Historical Background

Group therapy is a treatment in which carefully selected people who are emotionally ill meet in a group guided by a trained therapist and help one another effect personality change. Pratt (1908), who assembled together patients with tuberculosis in order to instruct them on medical aspects of their illness, is usually designated the father of group therapy. In 1931, Moreno coined the term "group psychotherapy" and published a detailed scientific method based on his ideas (Moreno, 1932).  The main roots of group therapy were in the experience of treating war neurosis in 1940s in UK. Northfield Military hospital was a centre of innovation where Bion & Foulkes tried new approaches. Yalom (1985) is another eminent figure whose works led to development of interpersonal group therapy.

Indications for group therapy & selection of patients

In group 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.

Inclusion criteria

1. Ability to perform the group task.

2. Problem areas compatible with goals of group.

3. Motivation to change.

Exclusion criteria

1. Marked incompatibility with group norms for acceptable behaviour

2. Inability to tolerate group setting

3. Severe incompatibility with one or more of the other members

COMPOSITION OF GROUPS

Size

Group 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 interpersonal difficulties.

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 group.

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 1-2 hours.

THERAPEUTIC FACTORS IN GROUP THERAPY

Following therapeutic factors in group therapy have been listed by Kaplan & Sadock (1983)

TYPES OF THERAPEUTIC GROUPS

1. Supportive groups

2. Self help groups

3. Medication groups

4. Interpersonal group therapy

5. Encounter groups

6. Psychodrama

Supportive groups

In this approach, therapist ensures that

1. The experiences of the group members are used positively

2. Relationship between group members is cordial

3. It should not become too intense

4. Protect vulnerable patients when necessary

5. 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.

Medication groups

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 nonjudgmental environment

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 problem.

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.

Encounter groups

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 emotional problems.

Psychodrama

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 eg. – how to deal with authority. This method is called sociodrama.

INPATIENT GROUP THERAPY

Group 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 decrease isolation.

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:

1. Patients become more socialized than in the past

2. They become aware that they are not alone with their problems

3. They become more comfortable in the hospital setting

4. They continued to discuss the topics with each other for sometime even after the session ended. This improved their interaction pattern.

Marsch (1931) used lecture approach with patients but supplemented his lectures with other techniques like music, dance and inspirational reading.

VARIOUS MODELS OF INPATIENT GROUP PSYCHOTHERAPY

Contemporary models of inpatients group psychotherapy share several features. Most models establish highly specific goals according to the particular needs of the patients.

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:

1. Clarifying the problem

2. Generating alternatives

3. Evaluating alternatives

4. Role playing

5. Reporting back to the group on the outcome of different solutions

Social skills model – The behaviorally oriented social skill model fosters acquisition of various interpersonal skills by dividing each skill into multiple behavioral components. For eg – 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.

Interpersonal model

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.

Group therapy for schizophrenia

Schizophrenia is a disorder with biological, psychological and social causes and effects. Not all schizophrenics achieve optimal stability with medication alone, thus necessitating psychosocial treatment. Group psychotherapy is useful in helping schizophrenia patients to deal with their symptoms and improve their ability to interact with others.

The prerequisite is a cohesive environment in which patients feel comfortable with one another and are free to discuss. Inpatient group can meet twice on thrice a week in sessions of 45-60 minutes. The number of patients range from 4 to 10, with 6-8 patients being optimal. Groups may be open or closed. In closed group, the goal should be made explicit in the first session. In open groups, the goals should be reviewed at the beginning of a new persons' first session. Patients are selected after proper history taking and detailed mental status examination. Selection of patients is another important aspect. Patients who are actively psychotic may be included as long as they do not become too disruptive or too disturbed. In fact, some overtly displayed psychotic material may be useful in group discussion. For example, in reaction to a patient who is responding behaviorally to an auditory hallucination, group members may be asked to comment on whether they also hear any voice. Doing so enhances reality testing and allows all members to discuss a similarly observed phenomenon and ways of coping. Patients who are withdrawn and patients with negative symptoms may be included in the group - though they may not actively participate, many patients benefit from sitting with people having similar problem. Patients who are too disruptive and cannot follow the discussion are mostly not included in the group.

Another important aspect is selection of topics for discussion. The topic selected for discussion should be congruent with the goal. Ideally, a patient begins a session by introducing an appropriate topic, all members relate that issue to their own situation and then start sharing coping strategies. Early discussions can be on problems related to hearing voices, relating poorly with other people etc. Each patient can be asked to comment on the issue and therapist can do a formal go around. Patients who do not respond should be specifically addressed. The discussion also focuses on the following issues:

1. Patients should be encouraged to look directly to each other.

2. Patients with negative symptoms or paranoid delusion are quiet and withdrawn. Giving opportunity and encouragement to each member increases cohesiveness and makes the patients feel that they are important.

3. Patient who are reluctant to speak should not be forced, but supportive and confrontative comments can be given which let the patient know that they are expected to participate.

Patients sometimes benefit from advice given to them by the therapists. But learning in a group primarily occurs through interaction between group members. They learn strategies of coping with their problems through topics discussed with others who have similar problem. Secondly, patients are able to practice interpersonal skill during the sessions that they may generalize to interactions outside the group.

Some problems faced in group therapy

1. Formation of sub-groups - some members may form a coalition based on age, class shared values or other characteristics. This disrupts the therapeutic process.

2. 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.

3. 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.

4. Conflict between 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.

5. 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.

Role of the therapist

1. The therapist should actively structure the discussion in a way that encourages the group members to stay in a topic.

2. Therapist should take cue from the process of the group.

3. When members interact spontaneously around an appropriate issue, the therapist should be quiet and allow the patients to feel a sense of mastery.

4. 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 members.

5. 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.

6. 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.

7. 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.

Limitations of group therapy

1. Not suitable when patient suffers from severe depression and suicide is a risk.

2. Similarly, manic patients are difficult to manage in the group setting. They tend to display excessive elation, talkativeness and irritability which are often difficult to control.

3. Patients with sub-normal intellectual level may not get adequate benefit from the group situation.

References

Kaplan, H.I. & Sadock, B.J. (1983) Comprehensive group psychotherapy. (3rd ed.) Williams & Wilkins, New York.

Lazell, E.W. (1921) The group treatment of dementia praecox. Psychoanalytic Review, 8, 168 - 179.

Marsch, L.C. (1931) Group treatment by the psychological equivalent of the revival. Mental Hygiene, 15, 381-349.

Maxmen, J.S. (1978) An educative model for inpatient group therapy. International Journal of Group Psychotherapy, 28, 3, 321-338.

Moreno, J.L. (1932) Application of the group method to classification (2nd ed.). National Committee on Prisons and Prison Labor: New York.

Pratt, J.H. (1908) Results obtained in treatment of pulmonary tuberculosis by the method. British Medical Journal, 2, 1070-1.

Spivack, G., Shure, M. (1974) Social adjustment of young children: A cognitive approach to solving real life problem. Jossey Bass: San Francisco.

Yalom, I.D. (1985) The theory and practice of group psychotherapy (3rd ed.). Basic Books: New York.