Group Therapy

1
Group Therapy

• Dr Sabar Rustomjee

Adapted in part from Principles of Group
Psychotherapy American Group Psychotherapy
Association Inc Authored by Robert L. Weber,
Ph.D.,CGP, FAGPA Email www.agpa.org
2
What is a Group?

• The existence of Group in our Minds.
• There is no such thing as an individual without a
  group. Just as we are not able to understand a
  melody if we listen separately to each note, so
  we are unable to understand different aspects of
  an individual if we isolate him / her from their
  groups of belonging.
• A group is defined by its task or function.
  Without a task focus it remains a collection of
  individuals.

3
Group Therapy

• Group Therapy focuses on interpersonal learning
• It helps individuals get along in a more honest
  and authentic way with other people.
• It provides a support network for specific
  problems and challenges.

• Analytic Group Psychotherapy (as distinct from
  all aspects of Group Therapy) provides the
  development of an awareness of both Conscious and
  Unconscious factors.
• Uses of Group Therapy. It provides an
  opportunity to learn
• With and From other group members and the
  accounts related by them
• That you are not as different as you think
• That you are not alone in your thinking
• An entire group can benefit from sharing thoughts
  and experiences

4
Group Therapy

• In addition to Group Therapy you could
• Engage in Individual Therapy Combined
  Individual Therapy and Group Therapy
• Engage in Couple Therapy
• Engage in Family Therapy
• Receive medication
• Have a combination of the above
• Analytic Group Psychotherapy will help you to
  enhance your self awareness of psychodynamics in
  all types of groups.
• This includes Psychodrama Groups, Behavioural
  Groups, Family Therapy Group, Organizational
  Groups, Groups for Children, Adolescents,
  Homogenous Groups of clients with certain medical
  illnesses, Homogenous or Heterogeneous groups of
  clients with psychological disorders
  depression, anxiety, grief reactions,
  Psychological trauma (homogenous groups
  preferred), Addictive disorders, first episode
  Psychosis etc.

5
History of Groups

• 1900 1909
• (1905) Joseph Henry Pratt MGH Boston,
  tuberculosis patients, focus, support and
  inspiration.
• 1920 to 1929
• (1922) Alfred Adler. Counselling with prison and
  child guidance populations
• 1930s
• Trigent Burrow. Psychoanalytic Group Analysis
• 1940 to 1949
• 1940s and World War II seen as beginning of
  modern work group
• Kurt Lewin (1940, 1951) founder and promoter of
  group dynamics and field theory
• Wilfred Bion (1948) broke away from his Freudian
  background and highlighted the importance of
  Group Dynamics
• Sigmund Foulkes (1940 onwards) started a method
  of Group-Analytic Psychotherapy
• 1941-1942 Moreno founded the American Society
  of Group Psychotherapy
• 1943 Slavson established the American Group
  Psychotherapy Association and later the
  International Journal of Group Psychotherapy
  (1948)

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History of Groups

• 1960 to 1969
• Development in a humanistic-existential
  orientation.
• Fritz Perls Gestalt and
• Eric Berne Transactional Analysis
• Carl Rogers Developed the T-group concept to
  make it more personal ie. basic encounter
  groups
• 1970 to 1979
• Yalom (1970)
• Lieberman (1971)
• 1980 to 1989
• Self help groups increased
• 1992
• J.Scott Rutan Developed the Psychodynamic Model
  for Groups

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i. Clinical Training in Group Psychotherapy

• An engagement in Experiential Groups of staff
  members only is an excellent clinical exercise in
  Attunement (tuning in with), Containing
  emotions of oneself and others, Holding keeping
  together without fragmentation. This should be
  with an experienced Group Leader.
• This will then help the staff in their work
• a) with clients to be able to do the same.
• b) with relatives of patients.
• c) to avoid burn out themselves.
• B. Supervision by an experienced Group
  Leader.

8
ii. Theoretical Training in Group Psychotherapy
in Australia

• The Australian Association of Group
  Psychotherapists offers an intensive 4 year
  training program, for membership of the
  Association. This can be reduced in duration as
  appropriate.

9
Group as a System

• Basic Concepts.
• 1. System - a structure composed of a whole
  and its parts.
• 2. Boundary
• 3. Opening / Closing / Permeability
• 4. Autonomy
• 5. Hierarchy
• 6. Homeostasis ability to maintain internal
  equilibrium
• 7. Specialization components lower in
  hierarchy may develop specialised
  functions that contribute to higher goals.
• B. System Structure.
• 1. External Group Boundary
• 2. Leadership Boundary
• 3. Therapist Boundary
• 4. Personal Boundary of the individual member
• 5. Interpersonal Boundary
• 6. Internal Boundary
• 7. Subgroup Boundary

10
Curative Factors in Groups through understanding
oneself and our roles in society(Adapted from
Irvin Yalom and Claudio Neri with inclusions by
Sabar Rustomjee)

• Hope
• Universality leading to Normalisation
• Ventilation
• Developing a sense of self, of being a person
  with a right to exist
• To develop a sense of belonging
• To develop independent thinking whilst being in a
  group
• Developing spontaneity
• Learning from experience
• Learning through being exposed to a Corrective
  Emotional Experience where appropriate
• Psycho-education where appropriate in educational
  groups
• Altruism as applicable to the role of the
  conductor and the role of the group member

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Curative Factors in Groups through understanding
oneself and our roles in society (Adapted from
Irvin Yalom and Claudio Neri with inclusions by
Sabar Rustomjee)

• Understanding Family Interactions and
  Psychodynamics
• Relating it to group Interactions
• Relating it to Society and Work Interactions
• In Analytically orientated groups, understanding
  the Freudian Unconscious and social Unconscious
• Transference and Counter Transference
• Attacking Myths and attacking Shame
• Differentiating between the Public Face and
  Private Inner Self
• Understanding Introjection, Projection, Denial,
  Splitting, Intellectualization, Rationalisation,
  reasons for overprotection etc in an analysis
  framework
• Developing sharing and patience
• To be able to live in a space, which is not
  always clear or well defined
• To engage in reciprocity and the capacity to
  invest in the individual and the group
• Understanding non-compliance
• Preparations for future choices in life

12
Roles of a Group Convenor

• To create a Potential space a Container in
  which group work can be done.
• Non-Directive although capable of assuming
  leadership
• To remain disengaged and hence, objective
• To enable people to learn a dialogue
• Group work is Observation, Thinking, Reflecting
  and Relating
• To convert mindlessness into understanding and
  meaning. ie to promote shared new meaning
• To keep boundaries
• To encourage every group to develop its own
  legitimacy, its own uniqueness, its focus and its
  dynamics

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Framework or Boundaries

• Time
• Place
• Criteria for inclusion to the Group
• Guidelines what will be valuable, acceptable
  and productive
• Guidelines regard emergency and routine contacts
  outside group hours
• Who is welcome to the group eg. Inclusion of
  children, spouses, etc.
• Confidentiality
• Limits what limits are unacceptable with
  regards to conduct
• What would lead to non-entry to the group
  temporary or permanent

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Group Dynamics Essential for productive groups
- adapted fromS. Freud.-Identification. Std ed.
8. P116.

• To recognise all Group members need to be treated
  alike with equal love eg. In the church or the
  army

The common Ego Ideal (Ideal of AIMS) the group
OR can be the Ideals of the Group Leader
Member
Egos of all members. Separate and also in
communication
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Group Dynamics Essential for productive groups

• Each members Ego Ideal can become the Collective
  Ideal for the group
• Individuality is maintained in their egos and
  needs to be maintained
• Ego Ideal needs to feed back into their separate
  egos
• Ideals that can be reached that are
  appropriate, are beneficial

16
Wilfred Bions 3 Basic Assumptions

• Basic Assumption Dependency
• Basic Assumption Fight Flight
• Basic Assumption Pairing
• When these are able to be overcome then the Work
  Group which can bear pain and work to accept the
  realities of life, can begin.
• Earl Hopper has in addition described the 4th
  Basic Assumption namely Incohesion
  Aggregation/Massification or basic assumption
  IA/M.
• He states that aggregates and masses are two most
  simple primitive social formations. He describes
  features of both. He describes both having
  survival value and that the social pattern of a
  flock of flamingos is analogous to that of say a
  social mass of a herd of walruses.

17
Foulksian Group Analytic Concepts as developed
by Sigmund FOULKES, E. J. Anthony , Earl Hopper,
Malcolm Pines and Farhad Dalal.

• Foulkes believed that psychology is neither
  Individual nor Group except by abstraction.
• Although symptom tolerance of any given culture
  may be considerable, it will fall far below the
  tolerance of a group analytic therapeutic
  situation.
• ( E.J.Anthony.)
•  
• According to Foulkes the Aim of Group Analysis is
  to establish harmony between the Individual and
  the world- not Conformity.
• The group functions as a hall of mirrors
  where resonance of thoughts occurs between group
  members. The thoughts of each group member in
  the group, will reverberate/ resonate with some
  aspect of the group theme which is discussed in
  the here and now of the group, and becomes
  linked with what is uppermost in her or his mind.
  When verbalized in the group, by the member, it
  may be interpreted appropriately.
• The Group Matrix is described by Foulkes as the
  hypothetical web of communication in a group.

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Foulksian Group Analytic Concepts as developed
by Sigmund FOULKES, E. J. Anthony , Earl Hopper,
Malcolm Pines and Farhad Dalal.

• The symbolic value of the group in the form of a
  circle is described aptly by Dalal who states
• To give a simple example ..the Circle has an
  inside, an outside and a boundary. The inside
  needs both the outside and the boundary to give
  it existence. Remove the inside and the circle
  collapses till there is nothing. Remove the
  outside and the circle expands until there is
  everything and thus nothing. Hence all 3 are
  interrelated and none can exist in isolation from
  the others.
•  
• He then follows it by describing Foulkes radical
  ideas openly leading to greater understanding of
  group analysis. He describes Foulkes description
  of inner process as in fact being
  internalized group dynamics. He clarifies that
  according to Foulkes, the Foulksian neonate is
  born into certain mechanisms and forces which it
  then introjects. The direction being from outside
  to inside.
• This is a different concept from the Kleinian
  infant using elements of its internal world to
  structure its external world.
• As in Yaloms Curative Factors, Foulksian group
  analysts highlight the importance of Hope in
  group work.

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The Social Unconscious

• Foulkes concept of the Social Unconcious is
  further developed by Earl Hopper, Malcolm Pines
  and Farhad Dalal among others.
•  
• Foulksian analysts state that the individual is
  embedded in the social and that the individual
  is also permeated by the social. This they claim
  differs from the concept of the Freudian
  unconscious in the id, being both repressed and
  unconscious.
•  
• Hopper describes clinical work occurring in both
  Time and Space in four related areas, namely
• The here and now.
• The here and then
• The there and now and
• The there and then

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Common Group Tension by H.Ezriel
Required Relationship with the Convenor/Group
Avoided Relationship with the Convenor/Group
Calamity

• Idealise the group to AVOID attacking the group
• The Required Relationship is primarily defensive
• Therapist needs to interpret the Common Group
  Tension

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Common Group Tension in Patients Group (H.Ezriel)
Required Relationship with the Convenor/Group
Avoided Relationship with the Convenor/Group

• Initial 0-8 sessions of Defensive material
  reveal
• Passivity, Dependency and Outward over
  Compliance with the false image of an ideal
  patient
• These lead to
• Rationalisations and masking of internal
  conflicts.
• Splitting of good/bad Convenor and patient
  being the good ones
• Lack of authenticity

• To avoid Ext. Reality with loss of control
• To avoid experiencing of negative transference
  with feelings of rejection and helplessness and
  feelings of aggression towards staff and partners
• TO ADMIT TO REBELLION AND NON COMPLIANCE

Calamity

• Fear of total abandonment similar to childhood
  experiences of deprivation. Fears that it will
  be repeated in the here and now

22
D. Stock Whitaker and Libermann Focal Conflict
Theory
Disturbing Motive
Group Solution
Reactive Motive
Group solution has a defensive and enabling
function
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Selection and Exclusion Criteria for Group
Treatment

• Exclusion Criteria Contraindications for Group
  Therapy.
• Protection of the Group
• 1. Adherence to the Group Contract - may not
  be possible
• 2. Physically dangerous
• Efficacy for the specific individual.
• 1. Crisis cases need individual attention
  before the client may be suitable for group
• 2. Limited Ego strength with regressive pull
• 3. Impulsive non controlled with acting out
• 4. Life style factors preventing attendance eg.
  Pilots, nurses traveling a lot
• 5. Acute psychosis
• 6. Not adequately psychologically minded
  prefers biological treatment rather than
  psychological
• 7. Severe somatisation when confronted with
  psychological issues in a group
• 8. Paranoid style of responding
• 9. Brittle denial
• 10. Antisocial personality lack of empathic
  capacity
• 11. Primitive character pathology

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Selection and Exclusion Criteria for Group
Treatment

• Questions worthy of contemplation before starting
  a client in a group.
• Is this the right patient for the group?
• Is this the right group for this patient?
• Am I the right therapist for this patient?
• Is this the right time for this person to join
  this group?
• (He) Why has person not engaged in a group
  previously or failed to attend (if he/she has
  been in a group)
• Preparation of Patients for Group Therapy (Rutan
  Stone 2001)
• Bonding Getting to know the patient apart from
  the group . Building a beginning alliance
• Evaluation Factors to asses an Individual for
• Specific tasks for preparation

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Types of Groups

• Small
• Medium
• Large

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Group Interventions for Treatment of
Psychological Trauma

• Module 1 Group Intervention for Treatment of
  Trauma in Adults
• Module 2 Group Intervention for Treatment of
  Trauma in Children
• Module 3 Group Intervention for Treatment of
  Trauma in Adolescents.
• Module 4 An Overview of Evidence-based Group
  Approaches to Trauma with Adults
• Module 5 An Overview of Evidence-based Group
  Approaches to Trauma with Children
  and Adolescents
• Module 6 The Later Stage The Role of Group
  Interventions in Coping with the
  Aftermath of Traumatic Events
• Module 7 Countertransference Effects on the
  Group Therapist Working with Trauma
• Module 8 Unique Aspects of Group work with
  Trauma
• Module 9 Identification and Management of Masked
  Trauma Reactions in Groups
• Module 10Group Interventions for Bereavement
  Following Traumatic Events
• These Modules are compiled by the American Group
  Psychotherapy Association 2004

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Brief History of Group Therapy

• Early Writings
• Le Bon (1920) The Crowd A study of the Popular
  Mind. Once individuals become part of a crowd,
  a type of hypnotic power engulfs
  themIndividuals loose their sense of
  responsibility and a group mind assumes control.
  
• These factors contribute to the diminishment of
  human functioning
• - sense of increased strength, even
  invincibility
• - contagion overtakes
• - suggestibility is greatly increased
• McDougall (1920) The Group Mind. Discusses that
  groups can also enhance the individuals
  behaviour through organization
• Freud (1921) Group Psychology and the Analysis of
  the Ego.

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Modern Theories Group as a Whole

• a) Group as a Whole approaches (Bion 1960).
  Experiences in Group
• b) Turquet (1974). Oneness.
• c) Hopper (1997). Incohesion Aggregation /
  Massification
• Ezriel.H. (1973). Psychoanalytic Group Therapy
• Foulkes (1948). Introduction to Group Analytic
  Psychotherapy
• Whitaker and Lieberman (1958, 1964).
  Psychotherapy through Group Process.

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Modern Theories Interpersonal Theories

• Yaloms interpersonal Theory (1995) The Theory
  and Practice of Group Psychotherapy.
• The major thrust for change occurs in the group
  interaction as it occurs in the here and now,
  maladaptive transactions are observed and
  interpreted, a corrective emotional experience is
  created, with an appropriate group culture, and
  concentration or the nature of the feedback.

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The Psycho-dynamic Model and Groups (Rutan 1992)

• Level of Intervention
• 1. Past (here and now) Future
• 2. Group-as-a-whole Interpersonal
  Individuals
• 3. In Group Out group
• 4. Affect Cognition
• 5. Process Content
• 6. Understanding Corrective emotional
  experience
• Avenues into the unconscious
• 1. Transference
• 2. Counter transference
• 3. Free Association

Brief History of Group Therapy and Modern
Theories are as per American Group Psychotherapy
Associations Manual Principles of Group
Psychotherapy
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Self Help Groups

• Self Help Groups process is a NON DIRECTIVE,
  NON-THREATENING process of RE-ORIENTATION
  occurring within a SAFE, COMFORTABLE and
  REASSURING HUMAN GROUP emphasizing the
  importance of mutual aid.
• They are a formalized mutual help network whose
  members share a specific problem

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Aims of Self Help Groups

1. Behavioural Change eg. Alcoholics Anonymous,
   Weight Watches, Gamblers Anonymous
2. Groups concerned primarily with enhancing primary
   care Self Help Groups associated with chronic
   illnesses, Blindness, Deafness, Arthritis,
   Diabetes, M.S., Muscular Dystrophy, Motor Neurone
   Disease, Lupus, Cystic Fibrosis, etc.
3. Groups concerned primarily with providing Social
   Support and new coping strategies Alanon,
   P.W.P, Grow etc, Alzheimers Support Group, Stroke
   Support Centre, P.R.O.P
4. Groups concerned with Rehabilitation Self Help
   Groups within the Schizophrenia Fellowship,
   Anorexia and Bulimia Foundation, Obsessive
   Compulsive Disorder Foundation, Vic Autistic
   Child and Adult Association
5. Self Help Groups concerned with Social Survival
   eg. Different womens groups, groups for Gay
   Activists
6. Self Help Groups concerned with personal growth
   and self actualization.

33
Enquiries.

• For all enquiries and purposes of circulation,
  correspond with Dr Sabar Rustomjee
• Email sabar_at_iprimus.com.au
• Postal address. 1A Erica Avenue
• Malvern East
• Vic 3145
• Australia
• .