Group Training Objectives
POST-GRADUATE TRAINING OBJECTIVES
IN GROUP PSYCHOTHERAPY
Drs. Molyn Leszcz, Phil Maerov, Shari Kirsh, Leo Murphy
I.
PREAMBLE
The following standards for training in group psychotherapy delineate guidelines for minimum
expectations for training in the modality of group therapy. It is not expected that residents will
necessarily be able to fulfil these requirements as they rotate through different clinical settings during
the course of their residency. In general, comprehensive training involves a mix of clinical work,
supervision, theory, observation of group work and experiential learning in a group format. The
intention is to provide training in psychodynamic/interpersonally based models of group therapy.
Competence using this model is necessary to conduct many types of groups, as the
psychodynamic/interpersonal model offers instruction in the fundamental principles of group
psychotherapy. Exposure to other models of group therapy is also encouraged, notably cognitive and
behavioral groups.
II. WORKING KNOWLEDGE TRAINING OBJECTIVES IN GROUP THERAPY
A. Knowledge
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Indications and contraindications for group therapy
Range of group treatments and their applications in relation to particular patient
diagnoses and treatment settings
Group dynamics in treatment groups and organizational activities
Leadership variables
Efficacy of group therapy
Process of referral for group therapy
Usefulness as a collaborative treatment
B. Skills
(1)
(2)
(3)
(4)
(5)
To be able to recommend group therapy appropriately and successfully
To evaluate and prepare patients for group therapy
To work in the here-and-now and make appropriate links to the patient's past;
clinical formulation and schema
To identify and address group dynamics and group phenomenon manifested in the group
To deal effectively with transference and countertransference
C. Attitudes
(1)
Awareness of the importance of group dynamics in therapy, educational, social
1
(2)
(3)
(4)
and professional groups
Appreciation of the effectiveness of group therapy to ameliorate patient distress and to modify
dysfunctional behaviour
Recognition that both process and content variables are generally present and require
appropriate consideration
Practice in an ethical manner, including:
(i)
ethical obligations as pertains to all psychotherapies, ensuring patient confidentiality,
protecting the integrity of the patient-therapist relationship, prohibiting sexual contact
between therapist and patient at any time and prohibiting any form of exploitation of the
patient by the therapist;
(ii)
unique aspects of group therapy regarding confidentiality, and boundary maintenance in
a multipersonal treatment;
(iii) to provide access to treatment without prejudice
(iv)
to provide care that is culturally competent and mindful of diversity and gender issues
D. Enabling Objectives
(1)
(2)
(3)
(4)
(5)
(6)
Seminar series participation for a minimum of 8 hours
Leadership or co-leadership of a treatment group, on an inpatient unit or ambulatory setting for a
minimum of 20 hours
Involvement in dynamically/interpersonally-oriented groups through
observation for a minimum of 6 hours
Group psychotherapy supervision in a group or individual format for a minimum of 12 hours
No clinical work should be done by trainees without supervision. Supervision entails a regular
meeting at an established frequency between the group therapy supervisor and the group therapy
trainee(s)
Seminar leaders and group therapy supervisors must be approved by the group
psychotherapy Subcommittee
III. FOR RESIDENTS SEEKING PROFICIENCY LEVEL TRAIING IN GROUP THERAPY ,
MINIMUM OBJECTIVES INCLUDE:
A. Working Knowledge Requirements, plus:
B. Knowledge
(1)
History of group psychotherapy
(2)
Range of group psychotherapy orientations:
1 - behavioral
2 - cognitive
3 - interpersonal
4 - psychodynamic/psychoanalytic
5 - psychoeducational
2
6 - group analysis
7 - group as a whole/systems
8 - self-psychology/object relations
9 - expressive arts
10 - self-help
11 - internet support groups
(3)
Range of group psychotherapy models:
1 - different frames of group therapy - long-term or short-term; open or closed
2 - setting - inpatient, day hospital and ambulatory
3 - general and specific populations - ex. homogenous target populations, chronic
mental illness, medical illness, addictions, eating disorders, mood disorders, multiple
family groups
4 - ages - child, adolescent, adult and geriatric
(4)
Pre-therapy issues:
1 - selection
2 - group composition
3 - preparation of patients
4 - treatment contract
5 - setting/institution variables
(5)
Group therapy issues:
1 - developmental stages
2 - premature termination/drop-outs
3 - therapeutic factors and their utilization
4 - group process variables
5 - norms and boundaries
6 - working in the here-and-now
7 - defences, resistances, roles and working through
8 - transference
9 - countertransference
10 - group therapy leadership
11 – co-therapy
12 - combined and conjoint individual and group therapy
13 – termination
14 – impact of trauma
(6)
Research issues:
1 - critical appraisal
2 - outcome and efficacy with general and specific patient populations, including
collaborative treatments
3 - process and outcome correlations
4 - predictors of outcomes
3
C. Skills
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
To plan and initiate the formation of a psychotherapy group
To intervene differentially at different group developmental stages
To identify and address practical issues regarding the norms and frame of the
treatment
To understand and address individual psychopathology manifested in the group
To introduce new members into ongoing group therapy
To deal with premature termination
To evaluate the process and outcome of treatment, including quantitative measurements
Management of crises and conflict
Termination
D. Attitudes
(1)
Appropriate therapist confidence and preparedness to conduct group psychotherapy
E. Enabling Objectives
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Seminar series participation for a minimum of 20 hours.
Clinical leadership or co-leadership of more than one psychotherapy group for a minimum of 60
hours. This is ideally met by the resident leading or co-leading a long-term, heterogenous group
for a minimum of 40 weeks, weekly for at least 90 minutes, with a minimum of six patients.
An additional group experience of shorter duration that may be homogenous.
A separate, inpatient group therapy experience is recommended, if it has not been
acquired in earlier training.
Supervision should be for a minimum of 40 hours of weekly meetings. Of this 40 hours, at least
20 hours should be in a dyadic or triadic format, with the remainder in a dyadic, triadic or group
format. Supervision entails a regular meeting at an established frequency between the group
therapy supervisor and the group therapy trainee(s).
Supervision should involve direct observation at regular intervals either directly or through
audio-video recordings, where possible.
Residents should have an opportunity to observe experienced group therapists doing group
therapy for a minimum of 6 hours.
Seminar leaders and group therapy supervisors must be approved by the Group
Psychotherapy Subcommittee.
IV.
EXPERIENTIAL TRAINING:
(1)
Residents are expected to participate in Group Day, for one day at least two times during the
course of their residency.
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(2)
Participation in Canadian Group Psychotherapy Association or American Group
Psychotherapy Association Institute training groups is to be encouraged.
V.
EVALUATION:
Evaluation should be done collaboratively by the resident and group therapy supervisor at an
informal level every three months, and in writing every six months. Specific comprehensive
group therapy training evaluation forms may be utilized for this training evaluation.
DOMAINS FOR EVALUATION:
Working Knowledge Level:
Is the resident able to:
1.
2.
3.
4.
5.
Recommend group therapy appropriately and successfully
Evaluate and prepare patients for group therapy
Deal effectively with transference and countertransference
Demonstrate appropriate therapist confidence and preparedness to conduct group
psychotherapy
To practice group therapy ethically
PROFICIENCY LEVEL:
In addition to the Working Knowledge domains for evaluation, is the resident able to:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Work in the here-and-now and make appropriate links to the patient’s past and clinical
formulation and schemas
Identify and address group dynamics and group phenomenon manifested in the group’
Plan and initiate the formation of a psychotherapy group
Intervene differentially at different group developmental stages
Deal with premature termination
Evaluate the process and outcome of treatment, including quantitative measurements
Prepare group members effectively for termination
Appraise group therapy literature critically
Work effectively in co-therapy
Lead groups with appropriate confidence
5
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
Alonso A: Training for group psychotherapy, in Group Therapy in Clinical Practice. Edited by
Alonso A and Swiller H. American Psychiatric Press, Inc., Washington, DC, 1993
American Group Psychotherapy Association: The Official AGPA Training Program. New
York, New York, 1986
Canadian Group Psychotherapy Association: Toronto Section Training Program Handbook,
1989
Group Psychotherapy Training Program, Institute of Psychotherapy. Calgary District Hospital
Group, Holy Cross Hospital, Calgary, Alberta, 1991-1993
National Standards for Group Psychotherapy Training in Canada. Approved by the Board of
C.G.P.A. at the 7th Annual Conference, October 1986
Salvendy J, Robson B, Babiak T: Group psychotherapy in psychiatric residency training.
Academic Psychiatry 14(1), 1990
Specialized Psychotherapy Supervision, Supplemental Evaluation Form F: Group
Psychotherapy. Teaching Assessment Services (TAS) Evaluation Form. Department of
Psychiatry, University of Toronto, March 1992
The Learning of Communication Skills and Psychotherapy. The Division of Psychological
Medicine of the Department of Mental Health Sciences
St. Georges Hospital: Medical School Tooting, London, 1990
GROUP PSYCHOTHERAPY: RECOMMENDED READINGS
I.
Difficulties of the Beginning Group Therapist
1.
Williams, M. (1966). Limitations, fantasies and security operations of beginning group
psychotherapists. Int. J. Group Psychotherapy, 16:150-162.
Yalom, I.D. (1966). Problems of neophyte group therapists. Int. J. Social Psychiatry, 12:52-59.
Zaslav, M.R. (1988). A model of group therapist development. Int. J. Group Psychotherapy,
38:511-519.
2.
3.
II.
Models of Group Psychotherapy
1.
Dies, R.R. (1992). Models of group psychotherapy: Sifting through confusion. Int. J. Group
Psychotherapy, 42:1-17.
Kauff, P.F. (1979). Diversity in analytic group psychotherapy: The relationship between
theoretical concepts and technique. Int. J. Group Psychotherapy, 29:51-65.
Rioch, M.J. (1970). The work of Wilfred Bion on groups. Psychiatry, 56-66.
Rutan, J.S. & Stone, W.N. (1993). History of small group therapy and practise. In,
Psychodynamic Group Psychotherapy, Lexington: The Collamore Press, pg. 9-30.
2.
3.
4.
III.
Therapeutic Mechanisms in Group Psychotherapy
1.
Bloch, S. (1986). Therapeutic factors in group Psychotherapy. In APA Annual Review V, pg.
6
2.
3.
4.
679-698.
Block, S. & Crouch, E. (1985). Acceptance. In Therapeutic Factors in Group Psychotherapy.
Eds. S. Bloch & E. Crouch. New York: Oxford Universities Press, pg. 98-125.
Hawkins, D.M. (1986). Understanding reactions to group instability in psychotherapy groups.
Int. J. Group Psychotherapy, 36:241-260.
Tschuschke, V., MacKenzie, K.R., Haaser, B. & Janke, G. (1996). Self-disclosure, feedback,
and outcome in long-term inpatient psychotherapy groups. J. of Psychotherapy Practice and
Research, 5:35-44.
IV.
Interpersonal Learning in Group Psychotherapy
1.
3.
Leszcz, M. (1982). The interpersonal approach to group psychotherapy. Int. J. Group
Psychotherapy, 42:42-67.
Rothke, S. (1986). The role of interpersonal feedback in group psychotherapy. Int. J. Group
Psychotherapy, 36:225-240.
Yalom, I.D. (1986). Interpersonal learning. In APA Annual Review V, pg. 699-714.
V.
Selection and Preparation for Therapy
1.
Bellak, L. (1980). On some limitations of dyadic psychotherapy and the role of the group
modalities. Int. J. Group Psychotherapy, 30:7-21.
Grunebaum, H. & Kates, W. (1977). Whom to refer for group psychotherapy. Am. J.
Psychiatry, 134:130-133.
Salvendy, J. (1993). Selection and preparation of patients and organization of the group. In H.I.
Kaplan and B.J. Sadock (Eds.) Comprehensive Group Psychotherapy, 3rd Ed., Baltimore:
Williams and Wilkins, pg. 72-83.
Yalom, I.D. (1985). Preparation for group therapy. In The Theory and Practice of Group
Psychotherapy. New York: Basic Books, pg. 285-298.
2.
2.
3.
4.
VI.
Conjoint Therapy
1.
Ormont, L. (1981). Principles and practise of conjoint psychoanalytic treatment. Am. J.
Psychiatry, 138:69-73.
Rutan, J.S. & Alonso, A. (1982). Group therapy, individual therapy, or both? Int. J. Group
Psychotherapy, 32:267-282.
2.
VII.
Duration of Treatment and Premature Termination
1.
Lothstein, L.M. (1978). The group psychotherapy dropout phenomenon revisited. Am. J.
Psychiatry, 135: 1492-1495.
Stone, W.N. & Rutan, J.S. (1984). Duration of treatment in group psychotherapy. Int. J. Group
Psychotherapy, 34: 93-109.
2.
3.
Roback, M.B. & Smith, M. (1987). Patient attrition in dynamically oriented treatment groups.
7
4.
Am. J. Psychiatry, 144:426-431.
Bernard, H.S. (1989). Guidelines to minimize premature terminations. Int. J. Group
Psychotherapy, 39:523-529.
VIII. Developmental Stages
1.
2.
Gruen, W. (1977). The stages in development of a therapy group: Tell-tale symptoms and their
origins in the dynamic group forces. Group, 1:10-26.
Mackenzie, K.R. & Livesley, W.J. (1984). Developmental stages: An integrating theory of
group psychotherapy, pg. 247-251.
IX.
Co-therapy
1.
Roller, B. & Nelson V. (1993). Co-therapy. In H.I. Kaplan & B.J. Sadock (Eds.)
Comprehensive Group Psychotherapy, New York: Williams and Wilkins, pg. 304-312.
X.
Time-limited Group Therapy
1.
Budman, S.M., Bennett, M.J. & Wisneski, M.J. (1980). Short-term group psychotherapy: An
adult developmental model. Int. J. Group Psychotherapy, 30:63-76.
Klein, R.M. (1985). Some principles of short-term group therapy. Int. J. Group Psychotherapy,
35:309-330.
Budman, S.M., Derby, A., & Reclondo, J.P. (1988). Comparative outcome in time-limited
individual and group psychotherapy, 38:63-86.
MacKenzie, K.R. (1993). Time-limited group theory and technique. In A. Alonso & H. Swiller
(Eds.) Group Therapy in Clinical Practice, Washington: APPI, pg. 423-447.
2.
3.
4.
XI.
Projective Identification and Scapegoating
1.
Scheidlinger, S. (1982). Presidential address: On scapegoating in group psychotherapy. Int. J.
Group Psychotherapy, 32:131-143.
Goldstein, W.N. (1991). Clarification of projective identification. Am. J. Psychiatry, 148:153161.
2.
XII.
Therapist Transparency and Leadership
1.
Dies, R.R. (1977). Group therapist transparency: A critique of theory and research. Int. J. Group
Psychotherapy, 27:177-200.
Volkan, V.V. (1980). Narcissistic personality organization and "reparative" leadership. Int. J.
Group Psychotherapy, 30:131-152.
2.
XIII. Leadership Issues and Functions
1.
2.
Weiner, M.F. (1983). The assessment and resolution of impasse in group psychotherapy. Int. J.
Group Psychotherapy, 33:313-331.
Ormont, L.R. (1988). The role of the leader in resolving resistances to intimacy in the group
setting. Int. J. Group Psychotherapy, 398:29-45.
8
3.
4.
Ormont, L.R. (1990). The craft of bridging. Int. J. Group Psychotherapy, 40:3-17.
Flowers, T.V. & Booraem, C.D. (1990). The frequency and effect on outcome of different types
of interpretation in psychodynamic and cognitive-behavioural group psychotherapy. Int. J.
Group Psychotherapy, 40:203-214.
XIV. Specific Treatment Issues
1.
2.
3.
Yalom, I.D. & Vinogradov, S. (1988). Bereavement groups: Techniques and themes. Int. J.
Group Psychotherapy, 38:419-446.
Leszcz, M. (1989). Group psychotherapy of the characterlogically difficult patient. Int. J. Group
Psychotherapy, 39:311-337.
Matano, R.A. & Yalom, I.D. (1991). Approaches to chemical dependency: Chemical
dependency and interactive group therapy: A synthesis. Int. J. Group Psychotherapy, 41:269294.
XV.
Research
1.
Tillitski, J. (1990). A meta-analysis of estimated effect sizes for group versus individual versus
control treatments. Int. J. Group Psychotherapy, 40(2):215-224.
Dies, R.R. (1993). Research on group psychotherapy overview and clinical applications. In. A.
Alonso & H. Swiller (Eds.), Group Therapy in Clinical Practice, Washington: APPI, pg. 473520.
2.
XVI. Termination
1.
2.
3.
McGee, T.F. (1974). Therapist termination in group psychotherapy. Int. J. Group
Psychotherapy, 24:3-11.
Long, K., Pendleton, L. & Winter, B. (1988). Effects of therapist termination on group process.
Int. J. Group Psychotherapy, 38:211-222.
Schermer, V.L. & Klein, R.H. (1995). Termination in group psychotherapy from the
perspectives of contemporary object relations theory and self psychology. Int. J. Group
Psychotherapy, 46:99-116.
Recommended Texts
Mackenzie, K.R. (1990). Introduction to time-limited group psychotherapy. Washington, DC:
APPI.
Piper, W.E, McCallum, M. & Azim, H.F.A. (1992). Adaptation to loss through short-term
group psychotherapy. New York: Guilford Press.
Rutan, J.S. & Stone, W.N. (1993). Psychodynamic group psychotherapy (2nd Ed.) New York:
Guilford Press.
Yalom, I.D. and Leszcz, M. (1995). The theory and practise of group psychotherapy (5th Ed.) New
York: Basic Books.
SELF-HELP GROUPS
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Mental Health Groups:
1.
2.
3.
Edmunson, E.D., J.R. Bedell, et al. (1982). Integrating Skill Building and Peer Support in
Mental Health Treatment: The Early Intervention and Community Network Developments
Projects. Community Mental Health and Behavioral Ecology. A.M. Jeger and R.S. Slotnick.
New York: Plenum Press: 127-139.
Galanter, M. (1988). Zealous self-help groups as adjuncts to psychiatric treatment: A study of
Recovery, Inc. American Journal of Psychiatry 145(10): 1248-1253.
Kurtz, L.F. (1988). Mutual aid for affective disorders: The Manic Depressive and Depressive
Association. American Journal of Orthopsychiatry 58(1): 152-155.
Weight Loss Groups:
1.
2.
Grimsmo, A., Helgesen, G. et al. (1981). Short-term and long-term effects of lay groups on
weight reduction. British Medical Journal 283: 1093-1095.
Peterson, G., Abrams, D.B. et al. (1985). Professional versus self-help weight loss at the
worksite: The challenge of making a public health impact. Behavior Therapy 16: 213-222.
Addiction-Related Recovery Groups:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Alemi, F., Mosavel, M., Stephens, R. et al. (1996). "Electronic self-help and support groups."
Medical Care 34 (Supplement): OS32-OS44.
Christo, G., Sutton, S. (1994). Anxiety and self-esteem as a function of abstinence time among
recovering addicts attending Narcotics Anonymous. British Journal of Clinical Psychology 33:
198-200.
Emrick, C.D., Tonigan, J.S. (1993). Alcoholics Anonymous: What is Currently Known? In
Research on Alcoholics Anonymous: Opportunities and Alternatives, edited by Barbara S.
McCrady and William R. Miller. New Brunswick, NJ: Rutgers Center of Alcohol Studies, pp.
41-75.
Hughes, J.M. (1977). Adolescent children of alcoholic parents and the relationship of Alateen to
these children. Journal of Consulting and Clinical Psychology 45(5): 946-947.
Humphreys, K., Mavis, B.E., Stoffelmayr, B.E. (1994). Are Twelve Step Programs appropriate
for disenfranchised groups? Evidence from a study of posttreatment mutual help involvement.
Prevention in Human Services 11(1): 165-179.
Humphreys, K., Moos, R.H. (1996). Reduced substance-abuse-related health care costs among
voluntary participants in Alcoholics Anonymous. Psychiatric Services 47: 709-713.
Jason, L.A., Gruder, C.L. (1987) Work site group meetings and the effectiveness of a televised
smoking cessation intervention. American Journal of Community Psychology 15: 57-77.
McAuliffe, W.E. (1990). A randomized controlled trial of recovery training and self-help for
opiod addicts in New England and Hong Kong. Journal of Psychoactive Drugs 22(2): 197-209.
McKay, J.R., Alterman, A.I. et al. (1994). Treatment goals, continuity of care, and outcome in a
Day Hospital Substance Abuse Rehabilitation Program. American Journal of Psychiatry 151(2):
254-259.
Tattersall, M.L, Hallstrom, C. (1992). Self-help and Benzodiazepine withdrawal. Journal of
Affective Disorders 24(3): 193-198.
Wash, D.C., Hingson, R.W., Merrigan, D.M. et al. (1991). A randomized trial of treatment
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options for alcohol-abusing workers. The New England Journal of Medicine 325(11): 775-782.
Bereavement Groups:
1.
2.
3.
4.
5.
Caserta, M.S., Lund, D.A. (1993). Intrapersonal resources and the effectiveness of self-help
groups for bereaved older adults. Gerontologist 33(5): 619-629.
Lieberman, M.A., Videka-Sherman, L. (1986). The impact of self-help groups on the mental
health of widows and widowers. American Journal of Orthopsychiatry 56(3): 435-449.
Marmar, C.R., Horowitz, M.J. et al. (1988). A controlled trial of brief psychotherapy and
mutual-help group treatment of conjugal bereavement. American Journal of Psychiatry 145(2):
203-209.
Vachon, M.L.S., Lyall, W.A.L. et al. (1980). A controlled study of self-help intervention for
widows. American Journal of Psychiatry 137(11): 1380-1384.
Videka-Sherman, L., Lieberman, M. (1985). The effects of self-help and psychotherapy
intervention on child loss: The limits of recovery. American Journal of Orthopsychiatry 55(1):
70-82.
Diabetes Groups:
1.
2.
Gilden, J.L., Hendryx, M.S. et al. (1992). Diabetes support groups improve health care of older
diabetic patients. Journal of American Geriatrics Society 40: 147-150.
Simmons, D. (1992). Diabetes self help facilitated by local diabetes research: The Coventry
Asian Diabetes Support Group. Diabetic Medicine 9: 866-869.
Caregiver Groups:
1.
Toseland, R.W., Rossiter, C.M., Labrecque, M.S. (1989). The effectiveness of two kinds of
support groups for caregivers. Social Service Review September: 415-432.
Groups For Elderly People:
1.
Lieberman, M.A., Bliwise, N.G. (1985). Comparisons among peer and professionally directed
groups for the elderly: Implications for the development of self-help groups. International
Journal of Group Psychotherapy 35(2): 155-175.
Chronic Illnesses:
1.
2.
3.
Becu, M., Becu, N., Manzur, G, Kochen, S. (1993). Self-help epilepsy groups: An evaluation of
effect on depression and schizophrenia. Epilepsia 34(5): 841-845.
Nash, K.B., Kramer, K.D. (1993). Self-help for Sickle Cell Disease in African American
communities. Journal of Applied Behavioral Science 29(2): 202-215.
Sibthorpe, B., Fleming, D. et al. (1994). Self-help groups: A key to HIV risk reduction for highrisk injection drug users? Journal of Acquired Immune Deficiency Syndromes 7(6) 592-598.
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