Group TherapyHeather Harrall RN

Wright State University

College of Nursing and Health

Introduction to Groups

Divide into 2 groups

Take a bag of candy

Create a story with the names of the candy

We will read the story at break

http://www.gamesforgroups.com/mixergames.html

Objectives

• History• Scientific Evidence• Theory• Starting a Group• Group Types• Group Development• Ethic• Integration into Practice

History

• 1900-1940– 1st therapy group with physical illness– Format was developed for psychiatrically hospitalized – Preliminary formulations on the role of the leader were

made– Aggression in group was explored

• 1940 after WWI– Moreno

• Coined “group therapy”

– Bion• Viewed the whole group and not just individuals within group

– Slavson• A founding father of American Group Psychotherapy Association• Children and adolescentsBrabender, et. al. 2004 p. 6 & Wheeler, 2014

History

• 1960-70– Many new approaches– Group therapy began entering into communities

• 1970-80– Yalom first published – Research findings supported groups

• 1985-present– Focus on training/credentialing group therapist– Increased attention to diversity topics

Brabender, Fallon, Smolar 2004 p. 10-14

Research

• Outpatient populations– Group therapy was equal to individual therapy

» Burlingame, MacKenzie, Strauss (2004)

• Cancer patients– Increased survival and enhanced quality of life

» Spiegel & Classen (2000)

• Postnatal Depression– Group therapy showed to have longer effects and

extended to other relationships» Mulcahy, Reay, Wilkinson, Owen (2010)

• Wheeler table 11.2 p. 418

Systems Theory• Shift in perspective from the individual as the center

around whom revolves to the individual as a system nested within a hierarchy of systems: a systems of systems

• Basic premise of systems-centered theory is that the systems of member, subgroup, and the group as a whole are isomorphically related and exist in a hierarchy.

• Every system in a hierarchy exists in the environment of the system above it and is the environment for the system below it.

• Every living system is influenced by its environment (inputs) and in turn influences its environment (output)

Sadock & Sadock 1993 p. 38

Theoretical approaches

• Psychodynamic– Examines interactions among and between group

members and the group leader, provides increased awareness of themselves, and deeper understanding of themselves.

• Cognitive behavioral – Identifying cognitive distortions and how it

influence feelings and emotions• Person centered

– Healing comes from the group members. Group leader provides trusting environment and honest feedback is provided to and among members

Wheeler, 2012 p. 410-411

Starting a Group

• Locations– Inpatient, outpatient, partial hospitalizations,

community settings• Composition• Open vs closed• 8-10 members is optimal size• Screening interview• Psychiatric history and MSE

Gupta, A. (2005)

Screening Interview

• Step 1– Identify needs, expectations, and commitment

• Ask “what would you like most to change” • Commitment to change is most important predictor of patient success

• Step 2– Challenge myths and misconceptions

• Most stem from media portrayal • May need to elicit by statement “there is a lot of incorrect information out

there, some people think groups are where you throw caution to the wind and tell everyone your secrets”

• Step 3– Convey information

• Stress confidentiality and inform them that unfortunately the group leader can not absolutely guarantee member behavior.

• Step 4– Screening

• Responsibility to screen potential group members that are likely to benefit from the group

– General consensus that those that are extremely hostile, angry, highly aggressive, brain damaged are contraindicated in a group setting

Couch, 1995

Criteria

• Inclusion criteria– Ability to perform the group task– Problem areas compatible with goals of group– Motivation to change

• Exclusion criteria– Marked incompatibility with group norms for

acceptable behavior– Inability to tolerate group setting– Severe incompatibility with one or more of the

other members

Gupta, A. (2005)

Break

• Time to share your candy bar story!

 ObjectiveFor people to begin to feel comfortable around one another, and for everyone to give input when in a group discussion.

Group Types

• Psychoeducational– Facilitate education or information to patients &/or

families about various topics• Support groups

– Groups that share a common experience• Self-help groups

– Provide mutual support; come together because of shared experience

• Skills training– Groups are formed for a specific purpose (i.e. learning

to manage anger or learning social skills)

Wheeler, 2014 p. 414

Self-help groups

• Most famous is Alcoholics Anonymous (AA)– NA, Al-non, CA, Adult children of Alcoholics

• Rely heavily on the 12 step program• Tend to avoid use of professionals as

leaders– Use group leaders who no longer use

• Early stage treatment• Late stage treatment

Self-help Group Therapy Kaplan & Sadock 1993

Cognitive-Behavioral GroupPsychotherapy

• Has been successful in stress reduction, social skills, reducing depression, reducing generalized anxiety, anger management, refining parental skills

• Assessment– Crucial step is analysis of situations that are most stressful to

patient and determine the most difficult moment AKA “the critical moment”

– Describe their behavior, affect, and cognition at “the critical moment”

• Treatment Planning– Systematic problem solving– Cognitive restructuring – Coping skills

Psychodrama

• Role Playing– Central feature is establishing an artificial world between

reality and fantasy• Group size and session length

– 10+ people– Averaging 2 hours

• Phases of Sessions– Warm-up– Transition to drama– Drama– Closure

• Joseph Moreno

Interpersonal GroupPsychotherapy

• Based on interpersonal theory which assumes that patients’ problems are the result of maladaptive interpersonal beliefs and behaviors

• Emphasis on interpersonal learning• Social microcosm• Role of Therapist

– Translating presenting complaints into interpersonal symptoms

– Activating the here and now• Primarily help members talk about interpersonal dynamics as they occur

– Processing the here and now• Secondly help member reflect back and learn from interactions

– Therapist transparency• The degree which the therapist reveals and relates honestly

• Irvin Yalom

Yalom Principles

• Instillation of hope• Universality• Imparting information• Altruism• Corrective recapitulation of the primary

family group• Development of socializing techniques

Yalom, 2005

Yalom Principles

• Imitative behavior• Interpersonal learning• Group cohesiveness• Catharsis• Existential factors• Self-understanding

Yalom, 2005

Leadership

• Attributes• Setting group goals• Selecting members• Making contracts• Initiating and maintaining therapeutic process• Protecting members from harm• Terminating• Evaluating the outcome

• How NOT to be a group leader

Challenging Group Members

• The monopolist• The silent client• The boring client• The help-rejecting complainer• The psychotic or bipolar client• The characterologically challenging client

– Schizoid, borderline, narcissistic

Yalom & Leszcz 2005 Chapter 13

Benefits of Groups

• Cost-effectiveness– Treating group vs individual

• Affordability– Lower cost

• Time management– 1 patient for 60 minutes for 6-10 sessions vs– 8-10 patients for 90 minutes for 6-10 sessions

• Can create a group for nearly any reason– Anxiety d/o, cancer, victims, couples, AA, etc…

Wheeler, 2012 p. 415

Group Development

Ethical issues

• Privacy: confidentiality and privileged communication– Establish expectations and consequences– Set an example– Giving reminders– Processing violations

• Informed consent– One who understands the goals of the group

and how individual goals are congruent

Brabender, Fallon, Smolar (2004)

Group Management Issues

• Group Rules– Confidentiality – Attendance– Translating feelings and impulses into words– No socializing with members outside the group

• Monetary Issues– Fee arrangement should be decided– Standard fee vs sliding scale

• Record Keeping– Development of treatment plan that specifies long-term goals

and short-term objectives– I.e. Jongsma, Arthur, 2005. The Group Therapy Treatment Planner

– Separate note for each group member• Remember to maintain privacy

Brabender, Fallon, Smolar (2004)

Integration into practice

• Solo vs co-leadership– Beneficial in learning situations– Ability to demonstrate how to disagree

• Better if used later in group settings

– Potential disadvantage • Relationship between leader and co-leader• Theoretical bases underlying both leader and co-

leader

Yalom & Leszcz, 2005 p. 443-446

Conclusion

• Highly effective treatment modality• Increased access to care• Diversity• Discussed underlying principles• Being aware of interpersonal interactions

– And how to handle them immediately

Questions???

Question 1

• Clients within a group begin to focus on goal achievement. Which group development stage are they in?

• A. Forming• B. Storming• C. Norming• D. Performing• E. Adjourning

Question 2

• As a APN student, you are asked to co-lead a group. You ask to be a part of the patient selection process. Which patient would you NOT consider for group therapy?

• A. recently widowed 75 yo• B. 15 yo diagnosed with social anxiety• C. 27 yo with violent impulses with a new

TBI• D. 48 yo addict wishing to quit

Question 3

• After working as an APN at a community mental health facility, you notice a theme of poor relationships among your clients and decide to establish a group for these patients. You are starting a _______ group:

• A. Social skills • B. Self help• C. CBT• D. Psychoeducational

Question 4

• As the leader of group therapy you begin to hear group members discuss their sense of relief that other members have similar situations to their own. You know this to be known as Yalom’s principle of:

• A. Altruism• B. Interpersonal learning• C. Instillation of hope• D. Universality

Question 5

• Groups take place:• A. Hospitals• B. Churches• C. Clinics• D. All of the above

References • Bernhardsdottir, J. J., Champion, J. D., & Skärsäter, I. I. (2014). The experience of participation in a brief

cognitive behavioural group therapy for psychologically distressed female university students. Journal Of Psychiatric & Mental Health Nursing, 21(8), 679-686. doi:10.1111/jpm.12106

• Brabender, V., Fallon, A., & Smolar, A. (2004). Essentials of group therapy / Virginia A. Brabender, April E. Fallon, Andrew I. Smolar. Hoboken, N.J., Wiley, c2004.

• Brook, D. (2003). Exploring group therapies. Psychiatric Times, 20(2), 29. Retrieved from: http://www.psychiatrictimes.com/articles/exploring-group-therapies

• Couch, R.D. (March 1995). Four steps for conducting a pregroup screening interview. The Journal for Specialists in Group Work. 20(1) p. 18-25

• Garza, Y. (2014). Supervision in Group Play Therapy: A Skills Checklist. Journal Of Individual Psychology, 70(1), 31-44.

• Gupta, A (2005). Group therapy for psychiatric disorders: an introduction. Mental Health Reviews. Retrieved from http:www.psyplexus.com/mhr/group_therapy.html

• Kaplan, H. I., & Sadock, B. J. (1993). Comprehensive group psychotherapy / edited by Harold I. Kaplan, Benjamin J. Sadock. Baltimore, MD : Williams & Wilkins, c1993.

• Okumura, Y., & Ichikura, K. (n.d). Efficacy and acceptability of group cognitive behavioral therapy for depression: A systematic review and meta-analysis. Journal Of Affective Disorders, 164155-164.

• Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock's synopsis of psychiatry : behavioral sciences/clinical psychiatry / Benjamin James Sadock, Virginia Alcott Sadock, Pedro Ruiz. Philadelphia : Wolters Kluwer, [2015].

• Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse : a how-to guide for evidence-based practice / Kathleen Wheeler. New York, NY : Springer Publishing Company, LLC, [2014].

• Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy / Irvin D. Yalom with Molyn Leszcz. New York : Basic Books, c2005.