Group therapy

J.L. Moreno

created the Theater of Spontaneity, the earliest form of psychodrama. Psychodrama was a technique developed to bring about mental and emotional catharsis for the purpose of tension relief.

S.r. Slavson

founded the American Group Psychotherapy Association in 1942. He offered activity therapy groups for children and reported that group activity sessions were equally as effective as individual counseling for stimulating change, catalyzing significant increases in the use of group treatment procedures for children and adolescents, resulting in the introduction of group counseling in schools.

marathon group

marathon group members met together for extended periods of time, usually between 24 and 48 hours, throughout which members were expected to become more authentic and engage in true self-disclosure.

Joseph Pratt versus Jesse Davis

Pratt - established the first group experience that was not intended specifically for psychoeducational or occupational purposes and organized groups to save time educating and supporting tuberculosis patients.

Davis- groups were intended to provide students with effective tools for making educational, vocational, and moral decisions ( Erford, 2015 ). Davis emphasized the use of the group as an effective environment for teaching life skills and values.

Frank Parsons:

cited as the founder of the vocational guidance and counseling profession, used groups to facilitate career and vocational development.

commitment

Group settings often enhance a member’s motivation to follow through with commitments that are made during group sessions. The support that members feel from others, and the desire to live up to their expectations so as not to let anyone down, are powerful forces that affect individual change.

4 types of group work

task groups, psychoeducational groups, counseling groups, and psychotherapy groups.

strengths of group work pt 1

• Time efficiency for the leader. Meeting with several members simultaneously for a common purpose (e.g., advising, problem solving, strengthening social support, aiding in personal development) can save substantial time and effort, especially when a counselor’s caseload is large.

• Less costly per individual. Lower cost is generally associated with group work, as compared with individual counseling; all other things being equal, a counselor seeing 5 to 10 members at a time is 5 to 10 times more time and cost-efficient.

• Greater resources. Group members often have access to a greater variety of resources (e.g., concrete information, problem-solving tools, abstract viewpoints and values) from multiple members within a group than a member in a one-on-one counseling relationship.

• Feeling of safety. Interpersonal safety can be achieved in groups. Member relationships are developed with a controlled intimacy, which makes it possible for individuals to open up and share their true emotions without the contingent obligations that often arise with this type of self-disclosure in personal relationships.

strengths of groups pt 2 (sense of belonging, replication, safe to practice new skills)

• Experiencing a sense of belonging. Most humans have a powerful need to belong. Working with a group of individuals in a therapeutic setting allows members to exchange ideas and feel greater self-confidence and a sense of belonging.

• Replication of the everyday world. The group is essentially a microcosm of society. Conflicts that arise in group settings are often similar in nature to those that are experienced in the outside world, especially if the group’s membership is diverse and true-to-life issues are addressed.

• It is safe to practice new skills and receive feedback. Members can use the group as a sounding board for trying out alternative problem-solving techniques and consequently can assess the likelihood that they will be successful when using those techniques in their everyday lives.

commitment, power of the peer group & interpersonal power

challenges of groups:

Reality distortion ( occurs when the group provides an example of social reality that is not achievable in the outside world.), avoidance, confidentiality, unhealthy attachments, institutional barriers

group goals types:

individual member goals (goals that a single member may be interested in achieving) & whole group goals (committed to by all group members)

whole group goals

• Understand the universality of member problems.

• Learn to trust and appropriately self-disclose.

• Display sensitivity to the needs of others and support for member goals.

• Experience the acceptance and support of other members.

• Put newly learned knowledge and skills into practice.

therapeutic factor or curative factor

created by the group leader or relationships with other members, that improve a member’s overall condition. landmark factors:

• Instillation of hope provides members with a sense of assurance that the treatment will work

. • Universality is the awareness of the similar concerns of others.

. • Imparting of information about healthy living is important to the growth of members and their ability to function more effectively.

• Altruism is exemplified by members giving of themselves and working for the common good.

• Family reenactment helps re-create early childhood dynamics so that members are able to relive early family conflicts and effectively resolve them. Psychotherapy (and sometimes counseling) groups can create a caring family environment in which issues of trauma can be safely aired and confronted.

• Development of socialization techniques is necessary for members to function successfully in their everyday lives. Group work allows members to give and receive personal feedback that facilitates learning about the desirability of one’s behaviors.

• Imitative behavior occurs when members have an opportunity to observe the behaviors of other members and witness the positive or negative responses elicited by their actions.

• Interpersonal learning occurs through member interactions with others.

• Group cohesiveness is similar to a feeling of unity and a sense of being bonded together. Cohesiveness indicates that effective therapy is occurring because it facilitates trust and a willingness to take risks.

• Catharsis is the expression of strong and often hidden emotions by an individual.

• Existential factors are realized when members are encouraged to consider important and sometimes painful truths about life, including an awareness of one’s own mortality and the unpredictability of existence.

Ethical & legal issues

• Informed consent allows members to understand their rights and responsibilities prior to beginning group work. Members are free to end treatment at any time and should be made aware of any general group planning in order to decide if the group will meet their needs.

• Confidentiality in group work is desirable and required of the group leader, but because more than one client is present at a time, confidentiality cannot be guaranteed— that is, there is no ethical requirement that clients will maintain confidentiality, just that counselors will.

• Group member screening must be conducted by the leader(s) to ensure the appropriateness of member and group fit.

• Leaders adhere to their scope of practice and only provide services for which they are qualified by training and experience.

task groups

designed around accomplishing a specific goal. Principles of group dynamics, and such methods as collaboration, problem solving, and team-building exercises, are used to reach goals. The focus is not on changing people but on completing the task at hand in an efficient and effective manner.

Psychoeducational groups

more structured than counseling or psychotherapy groups, emphasizing skill development through various nonthreatening skill-building exercises but at the same time encouraging discussion, sharing, and feedback among members. The goal of psychoeducational group work is to prevent psychological disturbance by increasing self-awareness, knowledge, and skills about specific developmentally relevant issues. The fact that a psychoeducational group can be preventive, growth-oriented, or remedial makes it a very versatile type of group model.

counseling groups

designed to help members work on interpersonal problems and promote behavioral changes related to these problems. Counseling groups are typically problem-oriented, helping members explore their problems and seek resolution, but counseling groups also can be preventive, growth-oriented, or remedial. Counseling groups are relatively short in length, focusing on adjustment issues for individuals who function relatively normally.

Psychotherapy groups

designed to treat those who may be experiencing severe or chronic problems in their lives. Ordinarily, members in psychotherapy groups display more dysfunctional behavior and typically carry a psychiatric.

primary tasks of leaders are threefold

• Executive functions. Leaders are responsible for planning for and creating the group, convening the sessions, and maintaining the organizational integrity of continued meetings, including establishing effective boundaries that will allow members to grow and develop from the experience (e.g., safe environment, stability of membership).

• Building a group culture. Groups are therapeutic social systems that operate on norms for social interactions. Leaders help group members establish norms that facilitate occurrence of curative factors.

• Bringing members into the here and now.As social entities, groups offer members the opportunity to deal with real-life, present-day issues.

Leader Styles

• Authoritarian . Takes control of and responsibility for the group; sets the agenda, goals, and rules; serves as the conduit for member interaction (i.e., discussion occurs through the leader).

• Democratic . Facilitates member interactions; with leader guidance, members make decisions, take responsibility, set agenda, goals, and rules; sets norms encouraging member interaction, self-disclosure, and feedback.

• Laissez-faire . Assumes little or no leadership or responsibility for group agenda, goals, or rules; assumes members all have abilities to make changes and take responsibility for the group on their own; lacks structure and directedness.

(Theory X, Theory Y, and Theory Z, respectively.)

Leader traits

self-awareness, flexibility, self-confidence, responsibility, honesty, trustworthiness, genuineness, empathy, compassion, respect, objectivity, creativity, spontaneity, humor, enthusiasm, and charisma.

Leader techniques pt 1

• Initiating . Provide direction for members by initiating group topics or activities, thereby allowing members to focus energy and achieve desired outcomes.

• Active listening . Attend to nonverbal and verbal behaviors of members to show that the leader is paying attention, and creating an environment that encourages self-disclosure.

• Clarifying . Help the leader check his or her understanding of what a member has said.

• Questioning . Use questions to elicit information from members and help them focus their comments on core issues and concerns.

Leader techniques pt 2

• Provide feedback. Model how to give and receive feedback to help members develop greater degrees of self-awareness and insight.

• Empathizing . Communicate understanding to promote trust and cohesion.

• Linking . Connect member themes, issues, and similarities to facilitate shared perspectives, commonalities, and goals.

• Blocking (cutting off). Stop a counterproductive member behavior in order to protect other members from potentially damaging interactions.

Leader techniques pt 3 (modeling, confronting, etc)

• Confronting . Promote member self-awareness by pointing out inconsistencies between or among member statements and actions.

• Instruction. Teach members various information or skills.

• Self-disclosure . Reveal a personal experience or feeling in the here-and-now context.

• Modeling . Demonstrate a particular skill or behavior so that members may learn through watching.

• Role playing. Demonstrate and practice (leader and members) skills and applications in a safe environment so that members gain experience and feedback that will allow them to apply the skills and behaviors in out-ofgroup situations.

group leader techniques pt 4

• Tracking. Verbally clarify to keep up with and clarify for members the content and process of group interactions.

• Interpreting . Offer explanations or hypotheses for why events, behaviors, or interactions may have occurred as they did both inside and outside of group.

• Summarizing . Review the important element of conversation in order to transition to another phase of group process (e.g., ending of the session, next topic, focus on an important point).

• Evaluating. Monitor and assess group progress, process, and outcomes.

group leader techniques pt 5 (indcludes: setting tone, drawing out, pairing, making rounds, pacing)

• Setting tone. Provide structure; the leader sets a style of interaction for group members to follow.

• Drawing out . Interact directly with a member to get the member to contribute to a discussion topic or activity. Used with shy members and members the leader believes have something pertinent to contribute.

• Pairing . Form smaller groups within the larger group to engage in activities or focused sharing.

• Making the rounds . Have group members take turns sharing their perspectives on a given focused topic; so named because the sharing usually proceeds in the direction of chairs positioned in a circle.

• Pacing . Facilitate the pace or rate at which the group process moves. At times, leaders will speed up the pace, and at other times the leader will slow the pace to allow group members to focus on a particularly relevant topic.

advantages of co-leadership

(a) creation of a team model or (if co-leaders are male and female) parental model for dealing with family-of-origin issues;

(b) help in handling difficult issues that may arise;

(c) insights provided by multiple leaders;

(d) leaders can give feedback to each other;

(e) different leader reactions can enrich the group process;

(f) more experienced leaders can train less experienced leaders;

(g) sharing of responsibilities;

(h) ability to continue the group in the event of leader illness, vacation, or incapacity;

(i) better support for lower functioning members; and

(j) efficient use of leader modeling and role-play. Disadvantages may include (a) potential competition/rivalry between leaders;

(b) inconsistency in pacing;

(c) lack of consistency in approach as leaders alternate;

(d) excessive focus on the leaders; and (e) appearance of collusion

informal roles

not specified but are developed through interactions with other group members, such as an advice giver or aggressor. Roles define one’s relationship to the group and can change over time but ordinarily result from self-expectations, personality characteristics, group leader characteristics, and group characteristics.

role conflict

occurs when members experience conflicting demands of various roles, such as when a member who prefers to avoid emotional expression is encouraged to self-disclose reactions to emotionally laden group content and process—that is, the roles a member plays come into conflict with each other.

role ambiguity

emerges when a member is not sure of the role expectations or behavior requirements he or she should fulfill.

In A pro-developmental approach to group work, all members must engage in two essential tasks: self-disclosure and feedback

• Self-disclosure requires members to take risks, share information, and describe their internal thoughts and feelings with the group.

• Feedback is shared by members when they notice and comment on group member interactions. It is an essential characteristic of effective groups. Good feedback is solicited, specific, descriptive, clear, and well timed. Advice-giving should be avoided.

group roles/behaviors 1 (include facilitation, encouragement, compromise, gatekeeping, initiation)

• Facilitation by group members helps promote group process and cohesion. Those who self-disclose and even attempt to identify group process variables or speak on behalf of the group when summarizing are using facilitation.

• Encouragement of others’ ideas helps promote cohesiveness and group member comfort.

• Compromise helps group members detach their ideas from their egos in order to promote group goals and enhance the group process.

• Gatekeeping occurs when group members and leaders insist on adherence to the established group norms.

• Initiation occurs when group members make suggestions or take action to move the group toward goals.

problematic group roles/behaviors 2 (observation)

• Information seeking occurs when group members ask for clarification or help promote self-disclosure in self or other group members.

• Opinion seeking involves self- or other-disclosure of group member values in relation to a group task. Often, group members want to know what others believe or value to gain insights into others’ worldviews.

• Evaluation includes the sharing of insights or judgments about whether a group is accomplishing agreed on goals.

• Observation includes member and leader feedback to the group.

problematic group roles/behaviors 3 (include hostility, attention-seeking, hostility)

• Aggressiveness is displayed as frequent disagreement with, and forceful attempt to impose ideas upon, the group leader and other members. Leaders should avoid negative confrontation and encourage the member to be specific about personal feelings. Leaders may also want to ask for a private conference to share feelings and ask for cooperation and point out the harmful effects on others.

• Attention-seeking behaviors call attention to the member and away from other members. Leaders should respond to member’s feelings of insecurity if present, avoid eye contact, and refrain from responding to offtask comments/behavior.

• Hostility or fighting can serve to disrupt the group’s focus, particularly when explosive reactions occur. Leaders should avoid negative confrontation, observe nonverbal behavior, and set limits firmly but not angrily. Often, by turning the task back to the group, group members can effectively process the hostile actions and explain the effects the reactions have on the group, leading to support, feedback, and self-disclosure.

problematic group roles/behaviors 4 (avoiding)

• Sarcasm is an attempt to mask and not express anger. A leader may want to interpret the sarcastic behavior, seek feedback from other group members, and encourage members to be emotionally honest in the here and now.

• Focusing on others is often an attempt to avoid self focus and self-disclosure. Leaders should encourage self disclosure and self-focus or group focus. In the end, the purpose of the group is to meet group goals and individual goals.

Johari window

quad, 1-4

Spontaneous content groups

do not have planned content themes and are designed to provide personal growth and support. Membership in a spontaneous group is generally dictated by the need for general development and member characteristics, such as age or severity of issues.

heterogeneous group

consists of members with diverse characteristics and concerns. May also may have diverse presenting problems (e.g., divorce, domestic abuse, career issues, depression, substance abuse ay consist of members with diverse age, gender, race, socioeconomic, and sexual orientation characteristics, and members)

LARGE VS. SMALL GROUPS

Task groups ordinarily function best when membership includes at least four or five individuals.

Informational presentations to parents or students often can be accomplished in groups of 50 or more, whereas interaction-based interventions (e.g., social skills, grief groups, divorce groups) often involve 6 to 12 members, or fewer if the members are younger than 8 years of age.

psychotherapy groups require smaller group sizes because of more serious member conditions and greater expectations for member interaction and feedback, usually 4 to 5 members at minimum and up to about 8 to 10 members at maximum

Members who drop out of groups prematurely are likely to have one or more of the following characteristics:

low motivation, lower socioeconomic status, lower IQ, high levels of problem denial, poor social skills, poor self-disclosure skills, unrealistic demands, lack of motivation to change, and lack of insight or interpersonal sensitivity. Poor leader skill or an incompatible leadership style may also contribute to a member’s decision to terminate prematurely.

factors contribute to group dynamics include

group structure, content, and process.

structure issues:

include group size, function (i.e., task, psychoeducational, counseling, psychotherapy), voluntary/ involuntary, and open/closed groups and were discussed earlier in this chapter.

• Content issues

s involve the “what” or actual subject under discussion by the group members. Sometimes this content or topic is agreed on at the outset of group formation (e.g., a changing family group will discuss topics related to parent separation/divorce), whereas at other times the content may be unstructured and involve a very recent topic or event that was not agreed on during the group’s formation (e.g., an event that just occurred in a member’s life yesterday).

Group process issues

s involve the interplay of forces or dynamics between and among members and leaders—or “how” the interaction is occurring in the here and now. Group process and group dynamics are often used interchangeably. Focus on group process leads to affective learning and understanding and to development of trust and group cohesion. Numerous forces have been identified as potential group process or dynamic issues, including norms (what is expected), cohesiveness, safety and trust, expression of feelings, catharsis, leadership patterns, reality testing, identification, power, conflict, and resistance.

Cohesion is an important determiner of

group effectiveness, attendance, and self disclosure

group cohesion facts

• Smaller groups tend to reach higher levels of cohesion more quickly because of fewer communication problems and higher member satisfaction.

• As groups become larger, subgroupings (cliques) and alienation are more likely to occur.

• Group members from similar backgrounds (e.g., race, socioeconomic status) and with similar characteristics and attitudes tend to reach higher levels of cohesion more quickly.

• When a cohesive group is challenged or attacked, greater cohesion usually results; challenges to low cohesion groups may lead to higher or lower degrees of group cohesion.

• Cohesiveness is enhanced when members set personal and group goals and when members are dependent on the group to meet those goals.

Yalom and Leszcz (2005) identified three primary factors of cohesion, each with various facets:

• Interpersonal (i.e., attractiveness of members, homogeneity of members, interdependence, and atmosphere)

• Group factors (i.e., size, goals, activity, history and leadership)

• Group environment (i.e., intergroup conflict, and group status)

positive alliances

can provide sources of support and strength and lead to high levels of group performance and cohesion, serving much the same intimacy function as friendships and families. However, alliances that are exclusionary can prevent members from forming productive relationships and achieving individual and group goals.

sociograms

graphical representations of group member interaction patterns and have been used to display member relationships and educate group members about the intricacies of group dynamics.

Group norms

Norms bring order and organization to the group process by defining permissible behaviors and the tolerable range of behaviors acceptable to the group. In other words, norms set standards for group behavior and interaction, and members may actually feel included or excluded depending on adherence to these norms.

group roles/behaviors 5

• Giving advice helps to prevent disclosure and keeps feedback on a superficial level. Leaders should observe the reaction to the advice of the member who receives it and encourage self-disclosure on the part of the advice giver while avoiding reinforcing the advice giver’s inappropriate advice.

• Blocking, or resisting, behaviors, when performed by a group member, impede group cohesion and progress, usually by not fully participating in exercises or discussions, thus keeping the group from progressing to a working stage. The resistance may be demonstrated as silence or nonparticipation. Leaders may find it helpful to interpret the member's behavior, have others self-disclose the effects on them, and invite the resistant member to fully participate.

Group/leader roles part 6 (monopolizing)

• Informing occurs when a member talks about other members outside group. Leaders should remind all members that what happens in group stays in group and underscore the importance of confidentiality to group work success and goal accomplishment.

• Monopolizing behaviors usually involve underlying anxieties demonstrated by neediness, demandingness, excessive talkativeness, and control through a focus on self. Leaders should confront and interpret the behavior, pointing to the effects it has on group process. Future attempts to monopolize could be handled using the blocking, or cutting off, technique.

• Manipulation ordinarily stems from the need for control and anger and promotes group tension and conflict. Leaders should block manipulative behavior or confront

transition stage

it is a time of testing boundaries and power structures that can range from subtle testing to full-blown rebellion and conflict. Research suggests that the dynamics of the transition stage are driven by anxiety and fear, which result in resistance, defensiveness, and conflict around the issues of control and power. Group work authors have referred to this stage as storming, conflict, resistance, and power and control; the transition stage involves all these and more.

informal member evaluations:

conducted during each session to help the leader understand how group members are progressing and perceiving the group process. Members frequently give helpful feedback and make suggestions for improvement when presented with basic questions such as the following:

• What did you like most (or least) about this session?

• What did and did not work well or go well in this session?

when group satisfaction highest?

high in the working and termination stages and substantially lower during the transition stage.

Key points of group work pt 1 (include org., self-help, and benefits)

• The ASGW is the ACA division devoted to group work.

• Self-help groups became prevalent in the 1980s. They differ from other types of groups in that members rather than leaders run them. Alcoholics Anonymous is one of the most well-known self-help groups.

• Benefits of group work include time efficiency for the leader, less cost per individual, greater sources, feelings of safety, a sense of belonging, replication of the everyday world, and a safe place to practice new behaviors.

Key points of group work pt 2

• Challenges of group work include reality distortions, avoidance, limitations to confidentiality, unhealthy attachments, and institutional barriers.

• Leaders should ensure that group goals and individual member goals are set

. • The following are curative factors in group work: instillation of hope, universality, imparting information, altruism, family reenactment, development of socialization techniques, imitative behaviors, interpersonal learning, group cohesiveness, catharsis, and existential factors.

• Confidentiality cannot be guaranteed in group work.

Key points of group work pt 3 (screening & 4 types)

• Leaders must screen group members prior to conducting a group to ensure that each member is appropriate for the group.

• There are four primary types of groups: task groups, psychoeducational groups, counseling groups, and psychotherapy groups. Task groups are formed to accomplish a specific goal. Psychoeducational groups are structured and emphasize skill development. Counseling groups are designed to help members work on interpersonal problems and promote behavioral change. Psychotherapy groups are created for individuals who are experiencing severe or chronic problems.

Key points of group work pt 4

• Group leaders have three main tasks: executive functions, building a group culture, and bringing the group into the here and now. Leadership styles are categorized as authoritarian, democratic, or laissez-faire.

• Conflicts in groups are normal and should be addressed within the group whenever possible.

Key points of group work pt 5 (including process eval)

• Planning is critical to group success. The planning process involves deciding whether the group will be planned or spontaneous, homogeneous or heterogeneous, open or closed, or large or small, and for how long the group will run.

• The four stages of group work are the forming and orienting stage, the transition stage, the working stage, and the termination stage.

• Group cohesion plays a significant role in determining group effectiveness, attendance, and level of self-disclosure.

• Process evaluation is the assessment of group dynamics and interaction processes; outcome evaluation is the assessment of the worth and effectiveness of a group.

Process and Outcome Measures Used in Group Work for Screening/selecting measures:

Elements ( Schutz, 1992 )

Group Psychotherapy Evaluation Scale ( Van Dyck, 1980 )

Group Therapy Survey ( Slocum, 1987 )

Hill Interaction Matrix ( Hill, 1965 , Simon and Agazarian, 1974, 1973)

Process and Outcome Measures Used in Group Work for Leader Behaviors/Skills measures:

Corrective Feedback Self-Efficacy Instrument ( Page & Hulse-Killacky, 1999 )

Group Leadership Self-Efficacy Instrument ( Page, Pietrzak, & Lewis, 2001 )

Leadership Characteristics Inventory ( Makuch, 1997 )

Skilled Group Counseling Scale ( Smaby, Maddux, TorresRivera, & Zimmick, 1999 )

Trainer Behavior Scale ( Bolman, 1971 )

Process and Outcome Measures Used in Group Climate Measures:

Group Climate Questionnaire–Short ( MacKenzie, 1983 , 1990 )

Group Environment Scale ( Moos, 1986 )

Process and Outcome Measures Used for Therapeutic Factors:

Critical Incidents Questionnaire ( Kivlighan & Goldfine, 1991 )

Curative Factors Scale–Revised ( Stone, Lewis, & Beck, 1994 )

Therapeutic Factors Inventory ( Lese & McNair-Semands, 2000 )

Therapeutic Factors Scale ( Yalom, Tinklenberg, & Gilula, 1968

Process and Outcome Measures Used for Member Behavior:

Group Cohesiveness Scale ( Budman & Gurman, 1988 )

Group Observer Form ( Romano & Sullivan, 2000 )

Group Sessions Rating Scale ( Cooney, Kadden, Litt, & Getter, 1991 )

Hill Interaction Matrix ( Hill, 1965 , MacKenzie, 1990, 1973)

Individual Group Member Interpersonal Process Scale ( Soldz, Budman, Davis, & Demby, 1993 )

Interaction Process Analysis ( Bales, 1950 )

Systems for Multiple Level Observation of Groups