Prof. Hani Hamed Dessoki, M.D.Psychiatry
Chairman of Psychiatry Department
Beni Suef University
Supervisor of Psychiatry Department
• Prospectives on group psychotherapy
• Negative ffects of group Psychotherapy
• How could psychotherapy ever be harmful?
• Ethical issues in group psychotherapy
• Take Home Message
A group is often more than the sum of its
parts. At times, however, it may be less
than the sum of its parts.
Ideally, therapeutic groups develop a work
culture under the skillful direction of a
leader knowledgeable not only in the
areas of psychopathology and
psychodiagnostics, but also in group
dynamics and interpersonal
Definition of Psychotherapy
• A classic definition of psychotherapy is use of
interpersonal influence skills and
psychological techniques by trained
professionals toward the goal of relieving the
signs and symptoms of psychiatric disorder.
• Psychotherapy is defined as a “procedure,”
similar to that of a medical procedure.
• Group psychotherapy offers multiple relationships to
assist an individual in growth and problem solving.
• In group therapy sessions, members are encouraged to
discuss the issues that brought them into therapy openly
• The therapists work to create an atmosphere of trust and
acceptance that encourages members to support one
• In contrast to all the pharmacotherapy
studies, there is precious little
information about the safety of
psychotherapeutic interventions -- which
are also, in some patients and in some
instances, associated with adverse events
that need to be noted.
• These may include undue stress,
potential overstimulation, and symptom
• Empirical research on the negative effects of
psychotherapy is insufficient, partly because
there is a lack of theoretical concept on how
to define, classify and assess psychotherapy
• Effective treatment causes side effects; this
applies for medical interventions and
• Due to its specific setting it is unusual to focus
on risks and damages within psychotherapy.
• The possibility of treatment-induced
deterioration among psychiatric patients was
first observed nearly 7 decades ago
(Masserman & Carmichael, 1938).
• Psychotherapy can sometimes be harmful: (a)
deterioration effects and (b) negative effect
What are negative effects?
• Slower response
• Less remission or recovery
• Higher rates of relapse or recurrence
• Some combination of these.
Rationale for Group Psychotherapy
Groups function as a microcosm of the world
Testing ground for new behavior
Give as well as receive help
Many problems are primarily social in nature
Learn new ways of being
The function of the group therapist
• Emotional Stimulation
– Modeling self-disclosure
– Showing support
– Providing praise, warmth, and acceptance
• Meaning Attribution
– Explaining and clarifying
• Executive Function
– Providing rules and setting limits
– Managing time
– Commenting on group dynamics
• The physician may be viewed as
superior to the patient, because
the physician has the knowledge
and credentials, and is most often
the one that is on home ground.
• A physician should at least be
aware of these disparities in order
to establish rapport and optimize
communication with the patient.
The Paternalistic Approach
“If I’ve told you once I told
you 1,000 times, stop
• Who benefits?
– Depends on the group
– Almost anyone can benefit from group
– People who have the most difficult time in relationships are
those who might most benefit from group therapy
• Possible reasons for exclusion
Acute situational crisis
Deeply depressed suicidal clients
Members who are unable to attend regularly
Clients with Antisocial Personality Disorder (unless the
group is specifically designed for them)
Stages of groups
Stage One (Orientation/Forming):
Group members orient to group and
Stage Two (Transition/Storming):
Anxiety, ambiguity, and conflict become prevalent as group members struggle
to define themselves and group norms.
Stage Three (Cohesiveness/Norming):
A therapeutic alliance forms between group members.
Stage Four (Working/Performing):
Group members experiment with new ideas, behaviors or ways of thinking.
Stage Five (Adjourning/Terminating):
The group disbands.
Causes of negative effects of group
• Negative effects may be due to techniques,
client variables, therapist variables, or some
combination of these.
The negative effects of group
• Acquiring new symptoms
• Worsening of symptoms (3-10%) and
• False memories
• Superficial insight (acquiring empty language)
Adverse Outcomes in Group Therapy
• Although much of the literature on adverse
outcomes in group therapy focuses on single
risk factors (e.g., negative leader, group
process, or patient characteristics).
• Remain alert to ways in which your personal
reactions might inhibit the group process, and
monitor your countertransference.
• Avoid using the group as a place where you
work through your personal problems.
• Therapist negative countertransference (e.g.,
direct expressions of hostility, lack of respect,
and sexual acting out) is associated with
harmful consequences for group members.
• Therapist personality maladjustment is
another major factor associated with harmful
“Side effects” of group psychotherapy
• In group psychotherapy, you never know what
• Any behaviour modification technique can be
misused or misapplied.
• "positive thinking" can actually have a
negative impact on the mental health of some
people (and this has been known for years in
regard to trauma counselling and sexual
Limitations/dangers of co-therapists
• If two leaders do not get along, it can be detrimental and
even harmful to group
• Co-leaders might develop competition between
themselves and this too is not good for the group
• If co-leaders have different skill levels, one might try to
lead the other. This can lead to coalitions with other
group members or even in the marginalization of the
more inexperienced leader
• Group members might feel unwell if both leaders become
adamant in getting across a therapeutic message
The negative effects of group psychotherapy
• The clients will go through a period of feeling
worse as their old habits of coping are replaced
with new strategies and ways of thinking.
• This process can temporarily highten anxiety and
insecurity and negative thoughts, feelings of
helplessness, hopelessness etc.
Indicators of Potential Deterioration
• The five indicators for “potential deterioration,” as a result of
interaction between therapeutic techniques, psychotherapists,
and clients include,
(a) the role of anticipation of emotional pain and therapeutically
(b) client suspiciousness toward the therapist and therapist
(c) level of interpersonal functioning and the focus of treatment
(d) diagnosis and treatment modality
(e) relaxation therapy and clients’ need for control
• Over 4-6 monthly sessions
• Review patient success
• Discuss potential vulnerabilities
– Identify strategies for management of
interpersonal difficulties and symptom relapses
• Encouragement about ability to use strategies
Concerns in Group Work
• Group Size: Varies from 3-4 members to several hundred
depending upon the group (e.g. psychotherapeutic or task group).
Group counseling and psychotherapy generally work best with 6-8
• Participant Selection: Screening is needed with counseling and
psychotherapy groups. Some people are not well suited for group
Concerns in Group Work (continued)
• Length and Duration of Sessions: Individual sessions are usually
50 minutes, group sessions range from 1-2 hours. Session
duration can be only once or in some cases might last for years
(e.g. open-ended psychotherapy group).
• Ethics: Confidentiality is hard to guarantee due to the number of
• Group Evaluation: Outcome measurements are difficult to obtain.
Paradoxal findings: Psychotherapy
diminishes side effects
• A number of the studies found associated
paradoxically psychotherapy to the reduction
of side effects of other treatments.
• This indicates that psychotherapy in general is
balancing the patient and helping the patient
with physical, mental, existential and sexual
Ethical Issues in
ACA Code of Ethics, 2005
• A.8. Group Work
Counselors screen prospective group
counseling/therapy participants. To the extent
possible, counselors select members whose
needs and goals are compatible with goals of
ACA Code of Ethics, 2005 (cont.)
• A.8.b. Protecting Clients
In a group setting, counselors take reasonable
precautions to protect clients from physical,
emotional, or psychological trauma.
• To encourage open and active participation from
group members, it is the therapist’s responsibility to
explain the client’s rights.
∞Format, procedures and ground rules
∞Group appropriate for client’s needs
∞Limits of confidentiality
∞The group process may or may not be
congruent with the cultural beliefs and
values of the group member
Informed Consent (cont.)
∞Right to leave the group if it
isn’t what they expected or wanted
∞Any research involved
∞If the sessions are taped
∞Freedom from group pressure
• Ethically, the therapist should inform clients of
their rights and responsibilities and inform
them of any possible consequences they may
face if they elect not to follow treatment.
Take Home Massage
Researchs must consider better
understand and reduce
iatrogenic effects in the
psychosocial therapies, as is
being done for pharmacological