Date:08-04-13

GROUP THERAPY
Presentee: Priya Puri Chairperson: Ms. Rudrani Chatterjee

Department of Clinical Psychology Institute of Psychiatry, Kolkata

It is in the shelter of each other that the people live

~ Irish Proverb~

a group is defined as two or more people who interact and

influence one another (Shaw, 1981).

intended to help people who would like to improve their

ability to cope with difficulties and problems in their lives

focuses on interpersonal interactions Aims to help with solving the emotional difficulties encourages the personal development Members feel that (s) he is not alone with her/his problem and

that there are others who feel the same

The group can become a source of support and strength in

times of stress

Feedback from the group can make one become aware of maladaptive patterns of behaviour, and thus change ones point of view and help one adopt more constructive and effective

reactions.

GROUP THERAPY

v/s INDIVIDUAL THERAPY

Group therapy usually costs much less as compared to individual therapy

meeting other people with problems can give a wider perspective of ones own problems

Listening to other people helps one understand that one can

view and handle problems in more than one way.

Other people can give encouragement and emotional support: "We are all in the same boat."

Group therapy is useful in treating problems involving communication with other people

Problem of confidentiality of secrets In group therapy the therapist needs to cater to each member

of the group, while in individual therapy the therapist gets

more time to handle an individuals particular problems

HISTORICAL BACKGROUND

Development of group psychotherapy can be seen in four phases

currently group therapy is in its fourth phase. The four phases of group therapy:

The first phase was ushered by World War II and the

enormous amount of psychological carnage that emerged from it. second phase of group therapy's development was the community mental health movement in the late 1960s and

1970s

The four phases of group therapy: third phase came in the 1990s which was the age of health care reform

fourth phase of group therapy came in the first decade of

this century and it was ushered by a rise in terrorism and natural calamities to address the issues of psychological trauma

Important contributors to the field of group therapy: Joseph Pratt (1905) Edward W. Lazell (1921)

Jacob Moreno, the founder of psychodrama

Trigant Burrow 1928, Samuel Slavson Maxwell Joness therapeutic community Kurt Lewins field theory

Nathan Ackerman

INDICATIONS FOR INCLUSION

Slavson (1955) sets four general criteria for inclusion into groups: The patient must have experienced minimal satisfaction in

his/her primary relations

A minimal degree of sexual disturbance A moderate ego-strength A minimal super-ego development

Other indicators: Motivation and preparation (Berne,1966)

people who define their problems as interpersonal

(Friedman,1976) willing to become susceptible to influences of the group willing to be of help to others. Relatedness and reality contact (Mullan and

Rosenbaum,1962)
Ability to withstand frustration (Horowitz, 1976) ability to maintain tolerance for others (Corsini, 1957)

THERAPEUTIC FACTORS IN GROUP THERAPY

Sadock (1989) delineated 20 therapeutic factors for group therapy: 1. Abreaction

2. Acceptance
3. Altruism 4. Catharsis 5. Cohesion 6. Consensual validation

7. Contagion 8. Corrective familial experience 9. Empathy

10. Identification
11. Imitation 12. Insight 13. Inspiration 14. Interaction

15. Interpretation 16. Learning 17. Reality testing

18. Transference
19. Universalization 20. Ventilation

TYPES OF GROUPS

Jacobs et al. (2010) have categorised groups into 7 types that are as follows: Education groups Discussion groups

Task groups
Growth and experiential groups Counselling and therapy groups Support groups Self-help groups

STAGES OF

GROUP THERAPY

The beginning stage: the time period used for introductions and for discussion of such topics as the purpose of the group, what to expect, fears, group rules, comfort levels, and the content of the

group.
In this stage, members are checking out other members and their own level of comfort with sharing in the group. members determine the focus of the group May take more than two sessions to feel enough trust and

comfort

The middle, or working, stage: the members focus on the purpose. learn new material, thoroughly discuss various topics, complete tasks, or engage in personal sharing and

therapeutic work.
This stage is the core of the group process it is the time when members benefit from being in a group

The closing, or ending, stage devoted to terminating the group members share what they have learned, how they have

changed, and how they plan to use what they have learned.
May be an emotional experience Most groups need only one session for this stage

APPLICATION OF
THEORETICAL MODELS

Cognitive Behaviour Therapy: efficient form of treatment for a wide range of specific problems for diverse client populations (Bieling, McCabe, & Antony, 2006).

emphasizes the interaction of thoughts, feelings, and

behaviours. The most direct way to change dysfunctional emotions and behaviours is to modify inaccurate and dysfunctional thinking.

 sound therapeutic relationship that emphasizes collaboration

and active participation is the foundation for effective

practice The cognitive therapist teaches group members how to identify these distorted and dysfunctional cognitions through a process of evaluation.

group leader assists members in forming hypotheses and

testing their assumptions, which is known as collaborative empiricism.

 learn to engage in more realistic thinking trained to test these automatic thoughts against reality.

therapeutic goals that guide group interventions include

providing symptom relief, assisting members in resolving their most pressing problems, and teaching them relapse prevention strategies.

Rational Emotive Behaviour Therapy: founded by Albert Ellis Ellis developed an ABC model of understanding feelings

and behaviours.
The theory is based on the premise that thoughts cause feelings, the leader helps members to focus on changing their feelings by looking at what they are telling themselves

Steps of REBT in group set-up:

Clarifying the event, person, or situation (A)

Clarifying the feelings and/or behaviour (C) Clarifying the negative self-talk (B) Changing the feelings by changing the self-talk

Transactional analysis: developed by Eric Berne everyone has three ego states: the Parent, Adult, and Child

developed as a result of childhood messages.

The key in TA is to help members get an Adult perspective on situations that tend to be negative or volatile.

Dialectical Behaviour Therapy: originally developed by Marsha M. Linehan, to treat people with borderline personality disorder(BPD). Combines standard cognitive behavioural techniques

for emotion regulation and reality-testing with concepts of

distress tolerance, acceptance, and mindful awareness.

 For DBT in group settings the group ordinarily meets once weekly for two to two-and-a-half hours and learns to use specific skills that are broken down into four skill modules: core mindfulness

interpersonal effectiveness
emotion regulation distress tolerance.

COMMON MISTAKES MADE WHEN LEADING THERAPY GROUPS

Attempting to Conduct Therapy Without a Contract

Not Involving the Other Members

Spending Too Much Time on One Person Spending Too Little Time on One Person Focusing on an Irrelevant Topic Letting Members Rescue Each Other

Letting the Session Become an Advice-Giving Session

DEALING WITH PROBLEM

SITUATIONS IN GROUPS

 The

chronic talker:

leader could attempt to speak to the member about his

talkativeness.
other strategy involves seeking feedback from the members. Another method could be to ask a question to the group and encouraging members who have not spoken yet to speak up.

The resistant member:

May have negative expectations about the effectiveness of a group

believe that the group will not be helpful, and therefore, they
refuse to participate cooperatively Leader should let the member share his feelings in the group or to talk to him in a dyad or after the session and try to help him work through his resistance. Do not to spend too much time with the resistant member if it takes productive time away from the other group members.

The member who tries to get the leader:

This occurs when a member attempts to sabotage what the

leader is saying or doing in the group. Leader should try to understand why the member has targeted him. talk to the member at the end of the session

the leader might be able to gain some insight from talking to

other members.

Dealing with crying: important to take into consideration when a member is

crying is whether the crying is a result of some struggle or

painful event or is an attempt to gain sympathy. Members may reach out and touch the person who is crying. it is appropriate to ask a member not to touch or hug another member

shift the focus away from that member and then seek
him/her out after the group.

CLINICAL APPLICATIONS OF
GROUP THERAPY

Groups for Mood Disorder: When one looks at the interpersonal sphere of depressed and

bipolar patients, one sees that their histories are riddled with
interpersonal problems. depressed patients are invariably withdrawn from social contact and/or show signs of irritability as a prominent symptom. Bauer and McBride (2003) created a life goals group program for bipolar disorder

Groups for personality disorders: personality disorders owing to the predominant affective disturbance and disturbance in the interpersonal sphere seen

in PDs.
In a group set-up, the therapist has more leverage to induce change in maladaptive behaviour, negative attitudinal

stances, and interpersonal deficits.

DBT can be used in group set-ups for borderline personality disorders.

Groups for Anxiety Disorders: The CBT group aims to empower patients to engage with

their anxieties by supplying them with a set of anxietyreducing skills. The advantages of a CBT group are having greater

opportunities for role modelling, practicing new behaviours

in vivo before testing them out in the world outside getting peer feedback from others with similar anxieties enjoying the positive reinforcement that comes from many people, not just the therapist, which serves to reinforce new habits and thought patterns.

Group therapy for substance dependence:

Velasquez, et al (2001) posit a comprehensive 29-session

group treatment model based on the transtheoretical model of behaviour change (TTM). The five distinct Stages of Change: Precontemplation, Contemplation, Preparation, Action, Maintenance.

The 29 sessions are divided into two sequences: the first 14

meetings are devoted to the Precontemplation,

Contemplation and Preparation (P/C/P) stages while the final 15 meetings focus on Action and Maintenance (A/M).

 Precontemplative/Contemplative/Preparation: Consciousness Raising

Self-re-evaluation
Decisional Balance Environmental Re-evaluation Efficacy Self-liberation

 Action/Maintenance Stimulus Control Counter-conditioning

Reinforcement Management
Social Liberation Helping Relationships

Parent training groups for behaviour management: focuses on helping the parent help a child learn new behaviours that he is having difficult time learning focus on helping parents reduce and eliminate undesirable or

challenging behaviours in the child

 Parent training programs are based on the following principles: Behaviours are learned. These behaviours become habits and they keep happening

because of the way parents and children interact with each

other. Behaviours and habits can be changed by changing the way parents respond to the childs behaviours.

 Parental training groups are usually of two types: Parent support group Special training groups

The goal of parent training groups is to make the parents experts and this cannot happen unless parents devote enough time to practicing the skills at home.

GROUP THERAPY IN INDIAN SCENARIO

Very few studies based on group psychotherapy in India A study by Bhaduri et al. (1967) suggested a positive relation between group therapy activities and intellectual, emotional

and behavioural improvement of maladjusted adolescents.

Bastani in 1974 conducted a study on group psychotherapy with 6 male exhibitionists. The study suggested that a group setting offered the male exhibitionists opportunities for support, introspection, coping adaptively with the environment

and a realistic relation with an interested group of peers and an

accepting therapist.

Ismail Shihabuddeen and Gopinath

(2005) conducted a

study to assess the perceived benefits and difficulties of group meetings among caregivers of persons with Schizophrenia and

Bipolar Mood Disorder. The study revealed that the group

meeting led to effective monitoring of the functioning of individuals, a reduction in the subjective family burden and family distress, a better support system with adequate coping skills and good compliance with the treatment programme.

EVIDENCE BASED STUDIES

Hovland et al. (2012) conducted a study to compare physical exercise in groups to group cognitive behaviour therapy for the treatment of panic disorder and found that Group CBT is

more effective than group physical exercise as treatment of

panic disorder, both immediately following treatment and at follow-up assessments.

A study conducted by Andion et al. (2012) to examine

the efficacy of Individual DBT in 37 BPD patients, compared

with combined individual/Group DBT in 14 BPD patients. Significant improvements on the outcome measures were

observed across both versions of DBT treatment, particularly

at the 18-month follow-up assessment but, no significant differences were observed between Individual DBT and

Combined individual/Group DBT on any of the post-treatment

evaluations.

In a study by Lecomte et al. (2012) intended to see whether

effects of Group CBT for early psychosis lasted even after one
year, it was found that there were Significant improvements at 12 months for social support and insight. Negative symptoms

remained low, whereas positive symptoms went back to pretherapy levels.

A study by Huntley, Araya, and Salisbury (2012) revealed that Group CBT confers benefit for individuals who are clinically depressed over that of usual care alone. Individually delivered CBT is more effective than group CBT immediately

following treatment but after 3 months there is no evidence of

difference.

A study by Klein, Skinner and Hawley (2012) evaluated the

feasibility of group-based DBT for binge eating within the

context of an operating community clinic. Positive outcomes included significant improvement in both binge eating and

secondary outcomes with the Eating Disorder Inventory

subscales of Bulimia, Ineffectiveness, Perfectionism and Interpersonal Distrust.

CONCLUSION

Group psychotherapy is suitable for a large variety of problems and difficulties, beginning with people who would

like to develop their interpersonal skills and ending with

people with emotional problems like anxiety, depression, etc.

It aims at helping individuals with solving the emotional

difficulties

encourages the personal development of the participants in the group.

But, as compared to other modes of therapy it is a relatively underexplored area.

More research needs to be done in this area especially in a collectivistic and developing country like India.