creating and maintaining a psychotherapeutic group

8/12/2019 Creating and Maintaining a Psychotherapeutic Group

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College Psychology:

Creating and Maintaining a Psychotherapeutic Group

Introduction: Group Psychotherapy Cannot Be Underestimated

There is no way to underestimate the value of group psychotherapy. In the past five years,

there has been a resurgence of interest in tackling trauma using psychotherapeutic groups.

At the same time, recent studies show that up to 40-60 percent of mental health patients

have histories of trauma. Thus, understanding and successfully treating trauma is

significant in the treatment of many serious mental disturbances such as posttraumatic

stress disorder, depression, substance abuse and severe personality disorders.

This is not to say that all people who decide to work their personal issues within the

context of a psychotherapeutic group are severely or even mildly mentally ill.

Psychotherapeutic group work, at its crux, is all about building trust in other human beings

and about building positive and healthy relationships. This is why group therapy works

well for trauma survivors, at the same time that it also works for less disturbed people who

are looking for ways to deepen and enrich their interpersonal relationships. Restoring trust

is an issue clearly at the heart of successful long-term treatment for trauma. People with

histories of trauma do not only suffer from disturbing and intrusive symptomssuch as

panic attacks and phobiasbut experience significant erosion of trust in significant others.

Sometimes, they even lose trust in life itself: They come to see the world as a dangerous

place where their very survival is threatened.

The Therapists Main Tasks in Group Therapy


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The main challenge, then for the therapist is to establish a group and fashion in it a healing

culture where the members can feel safe, risk exposure, restore their senses of self worth

and feel connected to others. (Schulte, 2001) These tasks involve first, creating the group,

and second, establishing and nurturing this healing and healthy culture. (Schulte)

The group therapist's job thus is to create the machinery of therapy, to set it in motion, and

to keep it operating at its most optimal. (Yalom & Leszc, 2005, p. 117)

Creating the Therapy Group

The first task is only deceptively simple. In reality, creating the psychotherapy group and

ensuring its survival for the first critical months is a difficult task that requires the

therapist to stretch himself/herself and to resort to an array of skills to help establish

trustand even to reestablish it in group members who have been traumatized in the past.

(Schulte)

The first crucial step is to exercise careful judgment in selecting and composing groups.

After this, the therapist must establish a clear group structure and contract. He or she must

pay close attention to personal psychological boundaries and boundary violations. At this

critical junction in the life of the group, it is important for the therapist to present

himself/herself as a steady, reliable and accepting role model who is open and willing to

examine patients painful narcissistic wounds and failures of attunement in the group

process. (Schulte)

Indeed, the therapist should stand as group leader, and his expertise in selecting and

preparing members will greatly influence the group's fate. After selection of members, the


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urgent task is to create a cohesive group. This task is so important, that at the initial stages

of group forming, the physical survival of the group must take precedence over other tasks.

(Yalom &Leszc, p.120)

At the start, group forming includes setting the time and place of the meetings. It also

involves gatekeeping. The serious group therapist should take pains to prevent members

from dropping out of the group, as any client who drops out early in the course should be

considered a therapeutic failure: Not only did this person fail to receive therapy, but the

progress of those who remain in the group is also affected. When dropouts do occur, the

therapist should add new members to maintain the group at its ideal size. (Yalom &Leszc,

p. 118)

However, the more important work of keeping the group together involves setting the

tone of future meetings. Since clients are all strangers to one another and only know the

therapist, it is an urgent role of the therapist early in the group to set the stage for eventual

group cohesion. Group therapists are also called on to recognize and deter any force that

threatens group cohesiveness, such as continued tardiness, absences, sub grouping,

disruptive extragroup socialization and scapegoating. (Yalom &Leszc, p. 118)

Creating a Healing Culture

As soon as the group is a physical reality, the therapist must direct his energy toward

shaping it into a therapeutic social system. This means that, early on, an unwritten code of

behavioral rules or norms must be established that will guide the interaction of the group

and ensure that it is a healthy and productive therapeutic group. (Yalom &Leszc, p.120)


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It can never be taken for granted that a therapeutic group will naturally evolve norms that

will facilitate the therapeutic process. In fact, studies and observation of therapy groups

reveal that many of these are throttled by crippling and unhealthy norms. (Yalom &Leszc,

p.122)

In addition, just what are the desirable norms that are good for a therapeutic group? These

are: (1) acceptance and support, (2) universality, (3) advice, (4) interpersonal learning, (5)

altruism and, (6) hope (Yalom &Leszc, p.120).

One of the things that should be instilled in the group, early in its life, is the belief of its

members that the group itselfand not the therapistis the agent of change. Here lies the

basic difference in the roles of individual therapist and leader of group therapy:

Therapeutic groups themselves should set into motion the therapeutic factors. (Yalom

&Leszc, p.120).

Naturally, creating the right norms to make for fruitful therapy can only be done when the

therapist himself/herself is consistent and has a positive relationship with all his/her

client. Concern, acceptance, genuineness and empathy should be the basic posture of the

therapist to all his/her clients. Nothing no technical consideration, credential, education

or skillcan take precedence over this. Surely, in time, the therapist will have to challenge

members of the group, show frustration and even anger, but the underlying attitude

toward all of them should be concern, acceptance, genuineness and empathy. (Yalom &

Leszc, p.117)


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This is very important because, while group therapists come from different theoretical

schools, all of them have the fundamental job of creating therapy groups where members

can feel safe and begin to trust each other. To be a successful therapeutic group, therapists

must be able to enjoin members to fully join the group and emerge from isolation, then

trust each other, experience feelings, and find their own voices. The group that is build

should be one that hears, supports, values and respects each member. Ultimately, the

groups should be able to offer a place where members can restore a sense of personal

dignity and mastery to begin, transform, and sustain healthy interpersonal relationships.

(Schulte)

A culture that is nurturing, that respects members' dignity and encourages them to develop

healthy relationships is one that all group therapists must strive to reach. (Yalom &Leszc,

p.121).

Other norms that are needed in a good therapeutic group are: (1) active involvement in the

group, nonjudgmental acceptance of others, (2) extensive self-disclosure, (3) desire for

self-understanding, (4) eagerness to change current modes of behavior. (Yalom &Leszc,

p.121)

The Group Therapist as a Norm Shaper

In addition, just who creates these norms?

In any social group, norms are built both from the expectations of its members and from

explicit and implicit directions of the leader and other influential members. (Yalom &Leszc,

p.122)


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In group psychotherapy, the therapist is called on to play a powerful role in determining

the norms established in the group. (Yalom &Leszc, p.122).

The leader's norm-setting role is not one that is only encouraged by psychology, but it is

one that is inherent: the therapist cannot avoid being enormously influential in norm

setting. Here, the therapist should consider that norms constructed early in the group are

bound to persevere. Thus, the diligent therapist is well advised to go about this important

function in an informed, deliberate manner. (Yalom &Leszc, p.123)

He or she can do this in many ways. His/her statements to the group play a powerful

albeit usually implicitrole in determining the norms established in the group. For

example, a member whose actions are commented upon by a group leader will gain the

attention of the other members of the group. (Yalom &Leszc, p.122)

Hence, a leader can set the norms by either being a (1) technical expert or a (2) model-

setting participant in the group. (Yalom &Leszc, p.123)

As a technical expert, the leader attempts to shape norms explicitly as he prepares clients

for group therapy. He/she does this by carefully instructing clients about rules. Then,

he/she reinforces this in two ways: by backing it with the weight of authority and

experience or by presenting the rationale behind the suggested mode of procedure. (Yalom

&Leszc, p. 123). As a technical expert, the therapist can draw on a wide range of techniques

to shape group culture: He/she can do this by explicit instruction or suggestion, or by using

subtle reinforcing techniques that may be verbal or nonverbal. Positive reinforcement

methods include smiling, nodding, leaning forward or offering interested mms and asking


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questions. To extinguish behavior, on the other hand, therapists can resort to commenting,

not nodding, ignoring the behavior, turning their attention to another client, looking

skeptical, raising their eyebrows, and so on.

Research shows that therapists who reinforce members' pro-group behavior with such

subtle, indirect means more often are more effective than those who prompt such behavior

explicitly. (Yalom &Leszc, p. 124).

Being a model-setting participant, on the other hand, refers to leaders shaping group

norms not only through explicit or implicit social engineering, but also through being an

example of their own behavior. (Yalom &Leszc, p. 125).

This is both the effective and the morally correct choice for therapists: Since the therapy

group culture encourages its members to depart radically from the social rules to which

clients are accustomed: clients are asked to be uncommonly brave, to discard familiar

social conventions, to try out new behavior and to take many risks, it is only right that the

therapist himself or herself be as brave. (Yalom &Leszc, p. 125).

Thus, by modeling the norms, they seek to create and enforce, and by reinforcing these in

both implicit and explicit ways, leaders are able to set lasting norms that will help facilitate

productive therapy.

Studies show that therapeutic groups that have as norms the increased engagement of

group members and decreased conflict have better clinical outcomes for their members.

(Yalom &Leszc, p. 122)


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By offering a model of nonjudgmental acceptance and appreciation of others' strengths as

well as their problem areas, group therapists are also able to help shape a group that is

healthy. (Yalom &Leszc, p. 125). They should also set themselves up as models of

interpersonal honesty and spontaneity, even as they seek to behave in ways that respect

the current needs of the group members. In addition, to model the right group norms

successfully, therapists are also required to admit their own personal fallibility. (Yalom

&Leszc, p. 126)

Self Disclosure as a Key Ingredient

Because the therapist must continue to serve as the chief model-setting figure in the group,

he/she must have the self confidence for this. (Yalom &Leszc, p. 128)

When therapists are not confident, they can veer from one extreme or the other in their

personal engagements with the group: First, they may fall back into the role of the

comfortable, concealed profession. On the other extreme, they may escape from the anxiety

and responsibility of the leader's role by abdicating and becoming simply one of the gang.

When group leaders fall into these extremes, the group suffers and psychotherapy is not as

productive. (Yalom &Leszc, p. 128).

One of the most important norms of a productive psychotherapy group is self-disclosure,

and the therapist is also called on to self disclose. (Yalom &Leszc, p. 129)

Self disclosure is absolutely essential in the group therapeutic process. Thus, members

should be encouraged to self-disclose, but at their own pace. In this regard, the therapist

plays many tricky roles: First, he/she should ensure that each member self-discloses at


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his or her own pace. If group members are to benefit from therapy, they must share very

intimate parts of themselves with the other group members. However, the therapist must

ensure that the process is not irredeemably damaging. For one, it is best if members do not

experience the group as a form of forced confessional.

Then, when members finally disclose the big secret, it is important for the therapist to

encourage the member to disclose more of the secret, but in a nonthreatening and

horizontalrather than verticalmanner. This means that the member who has made a

big disclosure should be encouraged to disclose more about his/her disclosure, rather than

about the secret itself. For instance, the therapist may ask the person how it had been like

to come each week to the group and remain silent about your secret. Alternatively, he/she

can ask about the reasons why the group member made the disclosure. (Yalom &Leszc,

p.133).

Far more important than the actual unburdening of a secret by a group member is the fact

that disclosure results in a deeper, richer and more complex relationship to others. Thus, it

is also very important for the therapist to welcome the belated disclosure, rather than

criticizing its delay. (Yalom &Leszc, p. 134).

When a group is placed under pressure to disclose even more, the therapist's role is to

relieve the pressure by examining the unsafe aspects of the group from the point of view of

all members: He/she can ask the following questions: what generates the fear? What are

the anticipated dreaded consequences? From whom in the group do members anticipate

disapproval? Even more important than the actual unburdening of oneself is the fact that


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disclosure results in a deeper, richer and more complex relationship to others. (Yalom

&Leszc, p. 134).

Most importantly, the therapist must ensure that no one in the group is ever be punished

for self disclosure. One of the most destructive things that can occur in a group is for

members to use personal, sensitive materialthat which had been trustingly disclosed

against one another in times of conflict. If and when this happens, the role of the therapist

is to point out that members are fighting dirty, and that such undermines the group

normsand the very health of the group itself. (Yalom &Leszc, p. 134). In such instances,

the therapist should intervene vigorously. He or she must immediately stop the action,

interrupt the conflict, point out the violation of trust, and show that something very

important has just happened in the life of the group. The incident must be underscored to

reinforce the norm that self-disclosure is not only important, but also safe. (Yalom &Leszc,

p. 135)

Other norms that should be established and nurtured are:

(1) A sense of the group as self-monitoring group. This is opposed to a passive group. Early

on, therapists must work hard to transfer to the group the responsibility of therapy.

Group members should be encouraged to see the group itself as an agent of change. (Yalom

&Leszc, p. 135)

(2) Procedural norms. The best procedural format in therapy is for group meetings to be

unstructured, spontaneous and freely interacting. Since such a format never evolves


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naturally, the therapist must try his/her best to shape these meetings actively. Formats

used should ensure continuity, spontaneity, support and confrontation

Sources:

Schulte, Robert, MSW, CPG (2001). Group Psychotherapy for Psychological Trauma.

American Group Psychotherapy Association. New York, New York.

Yalom, Irwin, Leszc, Molyn. The Therapist: Basic Tasks in the Theory and Practice of

Psychotherapy. Irwin Yalom with Molyn Leszc. pp. 117-138. Fifth ed. Basic Books, New

York

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