Group Psychotherapy: A Behavioral Approach

Abstract

This clinical report highlights some of the processes arising in a therapy group of persons with persistent and chronic psychiatric illnesses as they cope with the stress of their long–standing therapist’s impending retirement. Members were initially disbelieving that the therapist would leave and were also concerned about their future care, particularly in terms of medications. Gradually they were more able to experience their feelings of loss and their genuine caring for the therapist and the group, using higher level defenses and increasing their ability to tolerate strong affects. They became increasingly able to demonstrate empathy, notably in their ability to consider the therapist’s emotions. The clinical material also illustrates the therapist’s personal involvement, countertransferences and expressions of concern.     

The Greek Chorus and Other Techniques of Paradoxical Therapy

This paper has described some of the interventions developed at the Ackerman Brief Therapy Project in treating the families of symptomatic children. The interventions are based upon a differential diagnosis of the family system and upon an evaluation of that system's resistance to change. They are classified as compliance-based or defiance-based, depending upon the family's degree of anxiety, motivation, and resistance. Paradoxical interventions, which are defiance-based, are used as a clinical tool in dealing with resistance and circumventing the power struggle between therapist and family. A consultation group acting as a Greek chorus underlines the therapist's interventions and comments on the consequences of systemic change. This group is also sometimes used to form a therapeutic triangle among the family, therapist and group, with the therapist and group debating over the family's ability to change.     

Situational countertransference

Situational Countertransference refers to those responses on the part of the therapist that are generated primarily by severe, though temporary, distresses in the therapist's personal life. It has been this writer's experience that many patients are quite attuned to the inner turmoil of their therapist, and that they will react to it in a variety of ways, which will be described. Moreover, a comparison of the level of functioning of two similar therapy groups over the course of nine months found that the group which had inadvertently learned the source of their therapist's distress functioned significantly better than the group which ostensibly knew nothing about it.     

Therapist Self Disclosure in Group Psychotherapy from an Intersubjective and Self Psychological Standpoint

The history of therapist self disclosure is traced from the early struggles of Ferenczi and Burrow to its valued, yet still ambivalent, contemporary status. The symmetry of self disclosure by therapist and group members is differentiated from the parity of their different roles and responsibilities. Using a case example, the process is discussed through which a therapist's self disclosure fosters task-appropriate satisfaction of selfobject needs as it also helps group members articulate and loosen archaic selfobject binds. The therapy group is described as a transitional space within which a therapist's disclosure offers members an intersubjective bridge to the therapist as well as a model for members' own active participation in the group's work.     

Treatment of the chronically mentally ill: an opportunity for the group therapist

This article focuses on the therapist's task of engagement in the group treatment of the chronic mentally ill. The dynamics of individual and group processes are reviewed with an emphasis on the contributions of social, interpersonal, and intrapsychic factors. Drawing upon the observations of Friedman (1988), the presentation explores therapists' efforts to restore their inner balance by (1) acting like a therapist, that is, according to their theory; (2) satisfying their curiosity; and (3) eliciting "something desirable," which is formulated as the therapist's search for interactive responses. Examples illustrate these elements as they emerge in group psychotherapy.     

Group processes and the therapist's subjectivity: interactive transference in analytical group psychotherapy

Interactions among the group therapist, the group members, and the group as a whole, especially enactments, are conditioned by the therapist's identity, defenses, and present relationships within his or her social networks. It follows from these considerations that difficulties in a group process stem from the group therapist's inability to understand well-enough what the group members are acting out and that they can be overcome only if the therapist extends the limits of his or her identity. Therefore, it has to be taken into account that the leader of a group is always a member of other groups whose dynamics in turn determine one's capability to understand the interactions in the group in which he or she is a therapist.     

Therapist competence, therapy quality, and therapist training

Large numbers of therapists worldwide wish to receive training in how to deliver psychological treatments. Current methods of training are poorly suited to this task as they are costly and require scarce expertise. New forms of training therefore need to be developed that are more cost-effective and scalable. Internet-based methods might fulfil these requirements whilst having the added advantage of being able to provide trainees with extensive exposure to the treatment as practised. New strategies and procedures for evaluating training outcome are also required. These need to be capable of assessing the therapist's knowledge of the treatment and its use, as well as the therapist's ability to apply this knowledge in clinical practice. Standardised role play-based techniques might be of value in this regard.     

The therapeutic alliance in couples therapy: clinical considerations

This article presents clinical considerations about the therapeutic alliance in couples therapy, stimulated by pertinent new research findings reported in this issue. A loyalty dimension of the couple's relationship is described, as well as its influence on the therapeutic alliance in couples therapy. The therapist's establishment of a "meta-alliance" with the couple around their loyalty conflicts, avoidance of splits and disruptions, and prioritization of marital distress (versus individual symptoms) as the primary focus of treatment all serve to solidify the therapeutic alliance. In addition, identifying the partners' early family-of-origin distress can help predict and respond to strains in the therapeutic alliance that may occur later in therapy. Finally, the therapist helping the couple to balance their relational power differences in therapy and to address their concerns about the impact of the therapist's gender also strengthens their therapeutic alliance. A clinical case and vignettes are included to illustrate these issues.     

Mirror neurons: their implications for group psychotherapy

Recently discovered mirror neurons in the motor cortex of the brain register the actions and intentions of both the organism and others in the environment. As such, they may play a significant role in social behavior and groups. This paper considers the potential implications of mirror neurons and related neural networks for group therapists, proposing that mirror neurons and mirror systems provide "hard-wired" support for the group therapist's belief in the centrality of relationships in the treatment process and exploring their value in accounting for group-as-a-whole phenomena. Mirror neurons further confirm the holistic, social nature of perception, action, and intention as distinct from a stimulus-response behaviorism. The implications of mirror neurons and mirroring processes for the group therapist role, interventions, and training are also discussed.     

Developing the Working Alliance in Marital Therapy; A Psychodynamic Perspective

A good working alliance in marital therapy is one in which the partners are actively collaborating with their therapist to work through conflicts. The therapist begins to develop the alliance by setting the frame of therapy and helping the couple understand the guidelines of treatment. The partners gradually identify with and emulate the therapist's working style and use of self as a reflective instrument. The working alliance can be weakened by empathic failures and strengthened by increased feelings of trust in the therapist and the process of treatment This paper looks at the development of the working alliance in marital therapy from a psychodynamic perspective. A clinical illustration is included.     

The therapist's inner conversation in family therapy practice: some ideas about the self of the therapist, therapeutic impasse, and the process of reflection.

In this article, a distinction is made between the outer therapeutic conversation and the therapist's inner conversation. The therapeutic conversation is a circle of meaning in which both the therapist and the clients play a part. The therapist's inner conversation is described as a negotiation between the self of the therapist and his role. In this process of negotiation the therapist has to take seriously, not only his observations, but also what is evoked in him by these observations, that is, images, moods, emotions, associations, memories, and so on. Furthermore, therapeutic impasse is conceptualized as a paralysis of the circle of meaning and of the therapist's inner conversation. A process of reflection is proposed as a way out of the impasse. In that process, the inner conversation of the therapist is externalized with the help of an outsider. In the final part of this article, a case study illustrates the importance of these ideas for the family therapy practice.     

Group therapist countertransference to trauma and traumatogenic situations

In this introduction to the special issue on "Group Therapist Countertransference to Trauma and Traumatogenic Situations," the author notes that for many therapists it is not only group member disclosures and re-enactments, but also the co-occurring, sociopolitical contexts in which they live that may involve traumatic challenges. He considers three historically evolving views of countertransference: (1) the "classical"position, (2) the "totalistic" view, and (3) the "intersubjective/relational" view. He views the therapist's intense emotionality (as opposed to clinical detachment) in response to trauma as inevitable, and considers the particular roles of "bystander," "perpetrator," and "victim" induced in the therapist by traumatic re-enactments in the group. He concludes with a synopsis of some of the key points made in each of the contributions to the special issue.     

The therapist's self in dialogical family therapy: some ideas about not-knowing and the therapist's inner conversation

In this article, the focus is on the therapist's self, which will be in line with Bakhtin's thinking, viewed as a dialogical self. First, the dialogical view of the self is situated in the context of psychology's traditional focus on the individual self. Then, leaning on Bakhtin and Volosinov, the self is described as a dialogue of multiple inner voices. Some of the implications of this concept for family therapy practice are examined, focusing especially on the therapist's participation in the therapeutic process and on the therapist's inner conversation. The author argues that not-knowing does not only refer to the therapist's receptivity and respect but also implies that the therapist is aware of his or her experience and reflects on how his or her inner conversation might inform and enrich the therapeutic conversation. Finally, these ideas are illustrated with a brief clinical vignette.     

Sudden Death of the Therapist: The Effects on the Patient

While the termination phase of psychoanalytic psychotherapy has been discussed in the literature, the effects on the patient of a forced termination following the therapist's death have seldom been investigated. In this paper, two groups of patients (N = 35) were compared: those who experienced a planned termination and those who experienced a sudden termination as a result of their therapist's death. Data were gathered by means of detailed questionnaire and formal psychological assessment (i.e., the Grief Experience Inventory). Responses were also solicited from therapists who treated patients subsequent to the original therapist's death. Results indicate that patients forced to terminate due to the therapist's unexpected demise experienced significantly more intense grief reactions with regard to feelings of anger, despair, depersonalization, and somatization. The nature of the transference relationship with the original therapist at the time of the latter's death appeared to influence the subsequent therapeutic relationship as well. The authors present recommendations and practical guidelines concerning therapists' responsibility to their analytic patients to make reasonable accommodations in the event of their unexpected death.     

Sexual misconduct in psychotherapy: reactions to a consumer-oriented brochure

Reactions of subjects to a brochure addressing the topic of sexual intimacy in psychotherapy was assessed. Fifty-four psychotherapy clients and 52 licensed psychologists responded favorably to the brochure, with the majority indicating that the brochure should be made available before therapy begins or during the first session. Potential clients (120 college students) read either the brochure on sexual misconduct or a control brochure containing general information about psychology. Subjects who read the sexual misconduct brochure showed increased ability to understand what is appropriate and inappropriate therapist behavior, see unwanted touch as nontherapeutic, regard a therapist talking a lot about his or her own sex life as inappropriate, view sex in the therapeutic relationship as inappropriate, and intend to behave assertively within the session if their therapist's behavior should make them feel uncomfortable. Subjects who read the control brochure showed no such changes.     

Oppression, freedom, and recognition in an analytic therapy group: group and therapist interactions from relational and group analytic perspectives

Group analytic and relational writings point to the development of mutual recognition between individuals as a main treatment goal. To achieve this, it is necessary to face up to issues of control and oppression in the therapeutic relationship, particularly as enacted by the therapist. The relationship between the therapist and group members is a co-construction, shaped by their respective subjectivities. The therapist's willingness to enter into an open examination of his or her enactments can stimulate change in relationships with patients, resulting in freer and more spontaneous communication in the group. To illustrate, several sessions of an analytic therapy group are presented in which there were struggles between (1) the desire for equality and mutuality and (2) firm exercise of authority.     

The effects of feedback self-consistency, therapist status, and attitude toward therapy on reaction to personality feedback

Individuals' reactions to interpersonal feedback may depend on characteristics of the feedback and the feedback source. The present authors examined the effects of experimentally manipulated personality feedback that they--in the guise of therapists--e-mailed to participants on the degree of their acceptance of the feedback. Consistent with Self-Verification Theory (W. B. Swann Jr., 1987), participants accepted feedback that was consistent with their self-views more readily than they did feedback that was inconsistent with their self-views. Furthermore, the authors found main effects for therapist's status and participant's attitude toward therapy. Significant interactions showed effects in which high-status therapists and positive client attitudes increased acceptance of self-inconsistent feedback, effects that were only partially mediated by clients' perceptions of therapist competence. The present results indicate the possibility that participants may be susceptible to self-concept change or to self-fulfilling prophecy effects in therapy when they have a positive attitude toward therapy or are working with a high-status therapist.     

Collaboration and a Self-Help Orientation in Therapy with Suicidal Clients

Working with suicidal clients historically has placed a heavy burden of responsibility on the therapist for a successful outcome. This orientation generally has left clinicians feeling stressed and in need of controlling their clients' behavior; clients, in turn, often have developed unrealistic expectations of therapy or resistance of the therapist's interventions. In this context, the chance for a potentially valuable collaboration between client and therapist is often lost. This paper builds on previous work that has introduced the notion of a collaborative working relationship with suicidal clients. It is argued that the therapeutic process ideally should not only utilize the therapist's knowledge and skills in treating suicidal clients, but also cultivate self-efficacy by encouraging the client to adopt a self-help orientation to therapy. Several general principles of a collaborative/self-help orientation to working with suicidal clients are discussed and a variety of specific therapeutic strategies consistent with this orientation are described.     

The psychotherapeutic utility of the five-factor model of personality: a clinician's experience.

This article summarizes experience using the five-factor model of personality, operationalized by the NEO Personality Inventory (NEO-PI), to facilitate psychotherapy treatment with 119 private-practice, outpatient, psychotherapy patients and their family members over a period of 2 years. Trait theories such as the five-factor model implicitly challenge the premises of much clinical theory, yet they can be useful to clinicians, as they provide a detailed, accurate portrait of the client's needs, feelings, proximate motives, and interpersonal style. I suggest that: Neuroticism (N) influences the intensity and duration of the patient's distress, Extraversion (E) influences the patient's enthusiasm for treatment, Openness (O) influences the patient's reactions to the therapist's interventions, Agreeableness (A) influences the patient's reaction to the person of the therapist, and Conscientiousness (C) influences the patient's willingness to do the work of psychotherapy. Fundamental questions raised by the five-factor model about the nature of psychopathology and psychotherapy are discussed.