Examining Theories And Processes In Group Therapy Nursing Essay

Human beings live in groups. Family is the first and most powerful group association humans are born into. All members of one’s family are interwoven and as each person’s behavior affects others within it, a person begins to see himself or herself as directly influenced by the relationship he or she may have with the other family members. Human beings relate to others through perception and develop understanding of others subjectively. This is in different manner than how a person sees himself or herself. Families, although genetically connected are not all alike, and much like a group, run through a structure and hierarchy. Like families, “a therapeutic group is not about conforming, being all alike . . . it is however, about symmetry, everyone being equally important” (Foulkes, 1948, Chazan, 2001, p.10). The purpose of this paper is to develop a deeper understanding and appreciation of group therapy and processes.

History of Group Therapy

Group processes in relation to group therapy refers to how members and leaders react to each other, as well as reactions to

An alternative to individual therapy, group therapy presents a viable option for people to develop personal understanding or enhance relationships and interactions with others. Depending of the focus of the group it can afford the members a chance to identify and change behaviors, learn new skills, and more effective way to deal with stress and personal struggle. A group is made up of not only the members but also the “therapist whose principle function is to create a positive and safe group culture in which therapeutic experiences can take place” (MacKenzie, 2002, p.891).Groups also offer a supportive learning environment that can teach members more effective ways to interact with others. There are as many different types of group therapy as there are issues that need to be addressed, as group make up can vary by participant or by reason.

“Group psychotherapy is the treatment of psychological, behavioral, emotional and interpersonal problems in a group context” (IEBS, 2008, p.6426). Irvin Yalom (2005) refers to this process as interpersonal learning, and in Yalom’s view this is the cornerstone of group therapy simply because a person can see him or herself and how he or she is perceived by others through the group. This method naturally provides the client an opportunity to gain and build new skills, try them out within the safety of the group and in turn, internalize those skills to be used successfully in interactions with other relationships outside of the group.

Group therapy began as a didactic technique and has been developed to include contemporary psychoanalytic, behavioral, cognitive-behavioral psychodrama, and system theories. Although these techniques are different, the process goal is the same; to impact a sense of hope to the client, encourage social learning, and promote self disclosure, self expression and personal insight.

Defining Group

Groups become an entity when group members connect. The general system theory and understanding of groups is that as an entity, they are in totality the product of interactions between the members. The dynamics within a group can vary based on the individual group members and the focus of the group. As part of the system, members fulfill a function through participation. This takes place in the form of observing others, developing a desire to understand conflict that may arise and solve it, as well as the reciprocity of giving to the group and receiving from it. As a group member differentiates him self or herself while taking care of personal needs while integrating and doing things with other members of the group.

Groups can encompass any number of daily activities whether personal or business, and can even include inpatient treatment and substance abuse recovery. There are different therapeutic principles that psychotherapeutic groups can use: transactional analysis, reality therapy, Alderian, person centered, existential, Gestalt and psychodrama to name a few. Groups can also be used to address issues across the lifespan, with distinction by stages of development: Child, adolescent, adult, and older adult to address issues that one encounters through life. Regardless of the focus or purpose an integration of theories and philosophies can be utilized to increase the therapeutic effectiveness of the group.

Socio-metric choice is a process that happens within the group (Hogg, 1992) and develops through the patterns of member behavior. Member’s choices of preferences between individuals can influence how people within the group choose to conform to the group’s structure (in-group) or break into subgroups (out-group).

Governed by the same legal and ethical considerations as individual therapy, but by the nature and complexity of the group, the group leader must uphold the highest ethical behaviors and expectations. The group therapist is responsible for group diversity and understanding how the member’s similarities and differences will affect the group process. He or she is also responsible to be sure to obtain the credentialing and training as defined by the American Group Psychotherapy Association (APGA) that establishes standards for professional and ethical practice guidelines fostering diversity and competence. (ASWG.org)

Group Development

Preparation is “the work of the group begins long before the first meeting” (Yalom 2005 p.291) and a group’s success will depend on the therapists planning and development of the group. The preparation process includes the development of focus, rules, expectations, duration, norms and process. Consideration of insurance providers’ expectations and guidelines for treatment and establishing a good working relationship provides the best quality of services for the client and include:

Focus in treatment: By setting the leader is responsible for setting effective goals and emphasizing that changes are part of treatment and that the treatment is focused to address the issues.

Engagement: The leader is to facilitate interactions between group members to establish commitment to the group and allow members to feel heard, understood and accepted.

Conflict: The leader explains to group members that understandingengagement and conflict provide experiences required to develop commitment to the group.

Interpersonal work occurs through members feeling safe and supported [and this] can lead to disclosure, personal catharsis and feedback from the group.

Termination: The final step provides opportunities for members to assume responsibility for one-self.

MacKenzie, 2002, p.895-900

Theoretical Orientations

Group psychotherapy is currently used to treat an array of problems including depression, eating disorders and addiction to name just a few. Group processes can also be used for a work group, or contain a psycho-educational component like teaching parenting skills or a behavioral modification. There are as many different types of groups as there are issues to be addressed. “That which patients experience as curative may differ by theoretical orientation of the treatment and whether the treatment is a group . . . who is being treated and the setting of the treatment” (Johansson, Andrzej, 2009, p.122).

Psychoanalytic group-therapy is based in the work of Sigmund Freud. The analyst uses the traditional analytic methods of free association, interpretation and transference processes to learn about the client’s irresolute issues and conflicts. Psychoanalytic group therapy can help the client deal with issues of authority through the relationship formed with the group leader. Concerns about personal relationship and affection can be worked through the client’s relationships with the other groups’ members. By working in such a way that the client gains insight, transference to a cathartic release can take place so the client can let go of his or her unresolved anxieties.

Phenomenological therapy includes the practice of Gestalt, psychodrama and person- centered therapies. Where some therapeutic milieus seek to fix the client, phenomenological theories strive to see the client as an individual who has his or her own understanding of the world and through the work finds the potential he or she is capable of (Yalom, 2005).

Cognitive-Behavioral therapeutic groups are not concerned with the cause of the client’s problems or issues, but look at them through the lens of learning theory. Once identified, the therapist will work with the client “through cognitive restructuring, self-instructional training, and problem solving instruction” (IEBS, 2008, 6427). Members can be given homewoirk assignments which offer both the experience of a supported learning opportunity in the group and a second opportunity for learning when the results of the homework as reported back to the group.

Psycho-educational groups can focus on any number of activities. Originally developed for use in educational settings and for teaching academic skills the group can have needs that vary based on the group members, but all participants usually need to focus on the same concerns or share the same diagnosis. A psycho-educational group can help clients understand the diagnosis that he or she may have and work within the group to find ways to cope with it. The purpose of a psychoeducational group is to focus on learning as directed by the group leader. Groups of this type can also focus on topics like parenting, substance abuse or learning how to become part of a community. The goal of the group is to “prevent future development of [the] debilitating dysfunctions while strengthening coping skills and self esteem” (Coyne, 1999, p.157, Gladding, 2008, p, 28).

Interpersonal psychotherapeutic groups focus on member interaction. A member will relate to others within the group as he or she will relate to other people in his or her life. The group can provide insight to the member through feedback. Interpersonal learning takes place as the therapist models the behaviors that he or she wants the client to learn. Feedback from the therapist and in such, the group members provide reassurance and reinforcement. This is the basis of social learning as define by Irvin Yalom (1995). This process known as a curative power takes place as the members share and experience the process of sharing information.

Trauma Work

Groups can be designed to focus specifically on trauma. These types of groups can exist to deal with individual trauma (like rape or abuse) or groups of people who have experiences related to natural disasters or war. The therapist is charged iwth the responsibility to amke the group a place of safety to offer a client an opportunity to rebuild his or her confidence and learning that he or she still has the ability to garner faith in others.

As a group process may include reenactment of the incident, a leader should be aware of the many ways the group can change and how members may react as some members may provide a positive experience and identify with the survivor, while others may criticize him or her laying blame for lack of awareness or preparation. At the same time, other members can just remain quiet and passive.

Trauma survivors develop the ability to read a person’s facial cues, unspoken communication as well as body language. Members can react to these unspoken forms of communication to the leader or other members. This transference reaction can disrupt the group as the initial trauma is the driving force behind it, as the member is responding to perceived threats colored by the experience in his or her past. “Hypervigilance [can] lead to distortion, because [the member] responds to the uncon scious motives as if they were really acted out” (Weinberg, Nuttman & Gilmore, 2005, p.196).

The clinician also needs to take into account the importance of self care as working with trauma survivors may result in vicarious trauma for the therapist because he or she is exposed to recounts of abuse or violence as a group member recounts his or her experience. Since group members need to experience interactions with the leader as supportive, empathetic and accepting, the therapist needs to practice good self care strategies when working with clients who have experienced most forms of trauma.

A phenomenon called vicarious traumatization can result when a theapist is impacted by the experiences of the client (s) and should address these issues with therapist support groups, stress management techniques and supervision. Vicarious trauma is different from counter transferrence “in that it describes the impact on the therapist of vicariously experiencing many instances of trauma rather than specific countertransference reaction to a specific [client] (Weinberg, Nuttman & Gilmore, 2005, p.199).

Confidentiality

Ethical principles on confidentiality dictate that any information that the client shares with the therapist is not shared with others. The only instance when that does not apple is when there is an issue around the responsibility regarding duty to warn or protect or abuse, homicidal or suicidal plans or behavior. Group work presents a whole series of challenges based on the fact information once shared is disclosed to the whole group. “In groups . . . maintenance of trust is more complicated because many people have to be relied upon for keeping confidences” (Brandler, Roman, 1999, p.278). Once confidentiality is compromised, it may be impossible for the group to move past it returning to a point of safety and trust. The group leader must be clear on expectations his or her expectations of group members so it is understood from the very first meeting the importance of keeping identities and information shared private and the consequences that may have to be applied in the event of a breech.

Issues that may surface regarding a breech of confidentiality and resolutions may include a meeting between the offending member and the group leader as well as the opportunity to meet with the group. “Violations …should be processed within the group to rebuild trust and deter further violations” (Brabender, Fallon, Smolar (2004, p.184). Members should be given the chance to share feelings, and be part of the development of an action plan to address the understanding and importance of confidentiality.

Self disclosure

At one time or another, group leaders will be confronted with the opportunity to disclose personal information. There seems to be as many reasons to disclose as there are reasons not to.

Disclosure, if done correctly can bring the group closer together, generating acceptance and understanding. There is as much information available that states that clients need to know that a leader is empathatic and understands what he or she has gone through, and for those members, disclosure is helpful. Others within the group may feel that personal disclosure by the group leader bring with them issues around intimacy, and some clients may not be comfortable with it. Other reasons include presenting the group leader as falliable, and therefore judgment concerning the group can be questioned. The American Group Psychotherapy Association (AGPA) has this statement regarding self disclosure: “The judicious use of self disclosure can have substantial therapeutic impact” ( 2007 apga.org). It is important that any self disclosure by the group leader is done in a way that benefits the members, and is not done due to the therapists transference or for any other reason.

Core Competencies in Group Work

The Association for Specialists in Group Work ASGW) has a set of core competencies criteria of minimum competencies for group leaders, as well as a tool for self evaluation and standards of practice. Competencies and core training include:

Nature and Scope of Practice: Knowledge and skill development

Assessment of group members: Social systems in which clients live and work

Planning Group Interventions: Impact of group diversity, planning consultation

Implementation of group interventions: Principles of group formation, leadership

functions and group dynamics

Leadership and Co-Leadership: Leadership styles, group methods, co-leadership

Evaluation: Methods for evaluating group process, self-evaluation

(ASGW.org)

As with any leadership role, group leaders are expected to be able to effectively direct the group so it stays on task, allow all members time to express concerns open and close the group , and be empathetic and caring of all members.

There are considerations regarding Ethical Practice, Best Practice, and Diversity Practice guidelines and ethical considerations that are unique to group work. Failure to obtain the proper training and creditialing can put the clinician at risk for any number of ethics violations. A leader must be familiar with the process and materials of the groups that he or she is leading. Jacobs, Masson & Harvill (2009) posit the following as qualities of effective leadership. Leaders should have the following competencies:

Experience with individuals

Experience with groups

Planning and orgizational skills

Knowledge of the topic [that is the focus of the group]

A good understanding of basic human conflicts and dilemmas

A good understanding of counseling theory

(p. 25-27)

A clinician who chooses to develop or lead a group needs to be sure that he or she has been trained in leading groups. Failure to obtain the proper creditentialing can put the clinician at rsik for ethical violations. A leader must be familiar with the process and materials of the groups that he or she is leading.

Dual relationships and considerations

Dual relationships especially in rural communities at times cannot be avoided and must be monitored to be sure that the relationship outside of the group does not negatively impact the therapeutic impact within the group.

The authors define similarities and differences in how humans develop morals, values and virtue. Although interconnecting when looking at ethical judgment, each interaction is affected by how the people involved view the world. Within the context of treatment, and use of theory, the therapist should take into account a client’s culture and experiences and plan accordingly.

Counseling is a complex profession. Being aware of the existence for potential ethical issues and finding timely and appropriate resolution if one should surface is the responsibility of the counselor. As every counselor is different, personal value judgments cannot provide answers. Ethics codes are not just a guideline to behave in a certain way, but a tool on which to base responsible interactions that provide a consistent framework and process in which to address issues.

In Chapter one of The theory and practice of group psychotherapy Yalom & Leszcs (2005) ask the question does group therapy help clients? His answer to the question lies in therapeutic experiences realted to eleven primary factors that can result in therapeutic change. Dscribed as a complex process they are:

Instillation of hope

Universality

Imparting information

Altruism

The corrective recapituation of the promary family group

Development of socializing techniques

Imitative behavior

Cohesiveness

Existential factors

Catharsis

Interpersonal learning input

Interpersonal learning output

Self-understanding (p.1-2)