8 Psychotherapy8.5 Group therapies
8.5 Psychodynamic group therapy
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Written by Resident Doctor Committee · Published
What makes a group psychodynamic
Psychodynamic group therapy examines transference, countertransference, resistance and unconscious conflict, linking past with present and the group with life outside it, to build insight.
Interpretation puts into words an unconscious meaning that a member has not recognised, including the meaning of the transference, and is a defining tool of analytic group therapy.
Supportive, cognitive-behavioural, psychoeducational and self-help groups do not interpret unconscious material.
Psychological mindedness, with motivation and ego strength, predicts a good outcome in psychodynamic psychotherapy.
Other group formats
Groups can be classed on two axes: how specific the treatment goals are, and how actively the leader directs the group.
Group | What it does |
|---|---|
Psychodrama | Highly leader-directed, with broad, non-specific goals |
Behavioural | Treats a circumscribed phobia by repeated graded exposure along a hierarchy until the fear subsides |
Problem-focused cognitive-behavioural | Teaches coping skills by role-play and homework, for anger control and alcohol dependence |
Supportive | An active, directive therapist gives advice and praise and props up existing defences; suits severe and enduring illness |
Psychoeducational | Gives information about the illness |
Carer support | Peers share experience and practical tips, which relieves isolation |
Self-help | Members run it without a clinician around one shared problem, with strong cohesion and peer support |
In alcohol dependence, the cognitive-behavioural group works on relapse prevention: high-risk situations, cravings and rehearsing refusal.
Northfield
Wilfred Bion ran the first Northfield experiment at Northfield Military Hospital with John Rickman in 1943, and it lasted about six weeks.
Foulkes developed group analysis during the later Northfield work and located change in the matrix, the network of communication through which members understand one another.
Bion emphasises interpretation of shared defences; Foulkes emphasises the group's own communication.
Bion: work group and basic assumptions
The work group is the conscious, task-focused group, whose members cooperate, tolerate frustration and test ideas against the task.
Basic assumption activity is an unconscious defence of the whole group against anxiety, in which the group abandons its task.
The basic assumptions are a closed set of three: dependency, fight-flight and pairing.
Basic assumption | The group behaves as if | Signs | Example |
|---|---|---|---|
Dependency | One leader exists to direct, protect and think for everyone | Passive waiting and alarm when the leader is absent | A ward team waits for a locum consultant to tell it what to think |
Fight-flight | Survival depends on attacking or escaping an enemy, real or imagined | Lateness, walking out, shared attack on an outside target | A meeting criticises another ward instead of discussing the case |
Pairing | An alliance between two members will bring a future rescue | Expectant hope in a rescue that never arrives | A staff group pins its hope on two colleagues writing a new protocol |
Pairing differs from the other two in its mood of expectant hope rather than passivity or hostility, and the hope lasts because the solution is always yet to arrive.
Yalom's therapeutic factors
Yalom named a fixed list of eleven therapeutic (curative) factors. They are distinct from Bion's basic assumptions, from Bloch and Crouch's factors and from Foulkes's group-specific factors.
Factor | Meaning |
|---|---|
Instillation of hope | Seeing other members further along recover, as in an open group with members at different stages |
Universality | Relief at finding that others share a problem or thought one believed unique, often early in a group |
Imparting information | Direct teaching and shared practical knowledge |
Altruism | Gain in self-worth from helping other members |
Corrective recapitulation of the primary family group | Family patterns are re-enacted, with the conductor as parent and members as siblings, and are corrected rather than repeated |
Development of socialising techniques | Feedback and rehearsal of social skills |
Imitative behaviour | Change by copying a model, the therapist or a peer (spectator therapy); kept apart from unconscious identification |
Interpersonal learning | Feedback on one's effect on others, tested in the room |
Group cohesiveness | Belonging, acceptance and attraction to the group |
Catharsis | Relief from expressing previously suppressed feeling |
Existential factors | Accepting the givens of existence: mortality, unavoidable suffering, ultimate aloneness, personal responsibility and life's unfairness |
Cohesiveness is the group analogue of the therapeutic relationship and is regarded as the single most important factor for a positive therapeutic effect.
Only group psychotherapy provides corrective recapitulation.
Group processes
Anti-therapeutic processes include scapegoating, pairing or coupling, idealisation of the therapist, subgrouping and monopolising.
Scapegoating locates an unwanted quality in one member; the conductor explores the shared process rather than accepting the group's explanation or removing the member.
Psychodrama
Jacob Levy Moreno founded psychodrama, the action method of group psychotherapy.
The protagonist enacts a relationship before the group, and another member, an auxiliary ego, plays the absent person.
Doubling is when an auxiliary stands beside or behind the protagonist and voices feelings the protagonist has not yet expressed.
The leader directs role reversal during the enactment.
The session closes with sharing, in which members give their own reactions.
The therapeutic community
Person | Contribution |
|---|---|
William Tuke | A Quaker who introduced moral treatment at the York Retreat in 1796, replacing chains and restraint with kindness, occupation and self-government; the forerunner of the therapeutic community |
Samuel Tuke | Publicised moral treatment in 1813 |
Tom Main | Introduced the phrase "therapeutic community" in 1946 after the second Northfield experiment; later directed the Cassel Hospital |
Maxwell Jones | Established the therapeutic community as a working model at Belmont Hospital (later the Henderson Hospital), then at Dingleton |
Robert Rapoport | Studied the Belmont unit and drew four principles from it, published as Community as Doctor |
Rapoport's four principles are democratisation, communalism, permissiveness and reality confrontation.
Democratisation means residents share power with staff over how the community runs, including admissions and discharges.
Permissiveness is tolerance of emotional expression and disturbed behaviour.
Reality confrontation shows residents their behaviour as others see it, through peer feedback.
Practices that invert the principles, such as avoiding conflict or keeping analytic neutrality, contradict the model.
Selection and safety
Groups are closed (fixed membership for a set number of sessions), open (members join as others leave) or slow-open (vacancies filled as they arise, common in NHS practice).
Indications include recurring relationship difficulties, personality disorder, isolation and difficulty with intimacy or authority.
Contraindications are acute psychosis, severe paranoia, active intoxication and some antisocial presentations, each judged by individual assessment.