Inpatient and residential treatment groups

These groups form an integral part of most adolescent units and residential treatment centers (Chase, 1991; Kleiger and Helmig, 2000; Stein and Kymissis, 1989). The group format varies indefinitely according to the degree of pathology, intellectual level, and longevity of the group, and number of absences of group members. Inpatient psychotherapy groups (Kymissis, 1996) are advantageous in that they can focus on ongoing resistances and acting out in the group and the hospital network. Conformity and compliance as to weekend passes, attendance at meetings, and taking of medication are strengthened in the group context. The handling of confidentiality in inpatient groups is a delicate issue, and it seems wise to explain at the outset the team's sharing of information. In ward situations where adolescents are assigned to certain staff members, there often is conflict between the patients and different staff teams.

Adolescents with depression

Parentally bereaved adolescents were treated in a large discussion group format using other parentally bereaved adolescents as therapeutic assistants to help reduce the resistance to talking and giving feedback (Levy and Zelman, 1996)
A 7-week anti-depression, anti-suicide group was conducted with 7 teenage women using a collaborative feminist and narrative approach to externalize, empower, support and define the depression (Johnson, 1994).
Clarke et al., (1995) assessed a prevention program targeted for 150 adolescents at risk for future depressive disorder. A randomized 15-session trial of group cognitive intervention was compared with a usual case-control group. Survival analysis indicated a 12-month advantage for the prevention program and a decrease in depressive indices. In a further study (Clarke et al; 1999) compared maintenance cognitive behavioral with acute CBT groups with booster sessions. One hundred and twenty-three adolescents with major depression or dysthymia were assigned to 1 of 3 8-week acute conditions: adolescent group CBT (16 2-hour sessions) separate parent group, or a wait-list control. Subsequently, the members completing the CBT groups were randomly reassigned to 1 of 3 conditions for the 24-month follow-up period, namely assessments every 4 months with booster sessions, assessments only every 4 months, or assessments every 12 months period. Results indicated that acute CBT groups yielded higher depression recovery rates (66.7%) than the wait list (48.1%) and greater reduction in self reported depression. Outcomes for the adolescent-only and adolescent plus parent conditions were not significantly different. Rates of recurrence in the 2-year follow-up were lower than in treated adult depression. The booster sessions did not reduce the rate of recurrence in the follow-up period but appeared to accelerate recovery among the subjects who were still depressed at the end of the acute phase. The authors concluded that CBT was an effective intervention for adolescent depression. It is of some interest that the parallel parent group did not add significantly to the reduction in depression. This confirms this author?s belief that for adolescents, separate treatment, that protects confidentiality and allows separation from parents may be the treatment of choice whereas young children profit more from parallel, integrated modalities.
Fine et al. (1991) reported on the comparison of two forms of short-term group therapy for 66 outpatient adolescents clinically diagnosed as depressed. Subjects were randomly assigned to either a therapeutic support group or a social skills group. Post treatment, adolescents in the therapeutic support group showed a greater decrease in depressive symptoms and significant increases in self-concept. At the 9-month follow-up, adolescents in the therapeutic support groups maintained their improvements, but adolescents in the social skills group had now caught up in their improvement between the post treatment group and follow-up assessments. The authors postulated that the original gains made in the therapeutic support group were necessary to alleviate the depression before members were able to profit from the problem-solving strategies taught in the social skills groups. The manic defences in the mourning process was described for an adolescent group, using a Kleinian analytic framework. Group-as- a whole focussed on the process and the dynamics of the relationship between the adolescents, staff, and family (Toder-Golden, 1999).

Self-mutilation and self-destructive behavior .

This kind of behaviour has received scant attention in the group literature for children and adolescence. Sansome et al., (1996) have described an integrated psychotherapeutic approach is the management of self-destructive behavior in eating-disorder patients with borderline personality disorder. A group psychotherapy approach was found useful for a reasonable resolution over time of self-destructive behavior.

Hartman (1996) discusses deliberate self-cutting by adolescents in psychiatric inpatient units. The author suggests that the interpersonal aspects of the cutting are neglected, with undue attention given to the individual patient, who may be acting out the groups? conflicts and discontents as well as protesting against inadequate staff supervision.
Social Phobia

Cognitive-behavioral group therapy for social phobia in female adolescents was described by Albano et al., in 1995. The results of a pilot study, (Hayward et al., 2000) compared the outcome results for 35 girls with social phobia at high risk for major depression, 12 of whom were assigned to a treatment group and 23 to a non treatment group. Of the 11 subjects who completed treatment, there was a significant improvement and reduction in the symptoms of social anxiety and depression. However, at the 1- year follow-up there were no significant differences by treatment condition, but there was suggestive evidence that the treatment of social phobia lowers the risk for relapse of major depression among the subjects with a history of major depression. Combining the decline scores for social phobia and depression produced more robust treatment effects for the 1- year follow up. The results indicate that there was a moderate short- term effect of group CBT for female adolescents, and that a decrease in social phobia may also reduce the criteria for major depression. This latter finding suggests the usefulness of group based preventions programs for shy, socially incompetent children. The question of adjuvant pharmacotherapy for social phobia was raised because there have been positive findings with its use in adult social phobia (Heimberg et al., 1998).

Groups for the control of anger, violence, and conduct and criminal disorder
The interest in these disorders has increased in response to the rise in rebellious, destructive behavior in society. The following studies are included because of their innovative clinical and research approaches.

A structured group for undersocialized, acting-out adolescents, that used a pretherapy training program and an initial therapy contract showed positive clinical outcomes (Corder, 1996).

Cognitive-behavioral anger-management groups showed improved arousal control, cognitive restructuring and prosocial skills (Feindler and Scalley, 1998). A CBT group of 11 adolescents showed statistically significant changes in aggressive behavior, attentional problems, self esteem, anxiety, depression and somatic complaints, as shown on post treatment scores on the Youth Self-Report, the Achenbach Child Behavior Checklist, and the Piers-Harris Childrens? Self-Concept Scales (Kastner, 1998). A brief anger management group of 10 to 12 sessions showed improved functioning in 25 adolescents in hospitalised groups, compared with 25 in control groups (Snyder et al., 1999).

A Teen Abuse Group using a CBT model targeted socio-economically depressed black and white adolescents. The 10- week program was part of a Master?s-level social workers training module. The approach appeared clinically promising. Carlin (1996) describes a large group treatment of 25 severely disturbed, conduct-disordered adolescents. Needs for effective leadership, acceptance of the members' cultural differences, and the insurance of maximum safety influenced more positive interpersonal relations. Byrnes et al., (1999) compared reductions in criminality in 3 different formats - group, individual and family therapy - in a sample of 532 adolescents in a residential and day-treatment program over a 4- year period. The major findings were: a) the number of hours in group therapy explained the greatest variance in the reduction of criminal charges, followed closely by hours in individual therapy, whereas hours in family therapy was not a significant predictor; and b) Residential treatment was associated with greater reductions in adult correctional commitments than was day treatment period.

The findings that group therapies are effective treatment for delinquent adolescents confirm the early findings of Bratter, 1989, Friedman and Glickman, 1986, and Raubolt, 1983.

Trauma and abuse

Trauma groups for a variety of disorders have been described for children and adolescents who have become the victims of natural disasters, sexual abuse, violence, atrocities of war. Classification of posttraumatic disorders in the third (revised) and fourth editions of the Diagnostic and Statistical Manual of Mental Disorders emphasize significant cognitive, behavioral, and physiologic somatic effects after the trauma. A variety of group interventions, including supportive, CBT strategies have been used to reduce the posttraumatic stress disorder symptoms to expose the trauma and to work toward improved coping skills. (Foy et al., 2000, Kopola and Keitel, 1998). Glodich and Allen (1998) reviewed the group literature on preventing trauma reenactment in adolescents. Group CBT and psychoeducational strategies are considered important ways of interrupting the pernicious cycle of reenactment and further risk-taking behavior. Everly et al., (1999) compiled a meta-analysis of the effectiveness of psychological debriefing with vicarious trauma. An outline study of 41 sexually abused adolescent girls (13 to 18 years of age)were divided into small structured groups. Each of the seven treatment sessions consisted of a didactic presentation, an art activity, and the development of a positive associational cue. Posttest assessment revealed improved adaptive functioning and skill mastery.
Female adolescent survivors of sexual abuse responded to a goal-oriented therapy group Backos and Pagon, 1999); Furniss et al., 1988) . Adolescent girls facing the loss of their parents through acquired Immune Sufficiency Syndrome were treated in a 2-year psychoanalytic group. Cohen (1996) analyzed the transference-countertransference in this angry, depressed group of girls. It is likely that through the countertransference, the therapist was able to empathize with the adolescents? plight and work through a treatment plan. Henry (1996) explored human immune deficiency virus-related risk-taking in a psychodynamic group for adolescents.

Alcohol and Substance Abuse

The number of groups for adolescents addicted to alcohol and drugs has increased to meet treatment and prevention needs. A variety of models exist, including multimodal programs (Bratter, 1989; Friedman and Glickman, 1986) in residential and outpatient clinics (Bogdaniak and Percy, 1987; Gonet; (1998); Nastasi, 1998). The use of multi-family play groups for families in addiction recovery, was effective in promoting parent-child communication, the development of a non-blaming attitude, and an understand the children?s reactions to their addiction (Cwiakala and Mordock, 1997). A therapeutic community drug treatment program that studied 938 adolescents (15 to 17 years of age) who were admitted to residential treatment for substance abuse revealed that one-third of the sample showed histories of sexual abuse. A Cox regression analysis showed that a history of sexual abuse is related to earlier onset of alcohol and illicit drug use. It was suggested that drug use may function to ameliorate feelings of depression and poor self-esteem that accompany childhood abuse (Hawke et al., 2000).

Kaminer and his colleagues (1998) using manual-guided interventions measured the treatment process in CBT and interactional group therapies for adolescent substance abusers. In a 15-month follow-up of a pilot study, Kaminer and Burleson (1999) reported on the comparison of 32 dually diagnosed adolescents, randomized into 2 short-term outpatient group psychotherapy groups, one using CBT and the other an interactional treatment (IT). At the 3- months follow-up, no patient treatment matching effects were shown. However, adolescents in the CBT group showed a significant reduction in severity of substance abuse compared with those assigned to the IT group. At the 15 month follow-up, there were no differential improvements as a function of therapy type. However, subjects maintained significant treatment gains in the substance abuse, family function, and psychiatric status domains of the Teen-Addiction Severity Index, and both CBT and IT were associated with similar long-term gains. This study is the only one to date that demonstrates no superiority for short term group CBT compared with short-term group IT
Pressman and Brook (1999) have described a multiple group psychotherapy approach with adolescents with psychiatric and substance abuse comorbidity, treated in an inpatient psychiatric setting. The involvement of a multidisciplinary team using an integrative approach showed promising results.

A five-phase group model for outpatient adolescents who abuse substances was described by Spitz and Spitz (1996). It includes the following phases: a) evaluation and orientation, b) entry into the group, c) establishing a working climate, d) a middle or working stage, e) transition out of the group. The authors conclude that group therapy is the treatment of choice.
6.8.Eating Disorders .

Azima 1992, described an intensive group psychotherapeutic interactional model for outpatients seen in a heterogeneous group. Parental involvement was indicated for the younger but not the older teen group. A variety of techniques and activities, including dramatherapy and guided imagery, are used in short- and long-term eating disorder groups (Moreno, 1998; Wurr and Pope-Carter, 1998; ).

Mitchell and colloboraters (1990) compared the efficacy of antidepressant drug therapy with structural, manual-guided group therapy for a total of 12 weeks. The overall finding was that the addition of the antidepressant to the group psychotherapy did not significantly improve the eating disorder, but did ameliorate features of depression and anxiety. At six- month follow-up (Pyle et al., 1990), 30% of the sample had relapsed; however, group psychotherapy alone or combined with drug therapy showed lower relapse rates than treatment with medication alone. It also was found that neither attendance at the maintenance group sessions nor imipramine maintenance was associated with better outcome.

Leung et al. (1999) evaluated 10- week group CBT with 20 women diagnosed with anorexia nervosa, age 17 to 58 years. At post treatment, Group CBT was found to be ineffective in symptom reduction, and basic core beliefs were irrelevant to outcome. The authors concluded that group CBT in the current short form is insufficient to induce changes, and suggested further group treatments to address the issues of poor motivation, lack of insight, and ambivalence towards treatment.

A clinical study of an expressive group therapy eating disorders program reported positive behavioral change in this adolescent group, but there was no research to support these impressions (Shander and Orbanic, 1995).

It can only be concluded that eating disorders, especially anorexia nervosa, are resistant to change with short term formats. Further research is needed to assess multimodal programs, including motivational preparation before to group treatment. The links of eating disorders to sexual abuse, and borderline and self-destructive behavior need to be noted (Sansone et al. 1996).

Learning disabled adolescents.

These groups overlap with the previous children`s section in this review. Residential, outpatient and school programs offer specialized groups often integrated with other academic modules. Investigators agree that both the learning disability and social/emotional problems must be attended to in the group format, (Coché and Fisher, 1989; Mishna and Muskat, 1998). Computers and videos are helpful adjuncts to the group treatment (Cox and Lothstein, 1989; Gardano, 1994).

Bernstein et al., (2000) investigated the use of imipramine plus CBT in the treatment of 63 school-refusing adolescents with comorbid anxiety and major depressive disorders. The findings were that imipramine plus CBT is significantly more efficacious than placebo plus CBT in improving school attendance and decreasing symptoms of depression in school-refusing adolescents.

Parent and Family Group Therapy are combined more frequently in the treatment of younger children; Parallel and combined groups appear indicated with the acutely ill, traumatized adolescents, and where a return to living in the family is indicated.
The use of multi-family group therapy has been recommended in the treatment of dually-diagnosed adolescents (Kymissis et al., 1995), and with abusive and neglectful caregivers (Meezan and O`Keefe, 1998)
A father-adolescent son group was described by Ginsberg (1998). The goal of these groups was the developments of insight, closer communication, and understanding. A combined experimental/psychoeducational format was used as part of group therapy program called the Parent-Adolescent Relationship Development Program.
A multi modal group program for pregnant and parenting adolescents involved collaboration with parents, school and community (Stoiber et al., 1998).

Culture

The influence of culture and society on therapy groups has been the subject of increasing investigation (Serrano and Hou, 1995). Culture-focused group therapy has been reported as an enhancing bonding with both the shy and introverted adolescent, as well as dealing with identity issues in gang-motivated youth (Vargas and Diplato, 1999).
Psychotherapy groups were carried out with youth experiencing war (Schnieder and Cohen, 1996) and refugee trauma (Brumen-Budanko, 1999; Forgel 1997). (Azima, 2002) has reported on the use of groups with immigrant and refugee children and their families, and has outlined a training model for mental health professionals.

THE GROUP PSYCHOTHERAPIST: FUNCTIONS, REALITY ISSUES, AND COUNTERTRANSFERENCE

Functioning in the group context puts greater stress on the therapist, especially with children who act out physically and regress rapidly (Azima, 1986). With adolescents there is the accompanying disrespect and rebellion against authority figures (Azima, 1973). The reports of homogeneous groups for young patients with bulimia, anorexia, diabetes, migraine, thalassemia, and cancer indicate improvement in motivation and compliance with prescribed diets, exercise, and the use of medication.

A leader must solve the quandary of how to be a competent therapist and a respected authority figure, and not an admonishing disciplinarian. There is general agreement that today's child and adolescent group therapists have become more actively involved, less permissive, more spontaneous in their play, more confronting, and in general less distant in their relationship with group members. With adolescents, the therapist tries to assume an emotional/cognitive role model midway between the adolescent and the parent. Therapists with overclose identification with adolescents are put at risk of collusion, passivity, or acting out, while therapists with too distant an identification are rendered vulnerable to possible rebellion against parental figures. A good practice with adolescents is to assume an attitude of controlled curiosity and sophisticated ignorance, especially in the early stages of the group. An overintellectual approach on the part of the therapist is likely to produce silence, fear, withdrawal, and withholding in the group members.
Adding to the therapist's countertransference is the pressure from parents for the therapist to see the child from the parents' point of view. The therapist must be realistically empathic and not overjudgmental. In the clinic or day-hospital setting, the therapist is often caught in a tug of war between team members who side with or against the parent, teacher, or judge.

In many cases the therapist's reaction should not be classified as countertransferential unless. Group psychotherapists who do not overcentralize their position are more likely to be perceptive of the interactive psychodynamics and to reflect on the variety of positive and negative feelings and thoughts that corroborate or differ from their own. Some helpful qualities of the group therapist working with children and adolescents include comfort in a group, spontaneity, flexibility, playful creativity, and the ability to set adequate limits as a rational, empathic role model.