Art as a Therapeutic Experience

Group Therapy Theory

Below are outline notes which describe some of the best known approaches to the therapeutic process in groups. They are based on Group Therapy Theory which has to be adapted to the activities of the Art Therapy Group.

Following study of the notes, students are advised to follow up with reading selected from one of the approaches outlined. The notes are intended as a guide only and should not be used a quotable material. Further reading on Art Therapy groups is also recommended where the individual therapist will identify which group therapy approach they adopt.

Groups may be:

  • Small (7-10 persons), Medium (15-30 persons) or Large (30-70 +)
  • Open or closed
  • Brief (8-16 Sessions), Medium (12-18 Sessions) or Long (3+ years)
  • Single or mixed sex, age range, ethnic background and problem
  • Stranger or therapeutic milieu and community, in format
  • Therapy, self-help, skills acquisition, educational or encounter,
    in designation of purpose
DEFINITIONS
What most theories have in common is a group (usually a minimum of five in number) made up of people who interact and influence each other in the hope that from their membership they will derive some special benefit for problems that have been framed, by and large, in interpersonal terms.

In the case of small group therapy, the most common types of groups are: group analysis, interpersonal, encounter, gestalt, psychodrama, or cognitive-behavioural
Historical and Philosophical Sources of Group Therapies

Alfred ADLER, one of the three ‘founding fathers’ of psychoanalysis, differs from Freud and Jung whose approach, classically, is founded on intrapsychic principles (the unconscious) and is individual in practice (a dyadic relationship between analyst and analysand).

Adler’s principle was based on continuous action and reaction between the individual and the environment where; no person is in isolation or stasis; every person is in the process of change and subject to community feeling.

Whilst Freud’s concern was to look back in time to early infantile experiences, Alder looked forward to goals and intentions. Adler’s style is hence more open and collaborative and in which other members of the patient’s social system might, with their permission, be involved in the therapy. Adler also developed ‘therapeutic education’ which brings together all the parties concerned in a problem and more i.e. the parents, child, the involved teacher, and fellow teachers and students of the method, precursor perhaps the modern ‘case conference’.

Others, following Adler, include: in Britain, Joshua Bierer and Victor Frankl and in America, Karen Horney, Erich Fromm and Harry Stack Sullivan who all reflect his emphasis of the INTERPERSONAL approach. And, following on from them, Irving Yalom and Carl Rogers with the recognition of the importance of the ultimate existential concerns of meaning, purpose and death.
The Interpersonal Approach

“The self is a social construct, formed out of the appraisals made by others. How someone is seen by others is how they see themselves. Individual sense of self-worth arises out of these appraisals and is maintained by security operations such as selective inattention. In interaction, individual needs may be responded to in a complementary or reciprocal way; depending on the nature of the need and the response, needs will be satisfied or frustrated and, consequently, the relationship will prosper or decay.” (Sullivan 1953)

As example, a child needs tenderness and the complementary response of tenderness from the mother if that need it to be met. Later in development, if the natural impetus towards activity and curiosity is not to be destroyed, the child’s initiatives need to be responded to reciprocally by the parent making a facilitative space for the activity. Later in life, all parties are involved in a sequence of interaction and are active participants in what happens; the aggressive person elicits complementary aggression or reciprocal submission from others; the person who can trust generally brings out trust in others, though occasionally the response is one of exploitation; what happens becomes the foundation for what happens next, and so on.

This model provides a sequential framework which is well suited for the task of examining what happens in relationships between specific people.

In therapy groups, individuals can come to see how they relate in complementary and reciprocal ways to different members and the consequences that follow and, with hard work, learn more fruitful and less fearful ways of being with others.

Different Theories for Interaction between members of a group


Gestalt Therapy


Fritz PERLS is most closely associated with Gestalt therapy in which ‘character armour’ and body posture and tension is fundamentally associated with the way in which humans create meaning by singling out aspects of their experience from the rest, which then recedes into the background. In the gestalt world, therapeutic progress is achieved by making contact with what is out of the awareness. In a group, myriad Gestalts form and re-form, member to member, member(s) to leader, and with the group as a whole; the different elements can be brought into focus by the leader and by group members as they become skilled in the approach.


Systemic Therapy


Kurt LEWIN, and formally the Milan School, are associated with Systems Theory pioneered in the educational use of ‘T-groups’ (T for training). The provision of a new social environment is felt to have the capacity to unfreeze an individual from his or her past self-definitions and facilitate a movement towards ‘self-actualisation’ or as in the Jungian term ‘individuation’. A branch of Systems theory, is also derived from cybernetics, (Gregory Bateson) which emphasises the interdependent parts of the whole. Change in one part inevitably leads to change in others as systems are organised hierarchically, and the product of the whole is greater than that of the parts. Healthy living is then in a constant state of change and adaptation. Systems theory is particularly relevant to family and group therapeutic practice.

Psychodrama

Jacob Levy MORENO is most closely associated with Psychodrama as a group technique. Psychodrama seeks to resolve personally difficult situations through dramatisation and the release of creative forces inherent in the individual. The approach is not totally group orientated as the focus shifts from the individual or protagonist to the audience in the role of group members who share with the protagonist their own experience and associations to the tangible exploration of the inner world in which they have participated. Psychodrama provides a stage on which roles, counter-roles and potential roles can be experienced and the associated feelings can be cathartically faced. Increasingly the method is used reflexively to examine the process of an ongoing group.


It can be said that there are two distinction schools; psychoanalysis and behaviourism. Whilst the separation of the two into oppositions seems to be a current trend, is it the realms of cognitive-behavioural groups that the focus moves away from interpsychic and interaction as separate towards a consideration of finding solutions to real-life problems posed by client members through integration of the personal aspects of mind (understanding/cognitive) and behaviour (actions taken and physical movement).

From psychoanalysis we have a principle of Process Content, common to all group therapies, that deals with the way in which the fear underlying the factual focus and content of the session move the group as a whole or mobilise defensive strategies in the individual; it is the subtext that is there to be read by anyone who knows the language. It is intrapersonal rather than interpersonal and has three distinct forms.

Therapy in the group is when the leader works with one member at a time, clarifying and exploring their past and present conflicts and making intra personal interpretations; the leaders role is central, and the non-active members being passive learners.

Working with the group makes use of its special properties; they clarify unconscious group and individual processes, often with an historical perspective. The interpersonal school integrates therapy with and of the group, but with a here-and-now emphasis explicitly designed to mobilise the ability of members to help each other.

Therapy of the group has been specially developed in Britain. The leader directs to the whole group and only minimally to individual members; the aim is development of a healthy group which will of itself be the vehicle for therapeutic change. (Bion, Tavistock Clinic)

Common to this way of working are three further modes of working: the basic assumption states of:

fight-flight, (attack or avoidance of conflict)
dependency (expressing a need for others to take responsibility or blame)
pairing (linking up or identifying with another likeminded individual or sub-group, sometimes creating a scapegoat).

S. H. Foulkes (1967) founded the approach of group analysis based on the group matrix, a web of communication and interrelationship that evolve in the group, and form the common shared group that determines the meaning and significance of events in the life of the group. Within the group (and in a person’s life) the individual is seen as the nodal point of a social network which defines and shapes and facilitates an understanding of that person's needs in the social context, a context which both forms the person and is formed by them. The neurotic person brings into the group the incompatibility between them and their original family group and re-creates this by disturbed interpersonal processes with themselves at the focal point.

In group analysis, the communications of the group are viewed like the free associations of an analytic dyad. It is analytic thinking that underlies the useful concept of the mirror reaction whereby the individual reacts to repressed parts of himself or herself present in others, usually be either attacking or protecting them.

The potential to recognise and accept these aspects of self in others is a uniquely valuable feature of any form of group work and in group analysis is a major fulcrum in bringing about therapeutic change. Other analytic concepts are those of resonance, where unconscious communication results in conflict-specific bonding between members who need each other for the complementary roles of dominant/submissive and the like.

Polarisation, where the mental mechanism of splitting complex reactions leads to group members expressing the unresolved conflicts of some or one of their number through taking up contradictory, divergent attitudes or extruding the conflict through scapegoating, and finally the way in which shared deeply unconscious material is expressed in a loosening of group resistances through a chain of symbolic communications in the condenser phenomenon whose common meaning can be understood only on subsequent reflection by the group.

Group focal conflict theory is when the group as a whole is moved by shared themes which constitute a disturbing motive (wishes and impulses) that is in conflict with a reactive motive (fear or guilt) forming the group’s focal conflict, a classic analytic one of impulse and anxiety.

The innovation of this method being the considerations of solutions to the conflict which may be either restrictive or enabling. Restrictive solutions alleviate the shared guilt or fear but leave the wish unacknowledged, unsatisfied and unexplorable whilst enabling solutions put members in touch with their fears and wishes but in a climate of acceptance and the context of new forms of escape but in a climate of acceptance and the context of new forms of relationship. Successive solutions to the focal conflict(s) are the history of the group and form the group culture.

Some Comparative Comments

Group Analysis and Group Focal Conflict

Similarities

  • both are concerned with the group as a whole
  • both are concerned with the ‘here and now’ of the group experience
  • neither take for granted that the group will automatically become a therapeutic place
  • both charge the leader/conductor with partial responsibility for guiding the group

Differences
Communication and Experience

Group Analysis (Intra-Personal)
Group Conflict (Inter-Personal)
greater stress on clarity of communication
corrective emotional experiences
“Working towards an ever more articulate form of communication is identical with the therapeutic process itself”
Foulkes 1948
“For the neurotic patient, the therapeutic process involves the experience that the feared consequences (of recognising or expressing impulses) do not occur”
Whitacker & Leibmann 1964

Resonance
determind by transference phenomenon


Group Focal Conflict and Individual focal conflicts are the product of one, several or even all members of the group

The Leader

relatively austere

authority derived by projections of the group, uses this for the benefit of the group

an analytic ‘love for truth’, even when unpalatable

does not aim to give comfort or to be real

interprets the communications of the group and the social matrix
stays in background
works towards the group taking responsibility for itself
fellow traveller in the journey of life

facilitator of interpersonal transactions (Gestalt)
presents a model of good group membership by being open [responsibly so]

taking risks and being relatively undefended (Gestalt, Psychodrama and Cognitive-Behavioural)

definitely directive and possibly:
Gestalt: introduces technical procedures, acts to frustrate confluence and promotes antithesis, contact (bodily and emotionally)
Psychodrama: directs as in director role by selecting protagonist, analyst/producer secondary role, extrovert and sensitive
Cognitive-Behavioural: didactic, directive, evaluative, flexible in modifying techniques to needs, promotes the acquisition of skills
The roles of Conductor, facilitator, director and educator have:
1) different appeal to each therapist
2) are recognised in the selection of and for training

Comparison between classical psychoanalysis and group work
Presenting Current Relationship

classical psychoanalysis
Individual
Vertical
“There and Then”
History essential

group work
Group
Horizontal
“Here and Now”
History not essential
The Social Context (a group member.....
  • communicates his/her problem by symptoms of blocks to free communication
  • is at the nodal point of a network of disturbed communication whose meaning is initially unintelligible
    interpretation clarifies the latent meaning
  • progress is made by giving up the focus on the declared problem and entering into the ongoing life of the group
    - it is the conductor’s adherence to boundaries which has the effect of bringing transference issues into focus
  • brings to the group recurrent interpersonal difficulties and enacts them within the group
  • the group forms a laboratory in which maladaptive interactions can be identified
  • a workshop where new resolutions may be practised
    emphasis on responsibility and choice
  • meaning an purpose to life is strengthened
  • the individual gains the courage to enter 'selves' that might be kept at bay through fear
Time
Both methods may gain from brief, closed groups of eight to sixteen sessions or intensive workshops over a few days. The characteristic mode is weekly or bi-weekly work over upwards of eighteen months.

Group Membership
all group memberships requires....

members are physically present
members are emotionally available
members are open to change
members have sufficient sefl-generated willingness to commit themselves to meeting and involving themselves in each other's care
members have an ability to understand and work towards understanding the process
members have an ability to reflect on the evolving history

Reflexivity
Often, Gestalt and Psychodrama groups are not reflexive as they meet episodically and because the focus on work with the individual does not reflect on the significance to inter-member and member-leader interaction.


Basic Conceptual Frameworks
All groups (except cognitive-behavioural groups) make use of psychoanalytic concepts: transference, parataxic distortion, projection, splitting, and mirroring

Cognitive Behavioural Concepts are: goal directed, shorter meeting, symptom removal, modification of specific cognitions,
may or may not be interpersonal, taught how to manage e.g. anxiety, social skills, anger management; interpersonal effectiveness is secondary

As therapists are drawn to one form of training or another, so to are group members equally drawn to one form of therapy or another. This may take place via two considerations:

1) Subjects whose locus is external e.g. forces outside themselves, chance, fate, dictates of society, prefer directive behavioural approaches.
2) Subjects whose locus is internal e.g. self generative, reinforcements to behaviour follow causally, prefer non-directive analytic therapies.

Outcome is improved when the control orientation of the therapist, therapy and the subject is the same.

A ‘good’ therapy outcome may be marked by a person's locus moving more within themselves as they come to feel and be more in charge of their lives.

Therapeutic Factors in Group Therapy

In 1968, Irvin Yalom asked 64 questions to identify ‘value’ to individuals in groups. The highest scoring top three responses were:

Discovering and accepting previously unknown or unacceptable parts of myself
Being able to say what was bothering me instead of holding on to it
Other members honestly telling me what they think of me
Clearly, what is valued most might not be the same as what is actually helpful.

Bloch and Crouch (1985) defined ten factors, given the group’s goal, size, composition, duration, stage of development and context, which are overlapping and inter-dependent.

These are: acceptance, universality, altruism, installation of hope, guidance, vicarious learning, self understanding, learning from inter-personal action, self disclosure and catharsis.

From these they further identified three areas that make up a therapy group;

a therapeutic factor: an element of the group process which exerts a beneficial effect on group members
a condition of change: must be present for a therapeutic factor to operate but does not have an intrinsic therapeutic effect
a technique: which is a device available to the leader to promote the operation of the therapeutic factor

Once members sense that they can survive being in the group and have confidence that the group will endure, then they are ready to learn.

© Kate Broom

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