16 – Psychosocial Interventions




Abstract




Psychotherapy is an overarching term for any type of professional treatment for psychological and physical distress using verbal and nonverbal communication. Talking together, the patient and therapist engage collaboratively to understand the source of a dysfunction or suffering in order to reverse either maladaptive self-regulatory processes or to adapt and develop psychological strengths to cope with pathological conditions, developmental concerns, or trauma. Psychotherapy addresses multiple levels of functioning, including the neurobiology of the brain itself, the perception of the self to itself, the relationship of the self to others, the role of the individual in the social world, and the conceptual frameworks and beliefs that also may affect emotions and behavior.





16 Psychosocial Interventions


Marshall Forstein , Alfred Marguiles , Robert Goisman , Elizabeth Simpson , Eleanor Counselman , Miriam Tepper , Jennifer Greenwold , Zev Schuman-Olivier , and Darshan Mehta



What Is Psychotherapy?


Psychotherapy is an overarching term for any type of professional treatment for psychological and physical distress using verbal and nonverbal communication. Talking together, the patient and therapist engage collaboratively to understand the source of a dysfunction or suffering in order to reverse either maladaptive self-regulatory processes or to adapt and develop psychological strengths to cope with pathological conditions, developmental concerns, or trauma. Psychotherapy addresses multiple levels of functioning, including the neurobiology of the brain itself, the perception of the self to itself, the relationship of the self to others, the role of the individual in the social world, and the conceptual frameworks and beliefs that also may affect emotions and behavior.


Complex language is a unique characteristic of being human, and talking about thoughts, feelings, and behavior can help people feel connected to the world and make sense of the human condition. Listening to another human being is an active therapeutic intervention itself. In psychological or physical pain, the patient feels is seen and heard, thus validating the internal experience of the patient.


The following sections of this chapter explore some of the currently used forms of psychotherapy. What is common to all is the importance of the relationship between the patient and the therapist, establishing a trust (therapeutic alliance) that the process will lead to an improvement in feelings, thoughts, or behavior.


Psychotherapeutic interventions differ according to the “frame” of therapy. This “frame” varies in terms of parameters related to time (short visits, long visits), length of treatment (short term, long term, number of sessions, open-ended), and modality of treatment.


Sometimes referred to simply as “talk therapy,” psychotherapy may be used alone or in conjunction with psychoactive medications to alleviate anxiety, depression, and many other psychiatric disorders. Other somatic interventions, such as ECT (electroconvulsive therapy), TMS (transcranial magnetic stimulations), or VNS (vagus nerve stimulation) may also be used concurrently. Many physiological changes in brain function have been documented as a result of psychotherapeutic treatments.


Therapists may work with individuals, couples, families, or groups of people of any age. Pre-verbal and young children may be engaged in “play therapy,” while older children and adults talk with therapists about problems that help them become better at coping with difficult situations, relationships, or illness.


A useful concept corresponding to biological functioning is that of “mental homeostasis.” As with biological homeostasis, mental functioning occurs within a “bandwidth” of “normal” function (i.e., ability to be resilient, flexible, and adaptive to the trials and tribulations of life or to the impact of biological processes on mental function and coping). The more severe the disruptions are in the “hard wiring” of the brain, the greater the possibility for mental dysfunction. Psychotherapy requires the ability to process information, to have a basically intact remote and working memory, and to tolerate emotions and bodily sensations that arise in the course of treatment. As within the immune system, there are multiple mechanisms for restoring homeostasis when affected by either internal changes in biological function, or external assaults on the integrity of the organism. Similarly, when the “mental homeostasis” is disrupted by changes in brain function or external events that impact the capacity of the person to manage, psychological defenses are employed to try to maintain or restore a sense of psychological well-being. These defenses, although sometimes maladaptive, are intended to keep the person functioning at the highest level of function possible.


“Dynamic” forms of psychotherapy rooted in the psychoanalytic tradition often explore psychological defenses, enhancing their usefulness or replacing them with more effective ways to diminish suffering and maladaptive behavior. Distinguishing what are “normal” anxieties and mood fluctuations from internal or external experiences that impinge on the ability to function in the day-to-day world can enhance coping skills. “Cognitive” therapies make use of understanding the role of negative thinking in creating ambivalence or fear about change may diminish dysfunction. Negative thoughts, for example, about the past, may predispose the individual to anticipate that the future may be much the same, even when there are opportunities for it to be different. “Psychosocial interventions” using principles of psycho-education, help patients understand their psychiatric disorders and symptoms, and include rehabilitation strategies and social supports for improving quality of life, symptom management, and connection with the world. Often psychotherapy of any modality helps people learn to grieve and live with what may appear to be insurmountable barriers to living with loss that is an inevitable part of the human experience.


Research is underway to better define what type of therapeutic process is most effective with particular disorders. There is a growing body of research providing evidence, for example, that talk therapy in addition to antidepressant medication is most effective in treating more moderate and severe depression. In the following sections, each author describes the form of therapy and its indication for use. References are provided for further exploration of the various modalities of treatment.



Psychoanalysis


Beneath our conscious awareness lie forces that powerfully shape our behavior and indeed consciousness itself – and this is the terrain of psychoanalysis. Not rational in the sense of linear goal directedness, these irrational forces have their own logic and structure that are revealed through how we operationalize our approaches. And so this terrain of irrational behavior, the not-fully conscious, overlaps with other disciplines, a hot area of research in neurobiology, medication compliance and noncompliance, placebo effect, nocebo effect, pain, dream states, addictions, and medical errors. Moreover, recent research into nonconscious behavior extends beyond medicine to areas as diverse as economics and market behavior, advertising, unconscious stereotyping and racism, voting patterns and political rhetoric, rapid decision-making by experts and novices, facial displays and lying, unconscious jury bias, and more. What we mean by the unconscious or nonconscious is then rapidly expanding, and we are still coming to understand how these processes saturate our clinical work and, indeed, our everyday existence. Here psychoanalysis takes up the clinical relevance of these forces.


Though we pride ourselves on our rationality, scratch the surface and we encounter complex fantasies of love, desire, lust and sexuality; self-esteem and envy; aggression and hatred; power, dominance and hierarchy; deep attachments and tangled relationships; unbearable grief and fear and, of course, high ideals and a demanding and troubled conscience side-by-side with intense belief and hope. Complex creatures in a complex world, no wonder that we keep a lot unsaid – and even more out of mind. No wonder, too, that when it comes to the varieties of human suffering, these unconscious forces are particularly complex and daunting, with some aspects of non-rational mind and behavior close to awareness and some more elusive.


For example, a patient in her late twenties presented with feelings of unshakeable depression, lack of energy and interest in life, poor sleep, and difficulty accessing her feelings. These symptoms seemed to come out of the blue and were in contrast with what she thought was the promise of her life and its opportunities. About to leave the state for what should be an exciting job, she felt deadened and confused. In taking a history, it emerged quickly that she was seeking treatment almost exactly coinciding with the first year anniversary of her father’s death – and, up until the moment of her saying this, she had not been aware of the connection. Indeed, over the past year, she was aware of pushing aside her grief because she felt it would hamper her caring for her family. As the oldest child, she took charge of her siblings after her mother abandoned them all. In his despair, her father had relied on her. And despite her father’s death – especially with his death! – she never had the space to deal with her own feelings: others, she felt, still need to come first. But, this made no sense to her: life had settled down over the past year, her siblings were launched in their own lives, she herself now had a serious boyfriend, and it seemed strange to her that still she felt numb, closed up, and shutdown. And here in her first interview and for the first time since her father had died, she wept deeply in telling her story. Immediately she felt relief, freer, and eager to continue before she left town. Given the space to talk freely, this young woman quickly identified what had precipitated her depressive shutdown, and in doing so, her depressive symptoms evaporated. In subsequent meetings, she grieved with a lively openness (grief is not depression!), and spontaneously brought in family albums, talked about beloved memories of her father, and, more difficult to acknowledge, ways he both loved and disappointed her. She had never felt comfortable being angry with him because he meant so much to her. In talking, her father emerged as a fuller person – and so did she.



The Psychoanalytic Process


Perhaps more difficult to describe is the experience of the psychoanalytic process itself. The self-recursive process of reflection inherent in the analytic approach continually boot-straps awareness with the participatory help of another. That is, rather than attempting to remain outside of the observational field, the analytic clinician brings into mutual awareness the complex interaction as a vehicle to further unfold awareness. Some basic processes of this force field we refer to as “transference” and “counter-transference,” and their mutual interaction as “enactment.” Not so mysterious, transference is at heart a translation of earlier experiences, patterns of expectations, into present ones. Particularly when these patterns of experience involve important others, they become reflexive and entrenched, sometimes highly repetitive and self-defeating, ways of both experiencing and shaping the world at the same time. And so these interactions (transference, countertransference, enactment) entangle the participants (analyst and patient), but – and here’s the subtle psychoanalytic process – rather than attempting to step outside of the forces (an ultimate impossibility in a participant-observer field), the analyst and patient move into and through them as a way of becoming more aware of the reflexive and habitual impact on ways of being in a world that we also construct.


For example, with the patient above who was in a psychoanalytically oriented psychotherapy, imagine that she returns a few years later, now struggling in a marriage and with children of her own. And here she has a return of depressive symptoms – numbness and a disinterest in life – that she does not fully understand and that are spilling over into the lives of her husband and children, and this alarms her. Further, she suspects it is precisely in her new role as a mother that old concerns are being reawakened: Why am I afraid to attach and commit to another? What does it mean to love one’s children? Why did mother leave – didn’t she love me? Wasn’t I good enough? Why am I withdrawing? Why do I avoid conflict? How about love and loss, and what to do about anger and ambivalence? She wants to better understand how she lives – and the stakes feel high for everyone she loves. She is ready to go deeper.


Psychoanalysis is designed to deepen this self-exploration of memory, affect, longing, meaning, and significance. By intensifying the therapy through frequency and duration, there is a loosening of resistance to painful emotion so that there might be an opening up of a free flow of feelings, memories, and associations that are ordinarily pushed away from awareness. The analyst and patient take special notice of how repetitive patterns emerge within the analytic relationship itself (transference, countertransference) and how they entangle one another within enactments. And here awareness opens further. The aim is toward the freedom to speak one’s mind fully, letting it go where it will, in the presence and in conversation with another – with the goal of freeing up new possibilities of choosing how to live.


More than a hundred years after Freud launched his first investigations, this sketch belies the subtlety of the still-evolving field of psychoanalysis and its rich branches of theory and inquiry. The interested student might find the following resources ways to begin, though engaging these readings in conversation with a psychoanalytic supervisor in the context of clinical work will, of course, open a deeper awareness of the process itself.



Cognitive-Behavioral Therapy


Cognitive-behavioral therapy (CBT) is a highly operationalized form of psychotherapy with a strong evidence base justifying its use. In this section, we will briefly discuss the history and development of CBT, describe some of the basic principles believed to underlie the effectiveness of this method, discuss its indications and limitations, and provide resources with which the reader can further pursue areas of interest.


CBT is not an absolutely unified, monolithic body of doctrine; there are schools of thought within CBT that agree, disagree, and sometimes both agree and disagree with each other. Many clinicians and investigators separate the various streams of thought within CBT into “waves” (Kahl et al, 2012). The first wave is represented by classical behavior therapy or “behavior modification”; this is largely based on classical and operant conditioning models as described in the early 1900s by Pavlov, Skinner, and their intellectual descendants. Exposure treatment for anxiety disorders is a present-day “first wave” therapy (Barlow, 2007). The second wave is that of cognitive therapy, as pioneered by and exemplified by the work of Aaron Beck (Beck et al, 1979), Albert Ellis, and many others. Cognitive therapy of depression, perhaps the best-studied form of psychotherapy currently in existence, is one very commonly utilized second-wave treatment. The third wave of CBT is a rather heterogeneous group of treatments that have in common their use of mindfulness techniques, Eastern spirituality, meta-cognitive approaches, acceptance of dysphoric states, and so on; dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT) are currently popular versions of third-wave therapies (Kahl et al, 2012).


There are, however, certain characteristics that all of these “waves” share, which collectively distinguish CBT from other forms of psychosocial treatment. These are:




  1. 1. Delivery of psychotherapy in a structured and operationalized manner



  2. 2. Derivation from learning theory, cognitive psychology, information processing theory, and social learning theory



  3. 3. Selection of cognitions and behaviors as treatment targets in the expectation that changing these will lead to remission of symptoms



  4. 4. Relatively greater emphasis on current determinants of behavior and factors maintaining symptoms than on past hypothesized causes of symptoms



  5. 5. Treatment being relatively short-term and typically including formal agenda-setting and the assignment of homework in a collaborative manner


There are a number of treatment modalities within CBT that form the “building blocks” of treatment. These modalities are used in virtually all applications of CBT. These are:




  1. 1. Exposure



  2. 2. Cognitive restructuring



  3. 3. Skill deficit remediation



  4. 4. Contingency management



  5. 5. Stimulus control


Briefly, exposure methods involve getting into contact with (“exposed” to) a stimulus that evokes dysphoria and then staying in contact with it until the aversive emotion abates (Barlow, 2007); typically the dysphoria is that of anxiety, although Linehan (1993) and others have discussed exposure methods for guilt, shame, and other negative mood states. Cognitive restructuring involves the elicitation of thoughts which occur in given situations, usually those which are painful or otherwise problematic; these are then rated in intensity, categorized in terms of what type of cognitive distortion may be present, and discussed Socratically as to their truthfulness and usefulness, after which a less distorted thought is constructed and substituted (A. Beck et al., 1979). Skill deficit remediation involves conceptualizing psychopathology as a series of acquired or at times inborn skill deficits that can be corrected over time by didactic instruction, in vivo exercises including role-plays, and homework assignments; this has been shown to be particularly helpful in schizophrenia (Liberman, 2008) and borderline personality disorder (Linehan, 1993).


Contingency management, at its heart an operant conditioning intervention, describes a strategy of managing the consequences of a given behavior, so as to increase the frequency of desired behaviors and/or decrease the frequency of undesirable behaviors; token economies are examples of very elaborate contingency management systems, whereas the “pass” system used on many locked inpatient units, in which weekend passes are granted or not in part as a consequence of the frequency of desired behaviors such as group attendance during the week, is a simpler application of the same principle. Finally, stimulus control is a term used to describe efforts to alter the proximity of stimuli or “triggers” to a given behavior so as to increase their availability for desired behaviors and decrease their availability for those considered undesirable; an example of this would be to prescribe that a patient in early stages of recovery from alcoholism stay away from bars and liquor stores and go to Alcoholics Anonymous meetings instead, or to prescribe that a patient with pedophilia stay away from day care centers (Marlatt and Donovan, 2005). Psychoeducation is often mentioned as a sixth basic modality of CBT, but since clinicians from many schools of thought use psychoeducation, it is not listed here.


The earliest clinical work using principles of CBT (then known as “behavior modification”) was in the 1940s and 1950s with outpatients suffering from specific phobias and with long-term inpatients suffering from schizophrenia. From those two quite disparate starting points the indications for CBT have increased exponentially, so that in contemporary psychiatry CBT has been used for most of the types of illness listed in the Diagnostic and Statistical Manual. A reasonable list of specific indications for CBT would include:




  1. 1. Anxiety disorders (including post-traumatic stress disorder)



  2. 2. Depression



  3. 3. Borderline personality disorder



  4. 4. Schizophrenia



  5. 5. Bipolar disorder



  6. 6. Substance abuse



  7. 7. Eating disorders



  8. 8. Child psychiatric disorders (e.g., autism spectrum disorders, childhood obsessive-compulsive disorder, etc.)


Treatment for anxiety disorders usually involves exposure to the external or internal anxiety-provoking or phobic stimulus, often combined with cognitive restructuring around the actual dangerousness of the stimulus and some type of anxiety management training. Cognitive restructuring and behavioral activation are the main modalities used in the CBT of depression, and dialectical behavior therapy is the primary cognitive-behavioral method used in the treatment of borderline personality disorder. As an augmentation strategy for antipsychotic medication, CBT can be used in the treatment of schizophrenia via skill deficit remediation and also by some fascinating newer work in the cognitive restructuring of hallucinations and delusions (Kingdon and Turkington, 2005). Similarly, CBT can be used as an adjunctive treatment for bipolar disorder through psychoeducation, early detection of signs of relapse, lifestyle management, and some cognitive restructuring (Basco and Rush, 2007). Protocols for the cognitive-behavioral treatment of eating disorders and substance abuse disorders are easily found (e.g., Barlow, 2007). And the literature on CBT for children and adolescents is expanding rapidly (e.g., Szigethy et al., 2012).


Thus contemporary cognitive-behavioral therapy has emerged as a versatile set of interventions that can be helpful in the treatment of many types of psychiatric illness. CBT has the additional value of having a strong research base to provide evidence of its effectiveness and of the stability of its results over time. In addition to the sources cited here, there are a number of basic textbooks to which the interested reader can refer in order to obtain more information or to help clinicians who are novices in this area to get started (e.g., J. Beck, 2011; Wright et al., 2006). Further, the two major organizations promoting CBT in the U. S., the Academy of Cognitive Therapy in Philadelphia and the Association for Behavioral and Cognitive Therapies in New York, each have websites containing “Find a Therapist” listings, educational materials about CBT and its indications, and other useful information (www.academyofct.org, www.abct.org). In an era in which the perceived value of the doctor-patient relationship cannot be taken for granted, CBT offers an evidence-based method by which physicians can justify spending time with patients to their benefit.



Dialectical Behavior Therapy


People suffering with borderline personality disorder (BPD) are often quite miserable and tend to consume a lot of treatment, not always to great benefit. In response, Dr. Marsha Linehan, a professor of psychology at the University of Washington in Seattle, developed dialectical behavior therapy (DBT) to provide a principle-based, manualized approach to the complex myriad of problems of chronically suicidal, self-injurious women. In a randomized control trial, the first in the literature for this diagnosis, women with BPD were assigned to DBT or to “treatment as usual” in the community. In the final comparison, those who received DBT were much less likely to drop out of treatment, had fewer and less serious episodes of suicidal behavior, were less frequently hospitalized, used drugs and alcohol less, enhanced their social functioning and anger control, and were more globally improved (Linehan, Armstrong, et al., 1991; Linehan, Tutek, et al., 1993).


DBT posits a primary role for emotional dysregulation in the patient’s difficulties. People with BPD are hypothesized to be biologically vulnerable to overwhelming emotional experience. Exquisitely sensitive to emotional cues and intensely reactive and expressive, sudden surges of emotional arousal may overwhelm cognitive resources, having devastating consequences on good judgment, sound decision-making, mentalization, and self-control. It is vital, therefore, to have some regulatory sway over this passion, but people with BPD have not learned to let reason and reflection guide emotion. They may act impulsively to curtail the feeling (e.g., by cutting or suicide crisis) or resort to ineffective efforts to down-regulate it (e.g., rumination, disordered eating, depressive withdrawal), aiming to escape or avoid the experience of the emotion, rather than to solve the problem which elicited it.


Emotional dysregulation exerts its most ruinous consequences in relationships. Through interaction, all parties to any social exchange are vulnerable to unpredictable changes in their emotional state which may be potentially dysregulating (think of the crying baby on an airplane). The emotional arousal of one will influence that of the other, and vice versa, in a transaction of mutual effect, for good or for ill, in service of cooperation or conflict. People with BPD tend to experience the therapeutic context as the Marriott buffet of emotional cues, and their dysregulation creates an intense and potentially volatile context.


When things get hot, DBT activates acceptance and dialectics to keep the patient in the room. Dialectical philosophy guides the therapist to approach the patient with an open-minded curiosity, assuming that problem behavior makes sense from the patient’s perspective or they would not be doing it. Letting go of efforts to change the patient, at least for the moment, the therapist focuses on understanding and accepting him as he is, and communicating that acceptance to him. Typically, validation lowers arousal and facilitates the cooperative relationship necessary for change. In early stages, validation can be used to facilitate acceptance of primary emotions, to cue adaptive emotions, to strengthen their capacity for self-reflection, and to highlight what matters to the patient.


In balance to acceptance, Stage I DBT provides a comprehensive array of change-oriented interventions. It is a highly structured, outpatient treatment, consisting of weekly individual therapy and group skills training sessions, with a renewable one-year treatment contract. A behavior therapy, DBT is focused on current determinants of behavior and is highly collaborative. It combines cognitive behavioral therapy (chain analysis, contingency management, exposure, skills training, stimulus control, and cognitive modification) with mindfulness (to train attentional control) and dialectical strategies (to develop and enhance flexibility of perspective and social cooperation).


Problems are organized into a hierarchy and are targeted directly. For example, suicidal urges and actions are monitored on a diary card, incidents are functionally analyzed to determine controlling variables, and alternative responses, taught in the skills group, are proposed and rehearsed in the individual session. The therapist is available for telephone coaching after hours to assist with the implementation of the new behaviors into the patient’s life. The ultimate goal is to be able to engage in functional, life-enhancing behavior, even when strong emotions are present (Lynch, Chapman, et al., 2006).


In short, DBT therapy is a mindful dance between these fundamental truths: the wisdom in what is and the need for change. As a wise old analyst once said, “Meet the patient where they are and take them where they don’t want to go.”



Group Therapy


There are many kinds of group therapy: standard interpersonal or psychodynamic therapy groups, cognitive-behavioral (CBT), dialectic behavioral (DBT), psychodrama, and psycho-educational to name a few. This section will describe general interpersonal/psychodynamic group therapy. Such groups can be time-limited or open-term. The overall efficacy of group psychotherapy has been discussed in a meta-analysis by Burlingame, Fuhriman, and Mosier, 2003. Group psychotherapy can be useful for patients with general interpersonal difficulties (Yalom & Leszcz, 2005; Rutan, Shay & Stone, 2007). Group therapy is effective for symptoms such as depression (McDermut, Miller, and Brown, 2001) and for specific populations: for example, people infected with HIV, (Himelhoch, Medoff, and Oyeniyi, 2007), people with PTSD (Sloan, Bovin, and Schnurr, 2013), and school-age children (Matta and Terjesen, 2012). (See “Group Works!” on the American Group Psychotherapy Association website for additional references on different populations: www.agpa.org/group/consumersguide2000.html.)


What is helpful about group therapy? There is considerable evidence linking specific therapeutic factors and mechanisms with patient improvement in groups. A number of therapeutic factors in group therapy have been identified: universality, altruism, installation of hope, imparting information, corrective recapitulation of primary family experience, development of socializing techniques, imitative behavior, cohesiveness, existential factors, catharsis, interpersonal learning – input, interpersonal learning – output, self-understanding (Yalom & Leszcz, 2005).


A major therapeutic advantage of group is that in individual sessions a patient can talk about interpersonal problems, but in a group session, the patient will actually have them. The therapist can facilitate constructive feedback for the patient and the group setting provides a safe and protected space for the patient to try out new, more effective ways of relating. Many patients are not aware of the ways that they protect themselves emotionally and the impact of their defenses on relationships; group therapy with its “hall of mirrors” helps patients learn and change. An example of such change was the pleasant young man from an extremely critical family. He had learned not to reveal anything about how he felt inside because it would be judged. Not surprisingly, his relationships stayed very superficial, and he did not know why. In group therapy, he was gently helped to see how much he feared judgment and therefore protected himself with platitudes that deprived others of any real connection with him. In the safety of the group, he gradually risked revealing more of his inner experience and was able to develop deeper connections first with other group members and subsequently in his outside life.


A common factor across all types of therapy groups is the basic human support that membership in a group can offer – the sense of belonging. Research supports the therapeutic relationship as the mechanism of action that functions across all types of therapies (Martin et al., 2000). Furthermore, that relationship appears more significant for client improvement than any specific mechanism of action in formal treatment protocols (Norcross, 2001; Wampold, 2001). For group therapy, the equivalent of a therapeutic relationship is group cohesion – that is, the multiple relationships between members, between members and leader, and between members and group as a whole. Group structure, verbal interaction, and emotional climate have been found to significantly increase group cohesion (Burlingame et al., 2002).


As in individual therapy, a group must feel safe for effective work to occur. The role of the leader is to create and maintain a group climate that facilitates the work. An effective group leader establishes a group agreement that each member must understand and commit to. This agreement includes the basics of time and place, attendance requirements, fee, purpose of the group, confidentiality, and rules about outside contact with other members. The leader serves as gatekeeper and is responsible for screening and preparing prospective group members. In the pre-group screening, which consists of one or more individual meetings, the group therapist establishes an initial alliance with the patient, gives information about the group including the group agreement, deals with expectable anxiety about entering the group, explores any resistance, and assesses whether the patient is appropriate for the group being considered.


The selection of members for a group is dependent on the nature of the group. General principles include the ability to uphold the group agreement, the capacity to benefit from the group, and some capability for empathy and/or wish for connection. Most interpersonal groups are composed of members at the same level of psychological functioning. Groups typically have eight to ten members and can be led by a single leader or a co-leader pair. Co-leadership is an excellent training model but does add the co-leader relationship as an additional dimension.


Some patients should be excluded from group therapy. A general rule is that individuals should not be placed in group therapy if due to logistical, intellectual, psychological, and/or interpersonal reasons they cannot engage in the activity of the group (Yalom & Leszcz, 2005). As premature dropouts are hard on groups as well as the member who drops out, great care should be taken with patient selection and preparation. The best question to consider is: Is this the right group for this patient at this time?


A number of models of group development exist in the literature (Bion, 1961; MacKenzie, 1994; Tuckman, 1965; Rutan, Stone & Shay, 2007). All describe various stages of group development: (1) early “forming” or dependency, (2) a “storming” or counterdependency, (3) “norming” or intimacy, (4) “performing” or mature working, and (5) separation (of individual members) or termination (of the whole group). These stages are epigenetic, developing gradually over time, although various group events such as the entrance of a new member or a leader vacation can cause a group to regress back into an earlier state. For example, a group may react to the leader’s approaching vacation with greater reliance on the leader to facilitate (dependency) or may experience increased latenesses or absences (counterdependency). Also, groups with particular populations may tend to stay in a single stage; for example, a group for the chronically mentally ill may stay a dependency group and still offer considerable benefit to its members.


Group dynamics operate on a number of levels: individual, subgroup, group as a whole, and the larger system in which the group is embedded (e.g., hospital or clinic). At all times, the leader must attend to both content and process and needs to monitor the individual members, as well as the climate of the whole group.


Group therapy has risks as well as benefits. Possible risks include group pressures such as harsh confrontation or verbal abuse, inappropriate reassurance, isolation, and scapegoating (Corey & Corey, 1997). Poor member selection may result in inappropriate placement and a failed group therapy experience. Confidentiality cannot be guaranteed in group therapy in the same way as it can in individual treatment because clients are not bound (or protected) by the same restrictions as therapists.


In summary, with appropriate patient selection and preparation along with competent leadership, group therapy helps patients confront and change problematic interpersonal behavior, improve their social skills, decrease loneliness and isolation, deal with losses more effectively, diminish feelings of helplessness, enhance self-esteem, resolve feelings of shame, and develop hope. Notably, in an era of medical cost containment, it is economical because one therapist treats multiple patients at the same time. Thus group therapy is a cost-effective form of treatment worth considering for many psychiatric problems.

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Jul 27, 2021 | Posted by in PSYCHIATRY | Comments Off on 16 – Psychosocial Interventions

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