GROUP THERAPY

Time- Limited Groups

Many groups in clinical practice, including those in hospitals and agencies, are time limited in nature. The majority
of time-limited groups are structured to meet from 10 to 20 weeks, but others can run for a year or two. The key is
that they are contracted to meet for a specific number of sessions over a defined period of time, and this usually
means that new members are not added once the group begins. When members cannot be added after an initial
period, such groups are referred to as “closed groups.” Time limited groups are also focused on specific goals and/
or populations and are typically formed homogeneously.
For example, they can be formed demographically, such as women’s groups, men’s groups, lesbian and gay
groups, veterans groups, and so on, according to life issues (divorce groups, crisis groups, grief groups, and the
like), diagnostic issues, such as groups for those experiencing eating disorders, social anxiety, breast cancer, or
borderline personality.

Open- Ended Groups

Open-ended (or “long- term”) groups provide a more extensive exploration of interpersonal styles and defenses.
Whereas time- limited groups are typically formed homogeneously, the usual open-ended group is more a
miniature facsimile of society, a heterogeneous group of individuals. Mature open-ended groups do best when the
membership represents the diversity of the society at large. Hope is a particularly important curative factor in these
groups because nowhere else in psychotherapy can individuals observe the process working in others before they
experience change in themselves.

Composing a Group
The first decision a group leader has to make is: What kind of group will this be? Is this to be a time-limited,
homogeneous group, a CBT group, a psychoeducational group, or an open-ended psychodynamic group? Then the
leader must decide how to compose the group vis- à- vis age, gender, and cultural diversity. Generally speaking,
one can make the case that there is a group for everyone. Therapists run groups for children, for adolescents, and
for adults of every age. In addition, although most groups are heterosexual in composition, there are groups formed
by gender and by sexual identity. There are also therapy groups composed by cultural, ethnic, or religious
affiliation,for example, groups for Latinas/os, African Americans, Asian Americans, indigenous people, and so on.

For the typical open-ended heterogeneous psychotherapy group, two overarching principles may help the leader in
composing a group. The first is the “Noah’s Ark” principle. The leader should try to ensure that every member of
the group has at least one other member with whom he or she can identify along some meaningful dimension, for
example, having another member in the group who has never been married, or another who is also on medication,
or another who has been psychiatrically hospitalized.
The second is that every member of the group has at least some capacity for self-exploration, insight, and
mentalization. This is less important in support groups, where members come to share a sense of having gone
through a common painful experience or issue.

Screening Group Members

Having decided on the nature of the group, including its goals and composition, the leader then selects group
members by screening potential candidates in individual screening meetings. Some therapists prefer to meet only
once before having the individual join the group, while others will hold two or three preliminary sessions.
Besides no preexisting relationships with other group members, Rutan, Stone, and Shay list the following desirable
attributes to be considered when evaluating individuals for group therapy:
• Ability to acknowledge need for others
• Self- reflective capacity
• Role flexibility
• Ability to give and receive feedback
• Empathic capacity
• Frustration tolerance
If someone has a high degree of each of those attributes, he or she would likely not need therapy.

There are, of course, particular individuals for whom group is not generally considered a good choice. Often these
individuals can successfully join a group after a period of individual psychotherapy.
According to Rutan, Stone, and Shay, poor candidates for group include the following:
• Individuals who refuse to enter a group
• Individuals unable or unwilling to keep the group agreements
• Individuals with whom the therapist is too uncomfortable to work
• Individuals in acute crisis
• Individuals with poor impulse control
• Individuals with certain character defenses (e.g., externalizing responsibility exclusively)

Preparing Group Members

During the process of screening a member for the group, the therapist is also preparing the member for the group
experience. Though early dropouts are a fact of life in group therapy, good pre group preparation increases the
likelihood that members will remain in the group because they have an idea of what to expect. What, then, are the
elements of good pre group preparation?

First and foremost is the formation of the therapeutic alliance. Nothing is more central to a patient’s successful
experience in the group than to experience a solid alliance with the therapist.
At the same time, it is essential that the member also experiences a sense of cohesion with the entire group, which
comes to serve as the group equivalent of the individual alliance.
Together, the patient and leader negotiate and collaborate on developing particular goals for the patient to work on
in the group. Of importance here is that group leaders not impose their goals on the patient but listen carefully to
elicit what the patient reasonably and realistically wants to improve in life.
It is also important to impart information about how the group runs. Because most candidates for group therapy
have little or no experience in an actual therapy group, the leader needs to describe the general structure and
rationale of the group, and to help the candidate anticipate scenarios likely to occur. It is important for the leader to
make clear that group therapy can involve tense and conflictual interactions that are both expected and ultimately
helpful because they can lead to deeper self- awareness and personal growth. Leaders also make clear that they will
be less active, as a rule, than the activity level one may have experienced from an individual therapist.
Another central task in the preparation phase is to present the group agreements and to receive the member’s
acceptance of these agreements. Such agreements (sometimes called the “group contract”) vary depending on the
type of group.
Typical agreements in an open- ended psychodynamic group are as follows:
• To be present each week, to be on time, and to remain throughout the meeting
• To work actively on the problems that brought them to the group
• To put feelings into words, not actions
• To use the relationships made in the group therapeutically, not socially
• To remain in the group until the problems that brought them to the group have been resolved
• To be responsible for paying the therapy fees
• To protect the names and identities of fellow group members
• To terminate appropriately
It is important to note that these are group “agreements,” not group “laws.”

PRINCIPLES OF CHANGE AND CASE CONCEPTUALIZATION IN GROUP THERAPY

There are several attempts in the literature to distill what might be called “therapeutic factors” in group
therapy irrespective of which particular theory is espoused. The most thorough-going model, offered by lists 11
therapeutic factors in group therapy:
1. Instillation of hope. Most patients enter therapy with some modicum of hope even if mitigated by the anxiety of
exposing their issues in public or the reluctance to share the therapist. We can presume that most patients enter all
forms of psychotherapy with some vestige of hope, or why would they arrive at all? But, in therapy groups,
especially long- term groups, this hope is uniquely supported because individual patients can observe other group
members improve even before experiencing their own improvement.

2. Universality. Many patients enter therapy feeling a profound aloneness, especially about the aspects of self that
they consider shameful and have kept private. The feeling that “no one else is like me” is countered in powerful
ways in therapy groups as individuals learn that their experience is typically more universal than singular. As
Yalom and Leszcz (2005) state, “There is no human deed or thought that lies fully outside the experience of other
people”. The realization that one’s private and often shameful experience is shared by others is itself quite healing.

3. Imparting of information. Many types of groups rely on imparting of information. These “psychoeducational
groups” include symptom focused groups such as cancer support groups, eating disorder groups, cognitive-
behavioral groups for social anxiety, and dialectical behavior therapy groups for patients with borderline
personality disorder. While information is certainly imparted in all therapy groups, psychoeducational or theme-
centered groups rely predominantly on this factor. In other theoretical approaches to group therapy, direct advice or
coaching is not encouraged.

4. Altruism. Altruism, or selflessly helping others with no thought of return, can be a healing experience. Groups,
in marked contrast to individual therapy, offer opportunities for members to be altruistic and to glean the results of
such behavior.

5. The corrective recapitulation of the primary family group. One powerful therapeutic phenomenon in
psychodynamic psychotherapy is the occurrence of transference. In long-term groups, members often
unconsciously react to various group members in ways that they react (or have reacted) to family members. Indeed,
so powerful is this process that at times such reactions will begin on the group member’s first day in the group!

6. Development of socializing techniques. In individual therapy patients can talk about their difficulties in making
friends and getting along with others, and they might even role- play with the therapist some new ways to interact.
Therapy groups have the advantage of offering a more immediate opportunity to observe how others behave in
similar circumstances. Furthermore, groups offer a safe environment for group members to try different behaviors
for themselves in the here and now of the session.

7. Imitative behavior. Patients in individual therapy often model behavior after their therapists. The group
environment, in which patients can learn from watching and imitating many others, is a far richer venue.
Individuals learn behavioral responses from the family groups in which they are reared, and often these responses
are accepted as “givens.”

8. Interpersonal learning. More than any other treatment modality, group therapy offers the best medium for
interpersonal learning because it is, as suggested earlier, a social microcosm. Group members bring into the group
their personality, their relational styles, their patterned defenses, and their unexamined assumptions about life into
the group. A careful exploration of how members perceive and engage in relationships in the room can provide a
wealth of important experiences and observations that help members understand and change themselves.

9. Cohesion. Group cohesion is akin to the therapeutic alliance in individual therapy. For any group to be
maximally effective, there must be a sense of cohesion, a feeling that “we are in this together.” Often in groups,
difficult or painful exchanges occur. In a cohesive group there is always the underlying conviction that the
members are fundamentally trying to help, not hurt, one another.

10. Catharsis. Catharsis is the free expression of deep feeling. For many years this was held to be the primary
healing factor in psychotherapy. In classic psychoanalytic theory, the goal of therapy was making the unconscious
conscious, and a major vehicle for achieving this was the unleashing of previously repressed emotion. Josef Breuer
even developed a technique called “the cathartic treatment.” Yalom noted that two of the top four items rated most
helpful by group members were in the category of catharsis: Being able to say what was bothering me instead of
holding it in (rated second), and Learning how to express my feelings (rated fourth) In the current era, the
expression of emotion is still considered useful and necessary, but it is not considered by most clinicians to be the
primary healing factor. Nonetheless, groups tend to facilitate the experiencing and expressing of deep emotion.

11. Existential factors. Yalom grouped many things into this category. Coming from a theoretical basis in
existential philosophy and theory, he pointed out that groups are excellent places for members to accept
responsibility for their lives and to contemplate and consider the consequences of their decisions. In fact, tied for
the fifth most highly rated item by group members was: “Learning that I must take ultimate responsibility for the
way I live my life no matter how much guidance and support I get from others”

TREATMENT
Group therapy is considered by many to be more complicated than individual or couples therapy. There is so much
to keep in mind. Rutan, Stone, and Shay list various roles and areas of focus that the group therapists must
maintain. And these roles and foci will change depending on the theoretical orientation of the group therapist and
the goals of the group.

Roles. Group therapists must negotiate their roles along three axes. These are activity/ nonactivity,
transparency/opaqueness, and gratification/ frustration.

Activity/ Nonactivity. In many psychoeducational groups or other time- limited groups, the group therapist is
typically more active than the leader in an open-ended psychodynamic group. All group therapists are always
“active” in terms of listening, assessing, and understanding. But, depending on the therapeutic factors they rely on
and the goals of their groups, some will be less verbally active. For example, in the first meeting of a time- limited
or psychoeducational group, the leader might be quite active in assisting the members to get to know one another.
In a psychodynamic group, on the other hand, the leader would be far less active in order to observe the greeting
style that each member brings to the group.
Transparency/ Opaqueness. Psychodynamic therapists are usually on the opaque side of this axis because they
want to follow the natural group process without unduly influencing it. In many homogeneously formed groups,
such as groups for substance abusers or trauma survivors, the leader may have disclosed having had the same
problem in his or her life. In such instances, the leader is much more transparent. For example, if the therapist has
to cancel an appointment due to a “family illness,” those therapists relying less on transference would probably be
quite transparent in letting the group know who was ill and how ill they were. A psychodynamic therapist would
not be opposed to sharing that information but would typically be opaque for a while in order to learn what
fantasies the members might have

Gratification/ Frustration. Groups that focus on support rather than insight typically have leaders who are more
gratifying, for example, overtly encouraging and complimentary to group members. Groups that focus on helping
members gain insight into unconscious processes or motives can be more frustrating because leaders will allow
more anxiety to develop as members act out their interpersonal issues. Leaders will vary on this axis according to
how much affect they feel is needed for effective therapy or can be tolerated by the group to continue its work.

Foci. Depending on their theoretical orientation or goals for the group, group therapists will focus on different
areas. Rutan, Stone, and Shay describe the following areas of focus: past versus present, group as a whole versus
individual focus, affect versus cognition, process versus content, and insight versus relationship. Although these
are posed as either/ or, in practice, most clinicians vary their interventions across the spectrum of these foci,
depending on the particular nature of the group on any given day, the developmental stage of the group, and the
needs of specific group members in a specific session.

Past/ Present/ Future. Classic psychoanalysts focused on historic etiology of current psychopathology, and thus
they would continually look to history to help understand the present. Other therapists assume that group members
will bring all their personality traits and patterns into the group, and they will focus almost exclusively on the here-
and- now interactions between group members. Existential therapists focus on the future, both the predictable
results of current decisions and grappling with the dilemma of finding meaning in a life clearly limited by time.

Group as a Whole/ Individual. There are times when it is useful to use the power of the whole group In groups,
an individual is often singled out as the “cause” of the group’s unrest or dissatisfaction. There is a sense the group
would be far better if this person were removed, sent to the woods. Indeed, often individuals unconsciously
volunteer for this role because it is an historically familiar role, where the individual has learned the “lightning
rod” role to take on the negative feelings for the whole family.

Affect/ Cognition. Therapists of all persuasions face the dilemma of deciding how best to balance feelings with
cognitions. Cognitive- behavioral therapists tend to work primarily in the cognitive realm, while dynamic therapists
focus on affective issues, but there comes a time in even the most affectively focused therapy when some cognitive
closure is important, and vice-versa.

Process/ Content. To the degree that therapists use unconscious processes as an important therapeutic factor, they
will pay special attention to the process of the communications. In psychodynamic group therapy, it is assumed
that at some level groups never change the subject.

Insight/ Relationship. Groups are especially potent sources for interpersonal learning. Indeed, one could say the
main therapeutic factor at work in groups is the corrective relational experience.