A Pragamatic Approach To Group Psychotherapy

Henry Spitz, Susan Spitz

• Publisher: Routledge
• Year: 2013
• Topic: Psychology
• eBook ISBN:
  9781135062286
• Subtopic: Mental Health in Psychology
• Index: Psychology

Published in 1998, A Pragamatic Approach To Group Psychotherapy is a valuable contribution to the field of Psychotherapy.

I

GENERAL CLINICAL PRINCIPLES

1

Origins of Group Psychotherapy

One of the best ways to facilitate the understanding of contemporary uses of groups to treat psychological disorders is to briefly trace the historical path of the development of the field. In so doing, one can see the foundations for group therapy as well as the rationale for its different uses over time. This is not simply an intellectual foray into the past. When one understands the changes in theory and practice over time, it is possible to join the field of group therapy in its current “flight path” and to identify trends, techniques, and patterns that have stood the test of time. Many of these historical efforts were pioneering in their day and have been modified or adapted to meet the demands of present-day treatment of emotional distress.

Much has been written about the modern historical origins of group psychotherapy. Consensus exists among most group therapists that the embryonic elements of what we currently call group therapy can be traced back to the early 1900s and the work of Joseph Pratt (1907). Pratt was a nonpsychiatric physician treating medical inpatients suffering from tuberculosis. Since isolation from society and prolonged rest periods were the mainstays of the treatment of tuberculosis at that point in medical history, Pratt and others who cared for the sick were faced with the challenge of treating the physical condition and the concomitant task of managing the emotional health of the patient.

In an effort to provide an activity for TB patients who were demoralized as a result of their prolonged convalescence and social isolation, Pratt decided to hold “classes” on the ward to inform patients about the state of what was known about tuberculosis at the time. Quite serendipitously, it was noted that participants in these classes appeared to be less depressed and more cooperative with their individual medical treatment plans.

Pratt’s work affords an excellent example of the linkage between “ancient” group history and today’s common practices. How different are contemporary psychoeducational groups for the treatment of medically ill patients, people with psychotic disorders or bipolar affective disorders, and those with a variety of family problems in their goals and structure? The components of modern group therapy may be more streamlined, systematized, and even structured into specific protocols or manuals for leading psychoeducational groups, but the bare bones of Pratt’s work and those of the practitioner of the 1990s are strikingly similar.

The premise that the threads of the past are visible in the methods in practice today is a helpful orientation to a review of some of the major work that has influenced the field of group therapy. Putting contemporary practice into proper historical perspective gives a valuable context for understanding where the field has come from and where it is likely to be going. This point of view facilitates a better comprehension of the modifications and adaptations of traditional group therapies that have taken place over the course of this century.

EARLY INFLUENCES

Contemporaries of Pratt became aware of his work and began to apply it to different patient populations and in varied clinical settings. Cody Marsh (1931), a minister and psychiatrist, adopted the idea of giving inspirational lectures to psychiatric inpatients and also conducted classes for staff members. Many attribute the early origins of inpatient milieu therapy to Marsh’s work.

The 1920s was a period during which several efforts expanded the use of the inherent properties of the group for therapeutic benefit. Trigant Burrow (1927), a psychoanalyst, experimented with the format of “group analysis,” liberalizing the conventional practices of dyadic analysis to encompass small-group meetings of patients, family members, and hospital staff. At about the same time, Edward Lazell (1921) lectured to seriously disturbed psychiatric inpatients about Freudian theory and elements of the psychiatric treatment of that era. Lazell noted results similar to those of his predecessors and recommended the use of the didactic model for nearly all categories of hospitalized mental patients.

Alfred Adler (1956) and Rudolph Dreikurs (1959) worked in Europe and expanded Adler’s individual therapy model to one of a more collective nature. This system was noteworthy because it advocated including parents in sessions with children who were being seen as patients at the Vienna Child Guidance Center. Dreikurs experimented with the use of group methods in the therapy of both alcoholic patients and general psychiatric patients.

Sigmund Freud (1921) showed interest that went beyond the individual, intrapsychic model common at the time when he became intrigued with the dynamics of large groups. Group Psychology and the Analysis of the Ego illuminated much of Freud’s view, which was less focused on groups as a method of therapeutic intervention than on the motivation and dynamics of large groups in society.

Modern group techniques subsumed under the heading of psychodrama owe their origins to their founder, Jacob Moreno (1953), whose influence would be enormous in the expansion of the field of group therapy. Moreno’s contributions paved the way for several elements that are regular ingredients in modern group practice. Two of the most recognizable points of emphasis are the mobilization and constructive use of intense affect and emotional catharsis in groups and the reactivation of family dynamics and their therapeutic value. Role-playing, alter-ego techniques, and other elements of Moreno’s thinking are frequently used in group practice today.

The period encompassing the 1930s up to the onset of World War II included efforts by Paul Schilder (1936) and Louis Wender (1940) that are worthy of note. Both Wender and Schilder understood the untapped potential groups held for the creative expansion of individual psychoanalytic theory and practice. Early efforts at transposing free association, the analysis of transference and resistance, and other staples of classical psychoanalysis to their application in groups characterized the important work done by these pioneering group psychoanalysts.

Samuel Slavson (1943) began work with children in groups. His professional influence on the field of group theory and dynamics was profound in the formative thinking of practitioners in the 1930s through the 1950s. Slavson is generally recognized as one of the founding fathers of contemporary psychodynamically oriented group psychotherapy. His work expanded over the years to include activity group therapy with children and groups involving adolescent delinquents, adults, and families of children who were psychiatrically symptomatic. Slavson was instrumental in the creation of the American Group Psychotherapy Association and the original scientific journals devoted to the group therapies.

THE IMPACT OF WORLD WAR II

In the World War II period, psychotherapists working in the military system, as well as those in civilian life, were deluged with an enormous population in need of psychotherapeutic services and with an array of new psychiatric syndromes that emanated from the war and its physical and psychic carnage. “Shell shock,” family disruption and losses, “combat fatigue,” the forerunners of present-day posttraumatic stress disorder, and other by-products of war called for immediate and innovative therapies.

The earlier-noted expansion into group work that preceded and paralleled the Second World War offered new options for treating those in need of psychiatric services. Homogeneous groups composed of members who had experienced war-related trauma began to spring up in military hospitals. Self-help groups, outpatient psychotherapy groups, and new efforts designed to combine people with similar conditions in a single therapeutic milieu gave impetus to the expansion of the homogeneous group therapy model both within and outside the military community.

The effort to bridge the span between psychoanalysis and group therapy received great attention through the work of Alexander Wolf and Emanuel Schwartz (1962). Both men believed that it was essential to find group parallels to those techniques they believed were instrumental in helping individuals change through psychoanalysis. In the course of their work, they discovered and composed creative modifications and extensions of the analytic method, capitalizing on the added therapeutic avenues available by having many patients present in the same therapy session.

Wolf and Schwartz originated the leaderless aftersession wherein the group would continue in the absence of the leader and would compare experiences of the two formats in subsequent group meetings. The “go-around” or “round robin,” a technique frequently used to open groups, actually began with Wolf’s experiments on the use of free association and dream analysis in the group setting.

POST-WORLD WAR II INFLUENCES

At least two social and historical phenomena, the community mental health movement and the Vietnam War, were critical factors in shaping group psychotherapy trends following the post-World War II period. The former effort aimed to reduce the protracted and often inhumane warehousing of psychiatric patients in mental institutions by allowing them to go back to their homes and families. Aside from the economic and political forces that motivated this shift in psychiatric treatment philosophy, the concurrent development of a new generation of psychotropic medications, many of which were being developed in long-acting forms, allowed greater freedom in considering treatment options for seriously impaired psychiatric patients. Contemporary medication groups were born out of this confluence of factors. In addition, therapists became aware of the value of monitoring outpatients in groups as a way of directly observing their interpersonal as well as individual level of function.

The Vietnam War replicated many of the problems seen after World War II and added some new ones. The exponential increase in substance abuse that accompanied the war called upon group therapists to develop effective adaptations of conventional group techniques in order to address drug abuse problems. Large groups, such as therapeutic communities, emerged from this effort. Mutual-help groups derived from 12-step principles, which had long been in existence, experienced a rapid rise in membership and participation. A greater understanding of the components of substance abuse problems led to increased involvement of families in treatment plans, a historical trend directly traceable to Adler and Dreikurs’s earlier work.

The other critical postwar influence that had a dramatic presence in group work was the development of family therapy. Nathan Ackerman (1958), a psychoanalyst who was impressed with the power of the family in shaping personality structure, began to see whole families as a means of accelerating diagnosis and intervention in psychological problems. As family therapy grew, so did appreciation of the unique small-group dynamics of working with families. The intersection between group and family therapies is readily apparent in couples groups, multiple-family group psychotherapy, and parenting groups.

The 1960s and 1970s were politically active times, and, as an offshoot of this climate, certain group therapy experiences gained popularity. The encounter and sensitivity movement, designed to use groups as a vehicle for enhanced personal understanding and self-awareness as opposed to a form of psychiatric treatment, flourished during this period. What is perhaps most noteworthy about this point in the life cycle of modern group therapy is that it shed light on the deleterious as well as beneficial aspects of group experiences. Lieberman and Yalom (1972) studied psychological casualties emanating from groups without a membership selection and orientation process and directly related to extremes of group leadership. Their research demonstrated that passive group leaders and “charismatic” group leaders represent the two ends of the leadership spectrum related to poor group outcomes.

Yalom’s (1975) later work advocated the usefulness of keeping the focus in the “here and now,” based on the assumption that unresolved issues in the lives of group participants will play themselves out in the course of group interactions. The interpersonal manifestations of intrapsychic issues were the tools needed to supply group members with corrective emotional experiences in therapy.

Yalom’s scientific rigor and attention to research helped move the group therapy literature away from its subjective and anecdotal form to a more soundly based, documentable view of what actually transpires in groups and what contributes to positive outcomes. Along these lines, Yalom conducted a factor analysis of elements present in groups that have become widely known and used by clinicians. His categorization of “therapeutic” or “curative factors” delineated the natural resources present in all groups that can be harnessed and implemented by group leaders to maximize the chances for success.

THE 1990S

The current decade has been called by many the age of managed care. The emphasis on brevity of treatment and cost containment has led to a wider interest in the use of brief group psychotherapy experiences. The group literature of the 1990s has concerned itself largely with issues related to group treatment outcomes and the stretching of the borders of group therapy to reach untapped patient populations, address differing psychiatric and social conditions, and serve as a vehicle for training and education.

As with many of the earlier-noted trends in the history of group psychotherapy, it appears that circumstance has once again provided a stimulus to which group therapists are responding. While initially there were serious questions regarding the appropriate treatment of patients in time-limited group formats, increased experience with this model is resulting in a clearer appreciation of when, how, and with whom brief group experiences are applicable.

Technical eclecticism is on the rise. The group modality has always been flexible and can accommodate a range of therapeutic interventions. Cognitive, behavioral, family systems, and psychodynamic elements are finding a welcome place in brief group formats. The beneficial spillover of the increased interest in brief group therapies resides in the information that is emerging as this field grows.

Greater clarity is being demanded in defining what therapists actually do in group sessions, what contributes to positive outcomes or creates group dropouts, and how to reproduce methods that appear to work well, along with an emphasis on matching group members with each other and an increased awareness of the value of proper therapist-patient and therapist-group matching.

If past history is any predictor of future trends, then group therapy is currently undergoing yet another metamorphosis. This is likely to result in refined technical interventions, increased understanding of the mechanics and dynamics of groups, and, most important, enhanced provision of sensible and sensitive treatment of patients in groups.

2

Group Therapy: Definitions and Classification

A clinically oriented definition of group psychotherapy contains several critical elements. A therapy group involves specialized treatment conducted by a professionally trained leader who carefully evaluates and selects members who come together to address their individual psychological problems. Members define themselves as having difficulties that require psychotherapeutic intervention and/or input in order to be successfully resolved. The use of the interpersonal interactions of a group is a central factor in facilitating a process of change in the behavior, self-awareness, and symptoms present in each group member.

Not only is there nothing inherently therapeutic in assembling a random group of individuals, it may in fact be an emotionally hazardous experience. To counter this possibility and to maximize the inherent therapeutic potential of groups, careful attention to group composition and the matching of appropriate leaders to groups is another essential dimension that distinguishes bona fide therapy groups from other experiences transpiring in a group setting and purporting to be “therapeutic.”

Since the array of group experiences is so broad, it is essential for the group therapist to have a sense of clarity with respect to the group he or she is leading and where it fits in the overall schema of group work. There are several ways of categorizing groups that help realize this goal. By far the simplest method of gaining an orientation to where a particular group fits in the therapeutic cosmos is to identify the distinguishing characteristics of several major representative group models.

A basic list of commonly used group formats would include the following: psychodynamic group therapy (psychoanalytically oriented group psychotherapy), psychoanalysis in groups, group-centered analytic therapy (group analysis), behavior therapy/cognitive therapy groups, psychodrama groups, self-help/mutual-help groups, structured group experiences, family group therapies, crisis groups, Gestalt therapy groups, confrontational group ...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• Contents
• Preface
• I General Clinical Principles
• II Contemporary Applications of Group Psychotherapy
• References
• Index