Prof. Hani Hamed Dessoki, M.D.Psychiatry

Prof. Psychiatry

Chairman of Psychiatry Department

Beni Suef University

Supervisor of Psychiatry Department

El-Fayoum University

APA member

Agenda

• Introduction

• History

• Prospectives on group psychotherapy

• Negative ffects of group Psychotherapy

• How could psychotherapy ever be harmful?

• Ethical issues in group psychotherapy

• Take Home Message

A group is often more than the sum of its parts. At times, however, it may be less than the sum of its parts.

Ideally, therapeutic groups develop a work culture under the skillful direction of a leader knowledgeable not only in the areas of psychopathology and psychodiagnostics, but also in group dynamics and interpersonal communication.

Definition of Psychotherapy

• A classic definition of psychotherapy is use of interpersonal influence skills and psychological techniques by trained professionals toward the goal of relieving the signs and symptoms of psychiatric disorder.

• Psychotherapy is defined as a “procedure,” similar to that of a medical procedure.

Group Psychotherapy• Group psychotherapy offers multiple relationships to assist

an individual in growth and problem solving.

• In group therapy sessions, members are encouraged to discuss the issues that brought them into therapy openly and honestly.

• The therapists work to create an atmosphere of trust and acceptance that encourages members to support one another.

• In contrast to all the pharmacotherapy studies, there is precious little information about the safety of psychotherapeutic interventions -- which are also, in some patients and in some instances, associated with adverse events that need to be noted.

• These may include undue stress, potential overstimulation, and symptom exacerbation.

Introduction

Problems

• Empirical research on the negative effects of psychotherapy is insufficient, partly because there is a lack of theoretical concept on how to define, classify and assess psychotherapy side effects.

Side Effects

• Effective treatment causes side effects; this applies for medical interventions and psychotherapy alike.

• Due to its specific setting it is unusual to focus on risks and damages within psychotherapy.

History

• The possibility of treatment-induced deterioration among psychiatric patients was first observed nearly 7 decades ago (Masserman & Carmichael, 1938).

• Psychotherapy can sometimes be harmful: (a) deterioration effects and (b) negative effect

What are negative effects?

• Slower response

• Less remission or recovery

• Higher rates of relapse or recurrence

• Some combination of these.

Psychology, 4/e by Saul Kassin ©2004 Prentice Hall

Perspectives on PsychotherapyThe Bottom Line: Does Psychotherapy Work?

• Based on the results of 475 studies (Smith et al., 1980), the average psychotherapy client shows more improvement than 80% of those in the no-treatment control group.

The Benefits of Psychotherapy

Psychology, 4/e by Saul Kassin ©2004 Prentice Hall

Perspectives on PsychotherapyWhat is the Future of Psychotherapy? Orientations of Psychotherapists

Eclectic: Borrowing ideas and techniques from different approaches

Rationale for Group Psychotherapy

• Groups function as a microcosm of the world• Universality• Testing ground for new behavior• Give as well as receive help• Many problems are primarily social in nature• Learn new ways of being• Support

Group Counseling

Therapeutic Forces In Groups

Instillation of Hope Universality

Imparting of Information Altruism

Corrective Recapitulation Modeling

Interpersonal Learning Group Cohesiveness

Catharsis Existential Factors

Development of Socializing Techniques

“Copyright © Allyn & Bacon 2004”

The function of the group therapist

• Emotional Stimulation– Challenging– Confronting– Modeling self-disclosure

• Caring– Showing support– Providing praise, warmth, and acceptance

• Meaning Attribution– Explaining and clarifying– Interpreting– Linking

• Executive Function– Providing rules and setting limits– Managing time– Commenting on group dynamics

Therapist Physician superiority• The physician may be viewed as

superior to the patient, because the physician has the knowledge and credentials, and is most often the one that is on home ground.

• A physician should at least be aware of these disparities in order to establish rapport and optimize communication with the patient.

The Paternalistic Approach

“If I’ve told you once I told you 1,000 times, stop smoking!!”

Building a Partnership

Inclusion/Exclusion Criteria

• Who benefits?– Depends on the group– Almost anyone can benefit from group– People who have the most difficult time in relationships are

those who might most benefit from group therapy

• Possible reasons for exclusion– Acute situational crisis– Deeply depressed suicidal clients– Members who are unable to attend regularly– Clients with Antisocial Personality Disorder (unless the

group is specifically designed for them)

Stages of groups

• Stage One (Orientation/Forming): Group members orient to group and each other.

• Stage Two (Transition/Storming): Anxiety, ambiguity, and conflict become prevalent as group members struggle to define themselves and group norms.

• Stage Three (Cohesiveness/Norming):

A therapeutic alliance forms between group members.

• Stage Four (Working/Performing): Group members experiment with new ideas, behaviors or ways of thinking. Egalitarianism develops.

• Stage Five (Adjourning/Terminating): The group disbands.

Causes of negative effects of group psychotherapy

• Negative effects may be due to techniques, client variables, therapist variables, or some combination of these.

The negative effects of group psychotherapy

• Acquiring new symptoms• Worsening of symptoms (3-10%) and

regression• Depdendence• False memories• Superficial insight (acquiring empty language)

Adverse Outcomes in Group Therapy

• Although much of the literature on adverse outcomes in group therapy focuses on single risk factors (e.g., negative leader, group process, or patient characteristics).

Reactions

• Remain alert to ways in which your personal reactions might inhibit the group process, and monitor your countertransference.

• Avoid using the group as a place where you work through your personal problems.

Countertransference

• Therapist negative countertransference (e.g., direct expressions of hostility, lack of respect, and sexual acting out) is associated with harmful consequences for group members.

• Therapist personality maladjustment is another major factor associated with harmful outcomes.

“Side effects” of group psychotherapy are unpredictable

• In group psychotherapy, you never know what to expect.

• Any behaviour modification technique can be misused or misapplied.

• "positive thinking" can actually have a negative impact on the mental health of some people (and this has been known for years in regard to trauma counselling and sexual assault counselling).

Limitations/dangers of co-therapists

• If two leaders do not get along, it can be detrimental and even harmful to group

• Co-leaders might develop competition between themselves and this too is not good for the group

• If co-leaders have different skill levels, one might try to lead the other. This can lead to coalitions with other group members or even in the marginalization of the more inexperienced leader

• Group members might feel unwell if both leaders become adamant in getting across a therapeutic message

The negative effects of group psychotherapy

• The clients will go through a period of feeling worse as their old habits of coping are replaced with new strategies and ways of thinking.

• This process can temporarily highten anxiety and insecurity and negative thoughts, feelings of helplessness, hopelessness etc.

Indicators of Potential Deterioration

• The five indicators for “potential deterioration,” as a result of interaction between therapeutic techniques, psychotherapists, and clients include,

(a) the role of anticipation of emotional pain and therapeutically induced arousal

(b) client suspiciousness toward the therapist and therapist empathy

(c) level of interpersonal functioning and the focus of treatment (d) diagnosis and treatment modality (e) relaxation therapy and clients’ need for control

Termination

• Over 4-6 monthly sessions• Review patient success• Discuss potential vulnerabilities

– Identify strategies for management of interpersonal difficulties and symptom relapses

• Encouragement about ability to use strategies independently

Group Therapy

Advantages of Groups

• It provides a social atmosphere that is similar to the real world.

• Members can test and practice new interpersonal skills.

• They are cost effective.

• Groups help members see that they are not the only one who has that particular problem or issue.

• Members receive feedback/support/challenge that encourage or facilitate change

• Groups provide members with support.

“Copyright © Allyn & Bacon 2004”

Group Therapy

Disadvantages of Groups

• Less individualized attention from the therapist.

• Confidentiality is more difficult to maintain.

• Not enough time to deal with each person thoroughly

• Not everyone can be in a group (e.g. those with issues too severe or those with poor interpersonal skills.)

• Scapegoating may occur.

• Group leaders are not always properly trained.

“Copyright © Allyn & Bacon 2004”

Concerns in Group Work

• Group Size: Varies from 3-4 members to several hundred depending upon the group (e.g. psychotherapeutic or task group). Group counseling and psychotherapy generally work best with 6-8 members.

• Participant Selection: Screening is needed with counseling and psychotherapy groups. Some people are not well suited for group work.

“Copyright © Allyn & Bacon 2004”

Concerns in Group Work (continued)

• Length and Duration of Sessions: Individual sessions are usually 50 minutes, group sessions range from 1-2 hours. Session duration can be only once or in some cases might last for years (e.g. open-ended psychotherapy group).

• Ethics: Confidentiality is hard to guarantee due to the number of participants.

• Group Evaluation: Outcome measurements are difficult to obtain.

“Copyright © Allyn & Bacon 2004”

Paradoxal findings: Psychotherapy diminishes side effects

• A number of the studies found associated paradoxically psychotherapy to the reduction of side effects of other treatments.

• This indicates that psychotherapy in general is balancing the patient and helping the patient with physical, mental, existential and sexual problems.

Ethical Issues in Group Counseling

and psychotherapy

ACA Code of Ethics, 2005

• A.8. Group WorkA.8.a. Screening

Counselors screen prospective group counseling/therapy participants. To the extent possible, counselors select members whose needs and goals are compatible with goals of the group.

ACA Code of Ethics, 2005 (cont.)

• A.8.b. Protecting ClientsIn a group setting, counselors take reasonable

precautions to protect clients from physical, emotional, or psychological trauma.

Informed Consent• To encourage open and active participation from

group members, it is the therapist’s responsibility to explain the client’s rights.

Before∞Purpose∞Format, procedures and ground rules∞Group appropriate for client’s needs∞Limits of confidentiality∞The group process may or may not be congruent with the cultural beliefs and

values of the group member

Informed Consent (cont.)

During∞Right to leave the group if it isn’t what they expected or

wanted∞Any research involved∞If the sessions are taped∞Freedom from group pressure∞Expectations

Rights

• Ethically, the therapist should inform clients of their rights and responsibilities and inform them of any possible consequences they may face if they elect not to follow treatment.

Researchs must consider better understand and reduce iatrogenic effects in the psychosocial therapies, as is being done for pharmacological treatments.

Take Home Massage