Human beings live in a
social world in which their ability to gain esteem and
self definition significantly follows from their success
in their personal relationships. Psychotherapy in a group
setting provides a social arena in which the members can
learn about their assets and deficits through interactions
with peers and authority. Members also have opportunity to
experiment with newly learned behaviors in the protected
environment of the group in preparation for using them in
the external world.
Group psychotherapy began at
the turn of the century when Joseph Pratt, a Boston
physician, recognized the positive effects of bringing the
tuberculosis patients who did not have access to
Their recovery requires
strict hygienic regimens in their impoverished homes.
Using regular group meetings he educated his patients as
to how to combat the diseases. Other psychiatrists
were influenced by this method. Cody Marsh even included
dance classes in his hospital, he said that “By the crowd
they have been broken; by the crowd they shall be healed”.
The role of the charismatic leader and the dynamics of
group relationships were recognized by Freud later.
Group therapy received a
stimulus during World War II when many therapists were
initially exposed to group works during their military
experience. Theoreticians from England and US applied
psychoanalytic or interpersonal theory to group therapy
concepts. Interest in group process, stimulated by the
work of Kurt Lewin. The social revolutions in the 1960s
resulted in the beginning of sensitivity training
experiences (T groups), and a variety of personal growth
groups. The emergence of transactional analysis, gestalt
theory, bioenergetics, existential models for group
therapy and many additional innovative variations have
enriched the group therapy fields.
In Britain and America
during the second world war, an appreciation of group
psychology lead to a wide range of innovations, the most
important are the following- the use of the group
approaches for the selection and allocation of work
responsibilities, studies of group morale, the integration
of psychiatric knowledge in the management of large groups
through the role of the command psychiatrist.
Early pioneers – Jocob Moreno was the innovator of group psychodrama.
He also introduced sociometry, a scientific method for the
study of group affiliation and group conflicts. Slavson
was an educationalist of psychoanalytic persuasion that
became the central figure in the development of group
therapy and group psychodrama. His organizational efforts
leads to the formation of American Group Psychotherapy
Association. Alexander Wolf and Emanuel Schwarts began to
apply psychoanalytic ideas to the group therapy in the
late 1930’s in their therapy people underwent
psychoanalytic therapy under the group setting.
DEFINITION OF 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
type of psychiatric care in which several patients meet
with one or more therapists at the same time. The patients
form a support group for each other as well as receiving
expert care and advice. The group therapy model is
particularly appropriate for psychiatric illnesses that
are support-intensive, such as anxiety disorders, but is
not well suited for treatment of some other psychiatric
type of psychoanalysis in which patients analyze each
other with the assistance of one or more psychotherapists,
as in an "encounter group
form of psychotherapy that involves sessions guided by a
therapist and attended by several clients who confront
their personal problems together. The interaction among
clients is considered to be an integral part of the
therapy is a form of psychosocial treatment where a small
group of patients meet regularly to talk, interact, and
discuss problems with each other and the group leader
Cognitive behaviour group therapy
Definition: A form of group
therapy developed according to the principles of
cognitive-behavioral therapy (CBT). The two primary
techniques used in cognitive-behavioral group therapy
(also known as CBGT) are cognitive restructuring (changing
negative thinking patterns) and exposure (facing feared
situations). Also Known As: CBGT
PRINCIPAL MODELS OF
PSYCHODYNAMIC GROUP THERAPY
The therapist is responsible
to the group and to the institution in which it is set. He
should have an appropriate training to perform the task. A
formal qualification in psychotherapy is the ideal
training. This will have included theory, personal therapy
for the therapist and clinical supervision. Mental health
professionals from all the disciplines make an active
contribution to a rich and diverse service with the
training requirement of theory and supervision.
The establishment of a group
begins as a management task in the definition of its goals
, recruitment of its members , protection of its setting ,
venue etc. it evolves as a therapeutic task in which the
therapist is responsible for maintaining the therapeutic
attitude to the individual members and to the group as a
Structure, process and
content: the dynamic element of the group.
describes the more enduring aspects of any group’s make
up- the architecture of the interpersonal relationships
are conceptualized in terms of setting and its boundaries
and then conceptualizes in the bond between each
individual , the therapist and the group as a whole.
describes the fluid and the dynamics fluctuations of
emotions and experiences , the business of relating and
communicating the changes of association and the inter
content of a group’s exchange in its visible and audible
events in the narrative line and dramatic content of
peoples encounters, the topics raised , discussed and the
The dynamic elements
of a group
Models of group therapy
The focus is on
interpersonal learning as a primary mechanism of change.
The group provides the antidotes to mal adaptive
interpersonal beliefs and behaviors through feedback from
others and encouragement to experiment with healthier
behaviors, first with in the group and the outside. The
joint examination of inter group transference reactions
allows members to replace processes that have a historical
origin in the ‘there and then’ – the dynamic past – with
in those more appropriate to the here and now – the
The elements of an
The model represents that
the interpersonal dynamics are kept at fore front of
member’s attention by the therapist. The inter personal
approach places the therapist among the other members of
the group with out giving him or her distinctive identity
or any formal demarcation for the boundaries of the group
as a whole.
Yalom suggested 11 curative
factors according to this model. They are
B. THE TAVISTOCK
This model is developed by
Bion. According to this model, in a group at any point of
time, its culture and climate are governed by primitive
unconscious anxieties that impede its capacity for a
rational work. This is a therapist centered approach. The
two –body psychology used here to enforce a series of
interactions and it helps to reduce the complexity and the
constraints of the group work.
The element of Tavstock group.
C. THE GROUP
Groups may begin with
relatively high level of group activity and leadership
activity, referred to as dynamic administration. This
approach integrates the important aspects of the other two
models. The therapist is encouraged to address the
individuals as well as the whole group. This concept is
developed by an integrated set of concepts of structure,
process and outcome.
The elements of a group analytic group
group therapy & selection of patients
therapy, the interaction of group members offer
possibilities for change and growth. But whether patients
referred for group psychotherapy are going to benefit from
the treatment depends to a large extent on their careful
selection and preparation. Group therapy appears to be
most useful for patients whose problems are mainly in
relationships with other people. The most expected
candidates for group therapy define their problem as
interpersonal, they are committed to bring change in
relationship, are willing to be influenced by the group
and engage in appropriate self disclosure.
Patients should be
offered a group that is best suited for their problem and
it should be ascertained whether the patient is suitable
for group therapy or not. For this a therapist needs a
great deal of information. A screening interview,
psychiatric history and mental status examination can help
to select patients for group therapy. There are some
inclusion and exclusion criteria for group therapy.
Marked incompatibility with group norms for
Inability to tolerate group setting
Severe incompatibility with one or more of
the other member
Tendency to assume deviant role
COMPOSITION OF GROUPS
therapy has been successful with as few as three members
and as many as 15 but most therapists consider 8-10
members the optimal size.
Homogeneous versus heterogeneous groups
Many therapists believe
that a group should be as heterogeneous as possible to
ensure maximum interaction. Patients with different
diagnostic categories and behavioural patterns, and
patients from different races, social levels, educational
and backgrounds should be brought together. Patients
between 20 and 65 years of age can be effectively
included. Age differences aid in relieving and rectifying
Homogeneous group is
more suitable for children and adolescents. Patients with
similar problems like substance abuse, mild to moderate
depression etc. can also be benefited in a homogeneous
Open versus closed group
The closed groups begin
and ends with same membership. The open group permits
termination of members at different points and their
substitution by new patients
Frequency and length of sessions
Group therapies can be
conducted once or twice a week, each session lasting for
DOES GROUP PSYCHOTHERAPY WORK?
Members of the group share
with others personal issues which they are facing. A
participant can talk about events s/he was involved in
during the week, her/his responses to these events,
problems s/he had tackled, etc. The participant can share
his/her feelings and thoughts about what happened in
previous sessions, and relate to issues raised by other
members or to the leader's words. Other participants can
react to her/his words, give her/him feedback, encourage,
give support or criticism, or share their thoughts and
feelings following his/her words. The subjects for
discussion are not determined by the leader but rise
spontaneously from the group. The member in the group
feels 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
for the participant. The feedback (s) he gets from others
on her/his behavior in the group can make her/him become
aware to maladaptive patterns of behavior, change her/his
point of view and help him/her adopt more constructive and
effective reactions. It can become a laboratory for
practicing new behaviors.
Frequently the people you
meet in the group represent others in your past or current
life with whom you have difficulty. In group therapy you
have the opportunity to work through these situations.
WHO CAN BENEFIT
FROM GROUP PSYCHOTHERAPY?
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. There are support groups for people in the same
situation or crisis (e.g. groups for bereaved parents,
groups for sexually abused women), but usually the
recommendation for the therapeutic group is to be as
heterogeneous as possible and represent a micro-cosmos.
For that reason in building the group, the leader will try
to include men and women, young and old people, married
and singles, etc. The group is especially effective for
people with interpersonal difficulties and problems in
relations. Whether these difficulties are in social,
working, couple or even sexual relations, the participant
can benefit a lot in these areas.
Groups are ideally suited to
people who are struggling with relationship issues like
intimacy, trust, self-esteem. The group interactions help
the participants to identify, get feedback, and change the
patterns that are sabotaging the relations. The great
advantage of group psychotherapy is working on these
patterns in the "here and now" - in a group situation more
similar to reality and close to the interpersonal events.
FACTORS IN GROUP THERAPY
factors in group therapy have been listed by Kaplan &
TYPES OF THERAPEUTIC GROUPS
Self help groups
In this approach,
therapist ensures that
The experiences of the
group members are used positively
group members is cordial
It should not become
patients when necessary
Each member is
supported and gives support to other members
Self help groups
These groups are
organized and led by patients or ex-patients who have
learned ways of overcoming or adjusting to their
difficulties. The group members benefit from this
experience, from the opportunity to talk about their own
problems and express their feelings and mutual support.
Examples include self help groups for people who suffer
from problems like alcohol dependence, groups of parents
of handicapped children, etc.
These groups have been
used for the treatment of recurrent depression and bipolar
disorder. The emphasis is on compliance with prescribed
medication. The goals include increasing the patients'
knowledge about medication, increasing compliance,
educating patients about their illness, decreasing their
isolation and helping them to express their feelings in a
Interpersonal group therapy
This approach was
developed from the work of Yalom (1985). Treatment is
focused on problems in current relationships and examines
the ways in which these problems are reflected in the
group. The past is discussed only in so far as it helps to
make sense of the present problems. The treatment is
divided into three stages.
First stage – The group members try to depend on the therapist,
seeking expert advice about their problems and about the
way they should behave in the group. In this first stage
some members may leave the group due to anxiety in talking
in the group or the therapists' refusal to solve their
Second stage – The remaining members begin to know each other better,
they discuss their problems and try to seek answers to
their problems. During this period maximum change can be
expected. The therapist encourages looking into current
problems and relationships.
Third Stage – The group in this stage can become dominated by the
residual problems of the members who have made least
progress and shows most dependency. These points are
discussed before ending the group.
In encounter groups the
interaction between members is made more intense and rapid
in the hope that this will lead to greater change. The
encounter can be entirely verbal, like using challenging
language, or it can include touching or hugging between
the participants. Sometimes the experience is further
intensified by prolonging the group session for whole day
or even longer. This is not suitable for people with
In psychodrama, the
group enacts events from the life of one member in scenes
reflecting either current relationships or those of the
family in which the person grew up. This provokes strong
feelings in the person represented. The drama is followed
by discussion. Instead of personal experiences of one
member the drama can also focus on problems that all
participants share, for e.g.. – how to deal with authority.
This method is called sociodrama.
therapy is an important part of hospitalized patients'
therapeutic experiences. Groups may be organized in many
ways in a ward. The goals of each group vary, but they all
have common purpose to increase patients' awareness of
themselves through interaction with other group members
who provide feedback about their behaviour, to provide
patients with improved interpersonal social skills and
Lazell (1921) is
credited with founding inpatient group therapy. He
developed group treatment of schizophrenia patients. On
the basis of this experience he listed the following
advantages of group therapy in schizophrenia:
Patients become more
socialized than in the past
They become aware that
they are not alone with their problems
They become more
comfortable in the hospital setting
They continued to
discuss the topics with each other for sometime even
after the session ended. This improved their interaction
Marsch (1931) used
lecture approach with patients but supplemented his
lectures with other techniques like music, dance and
VARIOUS MODELS OF
INPATIENT GROUP PSYCHOTHERAPY
models of inpatients group psychotherapy share several
features. Most models establish highly specific goals
according to the particular needs of the patients.
1.Skills development model
This includes educative
model, problem solving model, social skill model, etc.
Educative model – This was developed by Maxmen (1978). Problems discussed
are specifically related to those problems for which
members were hospitalized. Patients are helped to
recognize circumstances that lead to an exacerbation of
symptoms, strategies of coping, etc.
Problem solving model – This approach, based on work of Spivack & Shure (1974),
assumes that psychiatric patients are deficient in problem
solving, and helps members to acquire good interpersonal
problem solving skills. Group members are taken through a
series of problem solving steps:
Social skills model – The behaviorally oriented social skill model fosters
acquisition of various interpersonal skills by dividing
each skill into multiple behavioral components. For e.g. –
the skill of initiating a conversation may be divided into
basic components as standing on appropriate distance from
another person, greeting him/her, formulating questions
and listening to the response.
The model emphasizes on
the social isolation of the inpatients and the
difficulties they face in interacting with other people.
Focus is placed on the patients' current interpersonal
problems and the here and now interaction during each
session. Within each session, members set an agenda
related to an interpersonal problem that can be addressed
within a single session.
faced in group therapy
of sub-groups - some members may form a coalition based on
age, class shared values or other characteristics. This
disrupts the therapeutic process.
Members who talk too
much - some members in a group are too talkative, and
does not allow other members to talk. As meetings
continue, group is likely to become dissatisfied.
Members who talk too
little - some members are too silent and talk very less.
They are generally awkward in company, some may be
afraid of talking and revealing problem.
members - many times conflict between members can
develop. It can be due to disagreement with others'
views, criticism of one group member by another, etc.
The usual focus of a
group is on current problem of the members. The past
experiences of members only assist in understanding.
Sometimes group members talk excessively about past and
avoid their present difficulties.
HOW TO CHOOSE A GROUP-PSYCHOTHERAPIST
When choosing a group psychotherapist you should look for
a well-trained, reliable, and ethical professional. If you
are in individual therapy you should consult your
therapist and be sure that your group and individual
therapists can collaborate. Reputable group
psychotherapists usually belong to professional
associations. In the U.S.A, for example, membership in
AGPA (the American Group Psychotherapy Association), and
certification as a Group Psychotherapist by AGPA assures
some degree of expertise. An experienced group therapist
will usually interview you before your entering the group
and will answer your questions about the group and his/her
experience without being uneasy. You can also ask the
prospective therapist how many years experience (s) he has
in the particular modality and as a therapist generally.
Make sure you clarify fees (including costs for missed
sessions). Above all, trust your feelings: If you do not
feel you can trust the therapist, find another.
Role of the
therapist should actively structure the discussion in a
way that encourages the group members to stay in a topic.
Decision to establish
Determine setting and
size of the group
Choose frequency and
length of the group sessions
Decide on open Vs closed
Select a co-therapist
for the group
Formulate policy on the
group therapy with other therapeutic modalities
Act of creating a therapy
Formulate appropriate group
Select patients who can
perform the group task
Prepare patient for group
maintenance of the therapeutic environment
Build the culture of the
group explicitly and simplicity
Identify and resolve common
problems (membership turn over, sub-grouping, conflict)
Therapist should take
cue from the process of the group.
When members interact
spontaneously around an appropriate issue, the therapist
should be quiet and allow the patients to feel a sense
If members are trying
to form some sub-groups, therapist should discourage
them by asking the group to discuss the reasons for
their formation or try to find some similarity with all
Therapist should try
to include all members in the group discussion by asking
each one to express their views and feelings. Therapist
should assist silent members to speak and should
understand their reasons for silence.
When there is conflict
between members then therapist should not take sides
rather encourage whole group to discuss issue in a way
that leads them to understand why conflict has arisen.
Above all, it is the
therapist's task to help the group develop into a
cohesive unit with an atmosphere maximally conducive to
the operation of curative factors and where
confidentiality and non judgmental approach can be
communicated to the group members.
WHY IS GROUP THERAPY HELPFUL?
people come into a group and interact freely with other
group members, they usually recreate those difficulties
that brought them to group therapy in the first place.
Under the direction of the group therapist, the group is
able to give support, offer alternatives, and comfort
members in such a way that these difficulties become
resolved and alternative behaviors are learned.
group also allows a person to develop new ways of relating
group therapy, people begin to see that they are not alone
and that there is hope and help. It is comforting to hear
that other people have a similar difficulty, or have
already worked through a problem that deeply disturbs
another group member.
reason for the success of group therapy is that people
feel free to care about each other because of the climate
of trust in a group.
the group members begin to feel more comfortable, you will
be able to speak freely. The psychological safety of the
group will allow the expression of those feelings which
are often difficult to express outside of group. You will
begin to ask for the support you need. You will be
encouraged tell people what you expect of them.
Not suitable when
patient suffers from severe depression and suicide is a
patients are difficult to manage in the group setting.
They tend to display excessive elation, talkativeness
and irritability which are often difficult to control.
sub-normal intellectual level may not get adequate
benefit from the group situation
ROLE OF NURSE IN
Nurse participates in
the group activities on a daily basis. In health care
setting the nurse serves on or led task groups that create
policy, describe procedures and plan client care. They are
also involved in a variety of other groups aimed at the
institutional efforts of serving the clients. Nurses are
encouraged to use the steps of the nursing process as a
framework for task group leadership
In psychiatry nurses may
lead various types of therapeutic groups such as
client education, assertiveness training, support , parent
and transition to discharge groups among others. To
function effectively in the leadership capacity for these
groups, nurses need to be able to recognize various
process that occur in the groups such as phases of group
development. They also should be able to select
appropriate leaderships style for the type of groups being
lead. Nurses may develop these skills as a part of their
training or they may pursue additional studies.
group is with in the realm of nursing practice because
group work is such a therapeutic approach. Nurses working in
this field should continuously strive for expanding their
knowledge and use of nursing process for the effective
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