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Group Therapy

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Title: 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)

6
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

7
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

11
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

13
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

14
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
15
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.

18
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.

19
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

20
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

21
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
23
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

24
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

25
Types of Groups
  • Small
  • Medium
  • Large

26
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

27
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.

28
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.

29
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.

30
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
31
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

32
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
  • .
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