NCE – Group Therapy Overview

What is a Group?

Various Modes of Counseling discussed in the counseling theories section are all useful in the Group Therapy Setting.  (Groups have a definable membership.  There is unity and members interact with a shared sense of purpose.  Before the 1960’s and 1970’s most help was given in a dyadic relationship.” (Rosenthal, 2005)

Historical Considerations

Founder of Social Work. Jane Addams, is credited with holding early “moralistic group discussions”, the early version of group therapy.  Henry Pratt, began running groups in the early 1900’s for TB patients, for purposes of support and mutual encouragement.  The term “group therapy” was coined in 1931 by Jacob Mureno, the father of psychodrama.  In 1941, he created the American Society for Group Psychotherapy and Psychodrama.  A year later S. R. Slavson founded the American Group Psychotherapy Association.  Practitioners of individual psychology are quick to point out that Alfred Adler’s group guidance in the 1920’s and 1930’s with families also help to spark the group movement.

Primary, Secondary, & Tertiary Groups…

These are classifications of groups.  Primary groups are preventative and attempt to ward off problems.  Nearly all guidance and psycho-educational groups fall into this category.  The group would be trying to prevent drug addiction or a medical problem.  Secondary groups are both preventative and remediative.  Some form of emotional or physical disturbance is already present.  Goal with secondary groups is to shorten the length of a disorder and prevent it from getting worse.  One example of a secondary group might be one for rape victims or individuals in recovery.  Tertiary groups are intended as psychotherapy for those with long-term emotional problems.  Teritiary groups focus more on each individual’s mental health than you would find in a primary mental health group.

The Good & The Bad…

Benefits of Group Therapy….

Human behavior can really be studied in a social context.  The group setting provides an opportunity to try out new behaviors in a safe setting.  It also allows individuals to receive feedback from other members in addition to the therapist.  They helpful in the improvement of social skills.

Therapeutic Factors According to Yalom

  1. Instillation of hope -faith that the treatment mode can and will be effective.
  2. Universality – Means that as human beings we are not the only person in the world with a given problem or difficulty.  This key benefit of group participation helps members feel that others have similar problems.  Sometimes referred to as Mutuality.
  3. Imparting of information – didactic instruction about mental health, mental illness, psychodynamics or whatever else might be the focal problem of the group. (Ex. OCOA, Alanon; learning about the disease process itself).
  4. Altruism – opportunity to rise out of oneself and help somebody else; the feeling of usefulness.
  5. Corrective recapitulation of the primary family group – experiencing transference relationships growing out of primary family experiences providing the opportunity to relearn and clarify distortions.
  6. Development of socializing techniques – social learning or development of interpersonal skills.
  7. Imitative behavior – taking on the manner of group members who function more adequately.
  8. Interpersonal learning – receiving feedback from others and experimenting with new ways of relating.
  9. Group cohesiveness – the most critical factor to consider when pre-screening individuals
  10. Catharsis – opportunity for expression of strong affect.
  11. Existential factor – recognition of the basic features of existence through sharing with others (e.g. ultimate aloneness, ultimate death, ultimate responsibility for our own actions).

Rosenthal on Benefits of Group Therapy…

  1. Groups allow counselors to see more clients in the same amount of time.
  2. Groups generally are more cost effective.
  3. Groups gives a sense of belonging support and is a microcosm of society.
  4. Groups provide opportunities for vicarious learning (spectator therapy)

Disadvantages of Group Therapy

  1. Less time is focused on the client than with individual therapy
  2. The client has less intensity with the leader versus what he /she would have in an individual counseling session with a helper.
  3. Groups can be intimidating and stifle client disclosure
  4. Group sessions are often longer than individual sessions and take more of the client’s time.
  5. Lack of assurance of confidentiality is a major issue.
  6. Misapplication of interventions when family or individual therapy would be more appropriate.
  7. Organizing the group is difficult and groups are complex to run.
  8. The Risky Shift Phenomenon “The risky shift phenomenon postulates that group decisions are generally riskier than decisions that would be made by individual members.” (Rosenthal, 2005)
  9. Group Polarization “Here the individual members exaggerate their original position on a topic so the group as a whole will have a more mainstream position.” (Rosenthal, 2005).

Types of Groups

Counseling & Therapy…

Within individual therapy these terms mean the same thing.  However, in group therapy a distinction is usually implied.

  1. Counseling groups usually focus on growth, prevention, and enhancement of self-awareness.
  2. Therapy groups focus more on remediation, and personality reconstruction.  Therapy groups usually have a longer duration and are much more likely to dwell on unconscious material and family of origin issues.

Why this distinction?  Group therapy emerged in a big way during and after WW2 due to a shortage of trained therapists.  Groups allowed professions to work with more patients when there was a shortage of helpers. Some counseling historians  believe that Carl Rogers helped popularize this idea.  Another individual who was helpful in promoting the group therapy movement after WW2 was Dr. Kurt Lewin who developed Field Theory and formed NTL or National Training Labs to study group dynamics in 1947.

Structured Groups

Group leaders often speak of Structured Groups.  These are groups with a central theme like anger control.   Themed groups are becoming very popular and they are often conducted as self-help groups or support groups.  Self-help support groups include meetings like AA, Al-Anon or Weight Watchers.  They are composed of people with a common interest.  Although they may use professional consultants, they are not led by professional helpers.

EXAM HINT – 20 or so years ago counselor’s rarely referred clients to support groups.  Today the practice is extremely common.

T-Groups

“T” stands for training. Sensitive group stresses skills desirable in a business or organizational setting.  The thrust is on the group process and not on personal growth.  Hence, the T Group deals with issues of leadership and decision making and how employees can conduct themselves in a more productive fashion.

Personal Growth Group

Purpose is to aid healthy individuals in their desire to deal better with daily life or major transitions (i.e. divorce, etc)…

Ideal Characteristics of a Group

Group Size

What exactly is effective?  Some books list 5-8 is a good size for adults.  Others recommend as much as 5-12.  However, Rosenthal (2005) states that 8 is the most-often recommended ideal size for adult therapy groups.  With children you might want 3-4 kids to a group.

Length of Sessions

Most experts would recommend two hours as more than enough time for adult groups.  However, with children you might want to shorten the time to 30-40 minutes and meet biweekly instead.  1.5 hours seems to be the average for most adult therapy groups.

Membership Screening

The American Counseling Association and the Association for Specialists in Group Work both recommend screening group members beforehand.  Pre-Group / Individual Interviews need to be seen beforehand to determine if their needs can be met through participation.  Moreover, you want to make sure person is appropriate and won’t hinder the groups functioning.  Suicidal individuals, sociopathic personalities, paranoid individuals and psychotics would generally be excluded from most counseling groups.   Another poor candidate would be the highly self-centered or hostile belligerent individual.

Click Here to Read the ASGW’s 2007 Ethical Guidelines.
Click here to read AGPA’s Ethical Guidelines

Most leaders prefer private screening session in order to increase the potential for a two-way exchange with clients.  However, Rosenthal (2005) states that group screenings are also important in order to assess how the client will interact with other potential members.  Yalom, states that cohesiveness is the primary consideration to keep in mind when you are selecting participants.  In terms of the person, their ability to trust is generally the most important trait for a group member.

Opened vs. Closed Groups

In Open Groups you can replace members when one leaves.  New members are admitted throughout the life of the group.  This keeps the number of clients attending the open group stable.   However, new members are unaware of prior interactions within a group.  Additionally, adding new members can be detrimental to group cohesiveness.

In the Closed Group, no new members can be added once it begins.  This is great for group cohesiveness, however if everybody quits, the group can really shrink over time.

Two Final Words of Caution

Remember that the client’s previous experience in group is one of the least important factors. Another caution, is that leaders may be prone to pick member are high in conformity.  Although this has benefits, research has shown that conformists are likely to be authoritarians.   This can produce its own dilemmas.

Group Dynamics

Concepts like leadership style and norms technically fall under the category of group dynamics.  Group dynamics is defined as the study or body of knowledge pertaining to how groups operate.  Group dynamics postulate that groups are dynamic and ever changing.  People are interacting and reacting constantly. People with an interest in group dynamics, want to know what forces internal and external are shaping the behavior of the group and its members.

Body Language…

My advice for groups is that you will find it nearly possible to face members squarely all the time, if they are sitting in a group.  Turn toward the person whom you are speaking.  Literature pertaining to proxemics indicate that during the initial sessions, the leaning forward behavior on behalf of the counselor could actually be perceived as negative, if the client’s are of a different race.

Clients and counselors tend to sit closer together when they are closer in social status, age, race, ethnicity, and mode of dress.  The feeling of psychological closeness can be observed in individual and group settings where the seating arrangements are flexible and individuals can choose any seat he/she wishes.

Types of Leaders…

  1. Process leaders are outcome oriented and focus more on behavioral goals.  They tend to be slanted towards behavioral approaches of therapy.  The emphasis is on the outcome.
  2. Process leaders are focused on the interactions between members.  A statement by a process leader.  “Bill always responds out of his critical parent whenever talking to Ann.”

styles of leadership

There are three basic styles of leadership:  Authoritarian, Democratic and Lassiez-Faire.  Each is described below:

  1. Authoritarian Style – leader determines policies and gives orders to of the group.  Members often dislike this style.
  2. Lassiez-Faire Style – Leader adopts a hands off policy and participates very and the group runs itself.
  3. Democratic Style – The policy is set by the group, aided by the leader, who urges group interaction.

A well-known study suggests that the democratic style is the most desirable and most cases but definitely every case.  For example, if you had to make a decision very rapidly in a crisis the authoritarian mode might be best.  Some literature does go beyond these three basic types:

  1. Charismatic Leader – use their personal power and attractiveness to run a group.  Clients can adore this type of leader and become irrational because of it.
  2. Confrontive Leadership Style – the leader reveals the impact of their own behavior on themselves as well as the impact on other group members.  The focus here is usually the present moment.
  3. Speculative Leadership Style – Focuses on the here and now and zeroes in on the meaning of the leaders own behavior and that of the group members.  Emphasize very heavily what is transpiring right now in the group.  Research indicates these leaders are often seen as somewhat charismatic and less peer-oriented than confrontive leaders.

Co-Leadership…

Advantages…

All leaders, regardless of style display empathy and caring.  Some groups rely on more than one leader.  This is known as co-leadership or co-facilitation.  The good news is with co-leadership you don’t need eyes in the back of your head to now everything that is going on.  Is also beneficial when one leader has to miss a session.  Shared leadership reduces burnout.  Allows leaders to process feelings between sessions.  If one leader is dealing with countertransference issues, the other leader can step in.  They frequently sit across from each other in order to minimize the us versus them notion.

Disadvantages…

Co-Leaders may view this setting that they are competing with one another.  This may cause co-leadership conflict.  If co-leaders don’t meet between sessions, they may be working against one another at times.  If leaders don’t trust one another, the group will not run smoothly.  When co-leaders are intimate, they may inappropriately use this time to work on their issues too much.

Norms, Groundrules & Group Norms

Every group has norms, parameters of acceptable behavior. T hey may be written or unwritten.  It is easier to experience them than consciously define them. The specific guidelines that the leader sets, are know the ground rules. When the ground rules become the norms of behavior, they are called group norms.

Presence of Shared Goals…

It is best if the group comes to a mutual concenseus in terms of goal setting.  That although goal setting, most researchers have found that goal setting is a weakness in many groups.

Structure of Groups…

In highly structured groups, the leader has specific activities or tasks for group members. Less structured groups do not have this.   The term “unstructured” has come under fire as it pertains to less structured groups, since technically all groups must have some form of structure.  A group cannot “not” have structure.  Some research does indicate that structured exercise with feedback can result in better communication and feeling.  However, structure alone is insufficient.

Cohesiveness

The strength of the bonding process between group members.  Some people use the word “unity” when discussing this concept.  Cohesiveness is really a double-edged sword  in the sense that although it is desirable it can stunt creativity and conformity at times.

Group Roles.

  1. The Joker – acts silly and jokes around all the time.
  2. Energizer – provides the group with enthusiasm
  3. Follower – non-assertively goes along with everything group wants.
  4. Scapegoat – person everybody expresses hostility toward and accuses them when something goes wrong.  They get dumped on
  5. Peeping Tom – This member insists on interrogating members a series of inappropriate questions
  6. Gatekeeper – believes it is his/her job to make certain everybody participates.  Secretly wishes they were running the group.  He/She may never get around to working on own problems.
  7. Storyteller – contributes irrelevant tales of woe whenever possible.
  8. The Social Isolate – present but nobody even knows that this person is there.  When they try to reach out, their contributions are unnoticed.
  9. Harmonizer – member who tries to placate or make things friendly. Smooth things over between members.

Finally, from a global standpoint, members may assume basic types of roles.  There are task roles and there are maintenance roles and self-serving roles.  Task and maintenance roles are considered positive. Self-serving roles hinder the groups roles.

  1. Task roles – facilitate the group’s ability to define goals and implement problem solving strategies.
    1. Information providers
    2. Clarifiers
    3. Summarizers
    4. Opinion Givers
    5. Elaborators
    6. Initiators.
  2. Maintence Roles -also seen as healthy and serve to alter, maintain, or strengthen the group overall.  Maintenance roles serve to enable compromise, supportive contribution and development of group standards.
    1. observer
    2. compromiser
    3. conciliator
    4. Follower
    5. Standard Setter
    6. Encourager
  3. Self-Serving Roles – These roles are seen as negative and hold the group back and work against it.  Clients who silent, resist, intellectualize, manipulate, withdraw, attack are said to be playing a negative group role.
    1. People who don’t participate
    2. Blockers
    3. Monopolists
    4. Critics
    5. Dominators

In a health group members are flexible and can move in and out of roles and change roles when necessary.  Both task and maintenance roles are necessary.  If only one is done, no progress occurs.

EXAM HINT:  Group therapists rely on the term role conflict to describe a situation in which there is a discrepancy between the way a member is expected to act versus the way he/she naturally behaves

Group Development

Exam Hint:  Since it is impossible to remember all the models of group development I want to suggest that most of them are similar enough that a basic grasp of group stages will get you by.

Group development is usually expressed in terms of stages.   These stages of development occurs as follows:

  1. STAGE ONE – Most models whether they call the first stage forming, orientation, pre-affiliation, or exploratory, deal with approach / avoidance behavior.  Clients may wish to participate but have a fear they won’t be accepted.  They may be uneasy and suspicious.  They may try to identify with members of a similar social status.  In fact you see similar people trying to sit together in this stage.
  2. STAGE TWO – Storming/Transition, or Power/Control.  Marks the time of the greatest conflict. Opposing subgroups may pop up and people may try to mentally rank order themselves with others.  A hierarchy or group pecking order may be evident.  People will fight each other for dominance, and members may even rebel against the leader.
  3. STAGE THREE – The stage becomes cohesive like a family.  Members are more intimate.  This is an action-oriented time and problem solving phase.  Since a lot of work happens here it is generally called the working stage.
  4. FINAL STAGE – termination stage, adjourning, separation, breaking away.

Sociogram

As a leader  you may wish to construct to a picture of sub-groups and coalitions an assess their overall impact on the group.  The sociogram was introduced by Marin Owen Jennings in 1950 and it graphically displays the relationships of group members. It is a picture of what is going on in the group.  A sociogram depicts attraction and repulsion by use of lines and arrows, etc.  The study of person to person relationships in a group setting is known as socioemetry.

Developing Competency…

  1. Training – A therapist can have a room full of degrees and licenses, and no training in group work.  Such a person should not be running groups according ot most groups.  ASGW recommends counselors who have compelted a groups course supplemented with at least ten hours of supervised experience, (twenty is recommended however).
  2. Counseling for Counselors – Some counselors just don’t have the personality to do so effectively.  Gerald Corey, believes that group leaders should first become the member of a group themselves before running one.  Individual therapy is also recommended before becoming a therapist.
  3. Group leaders should also provide members with informed consent information.  Information such as where the group will meet, when it meet, the counselor’s credentials, the methods used, the cost of meeting times and the fact that there are limitations to confidentiality.  You need to discuss the fact that you cannot guarantee confidentiality in the group since members may breach it and this is beyond your control.
  4. Groups leaders must keep in mind that group participants have rights.  One right is knowing what psychological risks will be evident by attending the group.  The ethical group leader discusses these risks during the first session and works throughout meetings to reduce these risks.  According to ASGW guidelines, if things get too bad, they may withdrawal.  Group participation is voluntary in nature, you should never force someone to stay in the group.  Two major risks are scapegoating (members gang up on a member) and breach of confidentiality.
  5. Group leaders can use all the skills utilized by individual counselors, (paraphrasing, attending, clarifying, empathizing, etc)…but, leaders can also utilize summarizing, blocking, and linking quite a bit.
    1. Summarizing – ask each member to recapitulate what learned in the group, or the leader may wish to do so.
    2. Blocking – used to stop/block inappropriate behaviors.
    3. Linking – Used to relate what one is saying/doing to another person’s predicament.  The leader illuminates points of mutual concern.
  6. Group Leaders can vary their approach by focusing either the group as a whole, or focus on one at a time.  This is a choice and can really be made regardless of what modality you are utilizing.
    1. Group as a whole strategies – are called “horizontal interventions”
    2. Focusing on an individual – called a “vertical interventions”
Final Exam Hint:  Some group counselors do a so-called ecological assessment to decide if a group is appropriate, and if so what methodology will work best.  This assessment provides information about psychological, social, cultural, and economic needs of group members. Community surveys, focus groups, and thorough demographic analysis can help you.  Adept leaders often secure information from textbooks, the internet to plan group on session-by-session basis.

References

Rosenthal, H. (2005). Vital information and review questions for the NCE and state counseling exams. Routledge
Yalom, I. & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books. pp.1 – 2.

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