Practice Guidelines for Group Psychotherapy

Group Process

Introduction.  While definitions vary considerably, group process generally refers to what happens in the group, particularly in terms of the development and evolution of patterns of relationships between and amongst group participants (Beck & Lewis, 2000; Yalom & Leszcz, 2005).  These processes occur at both observable and inferred levels. Observable processes consist of verbal (e.g. speech content; expressed affects) and nonverbal behaviors that have been conceptualized, operationalized and assessed from fine-grained to very abstract levels of analysis (cf. Beck & Lewis, 2000). Inferred or covert group processes refer to conscious and unconscious intentions, motivations, wishes, and needs enacted by individual participants, dyads, subgroups or the group-as-a-whole. These processes can serve both adaptive, work-oriented, therapeutic ends or defensive, work-avoidant or resistive purposes (Hartman & Gibbard, 1974).  Elucidation of group process serves a critical function in group psychotherapy. It contributes centrally to both the successful development of the group itself as a viable and therapeutic social system in which interpersonal interaction occurs and to the individual learning about self in relation to others. These are the mechanisms through which therapeutic change occurs. 

Group as a social system.  It is useful to view the therapy group as a social system with the group therapist as its manager. The group therapist’s primary function in that role is to monitor and safeguard the rational, work-oriented boundaries of the group, ensuring that members experience it as a safe, predictable and reliable container with an internal space for psychological work to occur (Cohn, 2005).  The literature describes many group-wide overt behaviors and latent group processes that aim at distorting the established therapeutic boundaries, therapeutic frame or group contract, i.e., the normative expectations and explicit structural arrangements established for running the group.  Commonplace examples of these processes include subtly changing the task of the group (known as task drift), acting out against the ground rules of promptness and regular attendance (time boundaries) and confidentiality (spatial boundaries), or resisting work (work role boundaries).  Such processes can impede or jeopardize task achievement.  There is a growing appreciation of the importance of understanding these overt or covert group processes so that the therapist may modulate anti-therapeutic forces and enhance positive ones (Lieberman, Miles and Yalom, 1973; Ward & Litchy, 2004). This is relevant even in those settings where the explicit examination of group process is not considered part of the usual therapeutic work (such as CBT (Bieling et al., 2006) and psychoeducational (Ettin, 1992) groups).

Work, therapeutic and anti-therapeutic processes.  Because of the prevalence of anti-therapeutic and anti-group processes, it is important for the therapist to develop and maintain clear and explicit conceptions of both the primary task of the group - the purpose or goal of the group- and how to achieve it. Clarity about what constitutes therapeutic work for the individual group participant and the group therapist is particularly useful (Newton & Levinson, 1973).  That is, the therapist needs to be able to distinguish processes that are work-oriented from those that resist, avoid or defend against therapeutic work.  While the capacity of the group to engage in work is directly related to therapeutic outcome (Beck & Lewis, 2000; Piper & McCallum, 2000), the therapist should consider work in a dialectic relationship to non-work processes, and strive for a balance that allows for therapeutic progress but at a pace that participants can tolerate.  The therapist should appreciate that containing and working through destructive forces (in the group, the context of the group, or in the group leader) holds the possibility for creative growth and therapeutic change (Nitsun, 1996).

Work processes are defined both by the particular school of psychotherapy or theoretical framework (for example, interpretations of underlying conflicts as dictated by psychodynamic theory) that guides the overall enterprise, as well as by common or nonspecific therapeutic processes, such as cohesion or the therapeutic alliance. Two pantheoretical processes have garnered considerable empirical and clinical-theoretical support as predictors of successful treatment outcome: interpersonal feedback, central to the therapeutic factor of interpersonal learning (Burlingame et al., 2004; Yalom and Leszcz, 2005); and the therapeutic alliance (Joyce et al., in press) between the individual group member and the therapist.  Other group process variables that have received some, although mixed, empirical support in terms of facilitating positive outcomes are cohesion and group emotional climate.

The Group as a Whole.  Group-as-a-whole processes refer to those behaviors or inferred dynamics that apply to the group as a distinct psychological construction.  Cohesion is the most extensively discussed group-as-a-whole process in the clinical-theoretical and empirical literatures.  While conceptual and operational definitions of the term vary (Dion, 2000; Burlingame et al., 2002), cohesion generally refers to the emotional bonds among members for each other and for a shared commitment to the group and its primary task (see also the previous section on therapeutic mechanisms).  Cohesion is often regarded as the equivalent of the concept of therapeutic alliance in individual psychotherapy and, like that latter term, is the group process variable generally linked to positive therapeutic outcome.  Exaggerated forms of group cohesion, however, ranging from such phenomena as massification (Hopper, 2003), fusion (Greene, 1983), oneness (Turquet, 1974), deindividuation (Deiner, 1977), contagion (Polansky et al., 1950) and groupthink (Janis, 1994) at one extreme, to aggregation (Hopper, 2003), fragmentation (Springmann, 1976), individuation (Greene, 1983) and the anti-group (Nitsun, 1996) at the other extreme, can divert the group from meaningful therapeutic work.  The therapist should monitor the nature of the emotional bonds and commitment of the members and help the group attain a dialectic balance between needs for relatedness and communion on one hand, and needs for autonomy and differentiation on the other.

Beyond the level of cohesion, the group-as-a-whole can be perceived, experienced and represented in the minds of the members with a range of positive (e.g., engaging) and negative (e.g., conflictual) attributes (MacKenzie, 1983; Greene, 1999), that the leader needs to assess since they can affect task accomplishment.  The group may be experienced as the “good mother” with protective, holding and containing capacities (Scheidlinger, 1974) or as the ‘bad-mother”, who can engulf, annihilate or devour the individual (Ganzarain, 1989). These contrasting images of the group, formed from socially-shared projections, have been well described in the clinical-theoretical literature. Other collusive group-wide processes and formations have been identified that can serve defensive and work-avoidant needs.  For example, Bion’s basic assumptions of dependency, fight-flight and pairing (Rioch, 1970) or devolution to a rigid, turn-taking pattern of communication, often arise in the context of some anxiety resonating among the members.  This regressive process needs to be dealt with as a priority, via interpretation or confrontation (Yalom & Leszcz, 2005; Ettin, 1992), in order to allow the group to shift towards more task-oriented, less defensive behavior.

Splits and subgroups.  To cope with group-induced anxieties, groups can form us-versus-them or in-versus-out polarities and splits via projective processes where disowned aspects of self, in concert with other participants, are externalized into some other segment of the group (Agazarian, 1997; Hinshelwood, 1987).  These internal arrangements are typically seen as defensive arrangements that can subvert task accomplishment and ultimately need to be managed by the group therapist.

The Pair or Couple.  The pair in the group (Rioch, 1970;Kernberg, 1980;) can represent a re-enactment and recapitulation of Oedipal-level or neurotic-level wishes and tensions as well as more primitive, group-level defensive processes against underlying depressive or other disturbing affect.  Such a dynamic can be acted out via extra-group liaisons (sexual or otherwise) or enactments in the group that can profoundly disrupt the therapeutic framework.  The group therapist will likely need to address such potentially destructive processes through exploration, interpretation or confrontation.

The Individual Member and Leader Roles.  The formation of the scapegoat (Horwitz, 1983; Moreno, in press) and other nonrational restrictive, delineated roles such as the spokesperson, hero, and difficult patient (Bogdanoff & Elbaum, 1978; Rutan, 2005) are prominent group phenomena.  It is important for the therapist to understand that these roles emerge not only from the needs and personalities of the individuals filling them, but also from collusive enactments, co-constructions or mutual projective identifications between the individual and the group (Gibbard, Hartman, & Mann, 1974).  Moreover, such unique roles are not “all bad” or destructive; they may serve important functions for the entire group, including speaking the unspeakable, stirring emotions and revitalizing the group, carrying unacceptable aspects of others, and even creating a sense of hope (Shields, 2000).

Beyond functioning as the rational work leader and manager of the social system of the therapy group, the therapist’s role may become endowed, via collective projective processes or shared transferences, with either all-good, idealized or all-bad, persecutory attributes (Kernberg, 1998, Slater, 1966), potentially resulting in non-therapeutic countertransference enactments.  The management of the therapist’s countertransference, through the containment of the group’s projections, is related to positive therapeutic outcome (cf. Powdermaker & Frank, 1953).  Management of countertransference in the group setting is considered more difficult than in individual therapy, however, because of the multiple and shared transferences directed towards the therapist and because of the public nature of the work. It is paramount for the leader to attend to his or her emotional reactions, especially if they fall outside the norm for the therapist, and to persist in exploring their roots, in an ongoing way. It is important to distinguish, whether these reactions emerge from the therapist’s internal world (“subjective countertransference”) or are induced from the social environment and interpersonal interaction (“objective countertransference”) (Counselman, 2005). Self-awareness and self-care are crucial in countertransference management. Regular consultation with a co-therapist or supervisor/consultant can also be very useful.

Summary

1.     Group process generally refers to what happens in the group, especially in

terms of the development and evolution of patterns of relationships between and

among group participants.

2.     The therapy group is a social system with the group therapist as its

manager, whose primary function is to monitor and safeguard the work-oriented

boundaries of the group so that members experience it as a safe container with

an internal space in which psychological work can occur.

3.     The therapist needs to be able to distinguish processes that are work-

oriented from those that resist, avoid or defend against work.  The therapist

should appreciate that containing and working through destructive forces (in the

group, the context of the group, or in the group leader) holds the possibility for

creative growth and therapeutic change.

4.     Cohesion generally refers to the emotional bonds among members for each

other and for a shared commitment to the group and its primary task.  It is often

regarded as the equivalent to the concept of therapeutic alliance in individual

psychotherapy and is the group process variable generally linked to positive

therapeutic outcome.

5.     The management of the therapist’s countertransference, through the

containment of the group’s projections, is related to positive therapeutic

outcome. Self-awareness and self-care are crucial in countertransference

management. Regular consultation with a co-therapist or supervisor/consultant

can also be very useful.

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©2007 American Group Psychotherapy Association