Basic methods and their applications

We now provide a more detailed overview of the current field, extending the picture by taking full account of the client categories, context, and setting in which the methods are applied. We also offer a brief set of training requirements for practitioners in each of the methods groups discussed.

The field can be divided between five basic methods: activity, supportive, problem-solving, psychoeducational, and psychodynamic. The first three methods are goal-specific, as indicated by their descriptions, the fourth is less specific, and the fifth is a non-directive analytic psychotherapy. In supportive and problem-solving groups therapeutic leadership may or may not be highly directed, depending on the approach. Activity and psychoeducational groups will inevitably have a high level of directed group leadership, whilst psychodynamic groups have a much lower level of directed group leadership. All five methods rely on the same basic procedures—the selection and grouping of a number of people seeking help who have regular meetings together with one or more well-trained therapist(s).

Activity groups

The most vulnerable and disturbed patients can be placed in therapy groups defined by an activity, such as exercise or cooking, that provides a convening function. They can then be used to create conditions for a wide range of secondary functions that foster affiliations, develop social skills, address unspoken anxieties, and express troubling emotions. Occupational therapists and nurses using art media or other socially syntonic activities like gardening or hairdressing have been developing a wide range of group services in both acute and rehabilitation psychiatry for many years. (8) The approach has been used in many other settings including medical rehabilitation, rehabilitation with refugees, social work, and fostering and adoption programmes. Groups that keep the original activity as their primary focus, working with art media for example, need to be differentiated from those which use such media to develop an analytic focus on psychological work. The arts psychotherapies belong to this latter group. They have non-specific therapeutic goals and may, as in the case of music therapy, have a high level of leadership activity or, in the case of art therapy, have a low level of leadership activity. (9)

Whilst therapists do not engage in the uncovering and exploration of unconscious dynamics, they will need leadership abilities and capabilities in the organization of group activities, and should have a basic understanding of psychopathology and group dynamics.

Supportive groups

Supportive groups function as a form of social support providing containment, the improvement of social skills, and the enhancement of participants' capacities for social adaptation. They aim to reduce the deleterious effects of social isolation, bring people out of withdrawal into a social context, and provide opportunities for problem sharing. They cater for patient populations with long-standing personality disorders not open to uncovering exploration, for those with chronic mental and physical illness, (!9 for those with physical mental handicap and mental retardation (learning disability), and for carers of those with any of these problems. They will often allow a certain amount of psychoeducation, with the group leader influencing members' attitudes as in the case, for example, of a group for young sexually active adults with mental retardation who might receive guidance on contraception.

Whilst therapists do not engage in the uncovering and exploration of unconscious dynamics, they will need leadership abilities and capabilities in the organization of group activities, and should have a basic understanding of psychopathology and group dynamics.

Problem-solving groups

Group therapy is provided for a set of referral criteria to resolve a defined and sometimes circumscribed problem. Alcoholics Anonymous, Alanon, Gamblers Anonymous, and groups for people with poor impulse control, eating disorders, or other habitual problems, such as smoking, are a few of the examples. (11> These groups can take on many of the features of long-term support groups in that they offer ego-supportive and adaptive resources, providing an extended service for monitoring by the patient or by professionals without necessarily committing members to the deeper and more radical analytic work entailed by a psychodynamic group. In many cases the problem-solving focus provides a convening frame by which to engage a population who are soon drawn into psychodynamic work that sees them through profound changes. Many of the groups run by clinicians in primary hospital care—occupational therapists, nurses, doctors, and psychologists—take this form. The Group Work Programme at the Medical Foundation for Victims of Torture in London is another example (this is discussed further below).

Where they cater for the more severely disturbed, staff will need to be well trained in one of the core professions. They will need leadership abilities and capabilities in the organization of group activities, and they should have a asic understanding of psychopathology and be sufficiently well trained to explore the dynamic group issues that lead from the problem back to the personality structure of their membership. If therapeutic goals involve major changes in personality and social functioning, this will involve the uncovering and exploration of unconscious dynamics.

Psychoeducational groups

The original groups for servicemen with war neurosis at Northfield took the form of psychoeducational groups in which people were given the role of students of their disorders rather than seen as 'sick' (see below). Patients become open to new information and better able to unlearn maladaptive attitudes about the nature of their disorder. This more cognitive approach can be applied in homogeneous problem-solving groups. Information can be provided through lectures, discussions, and suitable reading material. There are different ways of lowering anxiety and uncovering maladaptive and inappropriate attitudes towards such problems such as anxiety states, phobias and obsessions, and psychosomatic disorders. Many of the groups run for those with serious physical illness (see below) take this form. There is often a major psychoeducational component in support groups—for example, those for people with chronic mental illness who can be helped to understand and cope with delusions, hallucinations, and the stigma of illness.(1 B

Staff will need leadership abilities, capabilities in the organization of group activities, and a basic understanding of psychopathology, and will need to be sufficiently well trained in their chosen problem area to be able to relate its educational focus to thematic group issues. If therapeutic goals involve major changes in personality and social functioning, this will require the uncovering and exploration of unconscious dynamics.

Psychodynamic groups

There are supportive, problem-solving, and psychoeducational components in all psychodynamic groups, but the description 'psychodynamic' is reserved for those in which the declared goal is lasting personal change through a non-directive free-associative therapy. The range of different group contexts is so varied that, at first sight, they might appear to have little in common. But there will be common principles in offering therapy to a group of people in an inpatient unit recovering from psychosis and meeting thrice weekly, those in a secure unit for violent offenders meeting once weekly, and those, including mental health trainees, attending a group in private practice once or twice weekly.

All those attending will have been chosen by the therapist(s). They will themselves have chosen to participate and will be expected to justify their continuing place in the group by reliable attendance. The work will be governed by a psychotherapeutic contract of one kind or another in which confidentiality and other boundaries will be clear. Some clinicians establish a therapeutic alliance with individual members prior to the group's commencement, whilst others regard this as part of the group's task only after it is established. There will be some agreed parameters about the duration and time boundaries of the group and about its membership and composition. Groups may have a mixed heterogeneous membership or a homogeneous one, they may have a fixed time limit or be ongoing, and they may have a fixed composition or, if ongoing, therapists may arrange for individuals to leave the group at the conclusion of their therapy and allocate their places to newcomers. These are called slow-open groups; they meet once or twice weekly, and account for most private group psychotherapy.

Within these parameters therapy is born out of ordinary language in the free exchange of a group's members and occupies the cultural domain of all shared onversational experience in which people struggle with meaning—in congregational life, in the confessional, in theatre, narrative, or poetry. (1 ,14>

Staff will need to be trained to the level already described. They will need good leadership ability and, capabilities in the organization of group activities, and a good understanding of psychopathology. Beyond these requirements, therapeutic goals will involve major changes in personality and social functioning involving the uncovering and exploration of unconscious dynamics. So staff will need access to a range of specialized training opportunities which should provide psychodynamic theory, clinical supervision, and, ideally, some opportunity for the practitioners' own personal development. These issues are discussed more fully later in this chapter.

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