Group dynamics and the role of the facilitator Part 1

14th October, 2006

Summary

As a result of ever increasing pressure on the National Health Services’ resources, healthcare professionals are constantly seeking alternative ways in which to manage patient caseloads and, in turn, reduce the burden placed upon clinicians while at the same time, ensuring that the quality of service provided remains at an acceptable and effective level.

Psychotherapeutic group-work is perhaps one solution that can be of particular interest to mental health clinicians working with a specific patient group. This would appear to be a cost effective approach as it presents the therapist with the opportunity to deliver relevant support to a larger number of patients at the same time and, in turn, manage their own time more effectively (Heinzel, 2000).

It would appear that one of the most important aspects of group psychotherapy centres round the role of the facilitator who, potentially, can have a significant influence on positive and negative outcomes (Asselin, 2001). Furthermore, a great deal of consideration needs to be given to the facilitators knowledge and experience of the group process and group dynamics as well as therapeutic factors in group psychotherapy, all of which can potentially influence the likelihood of successful outcomes.

The purpose of this article is to firstly highlight and explore the therapeutic factors involved with group dynamics and, later in this edition of Scottish Nurse, to further explore the various skills and competencies that a group facilitator may need if he/she is to have an increased likelihood of achieving success.


Part 1. Therapeutic factors in group psychotherapy

The therapeutic factors that can influence group psychotherapy have been recognised for some time. Corsini and Rosenberg (1955) appeared to have been the first to delineate the therapeutic factors associated with group psychotherapy and, following an extensive literature review they were able to categorise 9 factors. Yalom (1995) who described therapeutic factors as being “the actual mechanisms of effecting change in the patient” added two further components to the list resulting in the following:

Yalom’s 11 Primary Factors in Group Psychotherapy

  1. Catharsis
  2. Altruism
  3. The corrective recapitulation of the primary family group
  4. The developing of socialisation techniques
  5. Imitative behaviour
  6. Imparting information
  7. Existential factors
  8. Group cohesiveness
  9. Interpersonal learning
  10. Instillation of hope
  11. The group as a social microcosm

Following a further study by Bloch (1980) whereby therapists and patients prepared brief written reports about which events in treatment they regarded as important, a comprehensive set of therapeutic factors was developed (see table 1 below). They also deliberately avoided using technical terminology in order to be more specific and to reduce the possibility of these factors being interpreted in many differing ways as, they had suggested, had been the case with the works of Yalom and Cursini & Rosenberg mentioned above.

It would appear that these therapeutic factors remain the cornerstone of group psychotherapy and will now be discussed individually.
Catharsis

A cathartic experience can be described as “one in which there is an uninhibited and often dramatic expression of pent up feelings” (Alexander 1986), whereby an individual will be able to express their distress with others who can truly understand this distress (Thienemann, 2005).
Its value is often highlighted in lay terms as “getting things off your chest” and “letting off steam”. If individuals are not given the opportunity to have a cathartic experience any distressing feelings may build up to the point where they ‘spill over’ or ‘explode’ in an unhelpful way.

Therapeutic factors (Bloch et al

  1. Catharsis
  2. Self-disclosure
  3. Learning from interpersonal actions
  4. Universality
  5. Acceptance
  6. Altruism
  7. Guidance
  8. Self-understanding
  9. Vicarious learning
  10. Instillation of hope

TABLE 1.

Whilst catharsis helps the patient to express a wide range of feelings such as anger, sadness, guilt and shame, it should be noted that Ballinger & Yalom (1995) found that it was only successful when coupled with cognitive reflection. This point is reinforced by Bloch (1986) who suggested that “catharsis alone is of limited value unless the patient makes intellectual sense of the emotionaly laden experience” by asking themselves questions such as ‘What happened when I was tearful?’, ‘What does this mean?’ and ‘Now that I have a better understanding of this experience, what should I do?’

 

Altruism

Altruism is the concept of providing help and support without the expectation of having this returned. Within group settings, opportunities can frequently arise whereby altruistic interactions can take place between group members. Bloch (1986) suggests that altruism is “one of the most unique assets of group-work”. Ballinger & Yalom (1995) suggest that altruism is widely known to play a part in the recovery from emotional problems. The reasons for this being that individuals with poor self worth and low self-esteem can often be caught up in a negative cognitive cycle and can be morbidly self-absorbed. For them to simply take part/contribute or to give as well as receive within the group setting can be very rewarding for the individual with a subsequent positive improvement in areas such as self-esteem and confidence.

Learning from interpersonal actions

Higginbotham et al (1988) suggested that in group therapy “members not only receive direct, explicit information in the form of therapeutic directives, but also gain (from the group itself), the opportunity to implicitly gather data about their own interpersonal behaviour.” Through feedback from other group members, the group leader and through self-observations, each group member can potentially enhance their understanding of their social selves. This, in turn, can promote positive change in both behaviour and cognitions.

There are however some limitations to learning from interpersonal actions as some group members may only provide positive feedback and completely avoid any negative feedback (which in some cases may be very therapeutic!). The individual concerned is therefore not receiving a true appraisal of himself or herself which can potentially be quite misleading.

Universality

Universality is about learning/realising that one is not alone i.e. others may have had similar difficulties/experiences and ultimately it can help the individual realise that they are not unique. In some cases people may believe that no one else could possibly understand or share their problems, impulses and fantasies. To suddenly realise that this is not the case and that others have similar problems can be very reassuring for all concerned. (Gelder et al, 2001).
Guidance

In early group psychotherapy sessions, members can feel anxious, confused and hesitant to contribute. The intensity of these feelings may be reduced by the therapist providing some guidance e.g. by conveying advice and information with a particular focus on “the simple technique of clarification through information and explanation” (Bloch, 1986) which can enable each member to perceive more clearly the nature of his/her difficulties.
Self Understanding

During group psychotherapy individuals may learn a great deal about themselves and the factors that have contributed to the way he/she thinks and behaves which Yalom (1975) describes as psychogenetic insight. Self understanding can also help the individual to ‘make sense’ of what has happened to them and subsequently provide them with a way forward whilst at the same time instilling hope for the future (Perkins & Repper, 2004). The overall aim of psychotherapy is to help each individual to understand why they feel the way you do, and what lies behind their responses to other people and to things that happen to them. Many people find that this understanding helps them to deal more successfully with problems and distress (MIND 2004).

Vicarious learning

This can be defined as a change in behaviour due to the experience of observing others. Human observers tend to learn more from models who are competent, likeable and attractive than from models who lack those characteristics. If the model being observed is given positive reinforcement, the person observing will be more persuaded to adopt some of those characteristics. Bandura (1986) argued that there are 4 processes that contribute to vicarious learning i.e.

  1. Attentional processes – Referring to the organism observing the relevant aspects of the model’s behaviour and its consequences.
  2. Retentional processes – refers to the acts the observer performs to aid recall of the model’s behaviour.
  3. Motor reproductivity processes – The observer must have the motor skills necessary to perform the modelled behaviour.
  4. Motivational processes – the observer must have an explanation that an imitated behaviour will produce reinforcement; otherwise, the behaviour will not be performed.

Instillation of hope

Some or all of the members of any psychotherapy group may experience varying degrees of hopelessness whereby they feel unable to make any positive changes to their lives, their future seems bleak and pointless or they may simply feel stuck. Being part of a group and recognising that other members are improving as a result of the group-work can lead the individual to develop a degree of hope and optimism about themselves and their own future. (Kapur et al, 1988)

Discussion

It would seem that there are a wide range of therapeutic factors that can influence the likelihood of success, or indeed, failure of group psychotherapy. Having an understanding of these factors, and the subsequent impact that group dynamics can have on each individual group member and the group as a whole, would appear to be crucial for any clinician undertaking this type of intervention.

Group psychotherapy has also been proven to be equally as successful, and in some cases more successful, than individual psychotherapy (Asselin, 2001). This can therefore theoretically ‘free up’ more time for clinicians who are working under ever increasing pressures and be much more cost effective. Cost-effectiveness should not however be the only consideration when embarking on group psychotherapy. It should be seen as a tool that can be used when evidence supports its use (Thienemann, 2005).

One should also be cautious with regards to other limitations to group psychotherapy. For example, preparation can take much longer than for individual psychotherapy, the group facilitator may need a co-facilitator to help monitor the group dynamics and who will provide supervision? Furthermore, some of these ‘therapeutic factors’ may actually have a negative impact on some individuals in the long term. For example, Th ieneman n (2005) highlighted a case where members of an adolescent trichotillomania group reported that previous experiences with support groups initially helped but left them feeling dejected after hearing about others’ experiences.

On a positive note, group psychotherapy can provide each member with a rich tapestry of positive factors that are simply not available in individual psychotherapy e.g. universality. Whilst having a good knowledge of these factors is clearly one competency that the group facilitator should possess, there are several others that need to be taken into consideration, mainly with regards to the role of the facilitator. This will subsequently be discussed later in this issue of Scottish Nurse.

References

Alexander, D, A. (1986) Psychodynamic psychotherapy. In: An outline of psychotherapy. Edited by Maxwell, H. IOP Publishing Ltd.

Asselin, M. (2001) Time to wear a third hat? Nursing Management Volume 32(3), March 2001, pp 24-29. Springhouse Corporation

Ballinger, B. & Yalom, I. (1995) Group Therapy in Practice. In: Comprehensive Textbook of Psychiatry. Edited by Bongar, B. & Beutler L, E. Oxford University Press.

Bandura, A. (1986) Social Foundations of Thought and Action. Prentice Hall

Bloch, S. (1986) Group Psychotherapy. In: An introduction to the psychotherapies (second edition). Edited by Bloch, S. Oxford University Press.

Bloch, S. & Reibstein, J. (1980) Perceptions by Patients and Therapists of Therapeutic Factors in Group Psychotherapy. British Journal of Psychiatry, 137, 274-278.

Corsini, R, J. &Rosenberg, B (1995) Mechanisms of group psychotherapy: Processes and dynamics. Journal of Abnormal Psychology. 51(3):406-411, November 1955.

Gelder, M., Mayou, R. & Cowen, P. (2001) The Shorter Oxford Textbook of Psychiatry. Oxford University Press.

Higginbotham, N, H.,West, S, G. & Forsyth, D, R. (1988) Psychotherapy and Behaviour Change (Social, cultral and methodological perspectives) Pergamon Press, Oxford.

Heinzel, R. (2000). Outpatient psychoanalytic individual and group psychotherapy in a nationwide follow-up study in Germany. Group Analysis, 33.

Kapur, R., Miller, K. & Mitchell, G. (1988) Therapeutic Factors Within In-patient and Out-patient Psychotherapy Groups (Implications for therapeutic techniques). British Journal of Psychiatry, 152,229-233.

MIND(2004). Psychotherapy.http://www.mind.org.uk/Information/Factsheets/Treatments+and+drugs/Psychotherapy.htm

Perkins, R. & Ripper, J. (2004) Rehabilitation and Recovery. In The Art and Science of Mental Health Nursing. Edited b y Norman, I. & Ryrie, I. Open University Press.

Thienemann, M, L. (2005). Group Psychotherapy. In Comprehensive Textbook of Psychiatry. Edited by Sadock, B, J. & Sadock, V, A. Lippincott Williams & Wilkins, 2005.

Yalom, I. D. (1985). The Theory and Practice of Group Psychotherapy (3rd Ed.). New York, NY: Basic Books, Inc.

Yalom, I. D. (1995). The Theory and Practice of Group Psychotherapy (4th Ed.). New York, NY: Basic Books, Inc.


Scott Kane (RMN, CBT, MSc). Clinical Nurse Specialist in Liaison Psychiatry.

Address for correspondence:
Department of Liaison Psychiatry,
The Carseview Centre,
4 Tom McDonald Avenue,
Dundee DD2 1NH.
E-mail: scottkane@nhs.net