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Group Therapy and Social Learning Principles: Purpose, Process, and Applications
Abnormal Psychology · Chapter 24: Therapeutic Approaches in Mental Health PracticeSection 24.2 · lesson 91 of 9716 min · free with a free account
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In this lesson
When what people do with each other is the treatment.
- Describe group therapy, its types, and its therapeutic factors
- Describe family and couple approaches, and the systemic concepts beneath them
- Explain when group and family work are indicated, and when contraindicated
- Describe the safeguards that apply
Transcript
Everything said in the video, section by section (2,181 words). Read along, or search it.
Therapeutic Approaches in Mental Health Practice
Group, Family, and Couple Therapy
This section moves from one-on-one work to groups, families, and couples. It describes group therapy, its types, and the therapeutic factors that operate within it. And it describes family and couple approaches, and the systemic concepts they rest on. Throughout, it asks when these formats are indicated, when they are contraindicated, and what safeguards apply.
Before You Begin
How These Approaches Work - Not How to Run Them
This material is educational. It describes how group and family approaches work. It is not a training manual. It is not a basis for running a group, and not a basis for intervening in a family. These treatments are delivered by trained, supervised practitioners. Anyone seeking help should approach a qualified professional.
What Group Therapy Is
The Group Itself Is Part of the Treatment
Group therapy is a structured therapeutic process in which the group itself is part of the treatment. The distinction that matters is from individual therapy delivered efficiently to several people at once. In that case, members happen to be in a room together, while each receives something addressed to them. In group therapy, what members do with and to each other is the mechanism. That distinction determines almost everything else. How members are selected, what the facilitator does, and what can go wrong. A group run as parallel individual therapy is not a weaker version of group therapy. It is a different intervention, with the costs of a group and few of its benefits.
Table 24.2.1
Types of Group
This table sets out the types of group. Read the aim and leadership columns together. Process-oriented groups aim at change through what happens between members. The leader is facilitative, working with the group's process. They are supported for interpersonal difficulties, but harder to evaluate. Structured, skills-based groups teach and practice specific skills. The leader is directive, and delivers content. Their evidence is good, and closest to the individual evidence base. Psychoeducational groups offer information and understanding, for members or families. In family psychoeducation, the evidence for reducing relapse is strong. Support groups offer shared experience and mutual encouragement. They are valued by members, but less studied as treatment. And peer-led mutual aid runs outside professional services, with no clinician. Participation is associated with better outcome, as section eighteen point four described. Notice that aim and leadership vary together. The more the group's own process is the mechanism, the less directive the leadership.
In the Clinic
Therapy, Support, and Mutual Aid Aren't the Same
Members, and referrers, frequently arrive expecting one kind of group and find another. A support group offers shared experience and encouragement. It is usually continuing, and it asks little. A therapy group asks members to notice and discuss what happens between them. That is uncomfortable, and it is the point. Peer-led mutual aid is different again, and it is not therapy. Nobody is a clinician, nothing is prescribed, and the relationship is between equals. It is distinct, and valuable. Referring someone to a therapy group when what they want is a support group produces early dropout, and a person who concludes that groups do not suit them. Naming the difference at referral prevents most of this.
Table 24.2.2 - Therapeutic Factors (1)
What Groups Supply That Individual Work Can't
A recognized set of therapeutic factors describes what groups supply that individual work does not. Universality is discovering that one's experience is not unique. It is often the first thing members report as helpful, and no clinician's reassurance can give it. Instillation of hope comes from members further on, who demonstrate that improvement is possible, rather than asserting it. Information comes from the facilitator, and from members' own experience. Altruism, being of use to someone else, restores a role many members have lost. Helping is itself therapeutic. Interpersonal learning means discovering how one comes across. The group supplies feedback that ordinary life withholds. And group cohesiveness, belonging to a group that matters to its members, is the group's equivalent of the alliance. It is its strongest single predictor of benefit.
Table 24.2.2 - Therapeutic Factors (2)
Social Learning, Applied
Catharsis, expressing feeling that has not been expressed, is useful with understanding attached. Expression alone changes little, as section four point four established. In corrective family recapitulation, the group reproduces familiar family roles, which can then be worked with, toward a different outcome. Socializing technique is learning how to be with people, practiced in the room rather than described. Imitative behavior means members model coping and disclosure for each other. And existential factors, facing responsibility, limits, and choice, arise in groups more readily than in individual work. Several of these rest on a mechanism taught in section five point three. Observational learning, vicarious reinforcement, and self-efficacy built by watching someone comparable succeed. Watching another member do the thing you fear gives you something a clinician's encouragement cannot supply. The model is credible, in a way the clinician is not.
Composition and Format
Who Is In the Room, and When They Join
Composition shapes what a group can do. Homogeneous groups, whose members share a presentation, reach cohesion faster, and suit skills-based work. Heterogeneous groups, whose members differ, supply a wider range of interpersonal feedback, and suit process work. Groups may also be closed, starting and finishing together, or open, admitting new members as others leave. Closed groups reach depth more reliably. Open groups sustain a service.
Figure 24.2.3
Stages of Group Development
Groups move through recognizable stages, and the facilitator's role changes across them. Early on, the facilitator establishes safety and norms. Next, they contain conflict without suppressing it. Once the group can, the facilitator lets it hold its own standards. And later, they use the group's process as material, rather than steering around it. Look at the second stage, the stage of conflict. It is the one facilitators most often try to prevent. And preventing it is what stops a group reaching the stages after it. Endings are named in advance. A group that finishes without acknowledgement teaches its members something about how relationships end.
Screening, Preparation, Confidentiality
Interventions, Not Administration
Screening establishes whether group work suits this person, now. Preparation explains what will happen, what is expected, and what to do with the discomfort of the early sessions. Poorly prepared members drop out early, at a rate that damages the group as well as themselves. That makes preparation an intervention, not an administrative step. Confidentiality in groups differs in one important respect. It depends on members, and not only on a professional duty. The facilitator is bound. The members are asked. So this is stated at the outset, agreed as a norm, and revisited. It is one of the things a person consents to when they join.
In the Clinic
Screening and Preparing for Group Work
Two questions do most of the work at screening. Can this person tolerate the early sessions, when a group is uncomfortable, and not yet useful? And can they be in a room where attention is shared? Preparation then does something specific. It tells the person that the first sessions will feel worse than individual work. It explains that this is expected, and not a sign they are unsuited to the group. And it warns that leaving then is the most common way people miss what the group offers. Saying this in advance works better than saying it afterwards.
Contraindications and Iatrogenic Effects
A Group Amplifies Whatever It Contains
Grouping people together is not automatically beneficial. The assumption that it is has caused documented harm. Deviancy training is the first example. Grouping young people with conduct difficulties can worsen outcomes, through mutual reinforcement of the very behavior the group was convened to address. The safeguard is to avoid aggregation, or to structure the group so that the behavior is not the shared identity. Contagion effects are the second. In groups where self-harm or disordered eating is discussed, discussion can spread what it addresses. No behavioral content belongs in this course, or in such a group. The safeguard is explicit content norms, set and enforced by the facilitator, and structured rather than open formats. A person in acute crisis needs individual attention a group cannot give. Acute psychosis is unsuited to a group's demands. And severe social anxiety may make a group the right treatment later, but the wrong first step. The general point is that a group amplifies whatever it contains. That is why it works, and it is why the safeguards are not optional.
Family Therapy and the Systemic Perspective
From Linear to Circular Causality
Family therapy shifts the unit of intervention from the individual to the relational system. Its central conceptual move is from linear to circular causality. Rather than asking what A did to cause B, it asks how A and B maintain each other. In a system, each person's response is both a reaction to the others, and a cause of theirs. This is not a way of spreading blame more widely. It is the opposite. Circular causality removes the question of who started it, which is usually unanswerable and always unhelpful. It replaces it with the question of what keeps the pattern going. Families do not cause their members' conditions. That was said in chapters sixteen, nineteen, twenty-one, and twenty-two, and it is repeated here.
Table 24.2.4
Core Systemic Concepts
This table sets out the core systemic concepts. Notice that each one points to a different intervention. Boundaries are the rules about who takes part in what. When a parent and child share confidences that exclude the other parent, the work is to reset who is in which conversation. Subsystems are smaller units, such as the parents. If the parental pair does not work as a unit, strengthen that subsystem, rather than working with everyone at once. Hierarchy is how authority is distributed. A child holding decisions a parent has given up calls for restoring an age-appropriate balance. Alliances are persisting coalitions, such as two members who consistently side against a third. Name the pattern, and work with what it protects. Homeostasis is a system's pull back to its usual balance. When one member improves and another then struggles, treat that as information, not failure. And the identified patient is the member brought for treatment, while the pattern is shared. Widen the frame, without denying that person's difficulty.
The Principal Schools
5 Central Ideas
The principal schools of family therapy can each be summarized by a central idea. Structural therapy works on boundaries and hierarchy. Strategic therapy works on the sequences that maintain a problem. Milan systemic therapy works through questioning that brings the family's own beliefs to the surface. Narrative therapy works on the story the family tells, and separates the person from the problem. And solution-focused therapy works from exceptions, and from what already works.
Family and Couple Applications
Families as a Resource
Family psychoeducation is used in psychotic and mood conditions, and builds on the expressed emotion findings of section eight point two. Its evidence for relapse reduction is strong. Its no-blame framing is not diplomatic packaging. High expressed emotion describes an interaction pattern, not a family's character. And families are among the most powerful resources for recovery. Family-based treatment in eating disorders, described by aim only, mobilizes the family as a resource, explicitly without blame. It has the strongest evidence for younger people. Parent-focused approaches, described by mechanism only, work by changing interaction patterns and increasing positive reinforcement, rather than by correcting parents. And couple therapy addresses communication, the meaning each partner attaches to the other's behavior, and specific difficulties. Behavioral, emotionally focused, and integrative approaches have reasonable evidence.
Safeguards in Conjoint Work
Absolute in Kind, Not in Degree
One contraindication is absolute in kind, rather than in degree. Where there is coercion or abuse in a relationship, joint sessions can be unsafe. A person cannot speak freely in the presence of someone who controls them. And what they do say may have consequences afterwards. So separate assessment is required before any joint work. That is a standard clinical safeguard, not a judgment about any particular couple. The safeguarding framework is in chapter twenty-five. Working with several clients at once also raises confidentiality questions. Whose interests does the therapist serve? How is information from individual contact handled? What happens when goals conflict? These are settled by explicit agreement at the outset, not improvised later. The framework is in section twenty-four point five.
Table 24.2.5
Choosing a Format
This table asks when group work suits a presentation. In most rows, the answer is not that group work is impossible, but that something has to be in place first. Social anxiety, once stabilized, suits group work, because the format supplies the exposure the difficulty requires. Where anxiety is severe, an individual phase comes first. Interpersonal difficulties are what process groups are for, and skills deficits suit structured skills groups well. Acute crisis and acute psychosis are contraindications. For psychosis, stabilize first, with family psychoeducation meanwhile. Conduct difficulties in young people call for care, and for avoiding aggregation. And self-harm or disordered eating call for structured formats only, with content norms enforced. The frequent answer is combination. The formats address different things, so the question is rarely which one, but in what order, and alongside what.
Evidence and Summary
Comparable Outcomes, Different Mechanisms
On evidence, group therapy gives outcomes comparable to individual therapy for several conditions. The advantages are cost and access. The disadvantage is higher dropout, much of it early, and much of it addressable through preparation. For family psychoeducation, the evidence for relapse reduction is strong. For couple therapy, it is reasonable. To summarize. Group therapy uses the group itself as the treatment, and several of its therapeutic factors cannot be supplied by any clinician. But grouping is not automatically beneficial. Deviancy training and contagion effects are documented, and need specific safeguards. Family therapy replaces linear with circular causality, which removes blame rather than widening it. And conjoint work is contraindicated where there is coercion, with separate assessment as the standard safeguard.
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