Group Therapy Models, Essay Example

Discuss and explain three ethical issues that are involved in group therapy.

In any psychotherapy group a therapist must first adhere to the maxim to do no harm. This is emphasized through creating a safe environment within the group to maximize the groups’ psychotherapy efficacy.  In no way should a person begin to feel “unsafe” within a group dynamic because it at once disturbs the bond of trust not only between patient and therapist but between patients. As groups sessions often expand upon deep seeded fears, and trust issues, this ethical idea of doing not harm is paramount to group therapy sessions (Leszcz & Kobos, 2008, p. 1253). Yalom states that one form of doing harm within a group therapy session is to have one of the patients removed from the group (Yalom, 1983, p. 155). This may cause harm to the group through upsetting habits that people have grown accustomed to (which in turn could create an environment that isn’t conducive to trust or fostering a caring environment for all of the patients), as well as upsetting the patient removed from the group. Yalom states that this is true especially for higher-level groups in which the policy the therapist adheres to is one that enriches the group through consistency (p. 110).

Another important ethical stance within group therapy is for the therapist to maintain privacy of the patients. Therapist work within a group dynamic should be focused on patient well-being, which extends beyond session work. There is the patient-therapist confidentiality that lawfully requires a therapist to keep session (even group sessions) private, as Leszcz & Kobos (2008) state, “In all jurisdictions, except Illinois, this privilege is not accorded to group members. In starting the group, it is incumbent upon the leaders to help the members develop therapeutic trust and know the legal context in which the group functions. Informed consent documents may be useful to help understand group confidentiality and its limits… Also, it is useful to describe ways that members may discuss their experience in group with others and not identify members of the group (Leszcz & Kobos, 2008, p. 1254). Yalom (1983) explains privacy as a way to foster trust between the patient and the therapist, for, “…such a comment [aka setting] models much that may be valuable in social interaction: honesty, caring, consideration for the other. Increasing a patient’s trust in the therapeutic procedure, patients will have more trust in a therapeutic procedure if they see that the therapist is willing to engage in the same procedure…”(Yalom, 1983, p. 165). Yalom means that trust is built by the therapist exposing themselves to the group (emotionally) in order to garner trust in the efficacy of group therapy.

Another interaction in group therapy dynamic that has ethical concerns is extra-curricular activities among members of the group,  outside of the group. While group therapy provides a safe and conducive-to-healing environment, the members of the group should not be encouraged to be friends outside of that dynamic. The group is not established as a means for friendships to form, but rather, as a way for members in the group to make clear goals, express themselves, and share their experience in hopes that such sharing may help them in their own healing process, or help others in theirs (Yalom, 1983, p. 39-40).

Describe the two stages of here and now (GROUP). Why is the here and now important to group development?

The here-and-now approach for Yalom (1983) deals with two stages, “the experiencing component, which is followed by the reflection upon (or processing of) that experience. Interpersonally based psychotherapy consists of an alternating sequence: first, affect is evoked, and then that affect must be analyzed and integrated. The final phase represents the second, the self-reflective, phase of the here-and-now.” (p. 263) The here-and-now phase deals with patients clarifications and interpretations about what occurs in the group (that is treated as an extension of what occurs in the real world). A therapist them must keep the group focused by turning the conversation back to the here-and-now so that patients aren’t focused on abstract problems. Yalom (1983) compares the therapist to a shepherd who must gather up stray thoughts that often focus on past events that beyond the patient’s control. A therapist stays in the here-and-now in order to keep patients discussing personal experiences for the group so that others in the group can focus on these events, discuss these events (be reflective) and direct comments to one another (p. 181). The therapist’s task is one of “channeling outside to inside” so that the patients get a sense of self-reflection through discussion, or, as Yalom states, from “outside to inside” (p. 181). As Leszcz & Kobos (2008) state, a therapist in the role as leader of a group therapy session must exhibit “Executive functioning, caring, emotional stimulation, meaning attribution, fostering client self awareness, establishing group norms, and therapist self disclosure/use of self” (p. 1252).

Yalom (1983) expressed that the here and now approach to group therapy “does not state that either the past history or the current life situation is irrelevant or unimportant. Every individual is shaped to a very great degree by the historical events of his or her personal life: every individual has to live in the outside world; and obviously effective [group] therapy must help one adapt more comfortably to one’s real life situation…” (p. 174). Yalom states that the “here-and-now” is important because it allows patients to function more viscerally as opposed to in the abstract. For instance, Yalom gives the example of a patient stating that they’re complaining (voiced as “I would like to be more assertive”), and the role of the therapist is “transform that abstract comment into something specific and into something involving…” (p. 181) practical application of real-world goals. In psychotherapy, the here-and-now focuses on the immediate therapy session and what is occurring in the therapy room at that very moment. It is important for patients to focus on the here-and-now because the problems in the therapy room don’t overwhelm them. Problems can be abstract instigators into negative thinking and the role of the therapist as the shepherd as Yalom suggests, entails keeping the patient focused on what they can change, what’s important, how they can’t change the past but rather how they can change their reaction to the past and their chooses in the future (Kosters et al., 2006, p. 148).

Horizontal and Longitudinal disclosure. What is an example of each? As a leader what type of interventions might you use to facilitate there type of disclosures?

Yalom (1983) states that there are two types of disclosures: longitudinal (vertical) and horizontal. Horizontal is a “multifaceted therapy program on the ward” (p. 54) and longitudinal is “a post-hospital course of psychotherapy” (p. 54). The horizontal program places heavy emphasis on a patient’s interactions while the longitudinal program establishes a time frame for the therapist for the patient to build “cohesiveness over many sessions” (p. 106) by way of observing patterns going from day-to-day, month-to-month, and year-to-year. The key to longitudinal progress is time; therapist work through patient’s issues in a patternistic way that lends itself to repetition.

As a therapist I may make use of longitudinal disclosure as its efficacy is seen after hospitalization. This means that integration back in a home setting, or the habits of life prior to hospitalization is going on. The importance of integration back into society is prevalent in this disclosure. For me, this means that the habit and patterns established in group therapy in the ward are no longer applicable to the degree with which they were established. Instead, the old factors of home life, jobs, relationships, come back into play. These elements may prove difficult as each offers a different stress in the patient’s life, and this stress may induce relapse into the hospital. As such, the importance of longitudinal disclosure becomes apparent.

There is a long-term need for the patient when it comes to longitudinal disclosure. Although the groundwork for their therapy and progress is clear in the horizontal disclosure, such comforts of the group are no longer available outside of the ward, and the patient may feel a sense of abandonment or loneliness at this juncture. In order to facilitate a salubrious return to society, it’s important to mark what’s working and what’s not working for the patient along a certain time frame. This allows the therapist to remark in their file whether or not they feel the patient is making proper progress in this re-integration stage, and if so (or if not) the necessary steps to make this feasible. In Yalom’s two-fold therapy process although horizontal focuses more on the here-and-now dynamic (with in-ward sessions that allow the patient to feel safe in this new environment and to not feel judged) it is with the longitudinal disclosure that more long-term work is being done. I will apply this in my work as I feel that its efficacy to patients, and patient’s lives, becomes more important when they leave the ward and venture out into the world or society whose stresses, choices, and myriad of variables have in some negative way affected the patient to the point where they had to be admitted into the hospital, as Leszcz & Kobos (2008) state, “to create more reflective space and reduce his tendency to react quickly and negatively” (p. 1246).

What is the role of resistance and conflict in the group? How can it be managed?

Resistance and conflict in a group can deal with patients showing resistence to authority or to comments from other patients made in a group that may ultimately lead to the patient leaving the group. In long-form group therapy, Yalom (1983) states that cohesion is key in forming lasting bonds. These bonds in the long-form therapy group must be established in order for the therapist to facilitate therapy and “facilitate the overt emergence of conflict” (p. 145). Yalom goes on to state that if no such cohesion exists in a group therapy group then “prolonged conflict will result in group fragmentation and premature termination on the part of many of them” (p. 145). In a group in which there is a lack of cohesion this perpetuates a lack of communication either between patients, or between patients and therapist. As such, when a patient exhibits this lack of communication because of cohesion problems it manifests itself in anger. This anger is then directed to either members of the group, the therapist, or the patient, as Yalom (1983) states, “The group members who are unable to confront the therapist directly with these disappointments may displace their anger onto a scapegoat, further increasing the general level of conflict and anger in the group” (p. 147).

In order to curtail the effects of conflict through anger in a group therapy dynamic a large amount of patience, communication and leadership is required of the therapist, as Leszcz & Kobos, (2008) state, “When conflict emerges, the leader and group members frequently feel that they would like to flee from the situation or fight among one another. It can be helpful to anticipate differences and power conflict. In this scenario, two subgroups of people with different experiences with the leader might lead to conflicts with the leader” (p. 1249). Yalom (1983) supports these author’s suggestions by stating that when conflict arises in the group it’s necessary for the leader to take charge before negative impact becomes detrimental to the therapy’s progressiveness. Being specific to emotional responses of conflict, Yalom states, “When anger is the affect in question, the therapist needs to guide the group quickly into the phase of understanding and clarification. Thus, at the first signs of conflict, the therapist may simply act decisively and change the flow of the group by commenting to this effect…” (p. 157) wherein the therapist addresses the group (as leader) by suggesting to them to stop interacting with their emotions, take a step away from the situation and try to come to a healthy conclusion as to why a certain topic angers a patient and the feeling responses from other patients to this reaction.

When conflict in a group occurs there are different stages that the group functions through. Leszcz & Kobos (2008) state that a leader must be aware of the group’s temperature in regards to certain subjects, or in regards to interpersonal relationship among its members. A leader must be aware that these patients will argue and then come to a treaty. It is vital for a therapist to understand their group’s dynamic in regards to certain things and to anticipate these things, patient’s triggers, and how to calm down the group to an acceptable level so that they may share their angst. Leszcz & Kobos (2008) state that “resolution of group conflicts will lead to the third stage of group development: the norming stage. A new level of trust is established based on conflict resolution rather than polite and superficial cooperation. The norming process begins as members develop a sense of the workability of the group (p. 1248).

Discuss how multicultural training/awareness is essential to co-facilitation, and with clients in the group psychotherapy process?

Yalom (1983) states that therapist may lack traditional training within multicultural groups and as such their ability to properly “facilitate member-to-member interaction and to help members learn from observing their own process” (p. 23) becomes a challenge. Therapists require group training and appropriate supervision in their training which is “rarely available with [multicultural] training” (p. 23). Yalom (1983) points out that there’s another reason there’s such a lack of multicultural training for therapist and this reason is fear (p. 23). The author states that many therapists fear an interactional approach which dominates a multicultural group session. Yalom states that therapist that ignore the multicultural dynamic of a group session, “find themselves drifting, confused, and without the sense of confidence that arises as a result of having a central coherent theory and a body of corresponding strategies and techniques” (p. 24).

Thus, it becomes apparent that a multicultural approach to group therapy is paramount in not only the group’s effectiveness but also the therapist’s effectiveness as leader. Fear, as Yalom states, acts as a deterrent to a therapist’s work and leadership capabilities. Being an effective therapist (aka, a therapist that includes a comprehensive understanding of multicultural issues and awareness) allows the group to function at full capacity. If fears of conflict are a problem then to curtail such insalubrious behavior and lack of communication a properly educated therapist must be placed as a group’s leader. These leaders suggest the worst possible outcomes for in-group therapy, as Yalom states, “…these leaders have received no adequate training. Consequently, inpatient leaders use an ineffective model, or each leader attempts to create an approach de novo…” (p. 13).

Curriculum offered at hospitals and residency programs often ignore or neglect multicultural issues or training. In order to curtail such ignorance, the clinical coordinator of these aforesaid programs must begin developing proper curriculum. This is especially important for post-graduate schools as specific training skills becomes apparent in the courses being taught. Generally speaking, Yalom states that these issues have previously (and still) are only being treated from nursing staff instead of from therapists leading group therapy sessions. Leszcz & Kobos, (2008) state,  “The written preparation also contained elements particularly relevant to those from ethnic and cultural minorities, particularly with regard to cultural prohibitions against self-disclosure and emotional expression (Laroche & Maxie, 2003). In both the preparation groups and the handouts, group norms were articulated and reinforced, with particular attention paid toward confidentiality, reassuring participants that what they talked about in the group would be treated as confidential by the group leaders. It was expected that group participants would do the same” (p. 1247-1248).

List and describe three problematic group members (identified by Yalom). Why are these clients potentially problematic?

Yalom (1983) lists three problematic group members as: the monopolist, silent client, and the help-rejecting complainer. The monopolist exhibits frustration and anger and pushes these feelings into the dynamic of the group. This member finds it difficult to deal with their anxiety. This member is also detrimental to the group’s cohesion. The monopolist exhibits feelings of “worthlessness and self hatred” (p. 135). Yalom (1983) states that supporting this member is a detriment to the cohesion of the group because to feed their negative feelings of worthlessness inflates their ego and they could very well take over the group’s dynamic, communication and trust. The monopolist will oftentimes not say what they’re feeling but rather go through a litany of what other people are putting upon them (feelings of frustration). Other members of the group will remain silent during a monopolist’s usurping of the group because they feel that it gives them a chance to not be the center of attention (depending on what type of member they are) or may not want to interrupt, or feel that that they’re not confident enough to interrupt them. The monopolist is an irritating individual who takes attention away from other patients and thus the other patients’ progress in the group therapy sessions are detrimentally affected. The monopolist will have a comment about everyone else’s problems and either a solution or they will try to steer the conversation back to their own life and problems. They speak in detail about these problems that becomes an issue in a group dynamic because there is a limited amount of time, and that time is effectively being usurped by one individual.

The silent client has a dread of self-disclosure and waits to be initiated by other members of the group or by the therapist. The silent member also often feels threatened by other members of the group thereby making therapeutic progress very difficult. Their silence is not a sign of silence but rather a symptom of an underlying behavior. The silent client may feel threatened by the group’s dynamic or by the therapist and this may prove detrimental to the group’s cohesion because an imbalance will be felt. If members of the group feel that one member isn’t contributing on the same level as they are then an issue of trust begins. The other members of the group begin to wonder why the person is silent and feel that they are being judged by this silence. As such, when a member remains silent it could be interpreted as a negative characteristic. The silent member may fear judgment or fear their own harsh criticism. Also, a silent patient may be scared of another member in the group because they feel threatened by them physically or threatened by them emotionally. The silent patient may also be overwhelmed by the situation that they’re in and have no way to express what they’re feeling because they feel as though they’re drowning in their thoughts and emotions. This causes them to be too anxious to speak up in a group setting.

The help rejecting complainer affects the group negatively by exhibiting extreme signs of irritation, frustration, and confusion. Yalom (1983) refers to this patient as the “yes but” client because everything the therapist says, the patient answers with “yes but”. This means that the  patient feels that there is always an excuse to any situation or an excuse to get out of a situation. They reject solutions given to them either by the group or by the therapist. The group may offer advice for a certain similar situation that the complainer has, and the complainer will reject the advice out of hand by stating that their problem is different in some fundamental way than the other patient’s problem. These patients seem to get a sense of satisfaction in their misery. They see no advice or course of action that could get them out of a certain situation.

References

Kosters, M., Nachtigall, C., Burlingame, G. M., & Strauss, B.  (2006). A meta-analytical review of the effectiveness of inpatient group therapy. Group Dynamics: Theory, Research, and Practice, 10(2), pp. 146-163.

Leszcz, M., & Kobos, J. (2008). Evidence-based group therapy: using AGPA’s practice guidelines to enhance clinical effectiveness. Journal of Clinical Psychology 64(11), pp. 1238-1260.

Yalom, I. D. (1983). Inpatient Group Psychotherapy. USA: Yalom Family Trust.