uniqueness often decrease, encouraging members to share
problems.
⮚ It allows clients to explore their specific styles of communication in a safe
atmosphere where they can receive feedback and undergo change.
⮚ Members learn from others multiple ways to solve problems, and group exploration
may help them to discover new ways.
⮚ Members learn about the functional roles of individuals in a group. Sometimes, a
members share the responsibility as the co-therapist. Members become culture
carriers.
⮚ The group provides for its members understanding, confrontation, and
identification with more than one person.
Disadvantages
⮚ A member’s privacy may be violated, such as when a conversation is shared outside
the group. This behaviour obstructs confidentiality and hampers complete and
honest participation.
⮚ Clients from various diagnostic groups may differ based on neurobiological
functioning.
⮚ Clients may experience difficulty exposing themselves to a group or believe that
they lack the skills to communicate effectively.
⮚ Group therapy is not helpful if the therapist conducts the group as if it is individual
therapy. Such a therapist may see dynamics and groups.

⮚
References

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