Practice Guidelines for Group Psychotherapy

Therapist Interventions

There are many ways that the therapist role has been defined in the literature over the years.  One of the most respected contributions was that of Lieberman, Yalom and Miles (1973) in their publication of a comprehensive study of a wide variety of groups and therapist functions.  They identified the groups they studied as “encounter groups,” but in fact they included some groups that traditionally fall under the rubric of therapy groups (e.g. psychoanalytic, transactional analysis, gestalt), along with some that do not (t-group, “Esalen”, personal growth).  Despite the fact that only some of the groups they studied were therapy groups per se, all were aimed at being therapeutic for their participants.  Utilizing factor analysis as their basic statistical tool, they identified four basic functions of the group leader:  executive function, caring, emotional stimulation, and meaning-attribution.  Though this work was done more than 30 years ago, no better schema has been developed for thinking about the different matters to which a group therapist must attend.  This section will review each of these functions in turn.

Executive Function. “Executive function” refers to setting up the parameters of the group, establishing rules and limits, managing time, and interceding when the group goes off course in some way.  All of these functions can be understood as various forms of “boundary management”.  The establishment of boundaries occurs when a group is formed, but the maintenance of those boundaries is a priority to which a therapist must attend at all times.  When a group is running well, there may be little for a therapist to do in this area, but a competent group therapist must be ever vigilant that boundaries are being maintained, and always ready to invoke them when necessary.  A partial listing of the boundaries to which a therapist must attend  includes membership (who is in and who is out), time (when the group begins and ends, whether punctuality becomes a problem), subject matter (is the group attending to what is important, and if not, what can be done about it?), affective expression (are the forms of emotional expression facilitative of therapeutic work?), and anxiety level (titrating it so that it is neither too low nor too high).  Effective executive functioning is essential for good group psychotherapy; it sets the stage for effective therapeutic work to occur. 

Caring. “Caring” refers to being concerned with the well-being of the members of the group, and with the effectiveness of the treatment they are receiving.  This is crucial because the therapist sets the tone for how the members of the group treat and regard each other.  Without the overarching understanding that group members are interested in being of help to each other, a group will founder and potentially become destructive.  This is not to say that members cannot be angry with each other, or give each other critical feedback, but it is imperative that there always be a substrate of trust that people are committed to trying to be of help to each other.  When a therapist senses that this is in question, it is crucial to address it and find a way to reinstitute it in the minds and hearts of the group members.  It is imperative for clients to feel that the group and its members are dedicated to trying to be helpful, even when critical feedback is offered.  Only in this way can members feel trusting of the group, a necessity for a positive therapeutic alliance between each member and the group to develop.  Useful therapeutic work cannot occur without a solid positive therapeutic alliance between each member and the group, including but not limited to the group therapist.

Emotional Stimulation. “Emotional stimulation” refers to the therapist’s efforts to uncover and encourage the expression of feelings, values and personal attitudes.  Of course there are some groups that need very little, if anything, from the therapist on this front, because the members bring all the energy and ability to work in this fashion that is needed.  Other groups require prodding, modeling, bridging (Ormont, 1990), and other forms of therapist-initiated interventions to move in this direction.  Therapy groups work optimally when the therapeutic dialogue is emotionally charged, and yet at the same time controlled enough that group members are able to pull back from the here-and-now exchanges to reflect upon what can be learned about themselves and others in the group.

Meaning-Attribution. “Meaning-attribution” refers to the cognitive aspect of group treatment, and involves the therapist  helping members to develop their ability to understand themselves, each other, and people outside the group, as well as what they might do to change things in their lives.  It is important to note that the development of understanding, or “insight,” is not an emotionally neutral experience; when insight is most useful, it carries an emotional charge because it centers upon matters that are of great emotional importance to the client. Insight may be facilitated by the therapist’s interpretation, but this is not the only way that insight is developed in a group setting.  Members make comments to each other that can facilitate insight.  The therapist might play an active role in promoting such an occurrence, or it might happen spontaneously between two or more group members with the therapist having no active role in the interaction. 

            All of the basic therapist functions (executive function, caring, emotional stimulation, and meaning-attribution) are of significant importance.  The therapist may have to attend to some of these functions a great deal in some groups and very little in others.  What is crucial is that the group have a healthy balance of leader activity ensuring that it runs efficiently with appropriate boundaries being maintained; that members feel they are in an environment in which they are genuinely cared about by the therapist and the other group members; and that there is an ability to move back and forth between emotionally charged exchanges and reflection about, and learning from, what transpires in the group. In addition to these four basic therapist functions, the contemporary group therapist also productively addresses the following allied therapeutic considerations.

Fostering Client Self-Awareness. There is a good deal of misunderstanding about the meaning of the term “insight” (Castonguay & Hill, 2006).  In the psychoanalytic literature, the word usually refers to what might be called “genetic” insight:  coming to understand how some aspect of one’s past is affecting one in the present.  This is indeed one form of insight, but it is not the only one.  Group therapy is particularly suited for helping participants develop other forms of insight:  how other people are affected by them and what is it about other people that elicit particular kinds of responses in them.  These forms of insight are more dynamic and are considered elements of “interpersonal learning” that are developed by the giving and receiving of interpersonal feedback (Yalom & Leszcz, 2005). 

Establishing Group Norms. Group therapists do not “teach” in the direct sense of imparting didactic information that group members are expected to take in.  However, they do establish and reinforce productive group norms that shape the therapy. At times the group norms develop spontaneously. At other times they require direct intervention. This may include directing the dialogue that occurs so that the exchanges are therapeutic for group members.  How do group leaders accomplish this?  By choosing what to respond to and what to ignore; by framing questions they believe are most worth pursuing; and by encouraging members to interact with each other in particular ways.  Of course it is possible that the group therapist’s efforts will be opposed or ignored, but usually groups come to interact in accord with the “shaping” of dialogue that the therapist has engaged in.  Why is this so?  Because the group therapist’s words carry disproportionate weight with group members by virtue of the therapist’s authority, both in objective terms and rooted in transference.

One of the primary modes of exchange that group therapists are most interested in bringing about in their groups is the giving and receiving of interpersonal feedback.  This usually begins when therapists ask questions like “How did people respond to the way Patricia asked Don her question? “, or “Why isn’t anyone saying anything about Linda’s lateness?”  Over time, the group picks up on this kind of prompting, and starts responding to each other without the therapist needing to prod.

Exchanging interpersonal feedback is often facilitated by the therapist modeling the optimal response to feedback that may be directed to her.  The goal is for members to neither accept nor reject feedback reflexively, but rather to consider such feedback as honestly as they can.  Thus, when feedback is offered to the therapist, or when the therapist asks for it, the therapist strives to be as open and non-defensive as possible.  When there is something to be acknowledged, it should be; when the therapist cannot see the validity of what is being suggested, this needs to be said as well, but conveyed with the sense that what has been said has been honestly considered rather than rejected in a defensive way.  Often a member’s feedback represents a perspective that is different from the therapist’s.  When the therapist sees it in this way, it should be acknowledged as such and distinguished from rejecting the feedback as “wrong”.

Another crucial component of effective group treatment is the use of the here-and-now to illuminate individual, sub-group, and group-as-a-whole themes.  Consistent with earlier principles, this is accomplished by the therapist shaping interventions that steer the group, over time, to pay attention to here-and-now phenomena.  When therapists ask, at any point in time, how members are responding to what is occurring at that moment, they are shaping the group in the direction of attending to here-and-now phenomena.  Talking about how members are relating to each other and to the therapist increases the anxiety level that everyone feels in a useful way, because it makes the opportunity for learning much more powerful.  This is not to say that the discussion of historical experiences is without value.  In a well-functioning group, there is a healthy balance between the exploration of members’ current lives outside the group, historical material, and here-and-now phenomena.  It is important to note that the exploration of here-and-now phenomena is not confined to the verbal level.  People communicate a great deal about themselves non-verbally, and these communications become evident in the group therapy setting.  By commenting on such communications when they occur, the therapist is once again shaping the group in a therapeutic direction.

Therapist Transparency and Use of Self.   It is widely recognized that group therapy is a more public form of therapy and that the therapist as a participant and observer is more exposed than in individual treatments.  One of the controversial matters pertaining to the group therapist’s role and technique is that of therapist transparency and how the therapist uses himself in the treatment (Kiesler, 1996; McCullough, 2002; Yalom and Leszcz, 2005).  What should therapists reveal about themselves, and what should they keep private?  Two principles are particularly important: Therapists should not reveal anything that they are uncomfortable sharing about themselves; and the only legitimate rationale for the therapist’s personal disclosure is the conviction that it will facilitate the work of the group at that moment in time.

            Therapists will have different thresholds for what they are prepared to reveal about themselves.  Rachman (1990) drew the distinction between “judicious” self-disclosures (appropriate level of detail, focus remains on the client) and “excessive” self-disclosures (self-aggrandizing stories, shifting the focus to the therapist).  It is also important to note that group therapists reveal things about themselves in a number of ways, including but not limited to the following:  body posture, voice inflection, what they wear, how they set up their offices, how they handle fees and other arrangements, and how they interact with an array of people.  All of these are forms of “metacommunication” that all human beings engage in.  We reveal things about ourselves all the time; effective group therapists are aware of what they are communicating.  Group therapists are more “exposed” than individual therapists because they interact with a variety of people, who elicit different aspects of their identity, simultaneously and in front of everyone in the group.

            Sometimes therapist self-disclosure involves telling group members about experiences outside the group that will hopefully be illuminating in relation to what is being discussed at a particular point in time.  At other times, a therapist self-disclosure will involve describing his or her experience of someone in the group. Feedback about the group member’s behavior and interpersonal impact can be very useful, particularly if it models for the group the process of feedback and is delivered in a way that is constructive without shaming or blaming the client.  If the therapist and member in question have a positive therapeutic alliance, and the therapist offers the feedback in a way that indicates interest and concern rather than anger and a wish to be hurtful, this kind of intervention can be enormously helpful, not only for the individual in question but for the group as a whole.

                                                       Summary

1.         The therapist’s interventions consist of a range of integrated but distinct actions that are most effective when they are well balanced with one another: These actions also establish the norms for group work.

2.         The therapist’s executive functions encompass the coordination of the group and regulation of the boundaries of the group.

3.         The therapist conveys care directly and also models caring for the group members.

4.         The therapist plays an important role in activating emotion within the group.

5.         The activation of emotion is ideally followed by the attribution of meaning to the group member’s personal experience.

6.         These actions contribute to the client’s learning and acquisition of insight.

7.         The judicious use of self-disclosure by the therapist can have substantial therapeutic impact.

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©2007 American Group Psychotherapy Association