Group Psychotherapy

Abstract

Group psychotherapy can be a valuable part of medical rehabilitation. Group psychotherapy facilitates interactions among people living with a similar situation and fosters formal and informal ways to navigate changes in clients’ lives, identities, and health. This chapter describes key factors that define the group psychotherapy experience, provides examples of common concerns explored and processed in groups, and identifies practical considerations before starting a psychotherapy group and tips for implementing groups.

Topic

Group psychotherapy is a form of psychotherapy where a group of clients are treated together. Group psychotherapy has a number of distinct features that differ from individual psychotherapy. There are many types and variations of groups and group formats. Groups may be psycho-educational, self-help, skills based, relationship oriented, or supportive. Groups may consist of people diagnosed with a shared medical or mental health diagnosis or be open to people with any condition. Types of group psychotherapy include those that focus on psycho-education, families, cognitive and behavioral psychotherapy, and psychodynamic psychotherapy. Groups may have a leader, or co-leaders, and may be run from a number of different theoretical orientations including cognitive behavioral, interpersonal, or psychodynamic.

One of the main features of group psychotherapy is the experience of interacting with other people with a shared experience. Group therapists are able to integrate discussion of these interactions as part of the therapeutic intervention. Specifically, group therapists help group members identify and process the thoughts and emotions these interactions elicit.

• A. Eleven primary factors that define the group therapy experience [1]

  • 1. Installation of hope

    Hope that the treatment will be effective is crucial to any successful psychotherapy. Providers should focus on the client’s belief and confidence in the efficacy of the group throughout the course of the group. Further, group members are able to observe the improvement and hope of other group members, which can be regularly discussed as part of the group. Therapists must also believe in themselves and in the efficacy of their work and discuss this with the group. Self-help groups especially rely on the installation of hope.

  • 2. Universality

    Group psychotherapy helps clients appreciate that they are “not alone” in their experiences. For example, clients realize that other people have similar disabilities, emotions, and thoughts that they do. This realization helps to diminish stigma and shame and increase self-disclosure.

  • 3. Imparting information

    Groups serve to educate group members about their illnesses, medical conditions, and symptoms, and convey information on effective treatment and coping strategies. Didactic instruction allows group members to learn factual information about their illnesses, to correct misconceptions about their conditions and treatments, and to understand treatment options and recommendations. Group members are able to provide advice to each other about symptom management and treatment, based on their own lived experiences.

  • 4. Altruism

    Both giving and receiving help in therapy groups can increase a client’s self-esteem and belief in their ability to help others. Clients with medical conditions may view themselves as burdens to others, and their ability to help other group members may shift this mind-set.

  • 5. The corrective recapitulations of the primary family group

    Many people have difficulties in their relationships with family members. Group members may interact with each other and with the group leader(s) in a manner that reflects how they interact with family members. These resemblances allow group members to explore their interpersonal and family relationships and, as part of group therapy, learn new ways to interact with others.

  • 6. Development of socializing techniques

    Group members can gain understanding and insight into their social skills and interpersonal relationships through direct and indirect ways in group psychotherapy. Group members can learn and practice specific social skills (i.e., being assertive) through instruction and/or experiential activities such as role-plays. Group members receive feedback on the manner in which they interact with others and learn more about how their communications are perceived by others.

  • 7. Imitative behavior

    Group members may model their own behaviors based on their observations of the actions of the group leader(s) and of the other group members. This may allow group members to engage in patterns of behavior they see as effective.

  • 8. Interpersonal learning

    Group members gain insight into the importance of their interpersonal relationships, learn new ways to handle emotional experiences, and learn new patterns of interacting with others. Group members may experience new emotions as a result of these interpersonal experiences and can process these emotions in the group. Further, group members can identify and discuss thought distortions they have when interacting with others. Finally, group members can identify and change maladaptive patterns in their interactions with others.

  • 9. Group cohesiveness

    Group members are able to accept each other’s experiences and emotions and form supportive and meaningful relationships with one another. Members may feel accepted and understood as a result. An increased sense of cohesion will likely lead to increased self-disclosure and stability of the group.

  • 10. Catharsis

    Catharsis occurs when group members are able to freely express their emotional reactions in a safe and supportive environment. Members may be able to share personal details, without shame or guilt.

  • 11. Existential factors

    Group members learn to make sense and to give meaning to their existence. They also learn to recognize that at times life is unfair and that each individual ultimately is responsible for their actions.

Importance

Group psychotherapy is frequently used in medical care and rehabilitation. Psychotherapy groups can address concerns that are specific to a particular illness or disability, as well as common concerns across medical conditions. Benefits include emotional support to clients and members of their family, psycho-education about medical conditions, learning coping skills particularly relevant to an illness or disability, as well as building motivation to sustain long-term changes in lifestyle and coping [2, 3].

Practical Applications

• A. Group topics: what to talk about

  • 1. Shared experiences across illnesses in medical settings [3]

    • Understanding diagnosis and prognosis

    • Coping with treatment, medications, and side effects

    • Adjusting to lifestyle changes and new levels of functioning

    • Coping with changes in mood and energy

    • Navigating relationships with family, friends, coworkers, medical personnel

    • Existential issues: changes in identity, self-image, and priorities

    • Living with uncertainty

  • 2. Unique experiences with a particular illness or injury [3]

    • Amputation: pain, grief, changes in body- and self-image

    • Arthritis: pain, loss of motoric functioning

    • Burn injuries: body image, pain, and sleep problems

    • Cancer: treatment side effects, fear of recurrence, fatigue, and body image

    • Chronic fatigue syndrome and fibromyalgia: lack of medical and social support, lack of concrete diagnosis, and variable course of illness

    • Coronary artery disease: stress, personality characteristics that may predispose, angina, loss of independence for a time, and the need to improve lifestyle behaviors

    • Multiple sclerosis: progressive but unpredictable course of illness, fatigue, and motor and cognitive changes

    • Spinal cord injury: stigma, the lack of accessibility, increased dependence on others, and pain

    • Stroke: motor, speech and cognitive changes, and physical vulnerability

    • Traumatic brain injury: invisible disability and cognitive and emotion regulation changes

  • 3. Family support

    Finally, in addition to client-focused groups, family members can also benefit from groups as a source of support, education, and a way to develop new coping skills, as illness affects the entire family unit. Groups for family members may focus on caregiver stress and self-care, how to cope with distress about loved ones, and ways to strengthen communication strategies.

• B. Setting up a group: planning and participation

  There are a number of considerations when using group psychotherapy as an intervention:

  • Appropriate physical space must be identified, particularly a space with accommodations for clients with disabilities related to their medical condition.

  • Selection of group members must be considered. That is, is a certain diagnosis required for group membership? What is the cognitive ability and insight needed for group membership?

  • Open or closed. Groups may be open to new members on an on-going bases (open groups) or may be limited to people who join in the first week or two (closed groups).

  • Time limited, with a predetermined number of sessions or open ended, with no specified end date.

  • The ideal number of participants per group is about eight, although this can vary depending on the type and nature of the group.

  • The duration and frequency of the group need to be specified before the group begins.

  • Assessments that will be conducted as part of the group need to be identified. These might include assessments of change in symptoms or satisfaction with the group therapy.

  • Will there be one group therapist or co-therapists? Either can be beneficial, and each approach has strengths and limitations. If there will be co-therapists, scheduling additional time to plan for the group, and process how the group is running, will be necessary.

  • Strategies to deal with difficult behaviors in group should be thought of, and planned for, prior to the group. That is, what resources are available if a client becomes unsafe in group, if a client dominates the group discussion, and if a client does not actively participate during the group?

Tips

• Educate team members on the benefits of group psychotherapy. Ensure that all members of the interdisciplinary team are familiar with the benefits of group psychotherapy, the format of the groups being run, and the way to refer clients. Informational materials about the group may be helpful.

• Some clients may experience anxiety about participating in group psychotherapy. When discussing potential group membership with clients, identify that anxiety is a normal response when considering joining a group and normalize the experience.

• Reinforce a therapeutic, trusting milieu atmosphere in the group. Discuss ground rules of the group, including respectful behavior, consequences of tardiness or nonattendance, safety protocols, and expectations of confidentiality, at the beginning of the group. Discuss these expectations throughout the group, and explore if a group member does not abide by these expectations in a therapeutic manner, as needed.