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31.18b Group Psychotherapy

inappropriate for the treatment. REFERENCES Albano AM. Cognitive-behavioral psychotherapy for children and adolescents. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:3721. Balasubramaniam M, Telles S, Doraiswamy PM. Yoga on our minds: A systematic review of yoga for neuropsychiatric disorders. Front Psychiatry. 2012;3:117. Biegel GM, Brown KW, Shapiro SL, Schubert CM. Mindfulness-based stress reduction for the treatment of adolescent outpatients: A randomized clinical trial. J Consult Clin Psychol. 2009;77:855–866. Chiesa A, Serretti A. A systematic review of neurobiological and clinical features of mindfulness meditations. Psychol Med.2010;40:1239–1252. Kaye DL. Individual psychodynamic psychotherapy. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. II Philadelphia: Lippincott Williams & Wilkins; 2009:3707. Kober D, Martin A. Inpatient psychiatric, partial hospital, and residential treatment for children and adolescents. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. II, Philadelphia: Lippincott Williams & Wilkins; 2009:3766. Kratochvil CJ, Wilens TE. Pediatric psychopharmacology. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. II Philadelphia: Lippincott Williams & Wilkins; 2009:3756. Pumariega A. Community-based treatment. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. II, Philadelphia: Lippincott Williams & Wilkins; 2009:3772. Rostain AL, Franklin ME. Brief psychotherapies for childhood and adolescence In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. II. Philadelphia: Lippincott Williams & Wilkins; 2009:3715. Rubia K. The neurobiology of meditation and its clinical effectiveness in psychiatric disorders. Biol Psychiatry. 2009;82:1– 11. Sargent J. Family therapy. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. II. Philadelphia: Lippincott Williams & Wilkins; 2009:3741. Schlozman SC, Beresin EV. The treatment of adolescents. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. II. Philadelphia: Lippincott Williams & Wilkins; 2009:3777. Siqueland L, Rynn M, Diamond GS. Cognitive behavioral and attachment based family therapy for anxious adolescents: Phase I and II studies. J Anxiety Disord. 2005;19:361. Spence SH, Holmes JM, March S, Lipp OV. The feasibility and outcome of clinic plus internet delivery of cognitivebehavior therapy for childhood anxiety. J Consult Clin Psychol. 2006;74:614. Zylowska L, Ackerman DL, Yang MH, Futrell JL, Horton NL, Hale TS, Pataki C, Smalley SL. Mindfulness meditation training in adults and adolescents with ADHD: A feasibility study. J Attention Dis. 2008;11:737–746. 31.18b Group Psychotherapy Therapeutic groups for children and adolescents are varied in terms of problems addressed, age of patients, group structure, and therapeutic approach implemented.

Group formats have been used to treat a broad range of clinical symptoms, including anger-management for aggressive children and adolescents, social skills improvement, support groups for survivors of childhood sexual abuse, and other traumatic events such as the September 11th World Trade Center tragedy. In addition, groups have also been settings for the treatment of adolescents with social anxiety and OCD, and youth with depressive disorders. Groups have successfully used cognitive-behavioral techniques to treat childhood anxiety disorders, adolescents with substance abuse, and youth with specific learning disorders. Support groups for youth exposed to loss have provided evidence of efficacy, including data from a study investigating the benefits of a psychotherapy group for adolescent survivors of homicide victims. Group therapies can be utilized with children of all ages using developmentally appropriate formats. The groups can focus on behavioral, educational, and social skills and psychodynamic issues. The mode in which the group functions depends on children’s developmental levels, intelligence, and problems to be addressed. In behaviorally oriented and cognitivebehavioral groups, the group leader is a directive, active participant who facilitates prosocial interactions and desired behaviors. In groups using psychodynamic approaches, the leader may monitor interpersonal interactions less actively than in behavior therapy groups. Gathering children and adolescents into groups may lead to greater psychological impact than treating them individually. A number of factors, described by Irving Yalom, may contribute to the effectiveness of groups. These factors include the following theoretical components: Hope: Hope may be generated by gathering with others who are experiencing similar difficulties and by observing others actively mastering the problems. Universality: Children and adolescents with psychiatric disorders often feel isolated and alienated from peers. Working together in groups may diffuse the isolation and help children and adolescents view their disorder as only a small part of their overall identity. Imparting Information: Children and adolescents are familiar with a format of gaining new information in a group setting, such as in school. The group therapy format provides an opportunity to reinforce learning when the child or adolescent “helps” or demonstrates what he or she has learned to peers. Altruism: Helping other peers in a group setting by supporting them and identifying with their struggles can improve a child or adolescent’s self-esteem and help them gain a sense of mastery over their own issues. Improved Social Skills: Group therapy is a safe format in which children and adolescents with poor social skills can improve their interpersonal and communication abilities under the supervision of a leader and with peers who also benefit from the practice scenarios. Groups can be highly effective modalities to provide peer feedback and support to children who are either socially isolated or unaware of their effects on their peers. Groups with very young children generally are highly structured by the leader and use

imagination and play to foster socially acceptable peer relationships and positive behavior. Therapists must be keenly aware of the level of children’s attention span and the need for consistency and limit setting. Leaders of preschool-age groups can model supportive adult behavior in meaningful ways for children who have been deprived or neglected. School-age children’s groups can be single sex or include both boys and girls. School-age children are more sophisticated in verbalizing their feelings than preschoolers, but they also benefit from structured therapeutic games. Children of school age need frequent reminders about rules, and they are quick to point out infractions of the rules to each other. Interpersonal skills can be addressed nicely in group settings with school-age children. Same-sex groups are often used among adolescents. Physiological changes in early adolescence and the new demands of high school lead to stress that may be ameliorated when groups of same-age peers compare and share. In older adolescence, groups more often include both boys and girls. Even with older adolescents, the leader often uses structure and direct intervention to maximize the therapeutic value of the group. Adolescents who are feeling dejected or alienated may find a special sense of belonging in a therapy group. Keith was a high-functioning, 14-year-old boy diagnosed with autism spectrum disorder. Keith was an awkward-looking adolescent who seemed younger than his chronological age. His academic level was above average, but his social development was odd. His pedantic speaking style contributed considerably to his social isolation, particularly after starting 7th grade. He was referred to a group of adolescents with social skills problems in order to improve his ability to make friends and have more successful social interactions. Initially, Keith limited his participation to monosyllabic answers to direct questions, and then he would go back to reading a book on the history of Napoleon, his favorite subject and object of fascination. Group members chose to ignore him after a while. Over a period of several weeks, his interest in the book seemed to abate. Keith brought it, but it remained unopened on his lap. He would make an occasional remark, which was often not related to the topic of conversation. The other adolescents in the group seemed to respect his “differentness”; however, it was still difficult to have successful social interactions. Two months later a very shy 13-year-old boy joined the group. After a few sessions Keith developed an unexpected interest in the newer member and sat near him and encouraged him to interact with the group. Soon Keith was not bringing a book any longer and was more involved with group members. In response to the group leader’s guidance and practice exercises in the group, Keith learned to respond to social cues in a more appropriate manner, and although he continued having morbid preoccupations with power and a fascination with Napoleon, he was able to converse with group members about more pertinent social topics. Keith’s increasing social skills and greater interest in people was clinically evident. Social skills practice within the group became a most significant tool to help Keith with his interpersonal interactions in school and with his

family. (Adapted from a case contributed by Alberto C. Serrano, M.D.) PRESCHOOL-AGE AND EARLY SCHOOL-AGE GROUPS Work with a preschool-age group usually is structured by a therapist through the use of a particular technique, such as puppets or artwork. In therapy with puppets, children project their fantasies onto the puppets in the same way as in ordinary play. Here, the group aids the child less by interaction with other members than by action with the puppets. In play group therapy, the emphasis rests on children’s interactional qualities with each other and with the therapist in the permissive playroom setting. A therapist should be a person who can allow children to produce fantasies verbally and in play but who can also use active restraint when children undergo excessive tension. The toys are the traditional ones used in individual play therapy. The children use the toys to act out aggressive impulses and to relive their home difficulties with group members and with the therapist. The children selected for group treatment have a common social hunger and need to be like their peers and be accepted by them. Selected children usually include those with phobias, effeminate boys, shy and withdrawn children, and children with disruptive behavior disorders. Modifications of these criteria have been used in group psychotherapy for autistic children, parent group therapy, and art therapy. A modification of group psychotherapy has been used for toddlers with physical disabilities who show speech and language delays. The experience of twice-weekly group activities involves mothers and children in a mutual teaching–learning setting. This experience has proved effective for mothers who received supportive psychotherapy in the group experience; their formerly hidden fantasies about their children emerged and were dealt with therapeutically. SCHOOL-AGE GROUPS Activity group psychotherapy is based on the idea that corrective experiences in a therapeutically conditioned environment may increase appropriate social interactions between children and with adults. The format uses interview techniques, verbal explanations of fantasies, group play, work, and other communications. In this type of group psychotherapy, children verbalize in a problem-oriented manner, with the awareness that problems brought them together and that the group aims to change them. They report dreams, fantasies, daydreams, and unpleasant experiences. Therapists vary in their use of time, co-therapists, food, and materials. Most groups meet after school for at least 1 hour, although other group leaders prefer a 90-minute session. Some therapists serve food during the last 10 minutes; others prefer serving times when the children are together for talking. Food, however, does not become a major feature and is never central to the group’s activities. PUBERTAL AND ADOLESCENT GROUPS

Group therapy methods similar to those used in younger-age groups can be modified to apply to pubertal children, who are often grouped monosexually. Their problems resemble those of late latency-age children, but they (especially the girls) are also beginning to feel the effects and pressures of early adolescence. Groups offer help during a transitional period; they seem to satisfy the social appetite of preadolescents, who compensate for feelings of inferiority and self-doubt by forming groups. This therapy takes advantage of the influence of the socialization process during these years. Because pubertal children experience difficulties in conceptualizing, pubertal therapy groups tend to use play, drawing, psychodrama, and other nonverbal modes of expression. The therapist’s role is active and directive. Activity group psychotherapy has been the recommended group therapy for pubertal children who do not have significantly disturbed personality patterns. The children, usually of the same sex and in groups of not more than eight, freely engage in activities in a setting especially designed and planned for its physical and environmental characteristics. Samuel Slavson, a pioneer in group psychotherapy, pictured the group as a substitute family in which the passive, neutral therapist becomes the surrogate for parents. The therapist assumes various roles, mostly in a nonverbal manner, as each child interacts with the therapist and other group members. Currently, however, therapists tend to see the group as a form of peer group, with its attendant socializing processes, rather than a reenactment of the family. Late adolescents, 16 years of age and older, often may be included in groups of adults. Group therapy has been useful in the treatment of substance-related disorders. Combined therapy (the use of group and individual therapy) also has been used successfully with adolescents. OTHER GROUP SITUATIONS Groups are also helpful in more focused treatments, such as specific social skills training for children with ADHD, cognitive-behavioral group interventions for depressed children and for children with bereavement problems or eating disorders. In these more specialized groups, the issues are more specific, and actual tasks (as in social skills groups) can be practiced within the group. Some residential and day treatment units use group psychotherapy techniques. Group psychotherapy in schools for underachievers and children from low socioeconomic levels has relied on reinforcement and on modeling theory, in addition to traditional techniques, and has been supplemented by parent groups. In controlled conditions, residential treatment units have been used for specific studies in group psychotherapy, such as behavioral contracting. Behavioral contracting with reward–punishment reinforcement provides positive reinforcements among preadolescent boys with severe concerns in basic trust, low self-esteem, and dependence conflicts. Somewhat akin to formal residential treatment units are social group work homes. For children who undergo many psychological assaults before placement, supportive group psychotherapy offers ventilation and catharsis, but more often it

succeeds in letting children become aware of the enjoyment of sharing activities and developing skills. Public schools—also a structured environment, although not usually considered the best site for group psychotherapy—have been used by several workers. Group psychotherapy as group counseling readily lends itself to school settings. One such group used gender- and problem-homogeneous selection for groups of six to eight students, who met once a week during school hours over 2 to 3 years. INDICATIONS Many indications exist for the use of group psychotherapy as a treatment modality. Some indications are situational; a therapist may work in a reformatory setting, in which group psychotherapy seems to reach adolescents better than individual treatment does. Another indication is time economics; more patients can be reached in a given time by the use of groups than by individual therapy. Group therapy best helps a child at a given age and developmental stage and with a given type of problem. In young age groups, children’s social hunger and their potential need for peer acceptance help determine their suitability for group therapy. Criteria for unsuitability are controversial and have been loosened progressively. PARENT GROUPS In group psychotherapy, as in most treatment procedures for children, parental difficulties can present obstacles. Sometimes, uncooperative parents refuse to bring a child or to participate in their own therapy. The extreme of this situation reveals itself when severely disturbed parents use a child as their channel of communication to work out their own needs. In such circumstances, a child is in the unfortunate position of receiving positive group experiences that seem to create havoc at home. Parent groups, therefore, can be a valuable aid to group psychotherapy for their children. A recent study of a cognitive-behavioral group intervention for parents to learn how to utilize therapeutic interventions with their anxiety disordered children suggested that parent groups to teach these skills can be successfully utilized with their children. Parents of children in therapy often have difficulty understanding their children’s ailments, discerning the line of demarcation between normal and pathological behavior, relating to the medical establishment, and coping with feelings of guilt. Parent groups assist in these areas and help members formulate guidelines for action. REFERENCES Baer S, Garland EJ. Pilot study of community-based cognitive behavioral group therapy for adolescents with social phobia. J Am Acad Child Adolesc Psychiatry. 2005;44:258. Eggers CH. Treatment of acute and chronic psychoses in childhood and adolescence. MMW Fortschr Med. 2005;147:43. Haen C. Rebuilding security: Group therapy with children affected by September 11. Int J Group Psychother. 2005;55:391. Kreidler M. Group therapy for survivors of childhood sexual abuse who have chronic mental illness. Arch Psychiatr Nurs. 2005:19:176.