NUR 650 STU Psychiatric Management Group Therapy Discussion

Tom is a 16-year-old who comes to you to evaluate his lack of attention because his grades are progressively getting worse. When you ask about stress in his life, he notes that his parents are always fighting, and this upsets him.  He believes that they fight more when they have been drinking, and he believes that his father is the heavier drinker of the two, but he cannot quantify either parent’s use.

PurchaseAmerican Psychological Association. (2019). Publication manual of the American Psychological Association (7th ed.). ISBN: 9781433832154Nussbaum, A. M. (2022). The pocket guide to the DSM5-TR diagnostic exam. American Psychiatric Pub. ISBN 9781615373574Tusaie, K. R., & Fitzpatrick, J. J. (2016). Advanced practice psychiatric nursing: Integrating psychotherapy, psychopharmacology, and complementary and alternative   approaches across the life span (3rd ed.). Springer. ISBN 9780826132536Wheeler, K (2020) Psychotherapy for the advanced practice psychiatric nurse (3rd ed.). Springer Publishing Company, New York, NY. ISBN 13: 9780826193797ReadTusaie, K. R., & Fitzpatrick, J. J. (2016). Pages 470-482Wheeler, K (2020). Chapter 12 Group Therapy
NUR 650: Psychiatric Management III
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INTRODUCTION
• Group therapy provides a cost-effective and evidence-based intervention for addressing mental
health issues.
• Group psychotherapy can be effective for many acute and chronic psychiatric conditions and has
been shown to…
o help individuals improve interpersonal skills,
o reduce a wide range of psychiatric symptoms, and
o provide positive outcomes for individuals facing an array of comorbid medical issues.
• Recent literature posits that group psychotherapeutic interventions may provide a means of further
enhancing brain development through the interpersonal relationships and bonds created by
participating in a group experience.
• For the advanced practice psychiatric nurse (APPN), group psychotherapy offers the ability to
increase access to care for patients and to diversify one’s practice by offering services other than
individual, couples, or family therapy.
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THE HISTORY OF GROUP PSYCHOTHERAPY
• Human beings have been discussing
mysteries and dilemmas, collaborating, and
arguing in groups since the dawn of
hominid time (Fehr, 2003).
• The formal practice of group therapy
emerged just after World War II, when
under-resourced military physicians were
swamped by psychiatrically disturbed
soldiers recoiling from the horrors of war.
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THE HISTORY OF GROUP PSYCHOTHERAPY (CONT’D)
Several practitioners and schools of thought have
contributed to the development of group
psychotherapy:
o Joseph Moreno introduced psychodrama as a
group psychotherapy intervention.
▪ He devised methods of role reversal in
improvised group dramatizations, wherein
patients could reenact current and past
scenarios from their lives in order to outface
their fears and handle anxiety-laden
situations less destructively.
▪ His view was that patients needed practice
in releasing their suppressed emotions
(catharsis) and utilizing their creative
potential in the here and now.
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THE HISTORY OF GROUP PSYCHOTHERAPY (CONT’D)
o Wilfred Bion (1959) focused on collective group processes and patterns.
▪ The “work group” is a term that describes the group’s focus on what is supposed to be
achieved.
▪ “Basic assumptions” are primitive, unconscious beliefs that powerfully influence and sabotage
conscious activity and action in the group.
▪ Bion identified three patterns that could undermine the work of the group:
Dependency
Flight or Fight
Pairing
The group, unsure how to
achieve its task, craves a
magic solution form a
charismatic leader.
Powerful anxieties are
deflected or projected
onto an “enemy” that
must be fled from or
fought.
Members pair up with one
another with the hope
of identifying or creating
a new leader that will
save the group.
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THE HISTORY OF GROUP PSYCHOTHERAPY (CONT’D)
o Samuel Slavson, one of the founders of the
American Group Psychotherapy Association
(AGPA), believed that when engaged in a
group task, participants could develop a
strong sense of common purpose and
solidarity.
▪ Group interactions were thought to bring
out dimensions to participants’
personalities that they rarely used, or
perhaps did not even know about
previously.
▪ Slavson directed his interventions to the
encouragement and cementing of group
cohesion.
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THE HISTORY OF GROUP PSYCHOTHERAPY (CONT’D)
• By the 1950s, group therapy was becoming
increasingly multivocal, with a range of
theoretical backgrounds informing different
approaches.
• In the 1960s and 1970s, the climate became
fractious, with disputes among various analytic
groups and group therapists (see right).
• By the 1980s, cognitive behavioral therapy
was making the transition from an individual
therapy to a group intervention.
• Today, discordant views have given way to
collaboration among practitioners and a
diversity of theoretical approaches.
o Berne’s (1961)
transactional analysis
method of group therapy,
o the Gestalt approach
pioneered by Peris (1969),
o existential group
psychotherapy
o group applications of
Rogers’s personcentered approach.
New group therapy approaches
emerged in the 1960s and ‘70s.
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THE PRINCIPLES OF GROUP PSYCHOTHERAPY: OVERVIEW
• Primary theoretical models of group psychotherapy include
psychodynamic, cognitive behavioral, interpersonal, solutionfocused, and person-centered.
• For progress to occur, therapists need to engage sensitively in the
here and now of every group session with the intricacies,
ambiguities, and subtleties of interpersonal interaction.
• Group therapy involves core principles and underlying
assumptions that are thought to be crucial to therapeutic progress
regardless of the theoretical orientation or model.
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THE 11 THERAPEUTIC PRINCIPLES
OF GROUP PSYCHOTHERAPY
Yalom and Leszcz (2005) identified eleven therapeutic factors that can be
applied to all group therapies:
1. Instillation of Hope
2. Universality
The promotion of a
belief that, with one
another’s shared
resources, progress
is possible.
The cultivation of a
belief among all
members that they
are not alone and
that no difficulty or
thought is fully
outside the
experience of others.
3. Imparting
Information
Interventions obstruct
the course of
destructive thought
processes by
imparting
knowledge.
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THE 11 THERAPEUTIC PRINCIPLES
OF GROUP PSYCHOTHERAPY (CONT’D)
4. Altruism
Receiving help with
gratitude appears to
elicit one’s own
generosity and desire
to help others in
need.
5. The Corrective
Recapitulation of the
Primary Family Group
The therapeutic group
offers a safe and
compassionately
corrective
environment in which
to address harmful
patterns from the
past.
6. Development of
Socializing Techniques
Group members learn
from each other
about how to correct
chronic and
maladaptive social
tendencies.
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THE 11 THERAPEUTIC PRINCIPLES
OF GROUP PSYCHOTHERAPY (CONT’D)
7. Imitative Behavior
Isolated people learn
to expand their
coping skills and
become more
accepting of
themselves by
“trying out” other
people’s behavior.
8. Interpersonal
Learning
9. Group
Cohesiveness
Interpersonal
connectedness leads
to greater selfunderstanding and
insight into the
origins and
underlying
motivation of one’s
behavior.
• When members feel
unconditionally
accepted by the
group, personal
exploration and selfdisclosure is possible
• This experience
facilitates improved
self-esteem, hope,
and well-being.
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THE 11 THERAPEUTIC PRINCIPLES
OF GROUP PSYCHOTHERAPY (CONT’D)
10. Catharsis
11. Existential Factors
Group members
express deep
emotional feeling
states, thereby
facilitating profound
feelings of release and
recovery.
Group members come
together to accept
responsibility for their
lives and face
universal truths of
human existence,
such as pain, loss, and
death
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TYPES OF GROUPS
Psychoeducational groups function to facilitate education or provide information to
patients and/or families about various psychiatric-mental topics, such as
▪ psychiatric diagnosis
▪ addictions
▪ medication
▪ self-care
▪ recovery issues.
o Can reinforce information, augment knowledge, and improve wellness
o Often time-limited, with a specified number of sessions being offered
o Can be facilitated by either a professional or nonprofessional group leader.
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TYPES OF GROUPS (CONT’D)
Support groups provide a therapeutic environment for people who share a
condition or experience in common (e.g., grief, cancer, multiple sclerosis,
diabetes).
o Typically allow group members to share their individual experiences,
listen to others, provide information, and offer sympathetic
understanding.
o Often have a specified number of sessions.
o Structure can be more formal, with specific topics that are covered each
week, or groups can be more fluid, allowing members to direct the formation
of topics.
o Can be led by professional or non-professional group leaders
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TYPES OF GROUPS (CONT’D)
Self-help groups are formed to provide mutual support to their
members.
o Include members with shared experiences (e.g., substance use
disorders)
o Provide a medium for group members to share their individual
stories, struggles, and successes with others so that they do not feel
alone
o Are not time-limited; participation can continue for months to years.
o Veteran members are called on to support newer group members.
o Professional group leaders not used; all group members take
responsibility for group leadership.
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BENEFITS OF GROUPS
• The cost-effectiveness of group psychotherapy has made this an ideal choice
for many patients.
o Patients with and without insurance coverage for mental health services may
find group psychotherapy an affordable treatment option.
o Group psychotherapy allows therapists to treat several patients at once,
providing patients with greater access to treatment.
• Group psychotherapy allows the therapist to diversify his or her practice so
that patients can choose from an array of services.
• Compared with individual psychotherapy, the accessibility of group psychotherapy
can increase the quantity of psychotherapy visits, which is linked to improved
sense of treatment adequacy.
• Group psychotherapy interventions cover a wide range of conditions and
problems.
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BENEFITS OF GROUPS (CONT’D)
• The diagnostic similarity of participants can positively influence the
group’s outcomes and efficacy.
o The greater the commonality among group participants, the greater the
opportunity for abatement of symptoms.
• Compared with individual psychotherapy, group psychotherapy provides
the following advantages:
o Allows members to share common experiences with others, which has
been positively linked to symptom resolution, particularly for those with
depression and anxiety
o Provides a forum and structured environment to work on relational
issues with other individuals
• Group psychotherapy via telehealth is a possible psychotherapeutic
option for patients.
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EVIDENCE-BASED RESEARCH
While more research is needed to further articulate how specific neurophysiological
mechanisms are responsible for creating the positive responses that are
appreciated in individuals participating in group therapy, a possible explanation may
lie in the neuroplasticity of the brain.
o Flores (2010) noted that the neuroplasticity of the brain has correlations to attachment
theory and group therapy.
o Early development of the human brain is thought to be influenced by early
attachments to other human beings.
o As the individual matures and grows, those relationships or attachments continue to
create neuronal and structural changes within the brain.
o Based on this framework, it is hypothesized that group psychotherapy can further
enhance brain development through the initiation of human connection and
attachment to others within a psychotherapeutic group experience.
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EVIDENCE-BASED RESEARCH (CONT’D)
• Participating in psychotherapeutic group interventions can have a positive impact on a wide
range of mental health issues and responses, including depression, anxiety, self-esteem,
stress, and grief.
• Group therapy can also benefit patients experiencing physical illnesses (e.g., cancer, HIV).
• Studies suggest that group psychotherapy is as effective as individual psychotherapy as a
treatment modality, and that it may be considerably more cost-effective.
o A review of 107 clinical studies and 14 meta-analyses by Burlingame, MacKenzie, and Strauss
(2004) concluded that, for outpatient populations, group therapy was equal in effectiveness to
individual therapy.
o A recent meta-analysis of the effectiveness of group therapy in the inpatient setting (Kosters et
al., 2006) found marked postintervention improvement.
• When treating substance use disorders, recent systemic reviews found that group therapy is
as effective as individual psychotherapy (Weiss, Jaffee, de Menil, & Cogley, 2004) and more
effective for opiate use disorder patients than methadone maintenance treatment (MMT) alone
(Scherbaum et al., 2005).
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THE DEVELOPMENT OF A GROUP
• Groups are complex systems with nonlinear
development.
• Group systems interact at multiple levels both within
the group and in relation to external environmental
influences.
• Group cohesion is the foundation for members to
establish trust, to explore sensitive issues, and to
enhance their ability to become more authentic and
vulnerable with others.
o The group leader is responsible for initiating and
developing a sense of group cohesion.
o Group cohesion among members is a strong
predictor of whether members will tolerate conflict,
feedback, and change within the group (Budman,
Soldz, Demby, Davis, & Merry, 1993).
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THE DEVELOPMENT OF A GROUP (CONT’D)
Forming
Storming
Norming
Performing
Adjourning
Phases of Group Development
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INTEGRATING GROUP TREATMENT INTO APPN PRACTICE
Expand the caseload of patients
Using a group
intervention or
starting a therapy
group can allow the
APPN to…
Diversify treatment options
Provide cost savings to patients
Possibly improve revenues for the APPN practice
Improve productivity
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INTEGRATING GROUP TREATMENT INTO APPN PRACTICE (CONT’D)
APPNs looking to lead and facilitate group treatment
should consider the following factors:
how to identify the
most appropriate
type of group
how to screen and
select appropriate
patients
how to implement
an advertising
strategy
how to establish a
fee schedule
whether or not use
a co-therapist
leader
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INTEGRATING GROUP TREATMENT INTO APPN PRACTICE (CONT’D)
Identify the purpose
of the group
Identify a target
population
Identify the type of
group to be offered
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INTEGRATING GROUP TREATMENT INTO APPN PRACTICE (CONT’D)
The APPN should decide whether the group will be led by one or two group leaders.
Advantages of a Co-therapist Model
Drawbacks of a Co-therapist Model
• Co-therapists can better observe and
manage the complex communications,
processes, and dynamics of a group
psychotherapy session.
• Co-therapists can model healthy
communication, relationship skills, and
conflict resolution.
• Two therapists bring additional therapeutic
styles, theoretical and clinical resources,
and wisdom.
• Helps to diminish anxieties when running
a group session.
• Therapists can identify, discuss, and
debrief clinical issues before and after
each group session.
• Co-therapists who do not get along will
struggle to manage their own
differences.
• Parent–child dynamics may arise if one
therapist is more skilled/experienced
• Forms of splitting may arise, with one
therapist apparently idealized while the
other becomes devalued or denigrated.
• Group members may feel coerced by cotherapists who are adamant in promoting a
particular therapeutic message, which can
set off underground dynamics of resistance
and rebellion.
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INTEGRATING GROUP TREATMENT INTO APPN PRACTICE (CONT’D)
• Fees for the group will typically be based on several factors,
including insurance reimbursement and geographic location.
• Fees vary from region to region
• They are market-driven and dependent on the skill-level
and experience of the psychotherapist(s) leading the
group.
• Marketing and advertising for group psychotherapy can
include the following:
o Networking with colleagues to identify potential group
members
o Advertising in local publications, schools, hospitals,
community centers, and on appropriate social media sites.
o Using professional websites for psychotherapists
o Designing a personal website
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INTEGRATING GROUP TREATMENT INTO APPN PRACTICE (CONT’D)
• In outpatient settings, it is beneficial for the group
therapist(s) to interview each potential group
member to determine if the group being formed
would be a good fit for the patient.
• If patients are not the right fit for a group, offering
alternative treatment options is important.
o Ensure that patients are connected to other
mental health treatment services.
o The therapist can offer to see the patient for
individual therapy or make a referral to another
provider who might be better suited to meet
the patient’s needs.
Factors to Help Determine if
Patients are the Right Fit for
Group Therapy
• Patient goals
• Group goals
• Motivation
• Ability to attend weekly sessions
• Past psychiatric history
• Intellectual functioning
• Past experience with
psychotherapy
• Personality characteristics
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INTEGRATING GROUP TREATMENT INTO APPN PRACTICE (CONT’D)
The following factors help to create a sense of trust, established
norms, and consistency in group therapy:
o Hold group sessions on the same day and time each week.
o Using the same established space for all group sessions
o Start and end on time to establish structure.
➢ Therapy groups typically run for 90 minutes.
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INTEGRATING GROUP TREATMENT INTO APPN PRACTICE (CONT’D)
At the start of the first group session, the group leader reviews the group’s
ground rules and articulates the expectations for group members.
o Discuss the importance of attending all sessions and arriving on time, how and
when to notify the group leader if a member cannot attend a session, and the
frequency and length of sessions.
o Each group member may be asked to sign a consent for treatment if this has
not been competed prior to the first session.
o Explain that socially accepted norms should be upheld by group members.
o Confidentiality should be discussed so that group members understand that
they can only talk about their own personal experience outside the group.
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POST-MASTER’S GROUP PSYCHOTHERAPY TRAINING AND
CERTIFICATION REQUIREMENTS
• The American Group Psychotherapy Association (AGPA) has established the competency
standards for group psychotherapy.
• The AGPA offers various training sessions and postgraduate education during its annual
meeting as well as through various regional chapters nationwide.
• The International Board for Certification of Group Psychotherapists (IBCGP) offers
Certification as a Certified Group Psychotherapist (CGP) to licensed mental health practitioners
with current malpractice coverage and a minimum of a master’s degree in their respective
discipline.
• APPNs seeking national board certification as either a psychiatric mental health clinical
nurse specialist (adult or child and adolescent designation) or a psychiatric nurse
practitioner are eligible for the CGP designation.
• Recertification must be maintained every 2 years. Recertification requirements include
ongoing clinical practice and completion of continuing education requirements.
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References
•
Berne, E. (1961). Transactional analysis in psychotherapy. New York, NY: Grove.
•
Bion, W. R. (1959). Experiences in groups and other papers. New York, NY: Basic Books.
•
Budman, S. H., Soldz, S., Demby, A., Davis, M., & Merry, J. (1993). What is coehesiveness: An
empirical examination. Small Group Research, 24(2), 199–216. doi:10.1177/1046496493242003
•
Burlingame, G. M., MacKenzie, K. R., & Strauss, B. (2004). Small group treatment: Evidence for
effectiveness and mechanisms of change. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of
psychotherapy and behavior change (5th ed., pp. 647–696). New York, NY: Wiley.
•
Kösters, M., Burlingame, G. M., Nachtigall, C., & Strauss, B. (2006). A meta-analytic review of the
effectiveness of inpatient group psychotherapy. Group Dynamics: Theory, Research, and Practice,
10(2), 146–163. doi:10.1037/1089-2699.10.2.146
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References
•
Fehr, S. S. (2003). Introduction to group psychotherapy: A practical guide. New York, NY: The
Haworth Press.
•
Flores, P. J. (2010). Group therapy and neuroplasticity: An attachment theory perspective.
International Journal of Group Psychotherapy, 60(4), 547–570. doi:10.1521/ijgp.2010.60.4.546
•
Scherbaum, N., Kluwig, J., Specka, M., Krause, D., Merget, B., Finkbeiner, T., & Gastpar, M. (2005).
Group psychotherapy for opiate addicts in methadone maintence treatment—A controlled trial.
European Addiction Research, 11(4), 163–171. doi:10.1159/000086397
•
Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New
York, NY: Basic Books.
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