Why Group Therapy Works and How to Do It

A Guide for Health and Social Care Professionals

Christer Sandahl, Hjördis Nilsson Ahlin, Catharina Asklin-Westerdahl, Mats Björling, Anna Malmquist Saracino, Lena Wennlund, Ulf Åkerström, Ann Örhammar

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000164206
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

This book describes how group treatment offers a unique opportunity for group members to learn and to change as they interact with other group members.

The group structure presents a social microcosm of relationships that people who seek psychotherapeutic treatment find problematic in their private and public lives. In groups, the participants can observe each other, provide feedback to each other, and practice change strategies. In short, group treatment has a powerful healing and supportive function. Based on the authors' many years of education and experience in academia, the private and public sectors, specific guidance is offered to group leaders on participation, organization, and communication in group treatment. The authors describe the history and characteristics of group treatment, how to organize a treatment group, the roles and responsibilities of the group leader, methods of group treatment, and typical responses of participants. Given its purpose and methodology, this book takes an original perspective on group treatment aimed ultimately at improving healing processes in healthcare and social care.

This book will provide a helpful introduction and guide for a range of professionals who work in primary healthcare, company healthcare, somatic care, psychiatric and social care, and the non-profit sector.

Chapter 1

Introduction

This chapter contains

Why a book on group therapy?

Why a book on group therapy?

Given the considerable evidence on the value of group therapy, it is difficult to understand why its full potential is not made use of in practice. Although group therapy for healthcare and social care is found in most Western countries, it is the rule rather than the exception that such care is provided and supported by people who often have minimal education and experience in group processes. The unfortunate result of such lack of preparedness is that the true potential of group therapy is rarely realized. Group leaders who lack proper understanding and knowledge of group processes must deal with poor group cohesion as well as group members’ silences, absences, and general disinterest in the treatment.

Much research exists on individual and group therapy in healthcare and social care. In comparisons between the two psychotherapeutic approaches, various researchers have been unable to identify significant difference between them as far as providing relief of symptoms. Unfortunately, some clinicians recognize only two benefits for group members from group therapy: the opportunity to share information about symptoms, and the communication of information on healthy lifestyles. This excludes the complex relational, interpersonal, and intrapersonal aspects of group therapy. The implication of this evaluation of group therapy is that it is a second-best alternative to individual treatment.

We challenge this view of group therapy. Man’s basic need to relate and communicate also includes the fundamental need for a group to belong to, to be included in and protected by. In this book we describe how group therapy offers a unique opportunity for group members to learn and to change as they interact with other group members. The group structure presents a social microcosm of the kind of relationships that people who seek psychotherapeutic treatment find problematic in their private and public lives. In groups, the members can observe each other, provide feedback to each other, explore the relationships that develop, and practice change strategies. In short, group therapy has a powerful healing and supportive function.

The number of patients and clients with psychiatric and psychological disorders is steadily increasing in many countries. The cost of their treatment is rising even more rapidly. The unavoidable reality is that healthcare and social care systems find this cost unsustainable. The authors of this book are convinced that group therapy, when provided as an alternative to individual treatment, can significantly reduce total treatment cost, perhaps by as much as one-third or one-half (Piper, 2008). Most research within this field is done on time-limited group therapy; i.e., 10–30 weekly sessions. When applied in healthcare or social care, the short-term format we focus on in this book is cost-effective and relatively easy to implement.

This book is intended for professionals in the private or public sectors who work with treatment and prevention in healthcare and with social care. Possible readers include nurses, physiotherapists, occupational therapists, social workers, teachers, psychologists, psychiatrists, psychotherapists, and general practitioners. The book may also be of value to any reader with general health and social care education who is interested in forming or supporting a therapy group that has clearly defined and limited goals. For professionals with more advanced education and training in psychotherapy, the book may inspire them to start and/or lead a therapy group that has psychotherapeutic goals.

Many therapists lack the training, experience, and courage to attempt group therapy. For example, they may fear that group members will offer negative criticism and pose difficult challenges. They may fear loss of control over the group, especially when certain members dominate the interaction and others decline to contribute. In short, they do not feel safe in the role of group therapy leader. The aim of this book is to help such group leaders overcome these fears by supporting and guiding them as they introduce and apply psychotherapeutic group methods in their work.

The authors of this book belong to the second and third generations of group psychotherapists in Sweden. As early as 1949, the psychiatrist and psychoanalyst Torsten Sjövall (1913–1998) went to Boston on a two-year Rockefeller grant. He worked at an outpatient psychiatric clinic at the Beth Israel Hospital. There he discovered American group psychotherapy in discussions with his supervisor Grete Bibring (1899–1977). In the 1960s and 1970s, a group of Swedish professionals interested in group dynamics travelled to England and the United States to study group psychotherapy. The first Swedish association for group psychotherapy was founded in 1962 by, among others, Torsten Sjövall. The Stockholm Group Analytic Institute (GAI) was founded in 1981 on the initiative of the psychologist and group analyst Lars Lorentzon and the psychiatrist, psychoanalyst, and group analyst Olov Dahlin. It was hoped that GAI would be able to develop a Swedish version of group analysis, based on the work of Siegmund Heinrich Foulkes and his co-workers. Compared to many other European countries, group therapy in Sweden developed relatively independently in relation to the London-based group analysis, at the same time as there has been a close relationship and exchanges with group analytic colleagues in the United Kingdom and the rest of Europe.

We, the authors, are experienced group analytic psychotherapists, while at the same time building on the work of the founders of group psychotherapy in Sweden. The first group psychotherapy training was undertaken during the 1960s at Stockholm University with psychologists Siv Boalt Boethius and Bo Sigrell as course leaders. The group analytic tradition was introduced in the 1970s through qualifying training programs under the leadership of psychologists Hans Gordon, Lars Lorentzon, and Eric Steadman. The culture of this training programme was indirectly influenced by Eric Steadman, who did not wish to teach but who brought his experience of the therapeutic community at the UK’s Henderson Hospital and as a student of Foulkes. Later the psychiatrist and group analyst Göran Ahlin was for many years in charge of a three-year group analytic training program in Stockholm. All these colleagues have contributed to our understanding of group psychotherapy and indirectly inspired us to write this book.

However, we are also inspired by other group therapy traditions, not least the one represented by the North American existential psychiatrist Irvin Yalom (Yalom & Leszcz, 2020). For one of us (Christer Sandahl) it was a liberating experience 40 years ago to have the privilege of observing Yalom’s work with an inpatient group and then to have the opportunity to discuss it with him after each session.

Another important teacher, mentor, and colleague was the British-American psychologist Yvonne Agazarian (1929–2017), who developed systems-centred therapy (SCT; Agazarian, 2006), a particular form of group therapy based on the Theory of Living Human Systems. This theory postulates that living human systems survive, develop, and transform from simple to more complex through discriminating and integrating differences. Implementing this idea is challenging for all human beings as integrating differences requires shifting from what we know to a difference; that means tolerating the unknown. Though the SCT approach as a whole is more complex than this introductory text can present, the heart of SCT work is its method of functional subgrouping which helps groups integrate differences. SCT’s functional subgrouping teaches groups to join around similarities instead of reacting with differences. Simply put, changing from “yes, but” to “yes, and” opens the pathway for integrating small differences in a climate of similarity. Establishing this kind of group norm makes it less likely that groups will scapegoat differences or create identified patients. Our approach to the interpersonal work, the group leader role, and the implementation in different kinds of organizations is influenced and inspired by Yvonne Agazarian’s work.

The book was created within the context of the relatively independent Swedish group therapy tradition, on the periphery of the mainstream discourse within group analysis. It is also the result of a creative group process in which we reviewed and discussed all chapters in joint writing seminars. The book is the outcome of a creative and rewarding group process. Our aim was to write an introductory book with wide applications, primarily in different forms of time-limited group therapy, and at the same time being deeply rooted in the group analytic tradition.

In several chapters of this book, we refer to Foulkes, the British psychiatrist and psychoanalyst who became the father of group analysis. Foulkes declined to use the term “group leader” in his work and writings. As a Jewish refugee from Germany, he was very sensitive to the idea of the “Führer”, although the word “leader” had an entirely different connotation in his profession. He preferred the word “conductor”. Using “conductor” to describe the group leader role in group therapy, Foulkes emphasized the idea of “musicality” – that is, interpreting the message behind what one hears in words. According to Foulkes, people should also listen to the undertones, nuances, rhythms, and silences in human conversation. He claimed that this skill is best acquired and developed in conversations that are characterized by sharing, openness, and feedback. In these conversations, people learn to reflect on their lives and to explore alternative ways of being.

We, however, prefer the term “group leader”. In contemporary times – far distant from Nazi Germany – “leader” rarely evokes the negative connotation that it did for Foulkes. Rather, “leader” today has a positive connotation. We often think of the modern leader as a respectful and trusted individual who listens and responds to others. Group leaders take responsibility for group members. The individual who aspires to be a group leader requires the kind of formal theoretical knowledge that this book presents. However, theoretical knowledge alone is not enough. In any new activity – such as sailing, skiing, playing the violin, painting watercolours, etc. – people require practice and experience.

We have identified a clear need for more extensive training in group therapy for clinicians and social workers. To that end, based on our many years of teaching and experience in academia and in the private and public sectors, we offer specific guidance to group leaders on participation, organization, and communication in group therapy. In the chapters of this book, we describe among other things the history and characteristics of group therapy, how to organize a therapy group, the roles and responsibilities of the group leader, and methods of group therapy. Given its purpose and methodology, this book’s key message is that group therapy supports and advances the healing processes in healthcare and social care.

The next four chapters provide the theoretical background to the more practice-oriented parts that will follow. Based on our conviction that it is essential for group leaders to understand the significance of groups in our lives, Chapter 2, “The significance of the group”, begins with a discussion of human beings as social animals, like other herd animals, who thrive in groups. It has been our biological heritage to seek the safety of the group since we first descended from the treetops to the dangers of the plains. With this discussion as its starting point, the chapter continues with a description of the child’s family and other group relationships and of the related psychological theories on human behaviour: for example, attachment, bonding, companionship, social cognitive theories, and group analysis. The chapter explains how the clinical use of these scientifically based theories has developed. It concludes with a commentary on how group therapy presents a golden opportunity for participants to develop new experiences in safe environments.

Chapter 3, “What is a group – really?”, begins with a discussion of how the following concepts – the group, the individual, and the person – have been interpreted in various contexts. This analysis leads to the researchers’ comparison of the group to an orchestra, a choir, or a jazz group in which the unique individuals act as a whole. Thus, the group is a phenomenon in which the whole is more than the sum of its members. In exploring the group phenomenon, the chapter also analyses group coercion (i.e., groupthink) that can elicit both positive responses/actions and negative responses/actions among group members. In the latter situation, the chapter emphasizes the importance of group leadership in counteracting destructive group behaviour.

Chapter 4, “The group as a learning and healing environment”, begins with a summary history of group therapy with a focus on the contributions of pioneers such as Adler, Burrow, Lewin, Foulkes, and others. The chapter then reviews the numerous trends in group therapy from the twentieth century to the present. It continues with a discussion and analysis of its main focus: members’ interactions (conversation and reflection) in groups, which is described as the central psychotherapeutic factor in group therapy. It is in such interactions that group members learn to explore their own and others’ experiences, emotions, ideas, and motivations. Although groups can exert a destructive force at times (“the anti-group” phenomenon), the chapter emphasizes that the group can be an environment where we learn, heal, and grow.

Chapter 5, “Group therapy”, introduces group therapy by giving a general description of therapy groups with emphasis on their varying aims, their different venues, and their different structures. In this chapter (and book), the focus in on the time-limited therapy group. This is a kind of group therapy that has a fixed schedule of meeting times and places with the same members and leader. Within this framework, the chapter examines various therapeutic group characteristics: focus, processes, boundaries, conditions, and structure. It also offers specific guidance for group leaders in their role as therapists and includes advice regarding how to match patients to suitable group treatments. Leaders should set reasonable expectations; not all patients/clients benefit from the same group model.

Chapter 6, “Starting a therapy group”, takes a very practice-oriented approach to group treatment that derives from the authors’ clinical experience. The chapter offers a practical, specific “hands-on” guide that organizers and leaders of group treatment will find useful. Initial comments on the importance of context and environment for group therapy are the lead-in to the guide on how to start a therapy group. This guide provides clear and specific advice on how to form and organize therapy groups, how to choose group participants, how to recruit suitable group leaders, how to prepare participants for group treatment sessions, how to establish group rules and a group framework, and much more. The chapter concludes with some recommendations on how to evaluate therapy groups.

Chapter 7, “Conducting a therapy group”, begins with a general discussion on the role of the leader. Although leaders have different backgrounds, different views and opinions, and different personalities, they have the same position: the central figure in a group. The chapter then narrows its scope to the role of therapeutic group leaders: their functions, tasks, and responsibilities. Therapeutic group leaders should clearly set out the group’s purpose, goals, and framework; establish an accepting, reflective group culture; and provide support in various ways. Leaders who are new to the role in particular require sensitive supervision and collegial support. The chapter deals specifically with the leader’s use of verbal or non-verbal interventions and also addresses the advantages of group treatment in which there is dual leadership.

Chapter 8, “Engagement and differentiation”, and Chapter 9, “Interpersonal work and termination”, discuss the development trajectories of various group types that group leaders need to understand so they can successfully lead group stages. The group stages are in some sense analogous to the identity development stages people pass through. Each group has its own mood, participant relationships, and themes. The chapters analyse the four characteristic group development stages: engagement, differentiation, interpersonal work, and termination. The leader’s role and responsibility in each stage is described and exemplified. The chapter also suggests ways that leaders can handle difficult situations in groups when conflicts or other problems arise in the context of closed, open, and slow-open groups.

Chapter 10, “Slow-open groups”, describes the advantages of such groups, the different developments in them, and how to deal with issues on boundaries, time limitations, and rules. The role of the group leader in such groups and how to start and end participation in slow-open groups are discussed.

Chapter 11, “Group therapy with pre-planned content structure”, highlights the importance of group processes in cognitive behavioural therapy (CBT) and in psycho-educational groups. The aim of this chapter is to summarize some general group dynamic principles that are relevant in the use of CBT and psycho-education in groups. It describes how group CBT can offer participants a unique opportunity to observe cognitive and behavioural problems in others that they can then discover in themselves. This is an opportunity not available in individual therapy. Another aspect addressed is the role of the leader in group CBT as the individual who maintains group structure by balancing techniques and processes. It also describes group treatment in which pedagogical and psychological support is provided to the group participants who have sought help because of difficult and challenging life situations. The chapter describes their complementary role in other care treatments and their emphasis on participants’ exchange of experiences and reflections.

Chapter 12, “Focused group therapy (FGT)”, explains a type of group therapy that the authors developed, beginning in the year 2000. The method was developed in a research project on stress and burnout with patients on long-term sick leave. The authors have considerable experience with FGT in their cli...

Table of contents

• Cover
• Endorsements
• Half Title
• Series Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• About the authors
• List of figures
• Foreword by Dr Earl Hopper
• 1. Introduction
• 2. The significance of the group
• 3. What is a group – really?
• 4. The group as a learning and healing environment
• 5. Group therapy
• 6. Starting a therapy group
• 7. Conducting a therapy group
• 8. Engagement and differentiation
• 9. Interpersonal work and termination
• 10. Slow-open groups
• 11. Group therapy with pre-planned content structure
• 12. Focused group therapy (FGT)
• 13. Concluding remarks
• References
• Index