Group Therapy Dr Sabar Rustomjee Adapted in part from Principles of Group

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
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.
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
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.
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
1930’s
Trigent Burrow. Psychoanalytic Group Analysis
1940 to 1949
1940’s 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)
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
i. Clinical Training in Group Psychotherapy
A.
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.
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.
Group as a System
A.
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
Curative Factors in Groups through understanding
oneself and our roles in society
(Adapted from Irvin Yalom and Claudio Neri with inclusions by Sabar Rustomjee)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
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
Curative Factors in Groups through understanding
oneself and our roles in society
(Adapted from Irvin Yalom and Claudio Neri with inclusions by Sabar Rustomjee)
12.
13.
14.
15.
16.
17.
18.
19.
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
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
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
Group Dynamics –
Essential for productive groups - adapted from
S. 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
Group Dynamics –
Essential for productive groups
• Each member’s 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
Wilfred Bion’s 3 Basic Assumptions
A) Basic Assumption Dependency
B) Basic Assumption Fight – Flight
C) 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
I;A/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.
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.’
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 Yalom’s Curative Factors, Foulksian group analysts highlight the importance of
Hope in group work.
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
Common Group Tension by H.Ezriel
Required
Relationship
Avoided
Relationship
with the
Convenor/Group
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
Common Group Tension in Patient’s Group (H.Ezriel)
Required Relationship
Avoided Relationship
with the Convenor/Group
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
Calamity
• Fear of total
abandonment similar to
childhood experiences
of deprivation. Fears
that it will be repeated in
the “here and now”
• 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
D. Stock Whitaker and Libermann –
Focal Conflict Theory
Disturbing Motive
Group Solution
Reactive Motive
Group solution has a defensive and enabling function
Selection and Exclusion Criteria for Group
Treatment
Exclusion Criteria – Contraindications for Group Therapy.
a)
Protection of the Group
1. Adherence to the Group Contract - may not be possible
2. Physically dangerous
b)
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
Selection and Exclusion Criteria for Group
Treatment
Questions worthy of contemplation before starting a client in a group.
1.
2.
3.
4.
5.
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)
A.
B.
C.
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
Types of Groups
• Small
• Medium
• Large
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 10:Group Interventions for Bereavement Following Traumatic Events
These Modules are compiled by the American Group Psychotherapy Association 2004
Brief History of Group Therapy
Early Writings
1.
Le Bon (1920) The Crowd: A study of the Popular Mind. “Once individuals become
2.
McDougall (1920) The Group Mind. Discusses that groups can also enhance the
3.
Freud (1921) Group Psychology and the Analysis of the Ego.
part of a crowd, a type of hypnotic power engulfs them……Individuals 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
individual’s behaviour through organization
Modern Theories – Group as a Whole
i.
a) Group as a Whole approaches (Bion 1960). Experiences in Group
b) Turquet (1974). Oneness.
c) Hopper (1997). Incohesion: Aggregation / Massification
ii.
Ezriel.H. (1973). Psychoanalytic Group Therapy
iii.
Foulkes (1948). Introduction to Group Analytic Psychotherapy
iv.
Whitaker and Lieberman (1958, 1964). Psychotherapy through Group
Process.
Modern Theories – Interpersonal Theories
Yalom’s 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.
The Psycho-dynamic Model and Groups
(Rutan 1992)
A. 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
B. 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 Association’s Manual – Principles of Group Psychotherapy
Self Help Groups
Self Help Groups process is a NON DIRECTIVE, NONTHREATENING 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
Aims of Self Help Groups
1.
2.
3.
4.
5.
6.
Behavioural Change – eg. Alcoholics Anonymous, Weight Watches,
Gamblers Anonymous
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.
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
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
Self Help Groups concerned with Social Survival eg. Different women’s
groups, groups for Gay Activists
Self Help Groups concerned with personal growth and self actualization.
Enquiries.
For all enquiries and purposes of circulation,
correspond with Dr Sabar Rustomjee
Email ; [email protected]
Postal address. 1A Erica Avenue
Malvern East
Vic 3145
Australia