Surgeon General’s Report

GROUP THERAPY WITH CHILDREN

Group psychotherapy is effective with emotional disorders in children ranging from severely disturbed children to young people with mild emotional disorders or situational emotional crises. Play group therapy for the pre-school aged child, activity group therapy and discussion-activity group therapy for younger and older latency-aged children, and theme centered groups, organized around a specific emotional disturbance such as bereavement, are proven as a preferred intervention that successfully heals children at risk with emotional traumas and problems when conducted by a qualified group psychotherapist.

REFERENCES:

Frank, M.G. (1976). Modification of activity group therapy: Response to ego-impoverished children. Clinical Social Work Journal, 4, 102-109.

Ginott, H. (1961). Group psychotherapy with children. New York: McGraw-Hill.

MacLennan, W.B. (1977). Modifications of activity group therapy for children. International Journal of Group Psychotherapy, 27, 85-96.

Redl, F., & Wineman, D. (1957). The aggressive child. New York: Free Press.

Riester, A.E., & Kraft, I.A., Eds. (1986). Child group therapy: Future tense. Madison, CT: International Universities Press.

Rosenthal, L. (1953). Countertransference in activity group therapy. International Journal of Group Psychotherapy, 3, 431-440.

Rosenthal, L. (1977). Qualification and tasks of the group therapist with children. Clinical Social Work Journal, 5, 191-199.

Schamess, H.G. (1976). Group treatment modalities for latency-age children. International Journal of Group Psychotherapy, 26, 455-473.

Schamess, H.G. (1986). Differential diagnosis and group structure in outpatient treatment of latency-age children. In A.E. Riester, & I.A. Kraft (Eds.), Child group psychotherapy: Future tense. (pp. 26-68). Madison, CT: International Universities Press.

Scheidlinger, S. (1974). On the concept of the “mother group.” International Journal of Group Psychotherapy, 24, 417-428.

Scheidlinger, S. (1992). Therapist gender in child and adolescent treatment groups. Journal of Child and Adolescent Group Therapy, 2, 105-108.

Schiffer, M. (1969). Therapeutic play group. New York: Grune and Stratton.

Schiffer, M. (1977). Activity-Interview group psychotherapy: Theory, principles and practice.

Slavson, S., & Schiffer, M. (1975). Group Psychotherapies for children. New York: International Universities Press.

Soo, E.S. (1985). Application of object relations in children’s group psychotherapy. International Journal of Group Psychotherapy.

Soo, E.S. (1986). Training and supervision in child and adolescent group psychotherapy. In A.E. Riester and I.A. Kraft (Eds.), Child group psychotherapy: Future tense. (pp. 157-171). Madison, CT: International Universities Press.

Trafimow, E., & Pattak, S. (1981). Group treatment of primitively fixated children. International Journal of Group Psychotherapy, 32, 445-452.


GROUP THERAPY FOR ADOLESCENTS

Group therapy is particularly suited to meet the developmental needs of adolescents, whose major psychological task is separation-individuation. Affiliation to a peer group is primary so that dependency can shift from parents to peers. Thus, in order for adolescents to develop normally, they need the social skills to operate in a group and connect with peers or adolescent pathology arises. The therapy group provides a constructive transitional object to build ego development, learn social skills and eventually achieve constructive independent functioning.

REFERENCES:

Kymissis, P., & Halperin, D.A., Eds. (1996). Group therapy with children and adolescents. Washington, DC: American Psychiatric Press.

MacLennan, B.W., & Dies, K.R. (1992). Group counseling and psychotherapy with adolescents. New York: Columbia University Press.

Rachman, A.W. (1995). Identity group psychotherapy with adolescents. New Jersey: Jason Aronson, Inc.

Scheidlinger, S. (1985). Group treatment of adolescents: An overview. American Journal of Orthopsychiatry, 55, 102-111.


GROUP THERAPY WITH GAY, LESBIAN AND BISEXUAL TEENS

Because peer influence is so great in adolescence, group therapy is a logical and effective treatment modality providing psychosexual education to provide accurate information about human sexuality, gender identity and sexual orientation; a forum to explore with peers myths, fears, stereotypes, concerns about dating and other age appropriate concerns; and the guidance of a therapist to resolve clinical psychological issues. Adolescence is a time of great personal upheaval, and for gay, lesbian and bisexual adolescents who must come to terms with a divergent sexual identity, this developmental task is particularly daunting. The higher incidence of suicide in gay adolescents (Report of the Secretary’s Task Force of Youth Suicide, U.S. Department of Health and Human Services, 1989) underscores the urgent need to support gay, lesbian and bisexual teens.

REFERENCES:

Hetrick, E., & Martin, D. (1987). Developmental issues and their resolution for gay and lesbian adolescents. Journal of Homosexuality, 17 (1/2), 25-43.

Malyon, A.K. (1981). The homosexual adolescent: Developmental issues and social bias. Child Welfare, LX(5), 321-330.

McLaughlin, R.J., & Morgan, P. (November 1993). Sexual minority students: Recognizing the struggles and reducing environmental risks. Presentation at the 37th annual Texas Counseling Association professional growth conference. Galveston, TX.

Report of the Secretary’s Task Force of Youth Suicide (1989). U.S. Department of Health and Human Services, ADAMHA, Washington, DC.


GROUP THERAPY FOR ADULTS IN CRISIS

Supportive group therapy is a treatment most suited to treat the blow to self-esteem and the impaired coping capacity that comes with a life crisis. Contact with others, experiencing commonality with others (“I am not alone”), identification with others, and hearing positive reflections helps self-esteem. Being able to articulate one’s thoughts and feelings, acquiring new information, and exposure to others’ coping mechanisms enhances ego strength, thus improving coping capacity.

REFERENCES:

Lonergan, Elaine (1982, 1985, 1989). Group intervention. New Jersey: Jason Aronson, Inc.

Lonergan, Elaine (1985). Utilizing group process in crisis, waiting list groups. International Journal of Group Psychotherapy, 35(3), July.


GROUP THERAPY FOR ADULTS WITH MOOD DISORDERS

Intensive group therapy lasting from 8 to 28 sessions within six months (MacKenzie, 1997) is as efficacious as individual therapy in the treatment of adult mood disorders (DeRubeis and Crits-Christoph, 1998; McRoberts, Burlingame and Hoag, 1998). When problems are well-defined and treatment episodes are short (i.e., less than ten sessions), group treatment may be more effective than individual (McRoberts, Burlingame and Hoag, 1998). Patients report satisfaction with, and benefit from, group therapy experiences that have been delivered under many different conditions (Seligman, 1998). Reports indicate that the incidence of adult mood disorders is high and group psychotherapy provides efficacious and effective treatment for these debilitating diagnoses.

REFERENCES:

DeRubeis, R.J., & Crits-Christoph, P. (1998). Empirically supported individual and group treatments for adult mental disorders. Journal of Consulting and Clinical Psychology, 66, 37-52.

MacKenzie, K.R. (1997). Time-managed group psychotherapy: Effective clinical applications. Washington, DC: American Psychiatric Press.

McRoberts, C., Burlingame, G.M., & Hoag, M.J. (1998). Comparative efficacy of individual and group psychotherapy: A meta-analytic perspective. Group Dynamics: Theory, Research and Practice 2, 101-178.

Seligman, M.E.P. (1995). The effectiveness of psychotherapy: The Consumer Reports study. American Psychologist, 50, 965-974.


GROUP THERAPY FOR ADDICTIVE DISORDERS

There is a growing consensus among substance abuse treatment specialists that group psychotherapy is the treatment of choice for addictive disorders (Khantzian, Halliday and McAuliffe, 1990; Vannicelli, 1988; Brown, 1985; Mahon and Flores, 1993; Mantano and Yalom, 1991; Flores, 1988, 1997). Cost effectiveness is just one of the many advantages that group therapy provides over individual and other forms of therapy (Vannicelli, 1988). The advantages of a properly conducted therapy group include, but are not limited to: promotion of abstinence, dilution of destructive aspects of relationships, support containment, identification, confrontation of self-defeating defenses, attachment, shame reduction, and ultimately the alteration of character pathology (Washton, 1992; Flores, 1997; Mantano and Yalom, 1992; Kemker, Kibel and Mahler, 1993).

REFERENCES:

Brown, S. (1985). Treating the alcoholic: A developmental model of recovery. New York: John Wiley & Sons.

Flores, P. (1997). Group psychotherapy with addicted populations: An integration of twelve-step and psychodynamic theory. 2nd edition. Binghampton, NY: The Haworth Press.

Flores, P. (1988). Group psychotherapy with addicted populations. New York: The Haworth Press.

Flores, P., & Mahon, L. (1993). The treatment of addiction in group psychotherapy. International Journal of Group Psychotherapy, 43, 205-224.

Kemker, S.S., Kibel, H.D., & Mahler, J.C. (1993). On becoming oriented to inpatient treatment: Inducing new patients and professionals to recovery movement. International Journal of Group Psychotherapy, 43, 285-302.

Khantzian, E.J., Halliday, K.S., & McAuliffe, W.E. (1990). Addiction and the vulnerable self. New York:

Guilford Press.

Matano, R.A., & Yalom, I. (1991). Approaches to chemical dependency: Chemical dependency and interactional group psychotherapy. International Journal of Group Psychotherapy, 41, 269-294.

Vannicelli, M. (1992). Removing the roadblocks: Group psychotherapy with substance abusers and family members. New York: Guilford Press.

Washton, A.M. (1992). Structured outpatient group psychotherapy with alcohol and substance abusers. In

J. Lowinson, P. Ruiz, & R. Millman (Eds.), Substance abuse: A comprehensive textbook. Baltimore: Williams and Wilkens.


GROUP THERAPY FOR ADULTS WITH GENDER IDENTITY ISSUES

Gender, including biological givens plus cognitive components of being a man or a woman, has three spheres of reality: (1) the psychological sphere; (2) the interpersonal/social sphere; and (3) the political sphere. When aspects of the self are split off or distorted, or relationships are gender stereotypical, living is impoverished and relationships vulnerable to dysfunction. In the “here and now” of the therapy group, these psychological, interpersonal and political problems can be addressed and understood so that group members increase options for themselves and their way of relating to others inside the therapy group and outside in their private and public life.

REFERENCES:

Jensen, S. Developments in a psychology of women and group psychotherapy. Lecture to Philadelphia Group Psychotherapy Society, April 3, 1998.

Lazerson, J.S., & Zilbach, J.J. (1996). Gender Issues in Group Psychotherapy. In H. Kibel (Ed.), Handbook of Group Psychotherapy.

Zilbach, J.J. (1993). Female Adolescence: Toward a Separate Line of Development. In Sugar (Ed.), Female Adolescence and Development. (pp. 45-61). New York: Brunner Mazel.


GROUP PSYCHOTHERAPY WITH PERSONALITY DISORDERS

Since personality disorders involve disturbances in relationships emanating from early childhood imprinting, they usually require extended psychotherapy to overcome well-learned, automatic behavior patterns. Group psychotherapy may be used to help change maladaptive behaviors through insights and new corrective experiences. Groups offer the opportunity (1) to receive useful feedback from both therapist and peers in a supportive setting; (2) to observe and identify with the healthy reactions of other members; and (3) to try new, more adaptive behaviors in a positive, accepting environment.

REFERENCES:

Azima, F.J. (1993). Group psychotherapy with personality disorders. In H.I. Kaplan, & B.J. Sadock (Eds.), Comprehensive Group Psychotherapy. (pp. 393-406). Baltimore: Williams and Wilkins.

Horwitz, L. (1994). Depth of transference in groups. International Journal of Group Psychotherapy, 44, 271-290.

Kauff, P.F. (1991). The unique contributions of analytic group therapy to the treatment of pre-oedipal character pathology. In S. Tuttman (Ed.), Psychoanalytic Group Therapy and Theory. (pp. 175-194). Madison, CT: International Universities Press.


GROUP THERAPY WITH GAY, LESBIAN AND BISEXUAL ADULTS

Group therapy for gay, lesbian and bisexual adults helps them complete a series of tasks in order to develop and maintain a positive gay identity (Cass 1979; Coleman, 1981); group psychotherapy provides fertile ground for this developmental process (Frost, 1996). Groups with gay, lesbian and bisexual members help group members to normalize their sexual feelings and experiences, give and receive social support from peers, explore cultural myths about sexuality and sexual orientation, work through their own negative stereotypes (Malyon, 1982), identify ways to deal with discrimination, and use group members as positive role models. Because stigma still surrounds homosexuality and bisexuality, heterogeneous groups can provide gay, lesbian and bisexual members an opportunity to learn to function visibly and comfortably as a sexual minority in the larger culture (Hawkins, 1998).

REFERENCES:

Cass, V. (1979). Homosexual identity formation: a theoretical model. Journal of Homosexuality, 4(3), 219-236.

Coleman, E. (1981/82). Developmental stages of the coming-out process. Journal of Homosexuality, 7(2/3), 31-44.

Frost, J.C. (1996). Working with gay men in psychotherapy groups. In M.P. Andronico (Ed.), Men in groups: Insights, interventions, and psychoeducational work. (163-169). Washington, DC: American Psychological Association.

Hawkins, D.M. (1998). Comments on countertransference considerations. International Journal of Group Psychotherapy, 48(1), 31-38.


INPATIENT GROUP PSYCHOTHERAPY FOR ADULTS

Benefits of inpatient group psychotherapy accrue from the sense of commonality that patients feel in being in the hospital or partial-hospital milieu. Sharing, catharsis and the mutual support that they provide one another are ego reinforcing. Patients give each other constructive feedback that differs from staff feedback because it comes from a peer. The bonding that patients feel in the group serves to reduce acting-out behavior on the unit and fosters a positive therapeutic alliance, enhancing overall compliance with treatment.

REFERENCES:

Kibel, H.D. (1993). Group Psychotherapy. In Leibenluft, E., Tasman, A., & Green, S.A. (Eds.), Less time to do more: Psychotherapy on the short-term inpatient unit. (pp. 80-109). Washington, DC: American Psychiatric Press, Inc.

Yalom, I.D. Inpatient group psychotherapy. New York: Basic Books, 1983.


GROUP THERAPY FOR THE ELDERLY

The group psychotherapies are important components of treatment of mental disturbance and distress in the elderly, including those in ambulatory, inpatient and residential environments. Group may be employed as an adjunct to other treatments, including pharmacotherapy, or as an independent treatment. Empirical evidence and clinical experience support group’s effectiveness in enhancing psychological well-being, improving social integration and interpersonal effectiveness, and reducing symptomatic disturbances while addressing the impact of interpersonal loss, social isolation and withdrawal that contribute to reduced quality of life and disorders of mood, in the elderly.

REFERENCES:

Leszcz, M. (1996). Group Therapy. In J. Sadavoy, L.W. Lazarus, L.F. Jarvik, & G.T. Grossberg (Eds.), Comprehensive review of geriatric psychiatry II. Washington, DC: AP Press, Inc.


GROUP THERAPY FOR THOSE DEALING WITH LOSS

Time-limited, short-term group therapy is an effective and efficient treatment for psychiatric outpatients who have not adapted well to the loss of one or more persons in their lives. In controlled trials, patients participating in loss groups have evidenced clinically important improvements in such areas as depression, low self-esteem, and preoccupation with their losses. The time-limited structure of the therapy group provides an ideal opportunity for learning and change regarding issues of loss.

REFERENCES:

Piper, W.E., McCallum, M., & Azim, H.F.A. (1992). Adaptation to loss through short-term group psychotherapy. New York: Guilford Press.

Stroebe, M.S., Stroebe, W., & Hansson, R.O., Eds. (1993). Handbook of bereavement. Cambridge, UK: Cambridge University Press.


GROUP PSYCHOTHERAPY AND MANAGED CARE

Group psychotherapy has demonstrated effectiveness and safety; the nature of the modality also provides a cost-effective method for providing intensive psychotherapy. Managed Care Organizations and insurance coverage must provide funding for this service at a rate that will encourage its utilization (for example, 40-50% of the individual 60-minute rate per 90-minute group session). MCOs must develop group psychotherapy programs that can stream clients into an appropriate array of groups at an early point. This requires the use of clinicians who have specialized training in the use of groups and who have been properly certified to provide that specific treatment. Formal “best practice” guidelines should be followed.

REFERENCES:

Budman, S.H., Demby, A., Redondo, J.P., Hannan, M., Feldstein, M., Ring, J., & Springer, T. (1988). Comparative outcome in time-limited individual and group psychotherapy. International Journal of Group Psychotherapy, 38, 63-86.

Budman, S.H., Cooley, S., Demby, A., Koppeneal, G., Koslof, J., & Powers, T. (1996). A model of time-effective group psychotherapy for patients with personality disorders: the clinical model. International Journal of Group Psychotherapy, 46, 329-355.

Budman, S.H., Demby, A., Soldz, S., & Merry, J. (1996). Time-limited group psychotherapy for patients with personality disorders: Outcomes and dropouts. International Journal of Group Psychotherapy, 46, 357-377.

Fuhriman, A., & Burlingame, G.M., Eds. (1994). Handbook of group psychotherapy: An empirical and clinical synthesis. New York: Wiley.

Glass, G.V., & Miller, T.I. (1980). The benefits of psychotherapy. Baltimore: Johns Hopkins University Press.

Joyce, A.S., Duncan, S.C., Duncan, A., Kipnes, D., & Piper, W.E. (1996). Limiting time-unlimited group psychotherapy. International Journal of Group Psychotherapy, 46, 61-79.

MacKenzie, K.R. (1997). Time-managed group psychotherapy: Effective clinical applications. Washington, DC: American Psychiatric Press.

MacKenzie, K.R., Ed. (1995). Effective use of group therapy in managed care. Washington, DC: American Psychiatric Press.

Piper, W.E., McCallum, M., & Azim, H.F.A. (1992). Adaptation to loss through short-term group psychotherapy. New York: Guilford Press.

Spitz, H. (1996). Group psychotherapy and managed mental health care: A clinical guide for Providers. New York: Brunner Mazel.

Tillitski, C.J. (1990). A meta-analysis of estimated effect size for group vs. individual vs. control treatments. International Journal of Group Psychotherapy, 40, 215-224.

Toseland, R.W., & Siporin, M. (1986). When to recommend group treatment: A review of the clinical and group literature. International Journal of Group Psychotherapy, 36, 171-201.


GROUP THERAPY FOR THE MEDICALLY ILL

Group psychotherapy specifically designed for those with medical illness may be the most powerful psychosocial intervention available for this population, as it serves the special needs of these patients in ways that are distinct from any other form of psychotherapy (Spira, 1997). By providing a safe and supportive environment, group psychotherapy can enable patients to confront some of life’s most significant issues (i.e., self-image, life goals, existential issues, etc.), which can allow them to live more fully in the face of illness or impending death. Additionally, group interventions for medically ill persons target the same psychosocial factors (i.e., life stresses, coping strategies, appraisal of stress, and depressed mood) which have been associated with altered immune functioning in humans, thus holding the promise of enhancing host resistance to illness, as well as quality of life (Spira, 1997). Empirical studies of group psychotherapy for cancer (Spiegel et. al., 1989; Fawzy et. al., 1993), human immunodeficiency virus (HIV) (Ironson et. al., 1994), and cardiac patients (Friedman et. al., 1986; Ornish et. al., 1992) have demonstrated that group treatment enhances both emotional adjustment and disease outcome.

REFERENCES:

Fawzy, F.I., Fawzy, N.W., Hyun, C.S., Guthrie, D., Fahey, J.L., & Morton, D.L. (1993). Malignant melanoma: Effects of an early structured psychiatric intervention, coping and affective state on recurrence and survival six years later. Archives of General Psychiatry, 50, 681-689.

Friedman, M., Thoresen, C.E., Gill, J., Ulmer, D., Powell, L.H., Price, V.A., Brown, B., Thompson, L., Rabin, D.D., Breall, W.S., Bourg, W., Levy, R., & Dixon, T. (1986). Alteration of Type A behavior and its effect on cardiac recurrences in post-myocardial infarction patients: Summary results of the Recurrent Coronary Prevention Project. American Heart Journal, 112, 653-665.

Ironson, G., Friedman, A., Klimas, N., Antoni, M.H., Fletcher, M.A., Simoneau, J., LaPerriere, A., & Schneiderman, N. (1994). Distress, denial and low adherence to behavioral interventions predict faster disease progression in HIV-1 infected gay men. International Journal of Behavioral Medicine, 1, 90-105.

Ornish, D., Brown, S.E., Scherwitz, L.W., Billings, J.H., Armstrong, W.T., Ports, T.A., McLanahan, S.M.,

Kirkeeide, R.L., Brand, S.J., & Gould, K.L. (1992). Can lifestyle changes reverse coronary heart disease? Lancet, 336(8708), 129-133.

Spiegel, D., Bloom, J.R., Kraemer, H.C., & Gottheil, E. (1989). Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet, 1(8668), 888-891.

Spira, J.L. (1997). Understanding and developing psychotherapy groups for medically ill patients. In J.L.

Spira (Ed.), Group therapy for medically ill patients. (pp. 3-11). New York: Guilford Press.


GROUP THERAPY FOR PATIENTS WITH SCHIZOPHRENIA

Group therapy is important treatment for individuals diagnosed with schizophrenia in two ways: members educated about the known facts of the illness and treatment options are more likely to comply and benefit from the treatment.

Additionally, groups provide patients the opportunity to learn to form and maintain social relations which is difficult because they feel different, and indeed, because of subtle neurological deficits and behavioral manifestations, they have been pushed aside or shunned early in life. Professionally led groups help individuals examine their difficulties in relationships — an antidote both to the prior experiences and as a protection against social isolation and further clinical deterioration.

REFERENCES:

Kanas, N. (1996). Group therapy for schizophrenic patients. Washington, DC: American Psychiatric Press.

Stone, W.N. (1996). Group psychotherapy for people with chronic mental illness. New York: Guilford Press.