EFPT Psychotherapy Guidebook • EFPT Psychotherapy Guidebook Group Therapy Miltos Vasiliadis, Chrysothemis Fryda, Jasper Kjaer Published on: Jul 12, 2019 License: Creative Commons Attribution 4.0 International License (CC-BY 4.0) EFPT Psychotherapy Guidebook • EFPT Psychotherapy Guidebook Group Therapy Overview “Hence it is evident that the state is a creation of nature, and that man is by nature a political animal” Aristotle, Politics 1253a Aristotle’s notion of the “political animal” reminds us of the fact that human beings cannot only be described as singularities, but also as a cluster of relationship dynamics. A group is a field where these dynamics come into play and are utilized in what we call group psychotherapy. Group psychotherapy is not a single type of therapy. It is a family of psychotherapies. Almost every individual psychotherapy model has its group counterpart and there are some types of psychotherapy which are group – dedicated. The purpose of this chapter is to provide the reader with some basic information about this family of psychotherapies and with a quick overview of some important group psychotherapy subtypes. The list is not extensive, as this would be impossible to do so in a single chapter of this guidebook. Historical Background In general, today’s group therapy is defined as a type of psychotherapy where the therapist(s) and the group meet together and use the intragroup and/or the group- therapist or client-therapist interactions for the purpose of treatment. By this definition, it is generally accepted that group psychotherapy began in the early 20th century, with the works of Joseph H. Pratt, an internist who developed what he called 2 EFPT Psychotherapy Guidebook • EFPT Psychotherapy Guidebook Group Therapy the “class method” (1905) for tuberculosis patients. He would lead groups of 15 patients and educate them on their disease, while they provided each other with mutual comfort. The defining characteristics of this type of therapy is that there was a set of rules in order to join the group and that patients would interact with each other and with the doctor. In its beginnings, group psychotherapy was an entirely new point of view that challenged the dyadic analyst-analysant relationship by exposing it into a greater pool of human interaction. In 1927 Trigant Burrow, an American psychiatrist and psychoanalyst, published The Group Method of Analysis and coined the term group analysis. He applied the basic analytic principle in groups, where the group was viewed as a whole and as a social constellation. Also, by being one of the first analysts to challenge the objective role of the therapist, he led the foundations for what was later referred to as intersubjectivity. In the meantime in Europe, Jacob Moreno was developing psychodrama through his Theater of Spontaneity in Vienna (see chapter on psychodrama). In 1931 he introduced group psychotherapy into the American Psychiatric Association and it is quite probable that he coined the term group psychotherapy. By the middle 30s Paul Ferdinand Schilder, an Austrian psychiatrist and psychoanalyst, was also laying the foundations of group psychotherapy; He was conducting group sessions with psychotic children in the Bellevue hospital in New York. The development of group psychotherapy as a practical method was largely atheoretical, but nevertheless was influenced by the study of group processes. Gustav Le Bon (1841-1931) was a major initial contributor. Le Bon dealt with the idea that a group is not a mere sum of its members and individuals tend to become more primitive once they join a large group, as they lose their sense of responsibility and their behaviors and feelings become contagious. During the same period (1920) William McDougal also described this “extra” power that groups provide to the individuals in his Group Mind theory, but he was also interested in the constructive properties of a group, rather than the destructive crowd, a process he called organization. It is self-evident that the events of WW1 provided thinkers with a field of study of human group dynamics. In this context, Sigmund Freud also studied group dynamics mostly in organized groups, such as armies (and other types). Also influenced by Le Bon, in 1921 he published Group Psychology and the Analysis of the Ego, where he highlighted that groups provide members with a sense of purpose and that individuals connect to each other through their relation to the leader, a father surrogate. Members must reduce their individuality to serve a common goal. In order to do this, they must 3 EFPT Psychotherapy Guidebook • EFPT Psychotherapy Guidebook Group Therapy replace their own ego ideal with that of the group. In order to re-acquire their individuality, they need to develop empathy. A practical shift in group psychotherapy occurred during WW2. During the war, when groups were needed to alleviate distress in massive amounts of soldiers, Wilfred Bion and John Rickman organized groups of soldiers in the Northfield Military Hospital in London (1942), with the purpose of improving the soldiers’ morale. Bion, influenced by Melanie Klein’s object relations, developed a group-as-a-whole approach, where the focus was on the group’s relation to the leader. Thus, he divided group processes into 2 types: The work group, where interactions represent a mature level of functioning and the basic assumption group, where modes of cognition are more primitive. During the same period, Siegmund H. Foulkes developed the idea of the group matrix, the network of direct communications within the group. In 1947, one of the major contributors in social psychology and group psychotherapy, Kurt Lewin, coined the term group dynamics, which refers to the way in which individuals and groups interact with their changing environment. The development of group psychotherapy in the 60s was mainly driven by financial factors; as the mental health centers in the USA were reaching their limits, group psychotherapy presented as an efficient psychotherapy method. Also, psychotherapy in general was starting to gain acceptance as a method of personal development, rather than as a diagnosis-oriented method. This situation led to a vast popularization of group therapies and many groups were being led by minimally trained or unqualified leaders. The publication of Irvin Yalom’s Theory and Practice of Group Psychotherapy in 1970 was a major contribution towards a scientific approach. Yalom, described certain therapeutic factors which come into place within the here-and-now context of the group and studied the group process. His 11 therapeutic factors became the basis of future group psychotherapy research. Since the 1980s, the development of brief models of psychotherapy also affected the groups. Closed-ended groups (Brabender, 1985), inpatient groups (Yalom, 1983) were developed, while short-term models for specific homogenous groups started to gain acceptance. Relational psychoanalysis was developed as an evolution of object relations theory in the 80s (Atwood, Storolow) and found application in group therapy, by utilizing the concept of intersubjectivity. 4 EFPT Psychotherapy Guidebook • EFPT Psychotherapy Guidebook Group Therapy During recent years, previous models have evolved and the current trend involves research and evidence based therapy. A major effort in dealing with the long-term problem of unqualified group psychotherapy took place in 1993 with the foundation of the International Board for Certification of Group Psychotherapists within the AGPA, which requires a core curriculum to provide the Certified Group Psychotherapist title (CGP). Nowadays, major world events such as war, trauma and immigration have influenced group and intergroup dynamics, cultural and racial compositions and arrangements and thus they have become once again a major area of study in group psychotherapy. Evidence-based group therapies have been developed for trauma, as well as numerous other conditions. Group psychotherapy is an ever-advancing field, responding to social change and science developments and it does so by viewing the world through a peculiar lens: the group. Group Psychotherapy models – Indications Since there are numerous models of group psychotherapy, the indications are virtually endless. Some models are indication-oriented, while others are not and can cover diverse fields, e.g. from depressive outpatients to trauma-exposed emergency service first responders. Regardless of the model, there are some variations within group therapy that should be noted. There can be many types of groups and the configuration can depend on many factors: Time, theoretical model, goals, composition (e.g. homogenous / heterogenous), clinical application (e.g. inpatient / outpatient) and more. The major distinction for practical application is the time-limited and open-ended group. In time- limited groups, the duration of therapy can vary from 10 weeks up to 1-2 years. These groups usually do not accept new members after initiation (closed groups), have specific goals and are usually homogenous in composition. They can be groups for life issues, general medical disease, specific diagnoses, etc. Open-ended groups are usually more heterogenous and diverse, in an attempt to represent social diversity as effectively as possible. These groups are usually more explorative and less goal- oriented. 5 EFPT Psychotherapy Guidebook • EFPT Psychotherapy Guidebook Group Therapy How does group psychotherapy work? This is a subject which has been extensively studied by many authors and many theories have been formulated. In this text we decided to mention Yalom’s therapeutic factors, which are some of the most commonly addressed in literature. YALOM’S THERAPEUTIC FACTORS 1. Instillation of hope: To create a frame of optimism increasing the belief and confidence that recovery is possible. The main goal of this factor is to engage the patients into the group process, by understanding the therapeutic potential of the group. 2. Universality: The understanding that patients are not alone in their problems and their thoughts, feelings and behaviors can be similar to those expressed by others. 3.