The Challenge for Group Psychotherapy

Types of Group Psychotherapy and Their Clinical Applications, Part 1

Both theory and practice support the principle that the effectiveness of psychotherapy is conditioned by its suitability to the nosological considerations and to the specific etiological and psychodynamic factors presented by the particular patient. Blanket use of any technique with patients for whom it may not be suitable can only result in failure to them and frustration to the therapist. To illustrate this principle we can classify patients into the three major generic categories—psychoneuroses, character disorders, and psychoses (which can be viewed as a special genre of character or ego disorder). Each requires its own type of therapy.

In his experience, the author has found that in cases of full-blown classical psychoneuroses—where the transference neurosis generated in psychoanalytic treatment is the central armamentarium—are not accessible by groups. Due to the divided or multitransferential phenomenon, only a limited degree of libidinal transference toward the therapist can be achieved in a group, not sufficient to unravel or dissolve the virulent oedipal and incestuous strivings with which such patients come for treatment. In addition, the very dynamics of group interaction militates against it. The therapist’s unavoidable divided attention and the interruptions of the communications by fellow group members prevent regressive catharsis in anyone of them. This blocks the dissolution of the psychoneurotic syndrome. Further, in the process of treatment of a true psychoneurosis, the transferential target (the therapist) must feed the regression by remaining passive and almost nonresponsive. This cannot occur in groups, for even if the therapist does play out this role suitably, other patients and at times the group as a whole react to the communicant. When this occurs, catharsis and regression are interrupted, hindering further the regressive process and frustrating the patient.

All the types of psychotherapies, reports on which appear in this section, are fundamentally based on the foundations of Freudian psychology (not his technique). We accept Freud’s formulations of the unconscious, infantile sexuality, the oedipal phenomena, his topological formulations of the id, ego, and superego. But because the type of patient we currently encounter in modern society, especially in the United States with its changed character due to the altered roles of the father and mother and its culture of greater permissiveness to instinctual realization, we were constrained to alter therapeutic procedures. Otherwise, we would have found ourselves ineffective.

The original project in intensive treatment in small groups in what came to be known as “group therapy” and later “group psychotherapy,” was initiated in 1934 by the present writer at the Jewish Board of Guardians, a leading community child-guidance clinic. Initially this work
was begun with girls and boys in latency years with primary behavior disorders. This modest project soon spread to include patients of all ages and clinical categories. In the more than thirty-six years that followed, we have initiated and tested a number of variations of the original idea with more than 4,000 patients. The need for these variations was pressed upon us by our pragmatic discovery that some patients did not respond to the original technique (activity group therapy). We have, therefore, modified settings and practices, some of which had to be discarded, while others proved effective with specific types of patients. These tests and studies have resulted in a number of specific methods that take into account the age of patients, clinical considerations, and the “depth” of the treatment most suitable for each patient.

The list of the group treatment techniques evolved are:

  • For adults and adolescents—counseling, guidance, analytic psychotherapy, para-analytic psychotherapy, psychonursing, child-centered group guidance of parents, coordinated “family therapy,” and vita-erg therapy (for hospitalized psychotic patients).
  • For children—activity group therapy, activity-interview therapy, play therapy, and transitional groups.

    Before we describe these various types of group psychotherapy to meet individual needs of patients for age, sex, life-roles, and clinical entities, we must point up the differentials in psychotherapeutic armamentaria employed in contemporary practice.

    In order to differentiate the “depth” of the therapeutic effort as indicated by a specific patient’s needs, we need to outline three distinct levels commonly used exclusively or at times contemporaneously as the flow of therapeutic content indicates. These three levels we have labeled as counseling, guidance, and psychotherapy.

    Counseling and Guidance
    The terms “counseling” and “guidance” are applied to individual or group experiences where the presenting difficulties are those of social adjustment; their solution, therefore, lies in cognitive areas and purposeful effort, as differentiated from intrapsychic problems and conflicts requiring basic resolution and personality reconstruction. In the former only superficial layers of the personality are involved and situational stresses with which an individual may not be able to cope by himself form the focus of attention. In these practices, one deals with people with difficulties who cannot (or need not) work toward radical inner change. Frequently such work is erroneously referred to as psychotherapy, when it is really guidance or counseling.

    Counseling. A counselor may or may not be a trained psychotherapist. He helps the counselee either to arrive at or to accept a solution of the difficulty that worries him. This can be achieved by explanation (as differentiated from insight) or advice. The counselor is an active agent, although he usually follows the rule of all good teaching that the learner (in this case, the counselee) should arrive as far as possible at conclusions by himself.

    This process can occur either in a one-to-one or group setting, but the counselor must be aware of the fact that group counseling is by far more difficult and sometimes even impossible. This is due to the fact that in counseling problems that concern specific individuals must be discussed, for it would be difficult to find a number of individuals with exactly identical problems, except, of course, in such cases as marital or premarital disharmony, family life, parents of children with special handicaps or illnesses, problems of normal adolescent adjustment, some type of delinquents, etc.

    Guidance. In guidance, on the other hand, pragmatic problems and their solutions are considered and, to a limited extent (and perhaps superficially), attitudes and feelings are exposed for consideration. But the underlying unconscious motivations and their sources are not brought to the surface as they are in psychotherapy. What determines the choice between counseling and guidance is the intensity of the affect involved, the chronicity of the problem, and the elements in the syndrome. Some problems of individuals arise from sources beyond ego functioning; they involve strong feelings that are elaborated in the psyche. Problems with one’s landlord, for example, can be resolved by counseling, but counseling can hardly be effective in resolving disharmony between marital partners. The emotional charge in the two relations is vastly different and requires different treatment. It is obvious that guidance is a much longer, as well as a deeper, process than is counseling.

    Groups help and accelerate the guidance process, especially where the problems of the members of the group are similar or identical, for during the intellectual and emotional interaction, the group participants activate (catalyze) one another’s communications; they also serve as models for each other. Another element is that of universalization, namely, the discovery that others are in the same difficulties, which reduces the stigma of uniqueness and feelings of worthlessness and guilt in each.

    A counselor need not be clinically trained, but the involvements inherent in guidance require that the leader be a professionally trained person with experience in psychotherapy. There is an obvious similarity between psychotherapy and guidance, though there is a vast difference in intensity and depth between the two practices.

    Unlike counseling and guidance, which aim to resolve more-or-less transitory problems that disturb an individual, psychotherapy is committed to resolve inner malformation of the personality from which his maladjustments flow. Its basic aim is to reweight the psychic forces that operate in the individual largely by regression to earlier stages of development thereby bringing to light the traumatic events in the patient’s life and by vicariously reliving them in the light of more mature insights and more realistic emotions. The importance of this process is that it releases the bound up anxiety, guilt, and hostility that obsess the individual and impel him to seek treatment in the first place. The repressed feelings and confusions generated by early traumata manifest themselves in a variety of symptoms in later life which psychotherapy aims to eradicate.

    The repressed memories and feelings are reawakened by regressive free association which is guardedly prevented in counseling and guidance, since the tensions it generates cannot be worked through in those settings. Free association unavoidably awakens the pains and sufferings experienced in the past, and the ego defenses, which are left untouched or little affected in counseling and guidance, are assailed in psychotherapy, which is the chief source of resistances. The task of psychoanalytic psychotherapy in particular is, therefore, the analysis of these resistances with consequent anxiety, guilt, and hostility. Since the real personality of the patient is brought into the open, the psychotherapist encourages their reappearance and employs them as grist in the therapeutic process.

    The course of therapy is fraught with much ambivalence and resistance; it oscillates between positive and negative transference feelings, communication and silence, confidence and distrust, frankness, deceit, and avoidance. All these have to be worked through as products of conscious and unconscious needs and causes. The patients pass through mood swings between elation and depression, submission, hostility, aggression, expansiveness and diffidence. These need to be observed and their meanings understood. All this takes a very long time, much longer than does guidance and even more so that counseling. Much of the time is consumed in evolving a positive transference, so that patients will grow secure enough to reveal themselves. This relation is strangely tinged with sexual libido. The therapist is invested with strong libidinal significance and may become the patient’s sexual object or aim. While the degree of regression to the preoedipal and pregenital stages is at its height in true psychoanalysis, the patients’ attitudes, in all real psychotherapy, are colored by these irrational, infantile strivings [Slavson, 1964, pp. 108-109].

    In the last three decades psychoanalysis has been modified to include a small number of preselected patients who can be treated simultaneously in small groups. Many interpersonal dynamics and personal reactions inherent in all small groups of humans appear also in therapy groups or are modified, while some are unique to therapeutic groups, as shown in the following table.

    Table 1
    Nontherapy Therapy
    Interaction Interaction
    Interstimulation Interstimulation
    Intensification Intensification
    Induction Induction
    Neutralization Neutralization
    Total compromise Partial resolution of conflict
    Identification Indentification
    Assimilation None
    Integration None or partial
    Motivations Motivations
    Collection Impulse Recovery
    Cohesion None
    Synergy Individuation

    The differences in the developmental and educational influences of nontherapeutic groups as differentiated from the effect of therapeutic groups appear in Table 2.

    Table 2
    Nontherapy Groups Therapy Groups
    Expansive Constrictive Expansive Constrictive
    Self-Expression Group-induced anxiety Status Cohesion
    Creative effort Interindividual threats Acceptance Homoeroticism
    Social intercourse Antipathies Freedom  
    Suppression Rivalries Security  
    Sublimation Antagonisms Restitution  
    Identification Restrictive behavior Knowable character of group  
    Allotropism Ego-functioning of others    
    Transition to social participation Reduction of ego-controls    
    Transition from family to ethos Reduction of superego controls    
    Enhancement of self-esteem Reinforcement of the id    
    Development of responsibility Defense against narcissistic injury    

    Differential Characteristics of Groups
    The characteristics of groups as differentiated from large assemblies of people are that (1) to insure significant interpersonal interactions they are small in number—a maximum of eight in the case of therapy groups; (2) all groups must have a leader; (3) ordinary groups have a common purpose, while members of therapy groups have individual aims though a similar purpose, namely, recovery, but the purpose is not a common one; (4) in all group activities the members are in dynamic interaction; and (5) all groups aid personality growth and affect character development. The special characteristic of groups as differentiated from crowds, assemblies, audiences, congregations, mobs, masses of people, is that each member of a group is in some kind of interaction with each of the others as well as with the network of their relations—that is, the individual is aware of and has feelings or reactions to the relations that exist among the members of the group. The simplest example of this is a family (which is a group of maximum intensity), where the father and mother react to each other’s relation with their children (as well as symbiotically) and the children in turn react to their relation as well as to the relation of each sibling and to each of the parents.

    The difference between therapy groups and other types of groupings in modern society lies in the fact that there is present In the former an element which we have characterized as commonality of problems. While the aim of a therapy group is not common, for it is individual recovery from illness that each member seeks, ideally the problems which the participants bring to the group should have common elements, nonetheless. This would create a climate of empathy and identification, so that the patients can be of most help to each other in their quest for health. In the absence of this factor, psychotherapy in a group can become individual treatment in the presence of the other members. However, the two common problems that inevitably disturb patients and invariably appear in the group interviews are feelings about parents and siblings and the area of sex.

    Perhaps the most important difference between ordinary and psychotherapeutic groups is the element of synergy. Synergy is the confluence of energies and effort in a number of persons for the achievement of a common aim or purpose dominant in the cathexis of the participants. It is essential that this phenomenon be prevented, for in synergy the individuality of each participant is to varying degrees submerged in the group. That is, each gives up at least partially the hegemony of his ego and superego, the integrity of which is essential in the therapeutic process and must be maintained. This is fed by each patient’s conflicts, values, and hostilities, which are transmuted into positive, negative, and ambivalent transference relations among the patients and toward the therapist. While groups generally are held together by a personal and social homogeneity and common aims, in therapeutic groups the members are held together by anxiety.

    Our operational structure of true psychotherapy (as differentiated from counseling and guidance and other means of “helping” people with their difficulties), rests on the specific use of the dynamics of transference, catharsis insight, reality testing, and sublimation. This difference is listed in Table 3 below.

    Table 3
    Dynamics Counseling Guidance Analytic Psychotherapy Para-analytic Psychotherapy
    Transference Slight positive Moderate positive Intense Intense
    Catharsis None Moderate associative Free association Associative and free association
    Insight None Slight Deep Moderate
    Reality testing Present Present Present Present
    Sublimation None Possible Present Present

    Anonymity. To maintain a therapeutically effective type and level of transferential relations among the patients in an analytic group, it is necessary that the patients refrain from personal and, if possible, also social contact outside the group sessions. Extragroup relations cannot but affect the impact of the personalities involved during the interviews, when there needs to be free-wheeling expression of hostility and resentment and unimpeded discharge of other types of feelings toward each other. Extragroup intimacy gives rise to friendships in some and sibling hostilities in others, which may deter frankness in reactions and criticism. Such friendships will prevent some patients from exposing each other in a negative light thereby vitiating the value of free-associative catharsis. During treatment, patients should maintain emotional distance from one another, except as feelings are engendered in the therapeutic interaction, positive or negative, which are viewed as transferential phenomena and are explored and analyzed. Such feelings most often are the keys to earlier traumatic relationships from which patients’ personalities and adjustment difficulties have arisen. As such, they are helpful, in fact essential, in analytic psychotherapy, while relationships acquired or carried on between sessions are prejudicial to sound psychotherapy.

    Sexual Acting Out. In heterosexual groups, one of the possible outcomes of extragroup contacts, which frequently occurs among patients, is sexual acting out (which cannot be ruled out in unisexual groups as well), which may present the psychotherapist and the group with an insoluble, and certainly very difficult situation, that may disrupt the group.

    It is expected that extragroup homo- or heterosexual acting out with fellow patients (as well as with other persons) is communicated to the group during its interview. However, this frankness occurs in practice only after a considerable period and the revelations prove shocking to some, arousing jealousy and resentment in others, and violent hostility in still others. It opens a Pandora’s box of difficulties for the therapist and group.

    It is obvious from the aforesaid that anonymity is an important consideration in selection of patients for a group, in grouping them, and in conducting a therapy group.

    The “Closed System.” Therapy groups operate on the principle of a “closed system,” that is, a complex of forces that sustains itself and by its nature allows little or no intrusion of outside forces. Ordinary groups, such as educational, recreational, social, political, or special-interest groups, operate on an “open system” plan. That is, they maintain contact and draw upon outside interests and resources rather than remaining self-contained. This is not the case with therapy groups. The very nature and purpose of a psychotherapy group sets it off from the life-stream around it. The emotional charge, in its intensity, does not permit intrusion from the outside or any diversional influences, interests, and activities that do not proceed from the ongoing therapeutic process of the group.

    The closed system principle must be guarded in true therapy groups if successful results are to be achieved. Too-frequent introduction of alien influences that do not arise out of the emotional vortex in the group, both from individuals and their interactions, will decelerate the ongoing process of therapy. They cool off feelings and divert the free-associative process that results from interstimulation and interaction of patients and from the introspective cogitation, which are the chief instrumentalities of psychotherapy. Betlheim suggested the analog of this phenomenon by comparing it to a kettle of boiling water: when cold water is added to a boiling kettle, it at once stops boiling. This principle applies to the interviews of a therapy group, for the patients gain most out of the therapeutic experience when they “boil,” as it were, and anything that would lower the emotional temperature should be avoided.

    Relative to adding new patients to an ongoing analytic therapy group, it may be said that such additions may not be a serious handicap in the earlier stages of a group’s life. However, added patients who are therapeutically on par with a group’s members in its advanced stages always presents a shock to the group, but in some instances this handicap can be overcome as the newcomer is therapeutically on par with the group and can be “assimilated” into it.

    More from this title coming soon!