Psychotherapy Group Plan

EDCO 711

Read: Yalom: Chapters 13 – 16

Yalom, I. D., Leszcz, M. (2020-12-01). The Theory and Practice of Group Psychotherapy, 6th Edition. [[VitalSource Bookshelf version]]. Retrieved from vbk://9781541617568

Chapters 13

Specialized Formats and Procedural Aids

A NUMBER OF IMPORTANT VARIABLES MAY IMPACT THE FAMILIAR group therapy format in which one therapist meets with six to eight members: the client may concurrently be in individual treatment, for example, or may be attending a twelve-step group in addition to the therapy group. The group may also be led by co-therapists instead of one. We shall discuss each of these in this chapter and describe as well some specialized techniques and approaches that may facilitate the course of therapy.

CONCURRENT INDIVIDUAL AND GROUP THERAPY

First, some definitions. Conjoint therapy refers to a treatment format in which the client is seen by one therapist in individual therapy and a different therapist (or two, if co-therapists) in group therapy. In combined therapy, the client is treated by the same therapist simultaneously in individual and group therapy. Little systematic data exists about the added value of concurrent group and individual therapy relative to each delivered alone, although most studies show comparable effectiveness for group and individual therapy.1 Despite the widespread practice of concurrent individual and group treatment, little research data exist to guide therapists. Therefore, we offer some guidelines and principles that arise from our clinical experience and the literature.2

Whenever we integrate two treatment modalities, we must first consider their compatibility. More is not always better! Are the different treatments working at cross-purposes, or do they enhance one another? If compatible, are they complementary, working together by addressing different aspects of the client’s therapy needs? Typically, we think of group therapy addressing interpersonal issues in the here-and-now and individual therapy addressing early life dynamics and intrapsychic issues.3 Integration of these two perspectives may strengthen each modality.

The relative frequencies of the two types of concurrent therapy are unknown, although it is likely that in private practice combined therapy is more commonly employed than conjoint therapy.4 The opposite appears to be true in institutional and mental health treatment settings.5 By no means should one consider conjoint and combined therapy to be equivalent. They have exceedingly different features and clinical indications, and we shall discuss them separately.

Conjoint Therapy

We believe that, with some exceptions, conjoint individual therapy is not essential to the practice of group therapy. If members are selected with a moderate degree of care, a weekly therapy group is ample therapy and should benefit the great majority of clients. But there are exceptions. The characterologically difficult client, whom we discussed in Chapter 12, frequently needs to be in concurrent individual and group therapy. In fact, the earliest models of concurrent group and individual therapy developed in response to the needs of these challenging clients, and concurrent treatment for these clients has evolved in both dynamically oriented and mentalization-based treatments.6 Clients with a history of childhood sexual abuse or who have other major issues around shame also often require concurrent therapy.7 Individual treatment can help clients develop tailored approaches to emotional self-regulation that may help them continue in their group during storms of affect and distress.

Group members frequently go through a severe life crisis (for example, bereavement or divorce) that requires temporary individual therapy support. Some clients are so fragile or blocked by anxiety or fearful of aggression that individual therapy is required to enable them to participate in the group. From time to time, individual therapy is required to prevent a client from dropping out of the group, or to monitor more closely a suicidal or impulsive client.

> Joan, a young woman with borderline personality disorder participating in her first therapy group, was considerably threatened by the first few meetings. She felt increasingly alienated because her bizarre fantasy and dream world seemed so far from the experience of the other members. In the fourth meeting, she verbally attacked one of the other members and was attacked in return. For several nights thereafter, she had terrifying nightmares. In one, her mouth turned to blood, an image that appeared to be related to her fear of being verbally aggressive and destructive. In another, she was walking along the beach when a huge wave engulfed her—this related to her fear of losing her boundaries and identity in the group. In a third dream, Joan was held down by several men who guided the therapist’s hands as he performed an operation on her brain—obviously related to her fears of therapy and of the therapist being overpowered by the male members of the group.

Joan’s hold on reality grew more tenuous, and it seemed unlikely that she could continue in the group without added support. Concurrent individual therapy with another therapist was arranged, and it helped her to contain her anxiety and remain in the group. <<

> Jim was referred to a group by his psychoanalyst, who had treated him for six years and was now terminating analysis.8 Despite considerable improvement, he still had not mastered the symptom for which he had originally sought treatment: fear of women. He found it difficult even to give direction to his female administrative assistant. In one of his first group meetings, he was made extremely uncomfortable by a woman in the group who complimented him. He stared at the floor for the rest of the session, and afterward called his analyst to say that he wanted to drop out of the group and reenter analysis.

His analyst discussed the situation with the group therapist and agreed to resume individual treatment with Jim on the condition that he return to the group as well. For the next few months, they had an individual session following each group session. The two therapists collaborated well, and the group therapist was able to increase support sufficiently to enable Jim to continue in the group. Within a few months, Jim was able to reach out emotionally to female group members for the first time, and he gradually grew more at ease with women in the real world. <<

Thus far, we have considered how individual therapy may facilitate the client’s course in group therapy. The reverse is also true: group therapy may be used to augment or facilitate the course of individual therapy.9 In fact, the majority of clients in conjoint therapy enter the group through referral by their individual therapists. The individual therapist might find a client exceptionally restricted and unable to access the material necessary for productive work. Often the rich, affective interpersonal interaction of a group is marvelously evocative and generates ample data for both individual and group work. At other times, clients have major blind spots that prevent them from accurately or objectively reporting what actually transpires in their lives. One older man was referred to group therapy by his individual therapist because individual therapy was at an impasse owing to an intense negative paternal transference. The male therapist could say nothing to this client without its being challenged and obsessively picked apart for its inaccuracy or incompleteness. It was a reenactment of the relationship between oppressed son and bullying father, and although both the client and the therapist were aware of this, the client made no real progress until he entered the more democratic, nonhierarchical group environment, where he was able to hear feedback that was free of paternal authority.

Other clients are referred to a therapy group because they have improved in the safe setting of the one-to-one therapy hour, yet have been unable to transfer the learning to outside life. The group setting may serve as a valuable way station for the next stage of therapy: experimentation with new behavior in a low-risk environment, which may effectively disconfirm the client’s fantasies of the calamitous consequences of that desired behavior.

Sometimes, in the individual therapy of characterologically difficult clients, severe, irreconcilable problems in the transference may arise. The therapy group may be particularly helpful in diluting the client’s intense transference and facilitating reality testing. The individual therapist may also benefit from a deintensification of the countertransference. This is particularly useful in the treatment of clients who use defenses that diffuse personal boundaries, such as splitting and projective identification, or other defenses which may be overwhelming to the therapist. Recall the earlier illustration of George (described in Chapter 2 in the story “Attack First”), whose female individual therapist referred him to conjoint group therapy in response to George’s mounting dependence. He had defended against his dependence by aggressively sexualizing their relationship. The group diffused the intensity of his dependence and both treatments progressed well.

In essence, conjoint therapy capitalizes on the presence in treatment of multiple settings, multiple transferences, multiple observers, multiple interpreters, and multiple maturational agents.10 The group therapist and the individual therapist may function effectively as peer consultants to one another.

Complications

Along with these advantages of conjoint therapy come a number of complications. When there is a marked difference in the basic approach of the individual therapist and the group therapist, the two therapies may work at cross-purposes, or even become competitive with each other. An overarching sense of a synthesis of the group and individual work is necessary for success.

Not infrequently, individual therapy clients beginning group therapy are discouraged and frustrated by the initial group meetings, which seem to offer less support and special attention than their individual therapy hours. They do not yet appreciate the group as a unique resource that offers new opportunity; instead, they see others as a source of competition and deprivation.11 Some clients, when attacked or stressed by the group, may defend themselves by unfavorably comparing the group to their individual therapy experience. Such an attack on the group invariably results in further deterioration of the situation.

Another complication of conjoint therapy arises when clients use individual therapy to drain off affect from the group. The client may interact like a sponge in the group, taking in feedback and carrying it away to gnaw on like a bone in the safe respite of the individual therapy hour. Clients may resist working in the group through the pseudo-altruistic rationalization, “I will allow the others to have the group time since I have my own hour.” Another form of resistance is to deal with important material in the opposite setting—to use the group to address the transference to the individual therapist and to use the individual therapy to address reactions to group members. When these patterns are particularly pronounced and resist all other interventions, the therapists, in collaboration, may insist that either the group or the individual therapy be terminated. We have known several clients whose involvement in the group dramatically accelerated when their concurrent individual therapy was stopped.

In our experience, the individual and the group therapeutic approaches complement each other particularly well if certain conditions are met. There must be a good working collaboration between the individual and group therapists. They must have the client’s explicit permission to share all information with each other as they see fit. Conjoint therapy cannot proceed without that agreement in place. It is important that both therapists (and the prescribing psychiatrist or physician, if pharmacotherapy is employed) be equally committed to the idea of conjoint therapy and in agreement about the rationale for the conjoint approach. A referral to a group for conjoint treatment should not be a cover for the sloughing off of clinical responsibility because the individual therapist is paving the way to terminate the treatment of a difficult client.12 Furthermore, it is essential that the therapists are mutually respectful—regarding both the therapeutic approach and the competence of the other.

A solid relationship between the individual and group therapists may prove essential in addressing the inevitable tensions that arise when clients compare their group and individual therapists, at times idealizing one and devaluing the other. This is a particularly uncomfortable issue for less experienced group therapists working conjointly with more senior individual therapists, whose invisible glowering presence in the group may inhibit group therapists and undermine their confidence. In such a scenario, the group therapist may become concerned about how he or she is being portrayed by the client to the individual therapist.13 It is exceedingly difficult to be the devalued therapist in a conjoint treatment. The position of the idealized therapist may be easier to bear, but it, too, is precarious.

Thus, the first condition for an effective conjoint therapy experience is that the individual and group therapists have an open, solid, mutually respectful working relationship. The second condition is that the individual therapy must complement the group approach—that is, it must encompass an interpersonal focus. Ideally, it devotes time to an exploration of the client’s feelings toward the group members and toward the incidents and themes of the current meetings. Such an exploration can serve to deepen the client’s involvement in the group.

Individual therapists who are experienced in group methods may significantly help some clients by coaching them on how to work in a therapy group, and often, this benefits the rest of the group as well. For example, one young man I (IY) was seeing in individual therapy was characteristically suffused with rage. He usually expressed it in explosions toward his wife or as road rage (which had gotten him into several dangerous situations). I referred him to a therapy group, and after a few weeks he reported in his individual hours that he had varying degrees of anger toward many of the group members. When I raised the question of him expressing this in the group, he paled: “No one ever confronts anyone directly in this group—that’s not the way this group works.… I would feel awful.… I’d devastate the others.… I couldn’t face them again.… I’d be drummed out of the group.” We rehearsed how he might confront his anger in the group. Sometimes I role-played how I might talk about it in the group if I were him, and I gave him examples of how to give feedback that would be unlikely to evoke retaliation. For example, “I have a problem I haven’t been able to discuss here before. I have a lot of anger. I blow up to my wife and kids and have serious road rage. I’d like help with it here and I’m not sure how to work on it. I wonder if I could start to tackle it by talking about some flashes of anger I feel sometimes in the group meeting.” At this point, any group therapist we have ever known would vibrate with pleasure and encourage him to try.

He might then continue, I suggested, by saying, “For example, you, John [one of the other members]: I have tremendous admiration toward you in so many ways, your intelligence, your devotion to the right causes, but nonetheless last week I felt a wave of irritation when you were speaking about your attitude toward the women you date—Was that all me or did others feel that way?” My client took notes during our session and followed my lead, and within a few weeks the group therapist told me it had been a success: not only was this client doing good work, but he had turned the whole group around. The meetings had become more interactional for everyone. Individual therapy can also help the client apply what he or she has learned in the group to new situations and other relationships—for example, with the individual therapist and with other important figures in the client’s social world.

Although it is more common for group therapy to be added to an ongoing individual therapy, the opposite also occurs. The group work can catalyze changes or evoke memories that cause great distress warranting more time and attention than the group may be able to provide.14 In general, it is best to launch one treatment first and then add the second, if required, rather than start both at once, to avoid confusing or overwhelming the client. Group therapists who recommend the addition of individual treatment to a group member should be alert to the meaning of that recommendation to the other group members and be prepared to discuss it openly.

Combined Therapy

Earlier we said that concurrent therapy is not essential to group therapy. We feel the same way about combined therapy, but we also agree with the many clinicians who find that combined therapy can be an exceptionally productive and powerful therapeutic format.

Generally in clinical practice, combined therapy begins with individual therapy. After several weeks or months of individual therapy, therapists place a client into one of their therapy groups—one generally composed entirely of clients who are also in individual therapy with the leader. Homogeneity in this regard—that is, that all the members of the group also be in individual therapy with the group leader—is helpful, but it is not essential. The pressures of everyday practice sometimes result in some clients being in individual therapy with the group leader while one or two are not. Not infrequently, issues of envy may arise in members who do not meet with the group leader individually.

Typically, the client attends one group session and one individual session weekly. Other, more cost-effective variants have been described—for example, a format in which each group member meets for one individual session every few weeks.15 Although such a format has much to offer, it has a different rationale from combined therapy, in that the occasional meeting is only an adjunct to the group: it is designed to facilitate norm formation and to optimize the member’s use of the group.

In combined therapy, the group is usually open-ended, with clients remaining in both therapies for months, even years. But combined therapy may also involve a time-limited group format. I (IY) have, on many occasions, formed a six-month group of my long-term individual clients. After the group terminates, the clients may continue individual therapy, which has been richly fertilized by group-spawned data. I continue to be impressed by the results of placing my individual clients into a group: almost invariably, therapy is accelerated and enriched.

There is no doubt that combined therapy (as well as conjoint therapy) decreases dropouts.16 Our informal survey of combined therapy groups—our own and those of supervisees and colleagues—over a period of several years reveals that early dropouts are exceedingly rare. In fact, of the clients who were already established in individual therapy before entering a group led by their individual therapist, not a single one dropped out in the first twelve sessions. This finding, of course, contrasts starkly with the high dropout rates for group therapy without concurrent individual therapy. The reasons are obvious. First, therapists know their individual therapy clients very well and can be more accurate in the selection process. Second, the therapists in their individual therapy sessions are able to prevent impending dropouts by addressing and resolving issues that have hindered the client’s work in the group.

> After seven meetings, David, a somewhat obsessional fifty-year-old confirmed bachelor, was on the verge of dropping out. The group had given him considerable feedback about several annoying characteristics he had: his frequent use of euphemisms; his concealment behind long, boring, repetitious anecdotes; and his persistence in asking distracting and irrelevant questions. Because David seemed untouched by the feedback, the group ultimately backed away and began to “mascot” him—tolerating him in a good-natured fashion, but not taking him seriously.

In an individual session, he lamented being “out of the loop” in the group and questioned whether he should continue. He also mentioned that he had not been wearing his hearing aid to the group, because of his fear of being ridiculed or stereotyped. Under ordinary circumstances, David would likely have dropped out of the group, but I (IY) could explore in his individual therapy many of the disturbing group events as well as the meaning of his being “out of the loop.” It turned out to be a core issue for David. Throughout his childhood and adolescence, he had felt socially shunned, and ultimately he had resigned himself to it. He became a loner and entered a profession (freelance IT consultant) that permitted a solitary, unattached lifestyle.

At my urging, he used his hearing aids in the group and expressed his feelings there of being out of the loop. His self-disclosure—and, even more important, his examination of his own role in putting himself out of the loop—were sufficient to reverse the process and bring him into greater engagement with the group. He remained in combined therapy with much profit for a year. <<

This example highlights another advantage of concurrent treatment: the rich and unpredictable interaction in the group commonly opens areas in therapy that might otherwise never have surfaced in the more insular individual format. David never felt “out of the loop” in his individual therapy—after all, I listened to his every word and strove to be present with him continually. Working in combined therapy helps us to realize the limits of our knowledge of our clients based upon individual therapy alone.

> Steven had for years engaged in many extramarital encounters but refused to take safer-sex precautions. In individual therapy I (IY) discussed this with him for months from every possible vantage point. We discussed his grandiosity and sense of immunity from biological law, his selfishness, and his concerns about impotence with a condom. I communicated my concern for him, for his wife, and for his sex partners. I expressed paternal feelings: both sadness at his self-destructiveness and outrage at his selfish behavior. All to no avail. When I placed Steven in a therapy group, he did not discuss his sexual risk-taking behavior, but some relevant experiences occurred.

On a number of occasions, he gave feedback to women members in a cruel, unfeeling manner. Gradually, the group confronted him on this and reflected on his uncaring, even vindictive, attitudes to women. Most of his group work centered on his lack of empathy. Gradually, he learned to enter the experiential worlds of others. The group was time limited (six months), and many months later in individual therapy, when we again focused in depth on his sexual behavior, Steven recalled, with considerable impact, how the group members had accused him of being uncaring. He was now able to consider his choices in the light of his lack of loving, and only then did his behavioral pattern change. <<

> Sam, a man who entered therapy because of his inhibitions and general flatness, encountered his inhibitions and general flatness, encountered his lack of openness and his rigidity far more powerfully in the therapy group than in the individual format. He kept three particularly important secrets from the group: that he had been trained as a therapist and practiced for a few years; that he had retired after inheriting a large fortune; and that he felt superior and held others in contempt. He kept secrets in the group (as he did in his social life), convincing himself that self-revelation would result in greater distance from others: he believed he would be stereotyped in one way or another, and “used,” envied, revered, or hated.

After three months of participation in a newly formed group, Sam became painfully aware of how he had re-created in the group the same onlooker role he assumed in his real life. All the members had started together, and all the others had revealed themselves and participated in a personal, uninhibited manner; he alone had chosen to stay outside the circle.

In our individual work, I (IY) urged Sam to reveal himself in the group. In session after session, I felt like a cornerman in a boxing ring exhorting him to take a chance. In fact, as the group meetings went by, I told him that delay was making things much worse. If he waited much longer to tell the group he had been a therapist, he would get a lot of flak when he did. (Sam had been receiving a steady stream of compliments about his perceptivity and sensitivity.)

Finally, Sam took the plunge and revealed his secrets. Immediately, he and the other members began to relate in a more genuine fashion. His disclosure enabled other members to reveal more about themselves. A member who was a student therapist discussed her fear of being judged for making superficial comments; another revealed that she was a closet snob, and a wealthy member revealed his concerns about others’ envy. Still others discussed strong, previously hidden feelings about money—including their anger at the therapist’s fees.

After the group ended, Sam continued to discuss these interactions in his individual therapy and to take new risks with me as well. The members’ acceptance of him after his disclosures was powerfully affirming. Previously, they had accepted him for his helpful insights, but that acceptance meant little to him, because he knew it was rooted in his bad faith: his false presentation of himself and his concealment of his training, wealth, and personal traits. <<

Sam’s experience points out some of the inherent pitfalls in combined therapy. For one thing, the role of the therapist changes significantly and increases in complexity. There is something refreshingly simple in leading a group when the leader knows the same thing about each member as everyone else does. But the combined therapist knows so much that life gets complicated. A member once referred to my (IY) role as that of Professor X from Marvel Comics. I knew everything: what members felt toward one another, what they chose to say, and, above all, what they chose to withhold. But this access to information can be a problem.

Group therapists who do not see any of their group clients in individual therapy can be more freewheeling. They can ask for information, take blind guesses, ask broad, general questions, call on members to describe their feelings about another member or some group incident. But the combined therapist knows too much! It becomes awkward to ask questions of members when you know the answer. Consequently, many therapists find that they are less active in groups of their own individual clients than when leading other groups. Another consideration is that when the same therapist provides both the individual and group therapies, client dependence and negative transference and countertransference reactions may even be amplified.

The therapist who provides combined treatment often struggles with the issue of boundaries and confidentiality. (This is also true in conjoint therapy at times when the group therapist has learned from the individual therapist about important feelings or events that their mutual client has not yet addressed in the group.) Is the content of the client’s individual therapy the property of the group? It is almost always best to urge clients to bring up group-relevant material in the group. If, for example, in the individual therapy hour, the client brings up angry feelings toward another member, the therapist urges the client to bring these feelings back to the group.

Suppose the client resists? Again, most therapists will pursue the least intrusive options: first, repeated urging of the client and investigation of the resistance; then focusing on in-group conflict between the two members, even if the conflict is mild; then sending knowing glances to the client; and, the final step, asking the client for permission to introduce the material into the group. Good judgment, of course, must be exercised. No technical rationale justifies humiliating a client. As noted earlier, a promise of absolute therapist confidentiality can rarely be provided without negatively constraining the therapy. Therapists can only promise that they will use their discretion and best professional judgment. Meanwhile, they must work toward helping the client accept the responsibility of bringing forward relevant material from one venue to the other.

The client’s shame often blocks disclosure, but this is rarely well addressed by bulldozing through the group member’s avoidance.17 In fact, bringing information from the individual setting to the group without permission may well be an ethical breach on the therapist’s part, as it violates client privacy. An added complexity arises when the group is co-led and the client is in individual therapy with one of the co-therapists. Many of these ethical matters emerge from dynamics regarding therapist power and privilege and client autonomy.18 Whatever the circumstance, informed consent about communication, boundaries, and confidentiality is essential in combined therapy, as noted in Chapter 9.19

COMBINING GROUP THERAPY AND TWELVE-STEP GROUPS

An increasingly common form of concurrent therapy is the treatment in group psychotherapy of clients who are also participating in twelve-step groups or other mutual support groups. Historically, antipathy existed between the proponents of these two modalities, each viewing the other competitively and with suspicion.20 Fortunately, there has been a growing rapprochement and appreciation for how these approaches complement one another. The vast economic costs and psychosocial scope of substance use disorders, which directly impact at least 20 million individuals in the United States at any moment and countless more indirectly; the high comorbidity rates with other psychological problems; the relapsing nature of the illness; and the social context of addiction make group therapy particularly relevant.21

Individuals with substance use disorders typically experience disturbances in their relationships at every stage of their illness. First, they have predisposing interpersonal difficulties resulting in emotional pain that they try to ease through substance use; second, they have relational difficulties resulting from the substance use itself; third, they have interpersonal difficulties that complicate the maintenance of sobriety. There is good evidence that group therapy can play an important role in recovery by helping these individuals develop coping skills that sustain sobriety and enhance resilience to relapse.22 Constructing a new support network together with interpersonal learning is often integral to recovery.23

There is also strong evidence that twelve-step groups are both effective and valued by clients.24 (Alcoholics Anonymous is the most prevalent of the twelve-step groups, but there are over 100 variations, including those for such conditions as drug addiction, gambling, sexual addiction, and overeating.)i It is inevitable that some of the many millions of members of AA, who attend one of the 115,000 weekly AA meetings worldwide, will also participate in group psychotherapy.25

Group therapy and AA complement one another when certain misunderstandings and obstacles are removed. First, group leaders must become informed about the mechanisms of twelve-step group work and learn to appreciate the inherent wisdom in the twelve-step program as well as the enormous support it offers to those struggling with addiction. Second, it is helpful to see that the models share some features in common: twelve-step groups use familiar group principles regarding bonding and belonging, employ role modeling, and recognize the importance of members developing new and rewarding relationships and gaining a sense of personal effectiveness.26 Third, there are several common misconceptions held by group therapists and/or by members of AA and similar groups that must be dispelled. These include the notions that:

1. Twelve-step groups are opposed to psychotherapy or medication.

2. Twelve-step groups encourage the abdication of personal responsibility by turning oneself over to a higher power.

3. Twelve-step groups discourage the expression of strong affects.

4. Mainstream group therapy neglects spirituality.

5. Mainstream group therapy is powerful enough to be effective without twelve-step groups.

6. Mainstream group therapy views relationships among twelve-step members and the relationship between sponsor and sponsee as regressive.27

Keep in mind that it is difficult to make blanket statements about twelve-step meetings, because meetings are not all the same: there is much variability from group to group. In general, however, there are two apparent major differences between the AA approach and the group therapy approach regarding the core of treatment.

The Twelve Steps of AA rest on the idea that reliance on a “Power greater than ourselves” is the essential component in staying sober. While the concept of “higher power” is left to each member to define for him or herself and the number of explicitly secular and humanistic twelve-step groups is growing, traditional, “old-school” AA focuses heavily on the members’ relationship to a higher power clearly defined in the AA Big Book as “God,” on surrender to God’s will, and on understanding the self in relationship to God.28 At the same time, however, a fundamental part of what propels change in AA is provision of a social network and fellowship, alternative and sober role models, and support for individual self-efficacy.29 These mechanisms are all very compatible with interpersonal group therapy.

Group therapy encourages member-to-member interaction, especially in the here-and-now: it is the lifeblood of the group. AA, by contrast, specifically prohibits “crosstalk”—that is, direct interaction between members during a meeting. “Crosstalk” could be any direct inquiry, suggestion, advice, feedback, or criticism. (This, too, is a generalization, however; if one searches, one can find AA groups that engage in considerable interaction—particularly before and after meetings.) The prohibition of “crosstalk” by no means leads to an impersonal meeting, however. AA members have pointed out to us that the knowledge that there will be no judgment or criticism is freeing to members and encourages them to self-disclose deeply. Since there is no designated trained group leader to modulate and process here-and-now interaction, AA’s decision to avoid intensive interpersonal interaction makes great sense.

Therapy group leaders introducing an AA member into their therapy group must keep in mind that group feedback will be an unfamiliar concept. Extra time and care should be taken in pregroup preparation sessions to explain this difference between the AA model and the therapy group model. We recommend that group leaders attend some AA meetings and become thoroughly familiar with the Twelve Steps. Demonstrate your respect for the steps and aim to convey to the client that most of the steps have meaning in the context of the therapy group as well and, if followed, will enhance the work of therapeutic change.

Table 13.1 lists the Twelve Steps and suggests related group therapy themes. We do not suggest a reinterpretation of the Twelve Steps but a loose translation of ideas in the steps into compatible and related interpersonal group concepts. With this framework, group leaders can readily employ a common language that covers both approaches and reinforces the idea that therapy and the recovery process are mutually facilitative.30

TABLE 13.1 The Convergence of Twelve-Step and Interpersonal Group Therapy Approaches

The Twelve Steps: 1. We admitted that we were powerless over alcohol and that our lives had become unmanageable.

Interpersonal Group Psychotherapy: Relinquish grandiosity and counterdependence.

Begin the process of trusting the process and the power of the group.

The Twelve Steps: 2. Came to believe that a Power greater than ourselves could restore us to sanity.

Interpersonal Group Psychotherapy: Self-repair through relationships and human connection.

Reframe “Power greater than ourselves” into a source of soothing, nurturance, and hope that may replace the reliance on substances.

The Twelve Steps: 3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

Interpersonal Group Psychotherapy: Make a leap of trust in the therapy procedure and the goodwill of fellow group members.

The Twelve Steps: 4. Made a searching and fearless moral inventory of ourselves.

Interpersonal Group Psychotherapy: Self-discovery. Search within. Learn as much about yourself as possible.

The Twelve Steps: 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

Interpersonal Group Psychotherapy: Self-disclosure. Share your inner world with others—the experiences that fill you with shame and guilt as well as your dreams and hopes.

The Twelve Steps: 6. Were entirely ready to have God remove all these defects of character.

Interpersonal Group Psychotherapy: Explore and illuminate, in the here-and-now of the treatment, all destructive interpersonal actions that invite relapses. The task of the group is to help members find the resources within themselves to prepare to take action.

The Twelve Steps: 7. Humbly asked Him to remove our shortcomings.

Interpersonal Group Psychotherapy: Acknowledge interpersonal feelings and behaviors that hinder satisfying relationships. Modify these by experimenting with new behaviors. Request and accept feedback in order to broaden your interpersonal repertoire. Though the group offers the opportunity to work on issues, it is your responsibility to do the work.

The Twelve Steps: 8. Made a list of all persons we had harmed, and became willing to make amends to them all.

Interpersonal Group Psychotherapy: Identify interpersonal injuries you have been responsible for; develop empathy for others’ feelings. Try to appreciate the impact of your actions on others and develop the willingness to repair injury.

The Twelve Steps: 9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

Interpersonal Group Psychotherapy: Use the group as a testing ground for the sequence of recognition and repair. Start the ninth-step work by making amends to other group members whom you have in any manner impeded or offended.

The Twelve Steps: 10. Continued to take personal inventory and when we were wrong promptly admit it.

Interpersonal Group Psychotherapy: Internalize the process of self-reflection, assumption of responsibility, and self-revelation. Make these attributes part of your way of being in the therapy group and in your outside life.

The Twelve Steps: 11. Sought through prayer and meditation to improve our conscious contact with God as we understand Him, praying only for knowledge of His will for us and the power to carry that out.

Interpersonal Group Psychotherapy: No direct psychotherapeutic focus, but the therapy group may support mind-calming meditation and spiritual exploration.

The Twelve Steps: 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to other addicts, and to practice these principles in all our affairs.

Interpersonal Group Psychotherapy: Become actively concerned for others, beginning with your fellow group members. Embracing an altruistic way of being in the world will raise your love and respect for yourself.

Source: Adapted from R. Matano and I. Yalom, “Approaches to Chemical Dependency: Chemical Dependency and Interactive Group Therapy: A Synthesis,” International Journal of Group Psychotherapy 41 (1991): 269–93. “The 12 Steps of AA,” Alcohol.org, www.alcohol.org/alcoholics-anonymous.

CO-THERAPY

Some group therapists choose to meet alone with a group, but the great majority prefer to work with a co-therapist.31 Indeed, the practice of co-therapy far outstrips the small amount of research evaluating its added clinical benefits. Although co-therapy adds some complexity, cohesion is not compromised in groups led by good co-therapy teams. One large head-to-head comparison of single vs. co-therapy leadership reported significant added clinical benefits for adolescents treated in co-therapy-led groups.32 Our own clinical experience has taught us that co-therapy presents both special advantages and potential hazards.

First, consider the advantages, both for the therapists and the clients. Co-therapists complement and support each other. Together, they have greater cognitive and observational range, and with their dual points of view they may generate more hunches and more strategies. When one therapist, for example, is intensively involved with one member, the co-therapist may be far more aware of the remaining members’ responses to the interchange and in a good position to broaden the range of the interaction and exploration. When one leader’s empathy and mentalization capacity falls short, the other can maintain the focus essential for the group.33 And do not underestimate the sheer instrumental value of being able to take vacations, knowing that the group will continue to meet with your colleague. For forty years, I (ML) have co-led a group every Wednesday night with a psychiatry resident, and I greatly value the added flexibility co-therapy has provided.

Because clients differ so much among themselves in their reactions to each of the co-therapists and to the co-therapists’ relationship, co-therapy also catalyzes transferential reactions and makes the nature of distortions more evident. In groups where strong therapist countertransference reactions occur or when personal identification with one’s clients is likely (for example, groups for clients with HIV or cancer, or trauma groups), the supportive function of co-therapy becomes particularly important for both clients and therapists.34 I (ML) vividly recall the last group meeting that Mary, a member of a group for women with advanced breast cancer, was able to attend. She knew she was dying and spoke about her family, her appreciation for the group, and what she valued in her life. My mother was very ill with cancer at the same time and I found myself emotionally overwhelmed and unable to regain my therapeutic composure. My co-therapist recognized this and facilitated the meeting effectively and then helped me debrief after the session.

Many clinicians have long believed that a male-female co-therapist team may have unique advantages. The image of the group as the primary family may be more strongly evoked; many fantasies and misconceptions about the relationship between the two therapists arise and may profitably be explored. Many clients benefit from the model of a male-female pair working together with mutual respect and inclusiveness, without the destructive competition, mutual derogation, exploitation, or pervasive sexual subtext they may associate with male-female pairings. For victims of early trauma and sexual abuse, a male-female co-therapy team provides an opportunity to address issues of mistrust, abuse of power, and helplessness. Clients from cultures in which men are dominant and women are subservient may experience a co-therapy team of a strong, competent woman and a tender, competent man as uniquely facilitative.35 It is also important to note that gender roles are changing rapidly in society, and male and female gender stereotypes are less and less relevant. In well-functioning co-therapy teams, roles are fluid, not rigid.

From our observations of over two hundred therapy groups led by neophyte therapists, we consider the co-therapy format to have special advantages for the beginning therapist. Many students consider co-leading a group to be one of their most effective and professionally impactful learning encounters. Where else in the training curriculum do two therapists have the opportunity to participate simultaneously in the same therapy experience with the same supervision?36 For one thing, the presence of a co-therapist reduces therapist anxiety and permits neophyte therapists to be more objective in understanding the meeting. In the postmeeting rehash, the co-therapists can provide valuable feedback about each other’s behavior. Similarly, co-therapists may aid each other in the identification and working-through of countertransference reactions toward various members.

It is especially difficult for beginning therapists to maintain objectivity in the face of massive group pressure. Weathering a group attack and helping a group make constructive use of it is one of the more unpleasant and difficult chores for neophyte therapists. When you are under the gun, you may feel too threatened either to clarify the attack or to encourage further attack without appearing defensive or condescending. There is nothing more squelching than an individual under fire saying, “It’s really great that you’re attacking me. Keep it going!” A co-therapist may prove invaluable here in helping the members continue to express their anger at the other therapist and ultimately to examine the source and meaning of that anger.

Whether co-therapists should openly disagree with each other during a group session is an issue of some controversy. We have generally found co-therapist disagreement unhelpful to the group in the first few meetings. The group is not yet stable or cohesive enough to tolerate such divisiveness in their leadership. Later, however, therapist disagreement may contribute greatly to therapy. In one study, I (IY) asked twenty clients who had concluded long-term group therapy about the effects of co-therapist disagreement on the course of the group and on their own therapy.37 They were unanimous in their judgment that it was beneficial. For many it was a model-setting experience: they observed individuals whom they respected disagree openly and resolve their differences with dignity and tact.

Consider a clinical example:

> During a group meeting, my co-leader, a resident, asked me (ML) why I seemed so quick to jump in with support whenever one of the men, Rob, received critical feedback. The question caught me off guard. I commented first that I had not noticed that until she drew it to my attention. I then invited feedback from others in the group, who agreed with her observation. It soon became clear to me that I was indeed overly protective of Rob, and I commented that although he had made substantial gains in controlling his anger and explosiveness, I still regarded him as fragile and I felt I needed to protect him from overreacting. Rob thanked me and my co-leader for our openness and added that, although he may have needed extra care in the past, he no longer did at this point. <<

In this way, group members experience therapists as human beings who, despite their imperfections, are genuinely attempting to help the members. Such a humanization process is inimical to irrational stereotyping, and clients learn to differentiate others according to their individual attributes rather than their roles. If group members wrestle with issues around power, status, race, or privilege, they may project these issues onto the co-therapy relationship. This may evoke co-therapist tension and rivalry. A respectful, transparent, in-group discussion between the two collaborative therapists can be very constructive. Unfortunately, co-therapists take far too little advantage of this wonderful modeling opportunity. Research into communicational patterns in therapy groups shows exceedingly few therapist-to-therapist remarks.38

Although some clients are made uncomfortable by disagreements between co-therapists, which may echo earlier parental conflict, for the most part it strengthens the honesty and the potency of the group. The principles of therapist transparency are critical in this context. As you disclose, be sure that your intent in doing so is therapeutic and that the impact of what you say aligns with that intent. We have observed many stagnant groups spring to life when the two therapists differentiated themselves as individuals.

The disadvantages of the co-therapy format flow from problems in the relationship between the two co-therapists. How the co-therapy goes, so goes the group. That is one of the main criticisms of the use of co-therapy outside of training environments.39 Why add another relationship (and one that drains professional resources) to the already interpersonally complex group environment?40

Hence, it is important that co-therapists feel comfortable and open with each other. They must learn to capitalize on each other’s strengths: one leader may be more able to nurture and support and the other more able to confront and to tolerate anger. If the co-therapists are competitive, however, and pursue their own brilliant interpretations rather than supporting lines of inquiry the other has begun, the group will be distracted and unsettled. It is also important that co-therapists speak the same professional language. A survey of forty-two co-therapy teams revealed that the most common source of co-therapy dissatisfaction was differing theoretical orientation.41

In some training programs, a junior therapist is paired with a senior therapist, a co-therapy format that offers much but is fraught with problems. Senior co-therapists must teach by modeling and encouragement; junior therapists must learn to individuate while avoiding both nonassertiveness and destructive competition. Most important, they must be willing, as equals, to examine their relationship—not only for themselves but as a model for the members. The impact of differences in gender, culture, age, and experience of each co-therapist must be addressed. Over time both therapists should exercise the full range of leadership, unconstricted by stereotypes or group members’ projections. A co-therapy team that entrenches the participants in dominant and subordinate roles will, unfortunately, model to the group that it is acceptable to withdraw and accept a submissive position.42

> Our own initial experience of co-therapy together reminds us of these principles. During my training, Irv invited me (ML) to co-lead an ongoing group of group therapists that he had been leading by himself. It was daunting to enter a group whose members were themselves experienced group leaders. Often a group member would carry the most recent edition of this book—which they had assigned their own students—into the session.

The group clients were exceedingly constrained and deferential to Irv, afraid to challenge one another or speak to the competitiveness they felt. Our hope was that shifting to co-leadership might help mobilize the group and unlock some of the unspoken tensions. For the first several sessions after my entry, every comment I made landed like a lead balloon in the oppressively quiet group. A bit exasperated, I finally proclaimed that the group members were stuck and afraid to take risks, leaving everything to “Irv, the wizened group leader.”

That seemed to help unlock the group somewhat, and later, in our postgroup discussion, Irv asked me if I was aware of my competitive feelings toward him, adding with humor that he assumed I intended to say, “Irv, the wise group therapist,” not “wizened,” i.e., shriveled. Alas, one cannot lie to one’s unconscious, as my slip of the tongue betrayed, in this instance, to good effect. <<

The choice of co-therapist is not to be taken lightly. We have seen many classes of psychotherapists choose co-therapists and have had the opportunity to follow the progress of these groups, and we are convinced that the ultimate success or failure of a group depends largely on the correctness of that choice. If the two therapists are uncomfortable with each other or are closed, rivalrous, or in wide disagreement about style and strategy—and if these differences are not resolvable through supervision—there is little likelihood that their group will develop into an effective work group.43 Co-leading a group with a hostile or untrusting co-therapist ranks as one of the worst professional experiences a group leader will endure.

Differences in temperament and natural rhythm are inevitable. What is not inevitable, however, is that these differences get locked into place in ways that limit the co-therapists’ roles and functions. Sometimes the group’s feedback can be illuminating and lead to important work, as was the case in a group for male spousal abusers, who questioned why the male co-therapist collected the group fee and the female co-therapist did the “straightening up” after each session.

When consultants or supervisors are called in to assist with a group that is not progressing satisfactorily, they can often offer the greatest service by directing their attention to the relationship between the co-therapists. (This will be discussed further in Chapter 16.) One study of neophyte group leaders noted that the factor common to all trainees who reported a disappointing clinical group experience was unaddressed and unresolved co-therapy tensions.44 One frustrated and demoralized co-therapist reported a transparent dream in supervision just after her arrogant but incompetent co-therapist withdrew from the training program. In the dream she was a hockey goalie defending her team’s net, and one of her own players (guess who?) kept firing the puck at her.

Co-therapist choices should not be made blindly. Do not agree to co-lead a group with someone you do not know well or do not like. Do not make the choice because of work pressures or an inability to say no to an invitation; it is far too important and too binding a relationship. You are far better off leading a solo group with good supervision than being locked into an incompatible co-therapy relationship. You will do well to select a co-therapist toward whom you feel close but who in personal characteristics is dissimilar to you: such complementarity enriches the experience of the group.

Spouses frequently co-lead marital couples’ groups. Co-leadership of a long-term interpersonal group, however, requires an unusually mature and stable marital relationship. We advise therapists who are involved in a newly formed romantic relationship with each other not to lead a group together. It is advisable to wait until the relationship has developed stability and permanence. Two former lovers, now estranged, do not make a good co-therapy team.

Characterologically difficult clients who are unable to integrate loving and hateful feelings may project these feelings onto the therapists in a way that ends up “splitting” the co-therapy team. One co-therapist may become the focus of the positive part of the split and is idealized while the other becomes the focus of hateful feelings and is attacked or shunned. Unless this is explored and worked through, it is a recipe for therapeutic failure for the client as well as for co-therapy fracturing.

Some groups divide into two factions, each co-therapist having a “team” of clients with whom he or she has a special relationship. Sometimes this division has its genesis in the relationship the therapist established with those clients before the group began, in prior individual therapy or in consultation. (For this reason, it is advisable that both therapists interview all clients, preferably simultaneously, in the pregroup screening. We have seen clients continue to feel a special bond throughout their entire group therapy course with the member of the co-therapy team who first interviewed them.) Other clients align themselves with one therapist because of his or her personal characteristics, or because they feel a particular therapist is more intelligent, more senior, or more sexually attractive than the other, or more ethnically or personally similar to themselves. Whatever the reasons for the subgrouping, the process should be noted and openly discussed.

Discussion time is essential for a co-therapy team. The co-therapy relationship takes time to develop and mature. Co-therapists must set aside time to talk together and tend to their relationship.45 At the very least, they need a few minutes before each meeting to talk about the last session and examine possible issues for that day’s meeting, and then fifteen to twenty minutes at the end to debrief and to share their reflections about the meeting and about each other’s behavior. If the group is supervised, it is imperative that both therapists attend the supervisory session. Many busy clinics, in the name of efficiency and economy, make the serious mistake of not setting aside time for co-therapist discussion. Because of their intense intimate experience in the group, deep and abiding friendships may develop between co-therapists.

DREAMS

The number and types of dreams that group members bring to therapy are largely a function of the therapist’s attentiveness to dreams. The therapist’s response to the first dreams presented by clients will influence the nature of dreams subsequently presented. The intensive, detailed, personalized investigation of dreams practiced in analytically oriented individual therapy is hardly feasible in group therapy. It would require a disproportionate amount of time to be centered upon one client and would likely be minimally useful to the remaining members, who become mere bystanders.

What useful role, then, can dreams play in group therapy? Usually therapists think of dreams as consisting of both manifest (conscious) and latent (unconscious) content. We suggest that therapists also think about dreams as carrying both intrapsychic and interpersonal dimensions. The dream is the client’s intrapsychic creation, but when the client shares it within the group, the dream is transformed into an interpersonal act.46

In individual psychodynamic treatment, therapists are usually presented with many dreams. They therefore never strive for complete analysis of all dreams, electing instead to work on aspects of dreams that seem pertinent to the current phase of therapy. Therapists may ignore some dreams and ask for extensive associations to others. For example, if a bereaved client brings in a dream full of anger toward her deceased husband as well as heavily disguised symbols relating to sexual identity, the therapist will generally focus upon the former theme and defer the latter. Moreover, the process is self-reinforcing. It is well recognized that clients who are deeply involved in therapy dream or remember dreams compliantly: that is, they produce dreams that are tied to the current thrust of therapy and reinforce the theoretical framework of the therapist (“tag-along” dreams, Freud termed them).

The investigation of certain dreams can accelerate group therapeutic work. Most valuable are group dreams—dreams that involve the group as an entity—or dreams that reflect the dreamer’s feelings toward one or more members of the group. Either of these types may elucidate not only the dreamer’s but also other members’ concerns that have not previously come fully into consciousness. Some dreams may introduce, in disguised form, material that is conscious but that members have been reluctant to discuss in the group. Hence, inviting all the group members to comment on the dream and associate to it and its impact on them is often productive. It is important also to explore the context of the disclosure of the dream: Why dream or disclose this dream at this particular time? How does exploration of this dream deepen the understanding of the dreamer and of the group?47

> In a meeting just preceding the entry of two new members to the group, one self-absorbed man, Jeff, reported his first dream to the group after several months of participation. “I am polishing my new BMW to a high sheen. Then, just after I clean the car interior to perfection, seven people dressed as clowns arrive, get into my car carrying all sorts of food, and mess it up. I just stand there watching and fuming.”

Both he and the group members presented associations to the dream around an old theme for Jeff—his frustrating pursuit of perfection and need to present a perfect image to the world. The leader’s inquiry about “why this dream now?” led to more significant insight. Jeff said that over the past few months he had begun to let the group into his less-than-perfect “interior” world. Perhaps, he said, the dream reflected his fear that the new members coming the next week would not take proper care of his interior. He was not alone in this anxiety: other members also worried that the new members might spoil the group. <<

At the twentieth meeting of another group, Sally related this dream:

> I am walking with my younger sister. As we walk, she grows smaller and smaller. Finally, I have to carry her. We arrive at the group room, where the members are sitting around sipping tea. I have to show the group my sister. By this time, she is so small she is in a package. I unwrap the package but all that is left of her is a tiny bronze head. <<

The investigation of this dream clarified several previously unconscious concerns of the dreamer. Sally had been extraordinarily lonely and immediately became deeply involved in the group—in fact, the group was her only important social contact. At the same time, however, she feared that the group had become too important to her. Sally modified herself rapidly to meet group expectations and, in so doing, lost sight of her own needs and identity. The rapidly shrinking sister symbolized herself becoming more infantile, more undifferentiated, and finally inanimate, as she immolated herself in a frantic quest for the group’s approval. Perhaps there was anger in the image of the group “sipping tea.” Was the group truly working? Did the other members really care about her? The lifeless, diminutive bronzed head—was that what they wanted? Dreams may reflect the state of the dreamer’s sense of self and need to be treated with great care and respect as an expression of self and not as a secret message that must be aggressively decoded.48 Think of the dream as a gift offered by the client to the group and to the therapist; pay careful attention to the group members’ emotional responses to the dream.

The following dream illustrates how the therapist may selectively focus on those aspects that further the group work:

> My husband locks me out of our grocery store. I am very concerned about the perishables spoiling. He gets a job in another store, where he is busy taking out the garbage. He is smiling and enjoying this, though it is clear he is being a fool. There is a young, attractive male clerk there who winks at me, and we go out dancing together. <<

This member was a middle-aged woman who was introduced into a group of younger members. From the standpoint of her personal dynamics, the dream was highly meaningful. Her husband, distant and work-oriented, locked her out of his life. She had a strong feeling of her life slipping by unused (the perishables spoiling). At a previous group meeting she had referred to her sexual fantasies as “garbage.” She also felt a considerable amount of previously unexpressed anger toward her husband and made him an absurd figure in the dream.

Though there were several tempting dream morsels, the therapist chose to focus on the group-relevant themes. The client had many concerns about being excluded from the group: she felt older than the other members, less attractive, and very isolated from them. Accordingly, the therapist focused on the theme of being locked out and on her desire for more attention from others in the group, especially the men (one of whom resembled the winking clerk in the dream).

Dreams often reveal unexpressed group concerns or shed light on group impasses.49 The following dream illustrates how conscious, but avoided, group material may, through dreams, be brought into the group for examination:

> There are two rooms side by side with a mirror in my house. I feel there is a burglar in the next room. I think I can pull the curtain back and see a person in a black mask stealing my possessions. <<

This dream was brought in at the mid-phase of a time-limited therapy group that was observed through a one-way mirror by the therapist’s students. Aside from a few comments in the first meeting, the group members had never expressed their feelings about the observers. A discussion of the dream led the group into a valuable and much-needed conversation about the therapist’s relationship to the group and to his students. Were the observers “stealing” something from the group? Was the therapist’s primary allegiance toward his students, and were the group members merely a means of presenting a good show or demonstration for them?

AUDIOVISUAL TECHNOLOGY

The advent of audiovisual technology seemed a great boon to the practicing group therapist, and early professional group therapy literature reflected an initial wave of tremendous enthusiasm. Video recording was a way to turbocharge feedback to our clients.50 It was part of our ongoing wish to maximize client learning and augment the direct clinical group work. Later in this chapter we discuss other useful feedback platforms.51

In recent years we have seen a steep decline in articles and books about the clinical use of audiovisual technology. It is likely that the current ethos of efficiency is to blame for this reduction, as clinical use of audiovisual equipment is often awkward and time-consuming. What remains yet to be determined is the therapeutic opportunities presented by the growing use of video teleconferencing for group therapy. These sessions are now easily recorded—with client consent, of course—and may have utility in providing direct feedback to group members and therapists as well as in the research on group therapy. Privacy concerns regarding the transmission and storage of video recordings are notable. Nevertheless, this technology still has much potential; at the very least, it merits a brief survey of how it has been used clinically, even if the methodologies seem anachronistic. The use of audiovisual techniques in teaching and in research is more enduring and still prominent.

In earlier approaches some clinicians taped each meeting and used immediate playback (“focused feedback”) of selected sections during the session. Some therapists used an auxiliary therapist whose chief task was to record the group and even to select suitable portions for playback. Other therapists recorded the meeting and devoted the following session to playback and discussion of certain key sections.52

Some therapists scheduled an extra playback meeting in which most of the previous taped session was viewed. Still others used a serial-viewing technique: they videotaped every session and retained short representative segments of each, which they later played back to the group.53 Some simply made the videos available to clients who wished to come in between meetings to review some segment of the meeting. The videos were also made available for absent members to view the meeting they missed.

Client response depends on the timing of the procedure. Clients will respond differently to the first playback session than to later sessions. In the first playback, clients attend primarily to their own images and are less attentive to their styles of interacting with others or to the process of the group. Our own experience, and that of others, is that group members may have a keen interest in viewing video recordings early in therapy, but once the group becomes cohesive and highly interactive, they rapidly lose interest in the viewing and resent time taken away from the live group meeting.54 Often a member’s long-cherished self-image is radically challenged by the video playback, and after viewing a recording, members may recall previous feedback offered by other members more readily and be more receptive to it. Self-observation is a powerful experience; nothing is as convincing as information one discovers for oneself.

We have on occasion found video recording to be of great value in crisis situations. For example, a man in a group of alcohol-dependent individuals arrived at a meeting intoxicated and proceeded to be monopolistic, insulting, and crude. Heavily intoxicated individuals obviously do not profit from meetings because they are not capable of retaining and integrating the events of the session. This meeting was recorded, however, and a subsequent viewing was enormously helpful to the client. He had been told but until this replay had never really understood how destructive his alcohol use was to himself and others.

On another occasion a different client arrived heavily intoxicated to this group and soon lost consciousness. He lay stretched out on the sofa while the group, encircling him, discussed various courses of action. Some time later, this client viewed the tape and was profoundly affected. People had often told him that he was killing himself with alcohol, but the sight of himself on video, laid out as if at his funeral, brought his twin brother—who had died of alcoholism—to mind.

In another group, a periodically manic client who had never accepted that her behavior was unusual had an opportunity to view herself in a particularly frenetic, disorganized state.55 In each of these instances, the video recording provided a powerful self-observatory experience—a necessary first step in the therapeutic process.

Many therapists are reluctant to inflict a video camera on a group. They feel that it will inhibit the group’s spontaneity and that the group members will resent the intrusion—though not necessarily overtly. In our experience, the person who experiences the most discomfort is often the therapist. The fear of being exposed and shamed, particularly in supervision, is a leading cause of therapist resistance and must be addressed in supervision.56

Clients who are to view the playback are usually receptive to the suggestion of video recording. Of course, they are concerned about confidentiality and need reassurance on this issue. If the video is to be viewed by anyone other than the group members (for example, students, researchers, or supervisors), the therapist must be explicit about the purpose of the viewing and the identity of the viewers and must also obtain written permission from each member with regard to each intended use: clinical, educational, and research. Clients should be full participants in the decision about the secure storage or deletion of the videos.

Video in Teaching

Video recording has proven its value in the teaching of all forms of psychotherapy. Students and supervisors are able to view a session with a minimum of distortion or defensive misrepresentation by the trainee.57 Important nonverbal aspects of behavior of both students and clients—which may be completely missed in the traditional supervisory format—become available for study. The student-therapist has a rich opportunity to observe his or her own presentation of self and body language. Frequently what gets missed in traditional supervision is not the students’ “mistakes,” but the very effective interventions that they employ intuitively without conscious awareness. Confusing aspects of the meeting may be viewed several times until some order appears. Valuable teaching sessions that clearly illustrate basic principles of therapy may be preserved and a teaching video library created. Videos have become a mainstay of training psychotherapists for both clinical practice and for leading manual-based groups in clinical trials, helping to ensure that therapists do not drift from the prescribed model.58

Video Recording in Research

The use of videotaping and video recording has also advanced the field significantly by allowing researchers to ensure that the psychotherapy being tested in clinical trials is delivered competently and aligns faithfully with the study protocol.59 It is no less important in a psychotherapy trial than it is in a drug therapy trial to monitor the treatment delivery and demonstrate that clients received the right kind and right amount of treatment. In pharmacotherapy research, blood-level assays can be used for this purpose. In psychotherapy research, video recordings are an excellent monitoring tool for the same purpose. It is virtually impossible to obtain psychotherapy research funding without a clear and reliable protocol to ensure that the psychotherapy was delivered in the right way across different therapists and different sites in multisite trials.

WRITTEN SUMMARIES

Throughout my practice of group psychotherapy, I (IY) have regularly used the ancillary technique of writing summaries of the groups I have led. At the end of each session, I dictate a detailed summary of the group session and send a copy to each group member.60 The summary is an editorialized narrative that describes the flow of the session, each member’s contribution, my contributions (not only what I said, but also what I wished I had said and what I did say but regretted), and any hunches or questions that occur to me after the session. This summary can be typed or dictated using voice recognition software and then emailed to the group members. Dictation of summaries (two or three single-spaced pages) requires approximately twenty to thirty minutes per group session. It is best done immediately after the session; the longer it is postponed, the longer it will take to complete and the more inaccurate it will be. The sequence of events in the group fades from memory quickly. Do not let even a phone call intervene between the meeting and your completion of the summary. To date, my students, co-therapists, colleagues, and I have written and mailed thousands of group summaries to group members. It is my strong belief that the procedure greatly facilitates therapy.

In these days of economically pressured psychotherapy, however, who can accommodate a task that requires yet another thirty minutes of therapist time and additional administrative support? For that matter, look back through this chapter: Who has time for setting up cameras and selecting portions of video to replay to the group? Who has time for even brief meetings with a co-therapist before and after meetings? Or for conferring with group members’ individual therapists? The answer, of course, is that harried therapists must make choices, and often, alas, they must sacrifice some potentially powerful but time-consuming adjuncts to therapy in order to meet the demands of contemporary practice. It is easy to be dismayed by the mountains of record keeping that need to be completed.61

Health-care administrators may believe that time can be saved by streamlining therapy—making it slicker, briefer, more uniform. However, therapists sacrifice the very core of therapy if they sacrifice their ingenuity and their ability to respond to unusual clinical situations with creative measures. Hence, even though the practice is not in wide clinical use at present, we continue to describe such techniques as the written summary. We believe it is a potent facilitating technique. Our experience has been that all group therapists willing to try it have found that it enhances the course of group therapy.62 Moreover, it plays a role in the education of young therapists by helping them use language skillfully.63 Writing the summary encourages the reflection and deliberate practice that hones our skills as therapists.64

The written summary may even do double service as a mechanism for documenting the course of therapy and turning the usually unrewarding and dry process of record keeping into a functional intervention.65 We are wise to remember that the client’s record belongs to the client and can be accessed by the client at any point. In all instances, it is appropriate to write notes expecting that they may be read by the client. Notes should use only first names and provide a transparent, therapeutic, de-pathologizing, considered, and empathic account of the treatment.

My (IY) first experience with the written summary was in individual therapy. A young woman, Ginny, had attended a therapy group for six months but had to terminate because she moved out of town and could not arrange transportation to get to the group on time. Moreover, her inordinate shyness and inhibition had made it difficult for her to participate in the group. Ginny was inhibited in her work as well: a gifted writer, she was crippled by severe writer’s block. Furthermore, because of her limited income, she could not afford individual therapy.

I agreed to treat her in individual therapy and waive the fee but with one unusual proviso: after each therapy hour, she had to write an impressionistic, freewheeling summary of the “underground” of the session—that is, what she was really thinking and feeling but had not verbally expressed. My hope was that the assignment would help penetrate the writing block and encourage greater spontaneity. I agreed to write an equally candid summary. Ginny had a pronounced positive transference. She idealized me in every way, and my hope was that a written summary conveying my honest feelings—pleasure, discouragement, puzzlement, fatigue—would permit her to relate more genuinely to me.

For a year and a half, Ginny and I wrote weekly summaries. We handed them, sealed, to my administrative assistant, and every few months we read each other’s summaries. The experiment turned out to be highly successful; Ginny did well in therapy, and the summaries contributed greatly to that success.ii I developed sufficient courage from the venture (and courage is needed: it is difficult at first for a therapist to be so self-revealing) to think about adapting the technique to a therapy group. The opportunity soon arose in two groups of alcoholic clients.66

My co-therapists and I had attempted to lead these groups in an interactional mode. The groups had gone well, in that the members were interacting openly and productively. However, here-and-now interaction always entails anxiety, and clients with alcohol use disorders are notoriously poor at regulating anxiety. By the eighth meeting, members who had been dry for months were drinking again (or threatening to drink again if they “ever had another meeting like the one last week!”). We hastily sought methods of modulating the anxiety: increased structure, a written agenda for each meeting, video playback, and written summaries distributed after each meeting. The group members considered the written summary to be the most efficacious method by far, and soon it replaced the others.

We believe that the summaries are most valuable if they are honest and straightforward about the process of therapy. They are virtually identical to summaries I (IY) make for my own files (which provide most of the clinical material for my writing) and are based on the assumption that the client is a full collaborator in the therapeutic process—that psychotherapy is strengthened, not weakened, by demystification.

The summary serves several functions: it provides understanding of the events of the session; takes note of good (or resistive) sessions; comments on client gains; predicts (and, by doing so, generally prevents) undesirable developments; brings in silent members; increases cohesiveness (by underscoring similarities, caring in the group, and so on); invites new behavior and interactions; provides interpretations (either repetition of interpretations made in the group or new interpretations occurring to the therapist later); and provides hope to the group members, helping them realize that the group is an orderly process and that the therapists have some coherent sense of the group’s long-term development. In fact, the summary may be used to augment every one of the group leader’s tasks in a group.

Let’s look at the functions of the summary. (In the following discussion we cite excerpts from actual summaries.)

Revivification and Continuity

The summary becomes another group contact during the week. The meeting is revivified for the members, and the group is more likely to maintain continuity. In Chapter 5 we stated that groups assume more power if the work is continuous—that is, if themes begun one week are not dropped, but instead explored more deeply, in succeeding meetings. The summary augments this process. Not infrequently, group members begin a meeting by referring to the previous summary—perhaps a theme they wish to explore or a statement with which they disagree.

Understanding Process

The summary helps clients reexperience and understand the important events of a meeting. In Chapter 6, we described the here-and-now as consisting of two phases: experience and the understanding of that experience. The summary facilitates the second stage, the understanding and integration of the affective experience. Sometimes group sessions may be so threatening or unsettling that members close down and move into a defensive, survival position. Only later (often with the help of the summary) can they review significant events and convert them into constructive learning experiences. The therapist’s process commentaries (especially complex ones) delivered in the midst of a melee tend to fall on deaf ears. These same comments, often fine-tuned, repeated in the summary, may be more effective, because the client is able to consider them at length with some distance from the intensity of the initial engagement.

Shaping Group Norms

The summaries may be used to reinforce norms both implicitly and explicitly. The following excerpt reinforces the here-and-now norm:

Phil’s relationship with his boss is very important and difficult for him at this time, and as such is certainly material for the group. However, the members do not know the boss, what he is like, what he is thinking and feeling, and thus are limited in offering help. However, they are beginning to know one another and can be more certain of their own reactions to one another in the group. They can give more accurate feedback about feelings that occur between them rather than trying to guess what the boss may be thinking.

Therapeutic Leverage

The therapist may, in the summary, reinforce risk-taking and focus clients on their primary task, their original purpose in coming to therapy. For example:

Irene felt hurt at Jim’s calling her an observer of life and fell silent for the next forty-five minutes. Later she said she felt clamped up and thought about leaving the group. It is important that Irene keep in mind that her main reason for being in therapy was that she felt estranged from others and unable to create closer, sustained relationships, especially with men. In that context, it is important for her to recognize, understand, and eventually overcome her impulse to clamp up and withdraw as a response to feedback.

Or the therapist may take care to repeat statements by clients that will offer leverage in the future. To illustrate:

Nancy began weeping at this point, but when Ed tried to console her, she snapped, “Stop being so kind. I don’t cry because I’m miserable, I cry when I’m pissed off. When you console me or let me off the hook because of my tears, you always stop me from looking at my anger.”

New Thoughts

Often the therapist understands an event only after the fact. On other occasions, the timing is not right for a clarifying remark during a session (there are times when too much cognition might squelch the emotional experience), or there has simply been no time available in the meeting, or a member has been so defensive that he or she would reject any efforts at clarification. The summaries provide the therapist with a second chance to convey such important thoughts.

Transmission of the Therapist’s Temporal Perspective

Far more than any member of the group, the therapist maintains a long-range temporal perspective and is cognizant of changes occurring over many weeks or months, both in the group and in each of the members. There are many times when the sharing of these observations offers hope, support, and meaning for the members. For example:

Seymour spoke quite openly in the group today about how hurt he was by Jack and Burt switching the topic off him. We [the co-therapists] were struck by the ease and forthrightness with which he was able to discuss these feelings. We can clearly remember his hurt, passive silence in similar situations in the past, and are impressed with how markedly he has changed in his ability to express his feelings openly.

The summaries provide temporal perspective in yet another way. Since the clients almost invariably save the reports, they have a comprehensive account of their progression through the group, which they may refer to with great profit in the future.

Therapist Self-Disclosure

Therapists, in the service of the clients’ therapy, may use the summary as a vehicle to disclose personal here-and-now feelings (of puzzlement, of discouragement, of irritation, of pleasure) and their views about the theory and rationale underlying their own behavior in the group. Consider the therapist self-disclosure in these illustrative excerpts:

We felt very much in a bind with Seymour. He was silent during the meeting. We felt very much that we wanted to bring him into the group and help him talk, especially since we knew that the reason he had dropped out of his previous group was because of his feeling that people were uninterested in what he had to say. On the other hand, today we decided to resist the desire to bring him in because we knew that by continually bringing Seymour into the group, we are infantilizing him, and it will be much better if, sooner or later, he is able to do it by himself.

Irv had a definite feeling of dissatisfaction with his own behavior in the meeting today. He felt he dominated things too much, that he was too active, too directive. No doubt this is due in large part to his feeling of guilt at having missed the previous two meetings and wanting to make up for it today by giving as much as possible.

Filling Gaps

An obvious and important function of the summary is to fill in gaps for members who miss meetings because of illness, vacation, or any other reason. The summaries keep them abreast of events and enable them to move more quickly back into the group.

New Group Members

The entrance of a new member may also be facilitated by providing summaries of the previous few meetings. I routinely ask new members to read such summaries before attending the first meeting.

General Impressions

We believe the written summary facilitates therapy. Clients have been unanimous in their positive evaluations: most read and consider the summaries very seriously; many reread them several times; almost all retain them for future use. The client’s therapeutic perspective and commitment is deepened; the therapeutic relationship is strengthened; and in our experience no serious negative transference complications or adverse consequences occurred. The dialogue and disagreement about summaries are always helpful and makes this a collaborative process. The intent of the summary should never be to convey a sense of the “last word.”

Many therapists have asked us about confidentiality and client privacy. To date we have not encountered problems in this area. Clients are asked to treat the summary with the same degree of confidentiality as they do any event in the group. As an extra precaution, we strongly recommend that therapists use only first names, that they avoid explicit identification of any particularly delicate issue (for example, an extramarital affair), and that they use a secure, agreed upon delivery system. When we first sent out summaries, we mailed them in a plain envelope with no return address. Today, of course, email, with encryption to protect privacy, is an easier alternative.

We suggest this approach to crafting the summary: first try to construct the skeleton of the meeting by recalling the two to four main issues of the meeting. When that is in place, next try to recall the transitions between issues. Then go back to each issue and try to describe each member’s contribution to the discussion of each issue. Pay special attention to your own role, including what you said (or didn’t say) and what was directed toward you.

Do not be perfectionistic: one cannot recall or remember everything. Do not try to refresh your memory by listening to a tape of a meeting—that would make the task far too time-consuming. Mail it out without proofreading it; clients overlook errors and omissions, or it becomes grist for exploration.

Like any event in the group, the summaries generate differential responses. For example, clients with severe dependency yearnings will cherish every word; those with a severe counterdependent posture will challenge every word, or, occasionally, be unable to spare the time to read them at all; obsessive clients obsess over the precise meaning of the words; and mistrustful individuals search for hidden meanings. Thus, although the summaries provide a clarifying force, they do not thwart the formation of the distortions whose corrections are intrinsic to therapy.

MONITORING GROUP THERAPY OUTCOME AND PROCESS

Throughout this text we have emphasized that every group leader can be an evidence-based practitioner. One important pathway is for leaders to obtain feedback about how their groups and group members are actually doing. This is referred to as “practice-based evidence” and is a central component of the accountability demanded of our work.67 Why is this feedback helpful? In the absence of feedback, group therapists must rely only on their clinical impressions. When therapy is progressing well, this is generally sufficient. However, as we have discussed elsewhere, a sizable percentage of our clients will not progress and will drop out of treatment. Both individual and group therapists generally do a poor job of recognizing who among their clients may be at risk of deterioration or dropout. Monitoring outcome and process helps in the earlier detection of problems, lessens negative clinical outcomes, and boosts therapy gains.68 This burgeoning area of research, enabled by modern technology, enables each group therapist to be, in essence, a clinical scientist.

Two widely used outcome-monitoring systems are the Outcome Questionnaire (OQ-45.2) and the Partners for Change Outcome Management System (PCOMS).69 Both provide feedback about each member of the group in terms of individual distress, interpersonal relationships, and social function. These systems also offer process measures regarding how each member is experiencing the session. Incorporating the Group Questionnaire (GQ)70 (referred to in Chapter 3) provides additional feedback to group therapists by measuring the client’s experience of relationships within the group. By comparing each member to other group members, therapists can be alerted to members who are out of sync and who may require additional attention. Outcome measurements also provide comparisons to a large pool of psychotherapy clients, and the trajectory of each group member can be compared to trajectories for thousands of clients. Feedback messages signal that the client is on track (green); may not be on track (yellow); or is clearly off track (red). Feedback is also provided to the group leader regarding what clinical areas may warrant particular attention. Guided by this information, the client who is strongly connected but avoidant of risk-taking may be more assertively challenged. The client who is compliantly attending but emotionally disengaged can similarly be identified.

Feedback can be provided at the individual or group level or aggregated system-wide to get a sense of how therapy groups in a particular organization or setting may be functioning. Clients can complete these questionnaires easily and securely on a range of handheld devices. Ideally these are completed before each session so that the group leaders can review the reports before the meeting. The reports can even facilitate record keeping. Clients can be engaged in providing this feedback if they understand its importance; they can be encouraged to view it as equivalent to getting blood work done to assist their family physician in providing good care. Sharing feedback with clients enhances the therapeutic alliance, builds a sense of partnership about the therapy, and allows for more collaborative and equitable decision-making. Using objective data promotes treatment efficiency and effectiveness.71

Pitfalls of Monitoring

Gathering information without using it in therapy will quickly discourage clients from completing the questionnaires in the future. Determining how best to incorporate the feedback into the clinical work requires consideration of timing and should be tailored to an understanding of one’s clients, particularly those who may find it easier to signal their distress on a questionnaire than in person. Therapists are sometimes reluctant to make use of this kind of feedback system, finding it intrusive and compromising of their autonomy or the sanctity of therapy. Others may balk at the potential added cost of this kind of monitoring.72 Some clinicians fear that getting negative feedback about their effectiveness will lead to punitive institutional responses. Organizational culture and organizational climate play a key role in the proper utilization of this feedback; it is important that the organizational culture supports and enhances clinicians’ capacity to do their work effectively. We should aim to create a culture that promotes professional development for group leaders ensuring that both clients and therapists benefit.73

STRUCTURED EXERCISES

We use the term structured exercise to denote an activity in which a group follows some specific set of directions. It is an experiment carried out in the group, generally suggested by the leader but occasionally by some experienced member. The precise rationale of structured exercises varies, but in general they are intended as accelerating devices to foster engagement or to enhance efficacy.

Structured exercises attempt to speed up the group with warm-up procedures that bypass the hesitant, uneasy first steps of the group; they speed up interaction by assigning individuals tasks that circumvent ritualized, introductory social behavior; and they may help members get in touch quickly with suppressed emotions and unknown parts of themselves, cope with intense affects, or reconnect with their physical and creative selves.74 In some settings and with some clinical populations, the structured exercise may be the central focus of the meeting. There are a wide range of possible exercises: some common models include action- and activity-oriented groups for the elderly (such as art, dance, and movement groups) that aim to reconnect clients to a sense of effectiveness, competence, and social interaction; structured activity groups for hospitalized psychotic patients; and guided imagery or body awareness after cancer surgery or for victims of trauma.75 Our group work with women with advanced breast cancer always concluded with an exercise in progressive muscle relaxation and guided imagery.76 Personal narratives that are authored individually can be shared to good effect in the group treatment of individuals with chronic medical illnesses and HIV.77

Mindfulness-based stress reduction (MBSR) groups that teach meditation, deep breathing, and relaxation and focus awareness on members’ moment-to-moment state of being are also prominent and have been used to remarkably good effect in the treatment of medical illnesses and anxiety disorders and in the prevention of relapse in depression.78 These techniques can also be incorporated as helpful components of broader-based group interventions.

> Sara, an eighty-two-year-old woman with anxiety and depression participating in a day hospital for seniors, told her group that she was intensely anxious about attending her granddaughter’s wedding five days hence. Getting dressed up and being exposed to a large crowd of people filled her with dread. As she spoke, Sara started to panic, hyperventilate, and cry. While the group therapists tried to be reassuring, Sara’s neighbor, an eighty-five-year-old woman, Doris, reached over, grabbed her hand, and lovingly stated: “You know what to do Sara; you know to breathe deeply, focus on your breath, and make yourself feel better. There is nothing to fear; I know how much you want to attend the wedding. I am going to breathe with you right now and I want you to join me. You have practiced this and now we will use it. You are not alone here.”

As Doris began to breathe deeply and slowly, others around the group circle joined in. Twelve group members, including the two group leaders, held hands around the circle and echoed Doris’s pace of breathing. Sara slowly calmed, regained her composure, and said, “Thank you so much for reminding me of that. It always helps but I forget about it when I start to get anxious. I felt so overwhelmed and alone.”

The remainder of the session focused on the sense of effectiveness the group members felt in working together and supporting one of their members. Sara committed to practicing her breathing exercises daily and to making a plan to have a close friend come over before the wedding to help her get ready. She promised to give the group a full report on the wedding, which she subsequently did with much gratitude. <<

A structured exercise in interactional groups may require only a few minutes or may consume an entire meeting. It may be predominantly verbal or nonverbal. Generally, the successful structured exercise will generate data that is subsequently discussed. To maximize the impact of the exercise, it must be both experienced and processed. Having the experience without attributing meaning to it, which occurred all too often in the early stages of the encounter group movement, is insufficient.79 Such exercises, common in the encounter groups but far less so in the therapy group, might involve the entire group as a group (the group may be asked, for example, to build something or to plan an outing); one member vis-à-vis the group (the “trust fall,” for example, in which one member stands, eyes closed, in the center and falls, allowing the group to catch, support, and then cradle and rock the person); the entire group as individuals (members may be asked in turn to give their initial impressions of everyone else in the group); the entire group as dyads (the “blind walk,” for example, in which the group is broken into dyads and each pair takes a walk with one member blindfolded and led by the other); one designated dyad (two members locked in a struggle may be asked to take turns pushing the other to the ground and then lifting him or her up again); or one designated member (“switching chairs”—a member may be asked to give voice to two or more conflicting inner roles, moving from one chair to another as he or she assumes one or the other role). Any prescribed exercise that involves physical contact needs to be carefully considered. If the usual boundaries of therapy are to be crossed, notwithstanding clear therapeutic intent, it is essential to obtain informed consent from the group members.

The injudicious use of structured exercises was a miscarriage of the intent of the approaches that spawned these techniques. The initial training group (or T-group) field formulated exercises that were designed to demonstrate principles of group dynamics (both between and within groups) and to accelerate group development. Since the typical T-group met for a sharply limited period of time, the leaders sought methods to speed the group past their initial reserve and ritualized social behavior. Their aim was for members to experience as much as possible of the developmental sequence of the small group. It was not intended to provide therapy.

What does research tell us about the effects of these procedures on the process and outcome of the group? My (IY) encounter group project with Morton Lieberman and Matthew Miles closely studied the impact of the structured exercise.80 We concluded that leaders who used many exercises were popular with their groups: immediately after the end of a group, the members regarded these leaders as more competent, more effective, and more perceptive than leaders who used these techniques sparingly. Yet the members of groups that used the most exercises had significantly less favorable outcomes than the members of groups with the fewest exercises. (The groups with the most exercises had fewer high changers, fewer total positive changers, and more negative changers than the groups that used the exercises more sparingly. Moreover, the high changers from the encounter groups with the most exercises were less likely to maintain their changes over time.)

The moral of this study is that if your goal is to have your group members think you’re competent and you know what you’re doing, then use an abundance of structured interventions; in doing so—in leading by providing explicit directions, assuming total executive function—you fulfill the group’s fantasies of what a leader should do. However, your group members will not be improved; in fact, excessive reliance on these techniques renders a group less effective. Groups that use many structured exercises never deal with several important group themes. Though structured exercises appear to plunge the members quickly into a great degree of expressivity, the group pays a price for its speed; it circumvents many group developmental tasks and the group does not develop a sense of autonomy and potency.

This encounter group project also demonstrated that it was not just the leaders’ interactions with a member that mediated change. Of even greater importance were many psychosocial forces in the change process: change was heavily influenced by an individual’s role in the group (centrality, level of influence, value congruence, and activity) and by characteristics of the group (cohesiveness, climate of high intensity and harmoniousness, and norm structure). In other words, the data failed to support the importance of the leaders’ direct therapeutic interaction with each member.

Though these research findings issued from short-term encounter groups that met for a total of thirty hours, they have much relevance for the therapy group. First, consider speed: structured exercises do indeed bypass early, slow stages of group interaction and plunge members quickly into an expression of positive and negative feelings. Whether or not they accelerate the process of therapy is another question entirely.

In short-term groups—T-groups or very brief therapy groups—it is often legitimate to employ techniques to bypass certain difficult stages, or to help the group move on when it is mired in an impasse. In long-term therapy groups, the process of bypassing is less germane; the leader more often wishes to guide the group through anxiety, through the impasse or difficult stages, rather than around them. Resistance, as we have emphasized throughout this text, is not an impediment to therapy; it is the stuff of therapy.

Yet another reason for urging caution in the use of multiple structured exercises in therapy groups is that leaders who do so run the risk of infantilizing the group. Members of a highly structured, leader-centered group begin to feel that help—all help—emanates from the leader; they await their turn to work with the leader; they deskill themselves; they cease to avail themselves of the help and resources available in the group. They divest themselves of responsibility.

We do not wish to overstate the case against the use of structured exercises. Surely there is a middle ground between allowing the group, on the one hand, to flounder pointlessly in some unproductive sequence and, on the other, assuming a frenetically active, overly structured leadership role. Indeed, that is the conclusion that we reached in the encounter group study. The study demonstrated that an active, executive, managerial leadership style relates to outcome in a curvilinear fashion: that is, too much structure and too little structure were both negatively correlated with good outcome. Too much structure created the types of problems discussed above (leader-centered, dependent groups), and too little (a laissez-faire approach) resulted in plodding, unenergetic, high-attrition groups.

The use of structured exercises is common to many types of groups. Many of the techniques we described in Chapter 5, which the leader employs in norm setting, in here-and-now activation, and in process-illumination functions, have a prescriptive quality. (“Who in the group do you feel closest to?” “Can you look at Mary as you talk to her?” “If you were going to be graded for your work in the group, what grade would you receive?” And so on.)

Every experienced group leader employs some structured exercises. For example, if a group is tense and experiences a silence of a minute or two (a minute’s silence feels very long in a group), we often ask for a go-around in which each member says, quickly, what he or she has been feeling or has thought of saying, but did not, during that silence. This simple exercise usually generates much surprising and valuable data.

What is important in the use of structured exercises is the purpose to which they are put. If structured interventions are suggested to help mold an autonomously functioning group, or to steer the group into the here-and-now, or to explicate process, they may be of value. In a brief group therapy format, they may be invaluable tools for focusing the group on its task and plunging it more quickly into that task. If used, they should be properly timed; nothing is as disconcerting as the right idea in the wrong place at the wrong time. It is a mistake to use exercises as emotional space filler—that is, as something interesting to do when the group seems at loose ends.

Nor should a structured exercise be used to generate affect in the group. A properly led therapy group should not need energizing from outside. If there seems to be insufficient energy in the group, if meetings seem listless, if, time and time again, the therapist feels it necessary to inject voltage into the group, there is most likely a significant developmental problem that a reliance on accelerating devices will only compound. What is needed instead is to explore the obstructions, the norm structure, the members’ passive posture toward the leader, the relationship of each member to his or her primary task, and so forth. Structured exercises often play a more important role in brief, specialized therapy groups than in the long-term general ambulatory group. In the next chapter, we shall describe uses of structured exercises in a number of specialty therapy groups.

GROUP THERAPY RECORD KEEPING

Every group therapist should be knowledgeable about the specific documentation requirements for their setting. Documentation of therapy must protect client confidentiality and meet a number of objectives: demonstrate that an appropriate standard of care has been provided; describe the process and effectiveness of the treatment; demonstrate the evaluation of clinical risk; facilitate continuity of care by another therapist at a later time, if required; and verify that a billable service has been provided at a certain time and date.

The record belongs to the client and the client may well read it. It should be written with that in mind: the tone should be objective, respectful, balanced, and transparent with regard to the therapist’s therapeutic rationale and plan for treatment.81 We encourage all practitioners to be well informed of the impact of the Health Insurance Portability and Accountability Act (HIPAA) on client privacy and personal health information.82 An added consideration is the need to protect the private health information of other group members when documenting the care provided to each individual group member.

For these purposes many recommend that the group therapist keep a combined or dual record: a group record and a separate file for each individual member.83 If written group summaries are used, they should be included in the group record. For students, the group record may also serve as the group process notes that will be reviewed in supervision. The group record should note attendance, major group themes, the state of group cohesion, prominent interactions, transference and countertransference, what was engaged and what was avoided, and anticipations of what will need to be addressed in the next session. The group therapist should always, without fail, review this record immediately before the following meeting.

In addition, a personal chart or record must be kept for each individual client. These serve as the client’s personal progress notes and include initial goals, symptoms, safety concerns (if any), engagement with the psychotherapy process, and achievement of therapy goals. Email exchanges between therapists and clients are also typically considered part of the clients’ individual clinical records and should be retained. The personal record pertains to each individual client, and the therapist must make certain that personal information or identifying details of other group members is not divulged in the individual chart. The group record pertains to the entire group. Whereas the group record should be made after each group meeting, the individual progress notes can be made at less frequent but regular intervals, with more frequent entries as the clinical situation warrants. Treatment teams in inpatient or intensive outpatient settings may require added record keeping. In all situations, secure storage of all clinical records is essential.

Footnotes

i Newer non-twelve-step peer support groups are also developing that use social learning approaches, such as the SMART Recovery and Women for Sobriety models.

ii I learned a great deal about psychotherapy from this experiment. For one thing, it brought home to me the Rashomon-like nature of the therapeutic venture. The client and I had extraordinarily different perspectives of the hours we shared. All my marvelous interpretations? She never even heard them! Instead, Ginny heard, and valued, very different parts of the therapy hour: the deeply human exchanges; the fleeting, supportive, accepting glances; the brief moments of real intimacy. The exchange of summaries also provided interesting instruction about psychotherapy, and I used the summaries in my teaching. Several years later Ginny and I decided to write a prologue and an afterword and publish the summaries as a book, the royalties from which we would share equally. See I. Yalom and G. Elkin, Every Day Gets a Little Closer: A Twice-Told Therapy (New York: Basic Books, 1974; reissued 1992).

Chapters 14

Online Psychotherapy Groups

BY FAR THIS IS THE SHORTEST AND THE YOUNGEST CHAPTER in the book. Shortly before the publication of the sixth edition we encountered a sudden explosion of a new way to deliver group psychotherapy.1 In an extremely short period of time, literally within a matter of a few weeks in early 2020, the COVID-19 pandemic changed the practice of group psychotherapy, shifting face-to-face groups to online group therapy.2 This new format, which we will refer to as video-teleconferencing (VTC) group therapy, has sustained group therapy during the many months of physical distancing necessitated by the pandemic. Though we have much yet to learn, there is sufficient scientific literature and accrued clinical wisdom to date to articulate some principles for group leaders running VTC groups. It is dicey to predict the future, but we fully expect VTC groups to be part of our field long after the COVID-19 pandemic recedes. In the following discussion we will describe what is unique about VTC groups and what is consistent with our previous discussion about group psychotherapy practice.

Much about VTC groups is the same as in face-to-face groups—time, size, duration, and focus—but the group members meet on a screen rather than live in an office. Participants are able to see one another onscreen even though they are many miles apart. The trajectory of change has been dramatic, and many group therapists have taken a rapid and deep dive into this work. Some therapists have noted the change from group circle to group screen is as profound as the change from the couch to the group circle in the early days of group therapy.3 Overall, VTC groups have maintained group therapy continuity and access to care, but not without substantial growing pains.

VTC GROUPS: EARLY FINDINGS

VTC groups were used prior to the COVID-19 pandemic and there is evidence that group therapy can be effective in this format. Brief, well-designed, well-planned VTC groups have reported outcomes comparable to in-person group therapy, notwithstanding some initial hesitation on the part of both clients and therapists. VTC treatment has been used to provide group cognitive-behavioral therapy (CBT-G) for depression, cognitive-processing group treatment for veterans with PTSD, groups for dementia caregivers and for cancer patients to address psychological distress, as well as treatment for a range of other clinical populations.4 Although some clients and therapists have initially found this new format to present challenges, support and training readily offset initial misgivings.5

What is evident at this early point? Client satisfaction appears to be good. Participants have reported feeling less alone, better informed, and well supported. Groups had high participation rates, low dropout rates, and excellent completion rates. Group cohesion measures in VTC groups do appear to be less strong than in traditional face-to-face group therapy, but not to the degree that therapeutic outcomes are compromised.6 Client privacy concerns were not prominent even before COVID-19, when VTC was done on older technical platforms that were less secure and less HIPAA compliant than the ones now available. The number of platforms has expanded exponentially, and developers are now paying greater attention to the security of client health information. The rapidly expanding use of VTC has increased these concerns and alerted practitioners and clients alike to privacy issues that will need to be addressed through the development of even better online platforms.

ALTHOUGH THE ISSUE HAS NOT BEEN DEEPLY STUDIED TO DATE, it appears that VTC groups utilize all the familiar group therapeutic factors.7 No doubt as we gain more clinical experience with VTC, we may need to develop new ways to conceptualize group cohesion, group dynamics, and group process in VTC groups. Research is understandably limited at this early point, but it will no doubt emerge over the years to come. We also need to understand how starting a VTC group by design, as opposed to transitioning to one from an in-person group out of necessity, impacts a group’s functioning.

The rapid and forced transition to VTC groups generated a range of reactions, including feelings of loss and upheaval among participants, and these feelings colored their experience in therapy. The transition was also associated with widespread anxiety about the physical, economic, and psychosocial upheaval precipitated by the COVID-19 pandemic. Although therapists are growing more comfortable with the technology, many are still uneasy about relying on the Internet to deliver care.8 We have all had frustrating encounters with problematic Internet connections that are distractions from the work of the group.

GUIDELINES FOR GROUP PSYCHOTHERAPISTS

Ethical guidelines require therapists to practice only in those areas in which they are competent. For the VTC group therapist, that includes competence in using the VTC technology. The group leader’s administrative tasks have always included responsibility for securing a safe, stable, secure environment for the group. Now it also entails managing the VTC technological platform.9 It can be challenging enough to organize a group within the bricks and mortar of one’s own familiar office or institution. Consider then how much more difficult it can be to establish a workable group environment that now includes nine group members each calling in from their home, office, or car.

VTC therapists must obtain written, informed consent to employ the VTC platform. In doing so, they must clarify the nature of the contract, including the limits of their ability to be responsive to clinical emergencies when therapy is delivered online. Since the client and therapist may be at great physical distance, the therapist must make a clear backup plan with clients to ensure client safety and access to emergency care. Hence, access to all group members’ phone numbers is essential. Moreover, the therapist and client may encounter problems with their Internet connections, and a phone connection can be a useful back-up plan. Group members may need some instruction in how to use the platform. An important point is how clients wish to name and identify themselves online. Attention to this detail can protect against inadvertent privacy breaches. We have seen group members unpleasantly surprised to see their family name on the screen, for example. Even learning what kind of lighting is best or how to position oneself with the camera requires discussion and experimentation to enhance the video quality.

As VTC grows in popularity, professional guidelines for the effective and ethical practice of online care will undergo development and revision.10 Practitioners should be aware of their respective professional association and jurisdictional licensure requirements. In all instances it is essential to ensure a HIPAA-compliant platform.

A common question, for example, is whether a professional in one state can treat a client in another state in which the therapist is not licensed. What if the treatment begins in one state, and then the client moves to another state and wishes to continue in therapy? Which ethical priority should guide the therapist’s decision—continuity of care, or licensing jurisdiction issues? This is a widening gray area and requires federal attention to match legislation with contemporary practice patterns.11

Informing clients about group participation during pregroup preparation now needs to include instruction about using the online platform and articulating each member’s responsibility to protect one another’s privacy. Group members must also appreciate that privacy and confidentiality are harder to ensure online even with a secure platform. There may be other people in a client’s home who may overhear the group, for example—a problem that even the best software cannot prevent. The online group leader must emphasize that group members participate without intrusions and distractions from their personal setting.

The boundaries protecting the group may come under pressure in the online world, and addressing these issues with the most up-to-date technical information is essential. For example, meetings should be password protected, and participants should never share their passwords with others. Participants should not connect to the session using unsecured WiFi—for example, from a coffee shop or hotel room. Meeting information should never be posted on social media. Screen-sharing, recording, and file-transfer features should be disabled. Finally, be sure to use the most up-to-date version of your VTC software, as security patches may help prevent problems. As VTC therapy becomes more common, these recommendations will evolve, so it is important to stay well informed.

Despite all your precautions, some clients may not like the VTC option. In our early VTC experience we had one group member refuse to switch to the VTC group because it required participating from her home, and this threatened her ability to separate the group from her personal life. Another client asked for a leave from his group, lamenting the loss of the inner sanctum of the group room and the opportunity it offered to discuss deeply personal issues. He felt that meeting online, with his family nearby in his small home, would strip him of his sense of privacy and safety.

VTC GROUP CHALLENGES AND OPPORTUNITIES

In addition to the unique challenges VTC groups face, they must also confront many of the same challenges as in-person groups: building group cohesion, creating constructive group norms, and addressing antigroup behavior, unhealthy group pressures, and scapegoating.12 We anticipate that there may be an increase in dropouts as a result of the transition to VTC, and there are reports of long-running groups withering in reaction to the shift. For vulnerable clients who experience emotional dysregulation, some of the technical difficulties of VTC may be almost too much for them to contain. For example, having a group member’s Internet connection fail in the midst of deep emotional work is particularly disturbing.

VTC groups simultaneously reduce and increase members’ access to information about one another. Group members and therapists lose access to nonverbal communication and may feel constrained by seeing only faces onscreen. Moreover, one cannot establish meaningful eye contact in VTC, particularly when the screen displays a gallery view with thumbnails of six or eight participants. One cannot tell who is looking at whom in the group, and on a computer screen it is virtually impossible to convey a calming, comforting, empathic response nonverbally. Scanning the group members to detect signs of engagement or distress is similarly difficult. At times, the audio and visual functions may be out of synchrony, adding a further sense of disjunction. These VTC drawbacks can be quite disheartening; some group therapists have described the limitations as equivalent to “working with one hand tied behind their back.” Adding this layer of uncertainty, unfamiliarity, and apprehension to the process may amplify therapist countertransference.13

Are there positive offsets to these potential losses? Undoubtedly, the answer is yes. Group members are now “invited” into each other’s homes. This can add texture to the relationships between group members. Each member’s personal life, pets, and art and furnishings are better illuminated to the group.14 The image of a member’s child coming onscreen and sitting on his or her parent’s lap may be worth a thousand words. Keep in mind that everything is grist for the mill in a group meeting, including an exploration of what is being brought into the group’s purview. Conversely, a member’s failure to protect the group session from intrusion and distraction will require exploration.

Some therapists and group members report very positive experiences in online groups. They believe that VTC groups are effective and efficient, especially as they sidestep hassles with commuting to a meeting place and finding a parking place, or having to take public transit. Members who travel may still attend when they are out of town. Some group members experience a heightened intensity, depth, and focus in VTC groups. Indeed, some clients feel more comfortable in VTC groups than when meeting in person and are more willing to take interpersonal risks.15 The interpersonal distance created by the online setting may serve a facilitating and protective function. Shame and the fear of judgment may be reduced.

Keep in mind that the normal warm-up to the group—walking to the meeting or sitting in the waiting room and chatting with other members—is absent. Some leaders actively encourage a deeper focus on engagement in the meeting and ask members to turn their full attention to the group, closing out the external world for the time of the session.

Leading a VTC group is different from leading an in-person group and requires flexibility, adaptability, and a spirit of openness to its potential, as illustrated in the following description.

> In one of the first sessions after abruptly transitioning from an ongoing in-person group to VTC as a result of the COVID-19 pandemic, Harold, a sixty-five-year-old retired teacher, became quite emotionally expressive. In uncharacteristic fashion, he was moved to tears talking about the impact of the pandemic. He was fearful for the health of his family and the mounting sense of loss of the familiar around him.

It had been an emotionally charged session. The impact of isolation and the threat of illness and death had shaken us all. It appeared as though Harold was carrying much of the emotional vulnerability we had all been feeling in the group. The group members longed for our familiar in-person meeting, but we realized that the video session at least enabled us to meet. It was the best we could do at this time.

The meeting was made more difficult by some Internet access problems that forced another group member, Sue, to come in and out of the meeting. This disruption distressed her and added to our feelings of vulnerability and helplessness in securing our sense of connection. In response, another member of the group, Sam, said that if we had been in the group together as we normally were, he would have offered Harold and Sue a comforting hug. That was no longer an option in a VTC meeting.

I (ML) joined in expressing disappointment that we could not meet in person, but suggested that we could fully harvest the warmth and caring in Sam‘s offer. I added that our session had been filled with a sense of the preciousness of our emotional connections to one another. We were doing as well as we could with VTC, and I hoped for a return to our familiar face-to-face meetings. But it was clear that our connection to one another mattered enormously—even more now, with the physical distancing required of us at that moment, than previously. We could not predict when we could meet in person again, but we could continue to make excellent use of the group. <<

Experience to date suggests that VTC therapists need to be more active than traditional in-person group leaders, checking in frequently with individual clients and the group as a whole. The group therapist’s attention to group process is perhaps even more important in VTC than in traditional group therapy because it is so easy to miss meaningful and subtle group and client information. Co-therapists will need to develop new ways of connecting with one another as well in order to offset the loss of their familiar communication expressed through a raised brow, a smile, or a quiet glance over to one another. With less access to nonverbal communication, greater therapist transparency may also be required to deepen and sustain engagement.16

Similarly, all group members need to be as open as possible in communicating their reactions to one another and to the group. Active inquiry of what group members are feeling physically in their bodies may be helpful in offsetting the lack of VTC access to members’ nonverbal communication and body language. It is worth noting one unexpected technological benefit of the VTC group: group members can hear one another better, as the audio in VTC groups can be easily amplified.

CONCERN HAS BEEN NOTED REGARDING THE COGNITIVE DEMANDS that VTC places on participants, and particularly group leaders. It can be exhausting to look for an extended period of time at a VTC session with seven or eight members. The gallery view shows all participants at one time, but in a constricted and limited fashion. Although we see each other’s faces, our brains are searching, even hungering, for more, for the nonverbal emotional cues that we seek in normal interaction that are not readily accessible online.17 Some clients also balk at seeing themselves onscreen, and it heightens their self-consciousness. Participation is easier at times if members shut off their own self-view. This issue, too, of course, warrants exploration.

We are in early days of VTC in the provision of mental health care, and so there are no doubt important age and generational considerations in preferences for how therapy is accessed and how these preferences will change in the future. To some skeptics, it may be a surprise to see technology increasing rather than decreasing human engagement. In our view, it represents a contemporary route to meaningful connection, and it is an irreplaceable resource when traditional in-person group work is not possible.18

Chapters 15

Specialized Therapy Groups

GROUP THERAPY METHODS HAVE PROVED TO BE SO USEFUL IN so many different clinical settings that it is no longer correct to speak of group therapy. Instead, we must refer to the group therapies. Even a cursory survey of professional journals shows that the number and scope of the group therapies are expanding dramatically. This is true for both face-to-face groups and for the explosion of online groups. The Internet, as noted, now makes it possible for almost any individual dealing with any malady or life challenge to find and join a suitable group.1

Clinical necessity sparks clinical innovation. This is particularly evident in college counseling centers.2 On campuses across North America, counselors tailor groups to help students with a wide array of concerns: eating disorders, social anxiety, developmental challenges, separation anxiety, depression, nonsuicidal self-injury disorder (NSSID), attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), diabetes, chronic fatigue, and issues around substance abuse, sexual abuse and trauma, writing blocks, gender identity and sexual orientation, communication skills, assertiveness training, stress management, and the effects of racism and discrimination. These are just a few of the commonly offered groups. The groups are often brief, delivered in modules of four to twelve sessions to fit within the academic semester.

Beyond the college campus we can find an even greater range of groups. Clinical applications are growing by the day as we respond to the many individuals seeking care for psychological, medical, and social distress. Many groups are homogeneous for particular conditions, responding to members’ needs for belonging, destigmatization, and coping strategies. There are groups for survivors of incest and sexual trauma, for people with HIV/AIDS, for clients with eating disorders or panic disorder, for the suicidal, for parents of sexually abused children, for compulsive gamblers and sex addicts, for alcoholics, for children of alcoholics, for women with postpartum depression, for sexually dysfunctional men, and for sexually dysfunctional gay men. There are groups for survivors of divorce, for children and spouses of people with Alzheimer’s, for male batterers, for mothers of drug addicts, for families of the mentally ill, for depressed older women, for angry adolescent boys, for survivors of terrorist attacks, for children of Holocaust survivors, for women with breast cancer, for dialysis patients, for people with multiple sclerosis, for the deaf and hard of hearing, for people with developmental disabilities, for transgendered individuals, for people with borderline personality disorder, for irritable bowel (IBS) sufferers, for amputees, for college dropouts, for people who have had a myocardial infarction or a stroke, for parents of adopted children, for bereaved spouses and parents, for the dying, for refugees and asylum seekers, and for many, many others.3

Obviously, no single text could address each of these specialized groups. Nor, even if it were possible, would it constitute an intelligent training approach. Does any sensible teacher of zoology, to take one example, undertake to teach anatomy by having the students memorize the structures of each subspecies separately? Of course not. Instead, the teacher teaches basic and general principles of form, structure, and function and then proceeds to teach the anatomy of a prototypical primal specimen that serves as a template for all others. Remember those biology dissection laboratories?

The extension of this analogy to group therapy is obvious. The group therapist must first master fundamental group therapy theory and obtain a deep understanding of a prototypical therapy group. But which group therapy best represents the original common ancestor? If there is an ancestral group therapy, it is the interpersonal outpatient group therapy described in this book. It was the first group therapy, and over the past seventy years it has been the subject of a great deal of systematic research and has stimulated an imposing body of professional literature containing the observations and conclusions of thoughtful clinicians and researchers.

Now that you have come this far in this text and are familiar with the fundamental principles and techniques of the prototypical therapy group, you are ready for the next step: the adaptation of basic group therapy principles to any specialized clinical situation. That step is the goal of this chapter. First, we describe the basic principles that allow the group therapy fundamentals to be adapted to different clinical situations, and then we present two distinct clinical illustrations—the adaptation of group therapy for the acute psychiatric inpatient ward, and the widespread use of groups for clients coping with a variety of medical illnesses. The chapter ends with a discussion of important developments in group therapy: structured group therapies, self-help and support groups, and online psychotherapy groups.

MODIFICATIONS FOR SPECIALIZED CLINICAL SITUATIONS: BASIC STEPS

To design a specialized therapy group, we suggest the following four steps: (1) assess the clinical situation; (2) formulate appropriate clinical goals; (3) modify traditional techniques to fit with the new clinical situation and the new set of clinical goals; (4) evaluate the effectiveness of your changes.

Assessment of the Clinical Situation

It is important to examine all the clinical factors that will bear on the therapy group. Take care to differentiate the intrinsic limiting factors (akin to computer hardware) from the extrinsic factors (akin to software). The intrinsic ones are built into the clinical situation and cannot be changed—for example, mandatory attendance for clients on legal probation, the prescribed duration of group treatment in a clinic, or frequent absences because of medical hospitalizations in an ambulatory cancer support group.

The extrinsic limiting factors are arbitrary and within the power of the therapist to change—for example, an inpatient ward may have a policy of rotating the group leadership so that each group session has a different leader, or an incest survivors group may traditionally open with a long “check-in” (which may consume most of the meeting) in which each member recounts the important events of the week.

In a sense, the message of the AA serenity prayer has relevance here: therapists must accept that which they cannot change (intrinsic factors); change that which can be changed (extrinsic factors), if necessary; and be wise enough to know the difference. Keep in mind that as therapists gain experience, they often find that more and more of the factors that seemed to be intrinsic are actually extrinsic—and can be changed. For example, by educating the program’s or institution’s decision-makers about the rationale and effectiveness of group therapy, it is possible to create a more favorable atmosphere for the therapy group.4 That is often the first task in creating successful group therapies.

Formulation of Goals

When you have a clear view of the clinical facts—number of clients, length of therapy, duration and frequency of group meetings, clinical focus, type and severity of pathology, availability of co-leadership—your next step is to construct a reasonable set of clinical goals.

You may not like the clinical situation. You may feel hampered by the many intrinsic restraints that prevent you from leading the ideal group. But do not wear yourself out by protesting an immutable situation. Better to light a candle than to curse the darkness! With proper modification of goals and technique, you will always be able to offer some form of help.

We cannot overemphasize the importance of setting clear and achievable goals. Nothing will so inevitably ensure failure as inappropriate goals. The goals of the interpersonal outpatient group we describe in this book are ambitious: to offer symptomatic relief and to change character structure. If you attempt to apply these same goals to, say, a group of young adults recently diagnosed with a first episode of schizophrenia, you will rapidly become a therapeutic nihilist and stamp yourself and group therapy as ineffective or even harmful. An allied principle: do not underestimate the broad impact of groups with tailored and circumscribed goals.

It is imperative that you shape a set of goals appropriate to the clinical situation and achievable in the available time frame. The goals must be clear not only to the therapists but to participants as well. In our discussion of group preparation in Chapter 9, we emphasized the importance of enlisting the client as a full collaborator in treatment. You facilitate collaboration by making explicit the goals and the group task and by linking the two: that is, by making it clear to the members how the work of the therapy group will help them attain those goals.

In time-limited, specialized groups, the goals must be tailored to the capacity and potential of the group members. It is important that the group be a success experience: clients enter therapy often feeling defeated and demoralized, and the last thing they need is another failure. In the discussion of the inpatient group in this chapter, we shall give a detailed example of this process of goal setting.

Modification of Technique

When you are clear about the clinical conditions and appropriate, realizable goals, you must next consider the implications of these conditions and goals for your therapeutic technique. In this step, it is important to consider the therapeutic factors and to determine which ones will play the greatest role in the achievement of the goals. It is a phase of disciplined experimentation in which you alter technique, style, and, if necessary, the basic form of the group to adapt to the clinical situation and new goals of therapy. Keep in mind as well that despite the unique clinical populations addressed and the group modifications required, your understanding of the core principles of group therapy process and of group leadership is an invaluable asset.5

To provide a brief hypothetical example, suppose you are asked to lead a group in an area that is unfamiliar to you. Say, for example, that a large network of family doctors asks you to lead a brief group for men who have suffered heart attacks. The men are often depressed and resist cardiac rehabilitation.6 Your overriding goal is to help these men become able and motivated to participate in their own rehabilitation.

During your screening interviews (never skip that step), you develop some additional goals: you discover that some clients are negligent about taking their medication and that all of them suffer from severe social isolation and pervasive feelings of hopelessness and meaninglessness. They feel compromised as men, and many dread their next heart attack. So, given the additional goals of working on these issues, how do you modify standard group techniques to achieve them most efficiently?

First, you must assiduously monitor the fluctuations and intensity of their depression. You might ask members to fill in a brief depression scale each week. Or you could begin each meeting with a brief check-in focused on isolation and mood. Because of their discouragement and social isolation, you may wish to encourage rather than discourage extragroup contact among the members, perhaps even mandating a certain number of phone calls, texts, or email messages from clients to therapists and between clients each week. You may decide to encourage an additional coffee hour after the meeting or between meetings. Or you may address both the isolation and the sense of uselessness by tapping the therapeutic factor of altruism—for example, by experimenting with a “buddy system,” in which new members are assigned to one of the more experienced members, who serves as a mentor. The experienced member would check in with the new member during the week to make sure he is taking his medication and participating in rehab. The veteran member can “sponsor” the new member in the group session, making sure he gets sufficient time and attention.

There is no better antidote to isolation than deep therapeutic engagement in the group; thus you must strive to create positive here-and-now interactions in each meeting. Focusing on the members’ immediate value to one another can work wonders. Instilling hope is critical for these men, and to facilitate this you may choose to include some clients in the group who have already regained their self-efficacy and ability to function in the world.

Shame about physical disability is also an isolating force. The therapist might wish to counteract this shame through physical contact—for example, asking members to join hands at the end of meetings for a brief guided meditation. In an ideal situation, you may launch a support group that will evolve, after the group therapy ends, into a freestanding self-help group for which you act as consultant.

It is clear from this example that therapists must know a good deal about the special problems of the clients in their group. This is true for each clinical population; there is no all-purpose formula. Therapists must do their homework, immersing themselves in the specific clinical area, in order to understand the unique problems and dynamics that are likely to develop during the course of the group.7

For instance, therapists leading interpersonal groups of clients with alcohol abuse must expect to deal with issues surrounding sobriety, AA attendance, sneak drinking, deception, emotional dependency, deficiencies in the ability to regulate anxiety, and a proclivity to act out.8

Bereavement groups must often focus on guilt (for not having done more, loved more, been a better spouse), on loneliness, on major life decisions, on life regrets, on adapting to a new, unpalatable life role, on feeling like a “fifth wheel” with old friends, and on the need to “let go” of the dead spouse despite the pain that is entailed. (Many widows and widowers feel that building a new life would signify a betrayal of their dead spouse.) These groups must also focus on issues around dating (and the ensuing guilt), and if the therapist is skillful, on personal growth.

Retirement groups must address such themes as recurrent losses, increased dependency, loss of one’s social role, the need for new sources of validation for one’s sense of self-worth, diminished income and expectancies, relinquishment of a sense of continued ascendancy, late life developmental tasks, and shifts in one’s spousal relationship as a result of more time shared together.9

Groups for burdened family caregivers of individuals with Alzheimer’s disease must focus on the experience of loss and on the horrific experience of caring for spouses or parents who are but a shell of their former selves, unable to acknowledge their caregivers’ efforts or even identify them by name. They focus also on caregivers’ isolation, on their strategies for coping with their burden, and the guilt they feel for wanting (or achieving) some emancipation from this burden. These groups may involve role playing of difficult caregiving scenarios, perhaps using trained actors (standardized patients) as the individuals with dementia to build skills for managing difficult, oppositional, or aggressive behavior. And importantly, these groups will provide validation and recognition of the caregivers’ efforts and personhood.10

Groups for health-care workers dealing with the stresses of providing care in a pandemic create opportunities for members to identify their chief concerns. These could include adequate access to resources to care for their patients, fear for their own safety, access to personal protective equipment, moral distress in not being able to provide care according to their professional and personal standards, and grief and loss. The groups would work to build safety for their members, foster social support, educate about coping strategies, restore a sense of efficacy, and promote hope for the future.11

Groups for psychological trauma would likely address a range of concerns, perhaps through a sequence of different group tasks. Building safety, trust, and security would be important at first. Being together with others who have experienced a similar trauma and learning about the impact of trauma on the mind and body can reduce feelings of isolation and confusion. Later these groups might use structured behavioral interventions, such as deep breathing or imagery, to treat specific trauma symptoms. Next, they might address how trauma has altered members’ basic beliefs and assumptions about the world. If the trauma was caused by sexual abuse, these groups would ideally be gender-specific in the earlier stage of work. Later, a mixed-gender group may be necessary to complete the process of the client’s reentry into the posttrauma world.12

Or, if the traumatized clients were refugees escaping war and violence, the leaders would need to modify the approach to provide sensitive, culturally attuned care. Any psychoeducational materials would need to be translated into the requisite language of the participants and adapted to the clients’ varying levels of mental health literacy. You might employ more nonverbal behavioral interventions that require less use of language. An example would be teaching parents how to play with their young children in ways that promote security, communication, and mastery of fear. Strengthening individual families increases, in turn, the sense of security of the larger community.13

In summary, to develop a specialized therapy group, we recommend taking the following steps:

1. Assess the clinical setting. Determine the immutable clinical restraints.

2. Formulate goals. Develop goals that are appropriate and achievable within the existing clinical restraints.

3. Modify traditional technique. Retain the basic principles and therapeutic factors of group therapy, but alter the techniques to achieve the specified goals: therapists must adapt to the clinical situation and the dynamics of the special clinical population.

4. Evaluate your work. Study and attempt to improve your work.

These steps are clear but too aseptic to be of immediate clinical usefulness. We shall illustrate the entire sequence in detail by describing the development of a therapy group for the acute psychiatric inpatient ward.

We focus on an acute inpatient therapy group for two reasons. First, it offers a particularly clear opportunity to demonstrate many principles of strategic and technical adaptation. The clinical challenge is severe: The acute inpatient setting is so inhospitable to group therapy that radical modifications of technique are required. Second, this particular example may have value to many readers since the inpatient group is a common specialized group: therapy groups are led on most acute psychiatric wards. This is true even in this era of ever briefer hospital stays. Inpatient psychiatric care appears to be increasing in prevalence as well, often as a result of inadequate community-based care for clients.14 Clients value the social and relationship opportunities on their inpatient units, yet in many units they spend a staggering amount of time idle and socially disconnected.15 Group therapy can address these relationship needs. For many clients, it is their first therapeutic group exposure; hence it behooves us to make it a constructive experience. And it is significantly impactful on overall clinical outcomes. Group therapy in inpatient settings also improves staff morale and increases the providers’ sense of purpose.16 As any staff member can easily perceive, group therapy is far more humane and effective than “beds and meds” as a treatment philosophy.

THE ACUTE INPATIENT THERAPY GROUP

The Clinical Setting

The outpatient group that we describe throughout this book is freestanding; all important negotiations occur between the group therapist(s) and the seven or eight group members. Not so for the inpatient group! When you lead an inpatient group, the first clinical fact of life you must face is that your group is never an independent, freestanding entity. It always has a complex relationship to the inpatient ward in which it is ensconced. What happens between members in the small therapy group reverberates with what transpires within the large group of the unit and institution.17

The inpatient group’s effectiveness, often its very existence, is heavily dependent upon administrative engagement and backing. It is important to distinguish between types of inpatient groups: ward community meetings, group activities and programming, and group therapy. All of these are important, but they have very different goals as well as different training and leadership requirements.18 Some groups exist at the interface, such as watching a well-selected film and discussing its relevance regarding recognition and communication of clients’ feelings and social relationships.19 If the ward medical director and the clinical nursing coordinator are not convinced that the group therapy approach is effective, they are unlikely to lend support and may undermine the prestige of the therapy groups in many ways: for example, they may not assign staff members to group leader positions on a regular schedule, they may ask less experienced staff members to lead the group, or they may not provide supervision or even schedule group sessions at a functional, consistent time. Therapy groups under such conditions are rendered ineffective. The group leaders are unsupported and rapidly grow demoralized. Meetings are scheduled irregularly and are often disrupted by members being yanked out for individual sessions or for a variety of other hospital appointments.

Is this state of affairs an intrinsic, immutable problem? Absolutely not! Rather, it is an extrinsic, attitudinal problem and stems from a number of sources, especially the professional education of the ward administrators. Many psychiatric training programs and nursing schools do not offer a comprehensive curriculum in group therapy (and virtually no programs offer sound instruction in inpatient group psychotherapy). It is completely understandable that ward directors decline to invest ward resources and energy into a treatment program about which they have little knowledge and in which they have no faith. Interprofessional tensions may also play a role: Is group therapy leadership valued, or considered a low-status activity? Which disciplines are entrusted to provide psychotherapy? The small therapy group must not be used as a battleground upon which professional interests are contested.

Without a potent psychosocial therapeutic intervention, inpatient wards rely only on medication, and the work of the staff is reduced to custodial care. We believe that inpatient care can be improved through greater clinical engagement. Copious research demonstrates the effectiveness of inpatient group therapy.20

A well-functioning group program can permeate and benefit the milieu as a whole, and the small group should be seen as a resource to the system as a whole.21 By combining training, supervision, and regular, measurement-based feedback to clinicians about their inpatient group work, a large US behavioral health care network, providing care to thirteen thousand clients annually, transformed clinical care. They demonstrated the following: significant improvements in clinical outcomes, significant improvements in client satisfaction, significant reductions in aggression and critical incidents, and significantly improved staff morale.22 Such is the power of properly led group therapy.

In addition to these extrinsic, programmatic problems, the acute inpatient ward poses several major intrinsic problems for the group therapist. There are several particularly challenging problems that must be faced by every inpatient group therapist.

Rapid Client Turnover. The duration of psychiatric hospitalization has shortened inexorably. On many wards, hospital stays range from a few days to a week or two. This means, of course, that the composition of the small therapy group will be highly unstable. In different inpatient settings we have led groups that have met three to five times a week for many years, and these groups have rarely had the same set of members for two consecutive meetings—almost never for three.

This appears to be an immutable situation. The group therapist has little influence on ward admission and discharge policy. In fact, more and more commonly, discharge decisions are based on economic and system pressures rather than individual clinical concerns. Staff members feel overburdened and stretched. The high-pressure, revolving-door inpatient unit is here to stay, and even as the door opens and shuts ever faster, clinicians must continue to keep primary focus on the client’s treatment, doing as much as they can within the imposed constraints.23 But we also must not create added staff demand without providing commensurate support.

Heterogeneity of Psychopathology. In Chapter 8, we stressed the importance of composing a group thoughtfully and of avoiding members who will fail to fit in with the group, and to selecting members with roughly the same amount of ego strength. How, then, to lead a group in which one has almost no control over the membership, a group in which there may be floridly psychotic individuals sitting side by side with higher-functioning, better-integrated members?

In addition to the major confounding factors of rapid client turnover and the range of psychopathology, several other intrinsic clinical factors exert significant influence on the functioning of an inpatient psychotherapy group, including time limitations, group boundaries, and unique group leader challenges.

Time Limitations. The therapist’s time is very limited. Generally, there is no time to see a client in a pregroup interview to establish a relationship, let alone a therapeutic alliance, and to prepare the person for the group. There is little time to integrate new members into the group, to address endings (someone terminates the group almost every meeting), to work through issues that arise in the group, or to focus on transfer of learning.

Group Boundaries. Group boundaries in inpatient settings are often blurred. Members are generally in other groups on the ward with some or many of the same members. Extragroup socializing is the rule rather than the exception: clients spend their entire day together. The boundaries of confidentiality are similarly blurred. There can be no true confidentiality in the small inpatient group: clients often share important small group events with others on the ward, and staff members freely share information with one another during rounds, nursing reports, and staff meetings. It is therefore imperative that the inpatient small group boundary of confidentiality be elastic and encompass the entire ward staff rather than being confined to any one group within that ward. Otherwise the small group becomes disconnected from the unit. Negotiating and managing these boundaries is a key group leader task.24

Challenges for the Group Leader. The role of inpatient group leaders is complex because they may be involved with clients throughout the day in other roles. Their attendance may often be often erratic. Group leaders are frequently psychiatric nurses who, because of the necessity of weekend, evening, and night coverage, are on a rotating schedule and often cannot be present at the group for several consecutive meetings.

Therapist autonomy is limited in other ways as well. For example, just as therapists have only limited control over group composition, they rarely have a choice about co-therapists, who are usually assigned on the basis of the rotation schedule. Inpatient group therapists usually feel more exposed than their outpatient colleagues. Difficulties in the group will be readily known by all on the unit. Lastly, the harried pace of the acute inpatient ward leaves little opportunity for supervision, or even for a postmeeting discussion between co-therapists.

Formulation of Goals

Once you have grasped these clinical facts of life of the inpatient therapy group and differentiated intrinsic from extrinsic factors, it is time to ask this question: Given the many confounding intrinsic factors that influence (and hobble) the course of the inpatient group, what can the group accomplish? What are reasonable and attainable goals?

Let us start by noting that the goals of the acute inpatient group are distinct from those of acute inpatient hospitalization. The goal of the group is not to resolve a psychotic episode, not to regulate a client with mania, not to diminish hallucinations or delusions, not to resolve a deep depression. Inpatient groups can do none of these things.

So much for what the inpatient group cannot do. What can it offer? We will describe six achievable goals.

1. Engage clients in the therapeutic process.

2. Demonstrate to clients that talking helps.

3. Help clients identify and spot problems.

4. Decrease clients’ isolation.

5. Provide opportunities for clients to help others.

6. Reduce ward tensions and hospital-related anxiety.

1. Engage clients in the therapeutic process.

The contemporary pattern of acute psychiatric hospitalization—brief but repeated admissions to psychiatric wards in general hospitals—can be more effective than longer hospitalization only if the inpatient stay is followed by adequate aftercare treatment. There is good evidence that group therapy is a particularly efficacious mode of aftercare treatment.25

A primary goal of inpatient group therapy emerges from these findings—namely, to engage the client in a process that he or she perceives as constructive and supportive and will wish to continue after discharge from the hospital.

2. Demonstrate to clients that talking helps.

The inpatient therapy group helps clients learn that talking about their problems is helpful. They learn that there is relief to be gained in sharing pain and in being heard, understood, and accepted by others. From listening to others, members also learn that others suffer from the same types of disabling distress as they do, that one is not unique in one’s suffering.

> In an inpatient therapy group, Sally, an agitated woman with paranoid delusions, demanded to know why her roommate, Rose, had asked her to play Ping-Pong on the unit table. Sally declared that she loved Ping-Pong, but how could Rose know that? Sally was concerned that Rose was able to read her mind and that Rose was stealing ideas from her brain. Rose responded that she had no knowledge of Sally’s thinking—it was an innocent request to pass the time. That message needed to be repeated and reinforced, and Sally eventually replied, “Then does that mean you cannot read my thoughts? I was so scared of that.” <<

3. Help clients identify problems.

The duration of therapy in the inpatient therapy group is far too brief to allow clients to work through problems. But participation in the group can efficiently help clients spot problems that they may work on effectively in ongoing individual therapy, both during their hospital stay and in their post-discharge therapy. By providing a discrete focus and direction for therapy, which clients value highly, inpatient groups increase the efficiency of other therapies.26

It is important that the group identify client problems that are circumscribed and malleable (not problems such as chronic unhappiness, depression, or suicidality, all of which are too generalized to offer a discrete handhold for therapy). The group is most adept at helping members identify problems in their mode of relating to other people. It offers the ideal arena to learn about maladaptive interpersonal behavior. Emily’s story is a good illustration of this point:

> Emily was an extremely isolated young woman who was admitted to the inpatient unit because of depression. She complained that she always called others to arrange social engagements but never received invitations, and she had no close girlfriends who sought her out. Her dates with men always turned into one-night stands. She attempted to please them by going to bed with them, but they never called for a second date. People seemed to forget her as soon as they met her. During the three group meetings she attended, the group gave her consistent feedback about the fact that she was always pleasant and always wore a gracious smile and always seemed to say what she thought would be pleasing to others. In this process, however, people soon lost track of who Emily was. What were her own desires and feelings? Her need to be eternally pleasing had a serious negative consequence: people found her uninteresting and inaccessible.

A dramatic example occurred in her second meeting, when I (IY) forgot her name and apologized to her. Her response was, “That’s all right, I don’t mind.” I suggested that the fact that she didn’t mind was probably one of the reasons I had forgotten her name. In other words, had she been the type of person who would have minded or made her needs more overt, then most likely I would have remembered her name. In her three group meetings, Emily had identified a major problem that had far-reaching consequences for her relationships: her tendency to submerge herself in a desperate but self-defeating attempt to capture the affection of others. <<

4. Decrease clients’ isolation.

The inpatient group can help break down the isolation that exists between members. The group is a laboratory exercise intended to sharpen communication skills: the better the communication, the less the isolation. It helps individuals share with one another, permits them to obtain feedback about how others perceive them, and helps them discover their blind spots.

Decreasing isolation between group members has two distinct payoffs. First, improved communication skills will help clients in their relationships with others outside the hospital. Virtually everyone who is admitted in crisis to an inpatient ward suffers from a breakdown or an absence of important supportive relationships with others. If the client is able to transfer communication skills from the group to his or her outside life, then the group will have fulfilled a very important goal.

A second payoff is evident in the client’s behavior on the ward: as isolation decreases, the client becomes increasingly able to use the therapeutic resources available, including relationships with other patients.27

> Jack, a man with chronic schizophrenia, reluctantly attended his first meeting on the inpatient ward. He told the group that his guardian angel, who regularly transmitted messages to him through the TV, advised him to be very cautious about talking with anyone on the unit or in the group. I (ML) welcomed Jack to the meeting, acknowledged his caution, and noted that in telling us about his guardian angel, he was informing us about his need for both safety and for connection. He relaxed notably when I commented that I hoped that he would see that the group and the ward were intended to be safe for him and for all participants: we all could benefit from feeling that there was someone out there looking out for us. Mary, admitted for depression marked by feelings of worthlessness and ineffectiveness, then asked Jack if they could eat together that evening. She had noticed his isolation and wanted him to feel more comfortable. She added that she was pushing herself hard to engage more and was taking a risk now. Jack responded positively, saying, “We can sit together, but don’t expect me to talk yet.” <<

5. Provide opportunities for clients to help others.

This goal, the therapeutic factor of altruism, is closely related to the previous one. Clients are not just helped by their peers; they are also helped by the knowledge that they themselves have been useful to others. Clients generally enter psychiatric hospitals in a state of profound demoralization. They feel that not only can they not help themselves, but they have nothing to offer others. The experience of being valuable to other ward members is enormously affirming to one’s sense of self-worth. Mary’s response to Jack in the last vignette is an illustration of that process.

6. Reduce ward tensions and hospital-related anxiety.

The process of psychiatric hospitalization can be intensely anxiety provoking. Many clients experience great shame and are concerned about stigmatization and the effects of hospitalization on their jobs and friendships. Many are distressed by events on the ward—not only the bizarre and frightening behavior of very ill clients, but also the evident staff tensions.

Many of these secondary sources of tension compound the client’s primary dysphoria and must be addressed in therapy. Inpatient group therapy (as well as the larger, unit-wide community meeting) provides a forum in which clients can air these issues, and often they are reassured simply from learning that other members share these concerns. They can learn, for example, that their roommates are not hostile or intentionally rejecting them, but preoccupied and fearful. One man who had been quite frightening on the unit while in an agitated manic state came to inpatient group therapy to apologize for his threatening behavior when he had been psychotic. He was mortified and wanted to tell us that such behavior was not typical of him. We have seen variations on the same theme many times. For this man, the experience was also a powerful reminder to adhere to his medication regimen.

Modifying Technique

We have now accomplished the first two steps of designing a group for the contemporary inpatient ward: (1) assessing the clinical setting, including identifying the intrinsic clinical facts of life on the unit, and (2) formulating an appropriate and realistic set of goals. Now we are ready to turn to the third step: designing a clinical strategy and technique that provides support, education, and the acquisition of communication, coping, and life skills.28

The Therapist’s Time Frame. In the conventional outpatient therapy group we have described earlier in this text, the therapist’s time frame is many weeks or months, sometimes years. Therapists must be patient, must build cohesiveness over many sessions, and work through issues repetitively from meeting to meeting. The inpatient group therapist faces an entirely different situation: the group composition changes almost every day, and the duration of therapy for members is often very brief—indeed, many attend the group for only a single session.

Hence the inpatient group therapist must adopt a radically shortened time frame. Perhaps there will be continuity from one meeting to the next, and perhaps there will be culture-bearers who will be present in several consecutive meetings, but do not count on it. It is best to assume that your group will last for only a single session, and you must strive to offer something useful for as many participants as possible during that session.

Efficiency and Activity. The single-session time frame demands efficiency. You have no time to allow issues to build, to let things develop in the group and slowly work them through. You have no time to waste; you have only a single opportunity to engage the clients, and you must not squander it. There is no place in inpatient group therapy for the passive, reflective group therapist. You must activate the group by calling on, supporting, and interacting personally with members. This increased level of activity requires a major shift in technique for the therapist who has been trained in long-term group therapy, but it is an absolutely essential modification of technique. Though leading inpatient group therapy is often more challenging than leading outpatient open-ended groups, all too often little attention is paid to the training, development, and supervision of the inpatient group therapist.29

Keep in mind that one of the major goals of the inpatient therapy group is to engage clients in a therapeutic process they will wish to continue after leaving the hospital. Thus, it is imperative that the therapist create in the group an atmosphere that members experience as supportive, positive, and constructive. Members must feel safe, understood, and accepted.

The inpatient therapy group is not the place for confrontation, for criticism, or for the expression and examination of intense anger. There will often be members in the group who are conning or manipulative and who may need powerful confrontation, but it is far better to let them pass unchallenged than to run the risk of making the group feel unsafe to the vast majority of participants. Recognizing group process and group dynamics is no less important in the inpatient setting than in the open-ended, longer-term group, but there is a difference: in the inpatient group, you use your understanding to make the group safe and supportive rather than to deepen exploration.30

Group leaders need to recognize and incorporate both the needs of the group and the needs of the individual into their intervention. Consider, for example, Jared, an angry man with bipolar disorder who arrived at the group the day after being forcibly restrained and secluded by unit staff. He had earlier threatened to harm a nurse who refused his request for a pass off the ward. Jared obstinately sat silently outside of the circle with his back to the group members. Addressing Jared’s behavior was essential—it was too threatening to ignore—but it was also potentially inflammatory to engage Jared against his evident wish. The group leader chose to acknowledge Jared’s presence, noting that it likely was hard for Jared to come to the group after the tensions of the night before. He was welcome to participate more fully if he chose, but if not, just coming was welcomed. Though Jared maintained his silent posture, the group was liberated and able to proceed.

In the long-term outpatient group, therapists provide support both directly and indirectly: direct support through personal engagement, empathic listening, and understanding, expressed in accepting glances, nods, and gestures; indirect support by building a cohesive group that then becomes a powerful agent of support.

Inpatient group therapists must learn to offer support quickly and directly. Support is not something that therapists reflexively provide. Therapists are often trained to become sniffers of pathology, experts in the detection of weaknesses, and often hold themselves back from engaging in basic supportive behavior with their clients.

Support may be offered in myriad ways. The most direct, the most valued by clients, and the most often overlooked by professional therapists is a gentle acknowledgment of the members’ efforts, intentions, strengths, positive contributions, and risks.31 If, to take an obvious example, one member states that he finds another member in the group very wise or very warm, it is important that this member be supported for the risk he has taken. You may wonder whether he has previously been able to express his admiration of another so openly and note, if appropriate, that this is reflective of real progress for him in the group. Or, suppose you note that several members have been more self-disclosing after one particular member took a risk and revealed delicate and important material—then openly comment on it! Do not assume that members automatically realize that their disclosures have helped others take risks. Identify and reinforce the adaptive parts of the client’s presentation.32

Try to emphasize the positive rather than the negative aspects of a defensive posture. Consider, for example, members who persist in playing assistant therapist. Do not confront them by challenging their refusal to work on personal issues; instead offer positive comments about how helpful they have been to others and then gently comment on their unselfishness and reluctance to ask for something personal from the group. It is the rare individual who resists the therapist’s suggestion that he or she needs to learn to be more selfish and to ask for more from others.

The therapist also can help members obtain support from the group. Some clients, for example, obtain very little support from the others because they characteristically present themselves in a highly objectionable fashion. A self-centered member who incessantly ruminates about a somatic condition will rapidly exhaust the patience of any group. When the leader spots such behavior, it is important to intervene quickly before animosity and rejection have time to well up and the client commits social suicide. The leader may try any number of tactics—for example, directly instructing the client about other modes of behaving in the group, or assigning the client the task of introducing new members into the group, giving feedback to other members, or attempting to guess and express what each person’s evaluation of the group is that day.

> Consider a woman who talked incessantly about her many surgical procedures. It became clear to me (IY) from listening to this woman’s description of her life situation that she felt she had given everything to her children and family and had received nothing in return. I suggested that when she talked about her surgical procedures, she was really saying, “I have some needs, too, but I have trouble asking for them. My talking about my surgery is a way of asking, ‘Pay some attention to me.’”

Over the course of three sessions, she agreed with my formulation and gave me permission, whenever she talked about her surgery, to translate that into the real message, “Pay more attention to me.” When she explicitly requested help, the members responded to her positively, in contrast to their negative response to the endless recitation of her litany of somatic complaints.33 <<

Another approach to support is to make certain the group feels safe by anticipating and avoiding conflict whenever possible. If clients are irritable or want to learn to be more assertive or to challenge others, it is best to channel that work onto yourself: you are, let us hope, in a far better position to handle criticism than are the group members.

The inpatient group is not the place for intensification of affect or hostility. If two members are engaged in conflict, it is best to intervene quickly and to search for positive aspects of the conflict. For example, keep in mind that sparks often fly between two individuals because of the group phenomenon of mirroring: one sees aspects of oneself (especially negative aspects) in another, and dislikes that person because of what one dislikes in oneself.34 Thus, you can deflect conflict by asking individuals to discuss the various ways in which they resemble their adversary. Can they put themselves into the shoes of the other and speculate on what their adversary might be feeling? In this way you may turn tension into empathy.

There are many other conflict-avoiding strategies. Envy is often an integral part of interpersonal conflict, and it can be constructive to ask adversaries to talk about those aspects of each other that they admire or envy. Role switching is sometimes a useful technique: ask adversaries to switch places and present the other’s point of view. An effective technique is to remind the group that opponents generally prove to be very helpful to each other, whereas those who are indifferent rarely help each other grow.

One reason some members experience the group as unsafe is that they fear things will go too far and that the group may coerce them to lose control—to say, think, or feel things that will result in interpersonal catastrophe. You can help these members feel safe in the group by encouraging them to exercise control over their own participation. Check in with members repeatedly by asking questions: “Do you feel we’re pushing you too hard?” or “Is this too uncomfortable for you?” or “Do you think you’ve revealed too much of yourself today?” Make small engagement contracts along the way.

In groups of more disturbed, regressed clients, group leaders must provide even more direct support. Find the latent human core beneath the manifest psychotic symptoms. Examine the behavior of the severely regressed client and find in it some positive aspect: support the mute member for staying the whole session, compliment the member who leaves early for having stayed twenty minutes, support the member who arrives late for having shown up, support inactive members for having paid attention throughout the meeting. If members try to give advice, even inappropriate advice, reward them for their intention to help. If statements are unintelligible or bizarre, label them as attempts to communicate. One group member, Jake, hospitalized because of a psychotic decompensation, angrily blurted out in the group that he intended to get Satan to rain “hellfire and brimstone upon this God-forsaken hospital.” Group members withdrew into apprehensive silence. I (ML) wondered aloud what had provoked this angry explosion. Another member commented that Jake had been agitated since his discharge planning meeting. Jake then said that he did not want to go to the hostel that was recommended. He wanted to go back to his boardinghouse because it was safer from theft and assault. That was something everyone in the group could understand and support. Finding the underlying and understandable human concern brought Jake and the group members back together—a far better situation than isolating Jake because of his bizarre behavior.

The Here-and-Now Focus of the Inpatient Group

Throughout this text, we have repeatedly emphasized the importance of here-and-now interaction in the group therapeutic process. We have stressed that work in the here-and-now is the heart of the group therapeutic process, the power cell that energizes the therapy group. Yet when we visit inpatient wards, we find that groups rarely focus on here-and-now interaction. Such avoidance of the here-and-now is, in our view, precisely the reason so many inpatient groups are ineffective.

If the inpatient group does not focus on the here-and-now, what other options are there? Most inpatient groups adopt a then-and-there focus in which members, following the therapist’s cues, take turns presenting their “back-home problems”—those that brought them into the hospital—while the rest of the group attempts to address those problems with exhortations and advice. This approach to inpatient group therapy is the least effective way to lead a therapy group and almost invariably sentences the group to failure.

The problems that brought a person into the hospital are complex and overwhelming. They have generally foiled the best efforts of skilled mental health professionals and will, without question, stump the therapy group members. The then-and-there focus has many other disadvantages as well. For one thing, it results in highly inequitable time sharing. If much or all of a meeting is devoted to one member, many of the remaining members will feel ignored or bored. Unlike outpatient group members, they cannot even bank on the idea that they have credit in the group—that is, that the group owes them time and attention. Since they will most likely soon be discharged or find themselves in a group composed of completely different members, they are left clutching worthless IOUs.

Some inpatient groups focus on ward problems—ward tensions, staff-client conflict, housekeeping disputes, access to smoking or passes, and so on. Generally, this is also an unsatisfactory use of the therapy group. In any therapy group meeting, only a few members and one or two staff members will be present. There is no quorum for meaningful discussion. A much better arena for dealing with ward problems and ward business is the community meeting, in which all clients and staff are present.35

Other inpatient groups focus on one or more common themes—for example, suicidal ideation, the experience of hospitalization and treatment, symptoms such as hallucinations, or drug side effects. Such meetings may be of value to some but rarely to all members. Often such meetings serve primarily to dispense information that could easily be provided to clients in other formats. It is not the most effective way of using the inherent power of the small group.

The clinical circumstances of the inpatient group do not make the here-and-now focus any less important or less advisable. In fact, the here-and-now focus is as effective in inpatient as in outpatient therapy. However, the clinical conditions of inpatient work demand modifications in technique. As we mentioned earlier, there is too little time to work through interpersonal issues. Instead, you must help clients spot interpersonal problems and reinforce interpersonal strengths while encouraging them to attend ongoing post-hospital treatment where they can pursue and work through the interpersonal issues they have identified in the group.

The most important point to be made about the use of the here-and-now in inpatient groups is already implicit in the foregoing discussion of support. We cannot emphasize too heavily that the here-and-now is not synonymous with conflict, confrontation, and critical feedback. We are certain that it is because of this erroneous assumption that so few inpatient group therapists capitalize on the value of here-and-now interaction.

Conflict is only one—and by no means the most important—facet of here-and-now interaction. The here-and-now focus helps members learn many invaluable interpersonal skills: how to communicate more clearly, get closer to others, and express positive feelings; how to become aware of personal mannerisms that push people away; and how to listen, offer support, reveal oneself, and form friendships.

The inpatient group therapist must pay special attention to the issue of the relevance of the here-and-now. All the members of an inpatient group are in crisis. All are preoccupied with their life problems and immobilized by dysphoria or confusion. Unlike many outpatient group members who are interested in self-exploration, in personal growth, and in improving their ability to cope with crisis, inpatients are in a survival mode, and unlikely to readily apprehend the relevance of the here-and-now focus for their problems.

Therefore, the therapist must provide explicit instruction about its relevance. We begin each group meeting with a brief orientation in which we emphasize that, though individuals may enter the hospital for different reasons, everyone in the group can benefit from examining how he or she relates to other people. Everyone can be helped by learning how to get more out of relationships with others. We focus on relationships in group therapy because that is what group therapy does best. In the group, there are other members and one or two mental health experts who are willing to provide feedback about how they relate to others in the group. We always acknowledge that members have important and painful problems other than interpersonal ones, but note that these problems need to be addressed in other therapeutic modalities: in individual therapy, in social work interviews, in couples or marital therapy, and/or with medication or other biological treatments.

Modes of Structure

In acute inpatient group work, regardless of model, there is no place for the nondirective group therapist. The group leader serves as an essential and stabilizing anchor for the group participants. You are a chief agent of any semblance of cohesion that the group will experience. The great majority of clients on an inpatient ward are confused, frightened, and disorganized; they crave structure and stability. Consider the experience of individuals newly admitted to the psychiatric unit: they are surrounded by other troubled, irrational clients; their mental acuity may be dulled by medication; they are introduced to many staff members who, because they are on a complex rotating schedule, may not appear to have consistent patterns of attendance; and they are being exposed, sometimes for the first time, to a wide array of treatments and treaters.

Often the first step to acquiring internal structure is exposure to a clearly perceived externally imposed structure. In a study of debriefing interviews with recently discharged inpatients, the overwhelming majority expressed a preference for group leaders who provided an active structure for the group.36 They appreciated a therapist who provided crystal-clear direction for the procedure of the group, who actively invited members to participate, who assured equal distribution of time, and who reminded the group of its basic group task and direction. The research and clinical literature strongly agree that such leaders obtain superior clinical results.37

Spatial and Temporal Boundaries

A secure space and time for the inpatient group should be considered sacrosanct. The ideal physical arrangement for an inpatient therapy group, as for any type of group, is a circle of members meeting in an appropriately sized room with a closed door and comfortable seating. It sounds simple, yet the physical plan of many wards makes these basic requirements difficult to meet. The failure to secure the group boundaries compromises group integrity and cohesiveness and in turn compromises the work of the group; it is far preferable to find some secure, safe, and reliable space, even if it means meeting off the ward (provided it is safe to do so).

Structure is also provided by temporal stability. The ideal meeting begins with all members present and punctual, and runs with no interruptions until its conclusion. It is difficult to approximate these conditions in an inpatient setting for several reasons: disorganized clients arrive late because they forget the time and place of the meeting; members may be called out for some medical or therapy appointment; members with a limited attention span may ask to leave early; heavily medicated members may fall asleep during a session and interrupt the group flow; and agitated or panicked patients may bolt from the group. Ward administration may advocate for an open-door policy to maximize client attendance even if that undermines the group boundaries.

Therapists must intervene in every way possible to provide maximum stability. You should urge the unit administration to declare the group time inviolable, so that group members cannot be called out of the group for any reason (not because the group is the most important therapy on the unit, but because these disruptions undermine it, and group therapy, by its nature, has little logistical flexibility). You may ask the staff members to remind disorganized clients about the group meeting and escort them into the room. It should be the ward staff’s responsibility, not the group leaders’ alone, to ensure that inpatients attend. And, of course, the group therapists should always model promptness. Be wary of your colleagues at the hospital using the phrase “your group.” It is not your group; it is the ward’s group led by you and it must be embedded in the unit structure and supported by the team.

The problem of bolters—members who run out of a group meeting—can be approached in several ways. First, clients are made more anxious if they perceive that they will not be permitted to leave the room. Therefore, it is best simply to express the hope that they can stay for the whole meeting. If they cannot, suggest that they return the next session, when they feel more settled. The member who attempts to leave the room in midsession cannot, of course, be physically blocked, but there are other options. You may reframe the situation in a way that provides a rationale for putting up with the discomfort of staying: for example, in the case of a person who has stated that he or she often flees from uncomfortable situations and is resolved to change that pattern, you might recall that resolution. You may comment, “Eleanor, it’s clear that you’re feeling very uncomfortable now. I know you want to leave the room, but I remember you saying just the other day that you’ve always isolated yourself when you felt bad and that you want to try to find ways to reach out to others. I wonder if this might not be a good time to work on that by simply trying extra hard to stay in the meeting today?” You may decrease Eleanor’s anxiety by suggesting that she simply be an observer for the rest of the session, or you may suggest that she change her seat to a place that feels more comfortable to her. You may validate her distress and endorse her courage in coming for as much of the meeting as possible. Reduce the client’s sense of failure.

Groups may be made more stable by a policy that prohibits latecomers from entering the group session once the door is closed, perhaps after a five-minute grace period. Employing such a policy poses an ethical dilemma in balancing inclusivity and protecting the group’s boundaries. It may need to be discussed with the leadership of the ward. This policy may create resentment in clients who arrive late, but it also conveys that you value the group time and work and that you want to get the maximum amount of uninterrupted work each session. Interviews with discharged inpatients highlight that they resent interruptions and approve of the therapists’ efforts to ensure stability.38

Therapist Style

The therapist also contributes greatly to the sense of structure through personal style and therapeutic presence. Confused or frightened clients are reassured by therapists who are firm, explicit, and decisive, yet who, at the same time are open about the reasons for their actions. Judicious therapist transparency, as we have discussed earlier (see Chapter 7), can reduce client anxiety and help them make sense of the experience of the group. Inpatient groups are disrupted repeatedly by major in-group events. Members are often too stressed and vulnerable to deal effectively with such events and are reassured if therapists act decisively and firmly. If, for example, a manic member veers out of control and monopolizes the group’s time, you must intervene and prevent that member from obstructing the group’s work in that session. You may, for example, tell the member that it is time to be quiet and to work on listening to others, or, if the member is unable to exercise any control, you may escort him or her from the room, inviting him to return when he is feeling more settled.

Generally, it is excellent modeling for therapists to talk about the dilemma they face and their ambivalent feelings in such a situation. You may, for example, share both your conviction that you have made the proper move for the welfare of the entire group and your great discomfort at assuming an authoritarian pose. Everyone in the group will be watching you and the manner in which you deal with such tensions. Keep in mind the principles of nonshaming and nonblaming, even in the context of firm limit setting. Conversely, you may interrupt a detached and irrelevant discourse by reminding the group members of their task regarding interpersonal support and communication. Don’t hesitate in that spirit to be directive when it is necessary to maintain the group’s therapeutic focus.

Group Session Protocol

One of the most potent ways of providing structure is to build a consistent, explicit sequence into each session. This is a radical departure from traditional outpatient group therapy technique, but in specialized groups it makes for the most efficient use of a limited number of sessions, as we shall see later when we examine cognitive-behavioral therapy groups. In the inpatient group, a structured protocol for each session increases efficiency and also ameliorates anxiety and confusion in severely ill participants. We recommend that rapid-turnover inpatient groups take the following form:

1. The first few minutes. The therapist provides explicit structure for the group and prepares the group members for therapy. (Shortly, we will describe a model group in which we offer a verbatim example of a preparatory statement.)

2. Definition of the task. The therapist attempts to determine the most profitable direction for the group to take in a particular session. Do not make the error of plunging in great depth into the first issue raised by a member, for in so doing you may miss other potentially productive agendas. You may determine the task in several ways. You may, for example, simply listen to get a feel of the urgent issues present that day. Or you may provide some structured exercise that will permit you to ascertain the most valuable direction for the group to take that day. Your inpatient colleagues may inform you of critical events that may affect the group members.

3. Filling the task. Once you have a broad view of the potentially fertile issues for a session, you attempt, in the main body of the meeting, to address these issues, involving as many members as possible in the group session.

4. Summing up. The last few minutes is the summing-up period. You indicate that the work phase is over, and you devote the remaining time to a review and analysis of the meeting. This is the self-reflective loop of the here-and-now in which you attempt to clarify, in the most lucid possible language, the interaction that occurred in the session. You may also wish to do some final mopping up: You may inquire about any jagged edges or ruffled feelings that members may take out of the session, or ask the members, both the active and the silent ones, about their experience and evaluation of the meeting.

Disadvantages of Structure

Earlier in this text we remonstrated against excessive structure. For example, in discussing the setting of norms, we urged that therapists strive to make the group as autonomous and as responsible for its own functioning as possible. As noted in Chapter 13, empirical research demonstrates that leaders who provide excessive structure may be positively evaluated by their members, but their groups fail to have positive outcomes.39 The golden mean prevails: Too much or too little leader structuring is detrimental to growth.

Thus, we face a dilemma. In many brief, specialized groups, we must provide structure; but if we provide too much, our group members will not learn to use their own resources. This is a major problem for the inpatient group therapist, who must, for all the reasons we have described, structure the group and yet avoid infantilizing its members.

There is a way out of this dilemma—a way so important that it constitutes a fundamental principle of therapy technique in many specialized groups. The leader must structure the group so as to encourage each member’s autonomous functioning. The following illustration of an inpatient group will clarify this apparent paradox.

A Working Model

In this section we describe in some detail a model for the inpatient group. It is best suited for those clients able to utilize a verbal format. Those who are less able to participate may make better use of group activities and group programming that engage clients in safe and accessible tasks. The highly successful and impactful implementation of this specific model across a large behavioral health network in the United States is notable. It began in an inner-city hospital treating indigent and marginalized psychiatric patients with an average length of stay of five days. Building upon this initial success, the model was used in the training of sixty group therapists caring for over thirteen thousand psychiatrically ill individuals annually. This model has been shown to produce better outcomes, higher client satisfaction, a safer milieu, and improved staff morale.40

We suggest this approach for a group that meets three to five times a week for approximately sixty to seventy-five minutes. Briefer time frames of forty-five minutes have been employed with smaller numbers of group participants. This model is described in greater detail in an earlier text, Inpatient Group Psychotherapy.41

1. Orientation and Preparation: three to five minutes

2. Personal Agenda Setting: twenty to thirty minutes

3. Agenda Filling: twenty to thirty-five minutes

4. Review: ten minutes

1. Orientation and Preparation. The preparation of clients for the therapy group is just as important in inpatient settings as it is in outpatient group therapy. The time frame, of course, is radically different. Instead of spending twenty to thirty minutes preparing an individual for group therapy during an individual session, the inpatient group therapist must accomplish such preparation for all members in the first few minutes of the inpatient group session. We suggest that the leader begin every meeting with a simple and brief introductory statement that includes a description of the ground rules (time and duration of meeting, need for punctuality), a clear exposition of the purpose of the group, and an outline of the basic procedure of the group, including the sequence of the meeting. The following is a typical preparatory statement:

I’m Irv Yalom and this is Mary Clark. We’ll co-lead this afternoon therapy group, which meets daily at two o’clock for one hour and fifteen minutes. The purpose of this group is to help members learn more about the way they communicate and relate to others. People come into the hospital with many different kinds of important problems, but one thing that most individuals have in common here is some unhappiness about the way some of their important relationships are going.

There are, of course, many other urgent problems that people have, but those are best worked on in some of your other forms of therapy. What this kind of group does best of all is to help people understand more about their relationships with others. One of the ways we can work best is to focus on the relationships that exist between the people in this room. The better you learn to communicate with each of the people here, the better it will become with people in your outside life. Other groups on our unit may emphasize other approaches and goals.

(If applicable you may add: It’s important to know that observers are present almost every day to watch the group through this one-way mirror. [Here, point toward the mirror and also toward the microphone, if appropriate, in an attempt to orient the group members as clearly as possible to the spatial surroundings.] The observers are professional mental health workers, often medical or nursing students, or other members of the ward staff. In the last ten minutes of the group these observers will join us and share their observations with us.)

We begin our meetings by going around the group and checking with each person and asking each to say something about the kinds of problems they’re having in their lives that they’d like to try to work on in the group. That should take fifteen to thirty minutes. It is very hard to come up with an agenda during your first meetings. But don’t sweat it. We will help you with it. That’s our job. After that, we then try to work together on as many of these problems as possible. Near the end of the meeting, the group leaders will discuss together how the meeting has been and any observers will join us at that point. [If there are no observers, then the group co-therapists use this time as form of rehash but with the group participants present]. Then, in the last few minutes, we check in with everyone here about how they size up the meeting and about the leftover feelings that should be looked at before the group ends. We don’t always get to each agenda fully each meeting, but we will do our best. Hopefully we can pick it up at the next meeting, and you may find also that you can work on it between sessions with your nurse or doctor or other supports.

Note the basic components of this preparation: (1) a description of the ground rules; (2) a statement of the purpose and goals of the group; (3) a description of the procedure of the group (including the precise structure of the meeting). Some inpatient therapists suggest that this preparation can be partly communicated outside of the group and should be even more detailed and explicit by, for example, including a discussion of blind spots, supportive and constructive feedback (providing illustrative examples), and the concept of the social microcosm.42 Written preparation handouts can be distributed in advance to each client on the unit, mindful of the need to have translated versions for ethnoculturally diverse clients.

2. Personal Agenda Setting. The second phase of the group is the formulation of the task. Many group leaders find this the most daunting component of the model. The overriding task of the group is to help members explore and improve their interpersonal relationships. The leaders then assist each member to formulate a brief personal agenda for the meeting. The agenda must be realistic and doable in the group that day. It must focus on interpersonal issues and, if possible, on issues that in some way relate to one or more members in the here-and-now of the group.

Formulating an appropriate agenda is a complex task. Clients need considerable assistance from the therapist, especially in their first couple of meetings. Each group member is, in effect, being asked to make a personal statement that involves three components: (1) an acknowledgment of the wish to change (2) in some interpersonal domain (3) that has some here-and-now manifestation. Think about this as an evolution from the general to the specific, the impersonal to the personal, and the personal to the interpersonal. “I feel unhappy” evolves into “I feel unhappy because I am isolated,” which evolves into “I want to be better connected,” which evolves into “with another member of the group.” There are innumerable ways clients might begin, but there are only a few core agendas that express the vast majority of client concerns:

• I want to be less isolated.

• I want to get closer to others.

• I want to be more assertive about what I need.

• I want to be a better communicator.

• I want to be a better listener and be less focused on myself.

• I want to not feel bottled up.

• I want to feel more trusting.

• I want specific feedback about how I come across regarding…

• I want to deal with anger more effectively and less destructively.

Having these examples in mind may make it easier for therapists to help clients create a workable focus.

Clients have relatively little difficulty with the first two aspects of the agenda, but most will need considerable help from the therapist in the third domain—framing the agenda in the here-and-now. Fortunately, the third part is less complex than it seems, and the therapist may move any agenda into the here-and-now by mastering only a few basic guidelines.

Consider the following common agenda: “I want to learn to communicate better with others.” The client has already accomplished the first two components of the agenda: (1) he or she has expressed a desire for change (2) in an interpersonal area. All that remains is to move the agenda into the here-and-now, a step that the therapist can easily facilitate with a comment such as, “Please look around the room. With whom in the group do you communicate well? With whom would you like to improve your communication?”

Another common agenda is the statement, “I’d like to learn to get closer to people.” The therapist’s procedure is the same: Thrust it into the here-and-now by asking, “Who in the group do you feel close to? With whom would you like to feel closer?” Another common agenda is, “I want to be able to express my needs and get them met. I keep my needs and pain hidden inside and keep trying to please everybody.” The therapist can shift that into the here-and-now by asking, “Would you be willing to try to let us know today what you need?” or “What kind of pain do you have? What would you like from us?”

Nota bene, the agenda is generally not the reason the client is in the hospital. But, often unbeknownst to the client, the agenda may be an underlying or contributory reason. It is rarely irrelevant. The client may have been hospitalized because of substance abuse, depression, or a suicide attempt. Underlying such behaviors or events, however, there are almost invariably important tensions or disruptions in interpersonal relationships.

Note also that the therapist strives for agendas that are gentle, positive, and nonconfrontational. In the agendas we just cited that deal with communication or closeness, we made sure to inquire first about the positive end of the scale (for example, “With whom in the group do you communicate well?”). That is often a powerful and yet safe way to help members begin to open up.

Many clients offer an agenda that directly addresses anger—for example, “I want to be able to express my rage. The doctors say I turn my anger inward and that causes me to be depressed.” This agenda must be handled with care. You do not want clients to express anger at one another, and you must reshape that agenda into a more constructive form.

We have found it helpful to use the following approach: “I believe that anger is often a serious problem because people let it build up to high levels and then are unable to express it. The release of so much anger would feel like a volcano exploding. It’s frightening both to you and to others. It’s much more useful in the group to work with young anger, before it turns into red anger. I’d like to suggest to you that today you focus on young anger—for example, impatience, frustration, or very minor feelings of annoyance. Would you be willing to express in the group any minor flickerings of impatience or annoyance when they first occur—for example, irritation at the way I lead the group today?”

The agenda exercise has many advantages. For one thing, it is a solution to the paradox that though structure is necessary it can also be growth inhibiting and infantilizing. The agenda exercise provides structure for the group, but it simultaneously encourages autonomous behavior on the part of the client. Thus, the agenda encourages members to assume a more active role in their own therapy and to make better use of the group. They learn that straightforward, explicit agendas involving another member of the group will guarantee that they do productive work in the session. An example of a clear, direct, and accessible client statement would be, “I tried to approach Sue earlier today to talk to her, and I have the feeling that she rejected me, wanted nothing to do with me, and I’d like to find out why.” Such a clear statement carries the added benefit of potentially reducing interpersonal tensions on the unit, which will also elevate the status of group therapy on the unit.

Some clients have great difficulty stating their needs directly and explicitly. In fact, many enter the hospital because of self-destructive behaviors that are indirect methods of signifying that they need help. The agenda task teaches them to state their needs clearly and directly and to ask explicitly for help from others. In fact, for many, the agenda exercise, rather than any subsequent work in the group meeting, is itself the therapy. If these clients can broaden their repertoire in asking for help verbally rather than through some nonverbal, self-destructive mode, then the hospitalization will have been very useful.

The agenda exercise also provides a wide-angle view of the group work that may be done that day. The group leader is quickly able to make an appraisal of what each client is willing to do and whose goals may dovetail with those of others in the group.

The agenda exercise is valuable but cannot immediately be installed in a group. Often a therapy group needs several meetings to catch on to the task and to recognize its usefulness. Personal agenda setting is not an exercise that the group members can accomplish on their own: the therapist must be extremely active, persistent, inventive, and often directive to make it work. Once it is established as a group norm however, a group culture will emerge that reinforces this mode of working. You can count on group members passing the model along to the next wave of participants, and your colleagues on the unit can also reinforce it.

If members are extremely resistant, sometimes a suitable agenda is for them to examine why it is so hard to formulate an agenda. Profound resistance or demoralization may be expressed by comments such as, “What difference will it make?” “I don’t have any problems!” “I don’t want to be here at all!” If it is quickly evident that you have no real therapeutic leverage, you may choose to ally with the resistance rather than occupy the group’s time in a futile struggle with the resistant member. You may simply say that it is not uncommon to feel this way on admission to the hospital, and perhaps the next meeting will feel different. You might add that the client may choose to participate at some point in the session. If anything catches his interest, he should speak about it. Remember, the experience should be nonblaming and nonshaming and, as much as possible, a nonfailure experience.

Sometimes if a client cannot articulate an agenda, one can be prescribed that involves listening and then providing feedback to a member the client selects. At other times, it is useful to ask other members to suggest a suitable agenda for a given individual. Recall that the group members often have a great deal of knowledge of one another stemming from the vast amount of time they may have spent together on the ward.

> Joey, a nineteen-year-old young man, offered an unworkable agenda: “My dad treats me like a kid.” He could not comprehend the agenda concept in his first meeting, and I (IY) asked for suggestions from the other members. There were several excellent ones: “I want to examine why I’m so scared in here,” or, “I want to be less silent in the group.” Ultimately, one member suggested a perfect agenda: “I want to learn what I do that makes my dad treat me like a kid. You guys tell me: Do I act like a kid in this group?” <<

Take note of why this was the perfect agenda. It addressed Joey’s stated concern about his father treating him like a kid; it addressed his behavior in the group that had made it difficult for him to use the group; and it focused on the here-and-now in a manner that would undoubtedly result in the group being useful to him.

3. Agenda Filling. Once the personal agenda setting has been completed, the next phase of the group begins. In many ways, this segment of the group resembles any interactionally based group therapy meeting in which members explore and attempt to change maladaptive interpersonal behavior. But there is one major difference: therapists have at their disposal agendas for each member of the group, which allows them to focus the work in a more customized and efficient manner. The presumed life span of the inpatient group is only a single session, and the therapist must be efficient in order to provide the greatest good for the greatest number of patients.

In our experience, six is the ideal size. But if the group is large—say, twelve members—and if there are new members who require a good bit of time to formulate an agenda, then there may be only thirty minutes in which to fill the twelve agendas. Obviously, work cannot be done on each agenda in each session, and it is important that clients be aware of this possibility. You may tell members explicitly that the personal agenda setting does not constitute a promise that each agenda will be focused on in the group. You may also convey this possibility through conditional language in the agenda formation phase: “If time permits, what would you like to work on today?” It is often helpful to encourage clients to continue their agenda work with their nurse, doctor, or other trusted supports. Even when an agenda may not be filled in that group session, clients report great value in clarifying a focus in the midst of feeling overwhelmed.43

Nonetheless, the efficient and active therapist should be able to work on the majority of agendas in each session. The single most valuable guideline we can offer is to try to fit agendas together so that you work on several at once. If, for example, John’s agenda is that he is very isolated and would like some feedback from the members about why it’s hard to approach him, then you can fill several agendas simultaneously by calling for feedback for John from members with agendas such as, “I want to learn to express my feelings,” “I want to learn how to communicate better to others,” or, “I want to learn how to state my opinions clearly.”

Similarly, if there’s a member in the group who is weeping and highly distressed, why should you, the therapist, be the only one to comfort that individual when you have, sitting in the group, members with the agenda of, “I want to learn to express my feelings,” or, “I want to learn how to be closer to other people”? By calling on these members, you stitch several agendas together.

In summary, during the personal agenda setting, the therapist collects commitments from members about certain work they want to do during the meeting. If, for example, one member states that she thinks it would be important for her to learn to take risks in the group, it is wise to store this and, at some appropriate time, call on her to take a risk by, for example, giving feedback or evaluating the meeting. If a member expresses the wish to open up and share his pain with others, it is facilitative to elicit some discrete contract—you may even make a contract for only two or three minutes of sharing—and then make sure that individual gets the time in the group and the opportunity to stop at the allotted time. It is possible, with such contracts, to increase responsibility assumption by asking the client to nominate one or two members to monitor him to ensure he has fulfilled the contract by a certain time in the session. This kind of “maestro-like conducting” may feel heavy-handed to the beginning therapist, but it leads to a more effective inpatient group. Group members generally can distinguish between the leader’s helpful facilitation and over-controlling behavior.

4. The End-of-Meeting Review. The final phase of the group meeting signals a formal end to the body of the meeting and consists of review and evaluation. We have often led inpatient groups on a teaching unit and generally had students observing the session through a one-way mirror. We prefer to divide the final phase of the group into two equal segments: a discussion of the meeting by the therapists and observers, followed by the group members’ response to this discussion.

In the first segment, therapists and observers (if present) form a small circle in the room and conduct an open analysis of a meeting, just as though there were no group members in the room listening and watching. In this discussion, leaders and observers review the meeting and focus on the group leadership and the experience of each of the members. For example, the leaders may question what they missed, consider what else they might have done in the group, or determine whether they left out certain members. We instruct the discussants to make some comment about each member: the type of agenda formulated, the work done on that agenda, and their guesses about that individual’s satisfaction with the group.

Although this group wrap-up format is unorthodox, it is, in our experience, effective. For one thing, it makes constructive use of observers. In the traditional teaching format, student-observers stay invisible and meet with the therapist in a postgroup discussion to which the members do not have access. Members generally resent this observation format and sometimes develop paranoid feelings about being watched. To bring the observers into the group transforms them from an opaque and negative force to a transparent and more positive one. In fact, we have often heard group members express disappointment when no observers are present.

This format requires therapist transparency and is an excellent opportunity to do invaluable modeling. Co-therapists may discuss their dilemmas, concerns, or puzzlement. They may ask the observers for feedback about their behavior. Did, for example, the observers think they were too intrusive or that they put too much pressure on a particular individual? What did the observers think about the relationship between the two leaders?

In the final segment of the review phase, the discussion is thrown open to the members. Generally, this is a time of great animation, since the therapist-observer discussion generates considerable data. There are two directions that the final few minutes can take.

First, the members may respond to the therapist-observer discussion: for example, they may comment on the openness, or lack thereof, of the therapists and observers. They may react to hearing the therapist express doubt or fallibility. They may agree with or challenge the observations that have been made about their experience in the group. This joint rehash invites genuine collaboration. The second direction is for the group members to process and evaluate their own meeting. The therapist may guide a discussion, making such inquiries as: “How did you feel about the meeting today?” “Did you get what you wanted out of it?” “What were your major disappointments with this session?” “If we had another half hour to go, how would you use the time?” The final few minutes are also a time for the therapist to make contact with silent members and inquire about their experience: “Were there times when you wanted to speak in the group?” “What stopped you?” “Had you wanted to be called on, or were you grateful not to have participated?” “If you had said something, what would it have been?” (This last question is often remarkably facilitative.)

This last phase of the meeting thus has many functions: review, evaluation, pointing to future directions. It is highly valued by the members.44 It is also a time for reflection and tying together loose ends before they leave the group session. Because the small group is embedded in the larger milieu, it is wise to make the group as self-contained as possible. It will not enhance your credibility to have the group members empty out for the evening onto the unit in a state of unsettled agitation because of the group.

Your final task is communicating about the group to the team at large. This should be a timely, bidirectional flow of information that promotes integration of care through team meetings and charting. A postgroup debrief by the group leaders at the nursing station with other team members present (who may be curious to know how the patients they are working with did in the group) provides efficient and timely communication.

A final comment about client boundaries. Clients will inevitably interact with one another outside of the group in an inpatient setting. That is highly desirable—but with the proviso that everyone commit to honoring each person’s privacy and treating in-group disclosures with respect on the unit.

GROUPS FOR THE MEDICALLY ILL

Group interventions play an increasingly important role in comprehensive medical care. Given their effectiveness and potential for reducing health-care costs, this trend is likely to continue and expand.45 The range of approaches used is as broad as the range of conditions addressed. These groups are often homogeneous for and include all the major medical illnesses and concerns that warrant medical care, such as cancer, cardiac disease, obesity, lupus, inflammatory bowel disease, pregnancy, postpartum depression, infertility, transplantation, arthritis, chronic obstructive pulmonary disease (COPD), brain injury, Parkinson’s, multiple sclerosis, diabetes, HIV/AIDS, and somatic symptom disorder (SSD).46 These groups are typically led by mental health experts in collaboration with the medical providers whose support for their patients participation is essential.

There has been a dramatic increase in the use of groups in the integrated medical and psychological treatment of clients with heterogeneous chronic medical illnesses.47 These groups are held in primary care practices and are often co-led by a primary care physician and a mental health professional. It serves as an effective way to provide follow-up care. Many of the participating clients experience significant psychosocial challenges in addition to their chronic medical illnesses.48 Group medical visits offer peer support and teach participants about their illnesses and related coping skills in a cost-efficient way. Both medical and psychological clinical outcomes are significantly improved.

Earlier in this chapter we identified several key principles for the adaptation of group therapy: determine the clients’ needs, set relevant goals, modify the group to meet those goals, and evaluate outcomes to improve the group’s effectiveness. Distinguish between the fixed and the mutable elements that may constrain the group therapy. With medically ill clients there is an additional consideration: these groups are most valuable for those in need of help and support; they may not be valuable for those who are already coping well.49

What psychological needs do the medically ill have? Depression, anxiety, and stress reactions are common consequences of serious medical illness and often amplify the impact of the medical illness.50 We know, for example, that depression after a heart attack occurs in up to 50 percent of men, significantly elevating the risk of another heart attack.51 Furthermore, the anxiety and depression accompanying serious medical illness tend to increase health-compromising behaviors such as alcohol use and smoking. They also disrupt compliance with recovery regimens of diet, exercise, medication, and stress reduction.52

Ironically, recent advances in medical treatment have created new sources of psychological stress. For instance, many diseases which were formerly fatal can now be managed as long-term chronic illnesses. These lifesaving outcomes bring with them constant worries of recurrence, or the need to adapt to body- or life-altering surgeries.53 Recent breakthroughs in prevention and early detection similarly may save lives at the cost of increased stress. Genetic testing now plays an important role in medical practice, allowing physicians to compute individual risk of developing such illnesses as Huntington’s disease or breast, ovarian, and colon cancer.54 Yet this knowledge comes with a cost. Large numbers of individuals are tormented by momentous, anxiety-laden decisions. When one learns, for example, of a genetic predisposition to breast cancer, one is faced with numerous questions: Should I have a prophylactic mastectomy? Is it fair for me to get married? To have children? Do I share this information with my siblings, who may prefer not to know? Am I doomed to follow in the footsteps of my mother? Many individuals overestimate their risk and suffer significant emotional distress as a result.55

There is also the great psychological stigma attached to many medical illnesses, such as COVID-19, HIV/AIDS, hepatitis C, and Parkinson’s. At a time when individuals are in great need of social support, the shame and stigma of illness can cause social withdrawal and isolation that is both stressful and harmful.56

Additionally, seriously ill individuals and their families fear uttering anything that might amplify worry or fear in loved ones. The pressure to “think positive” invites tentativeness in communication, which further increases the affected individual’s sense of isolation.57

Collaborative, trusting communication between client and doctor is generally associated with greater well-being and better decision-making. Yet many clients, dissatisfied with their relationship with their physicians, feel powerless to improve it. They need assistance in asserting their needs and advocating for their care.58

Medical illness confronts us with vulnerability and limits. Illusions that have sustained us and offered comfort are challenged. We lose, for example, the sense that life is under our control; that we are special, immune to natural law; that we have unlimited time, energy, and choice. Serious illness confronts us with death and evokes fundamental existential questions about the meaning of life, transiency, and our place in the universe.59

And, of course, the strain of medical illness extends far beyond the person with the illness. Family members and caregivers may suffer significant stress and dysphoria.60 Groups often play an important role in their support. Consider, to cite one example, the enormous growth in groups for caretakers of individuals with Alzheimer’s disease.61

General Characteristics

We may categorize the medical groups according to their emphasis:

1. Emotion-based coping—social support, emotional ventilation

2. Problem-based coping—active cognitive and behavioral strategies, psychoeducation, stress reduction techniques

3. Meaning-based coping—increasing existential awareness, realigning life priorities and finding purpose. These three different foci are readily combined into integrative group models.62

Typically, groups for the medically ill are homogeneous for the illness. They are typically brief and run for four to twenty sessions. As we discussed in Chapter 9, brief groups require clear structure and high levels of focused therapist activity. But even in brief, highly structured, manual-guided group interventions, the group leader must attend to group dynamics and group process, managing them effectively so that the group stays on track. The quality of leadership is just as important here as it is in traditional group therapy.63

Homogeneous groups tend to jell quickly. Still, the leader must endeavor to engage outliers who resist group involvement. Certain behaviors may need to be tactfully and empathically reframed into a more workable fashion. For example, consider the bombastic, hostile man in a ten-session post-myocardial infarction group who angrily complains about the lack of concern and affection he feels from his sons. Since deep personal work is not part of the group contract, the therapist needs to have constructive methods of addressing such a client’s concerns without violating the groups norms. For example, the leader might take a psychoeducational stance and discuss how anger and hostility are noxious to one’s cardiac health. The group might address the latent sadness that the anger is masking and invite the man to express those primary emotions more directly. Or others in the group might be asked to share how they cope with anger or with disappointment.

These groups do not emphasize interpersonal learning and the leaders generally avoid strong here-and-now focus. Nonetheless, many of the other therapeutic factors are particularly potent in group therapy with the medically ill. Universality is prominent and serves to diminish clients’ stigmatization and isolation. Self-disclosure of anxiety and fear can generate relief and connection with group members. Cohesiveness provides social support directly. Extragroup contact is often encouraged and viewed as a successful outcome, not as resistance to the work of the group. Seeing others cope effectively with a shared illness instills hope, which can take many forms at different stages of the illness: hope for a cure, for courage, for dignity, for comfort, for companionship, or for peace of mind. Generally, members learn coping skills more effectively from the modeling of their peers than from experts.64

Imparting of information (psychoeducation about one’s particular illness and more generally about health-related matters) plays a major role in these groups and comes not only from the leaders but from the exchange of information and advice between members. Altruism is strongly evident and contributes to well-being through one’s sense of usefulness to others. Existential factors are also common, as the group supports its members in confronting the fundamental anxieties of life that we conceal from ourselves until we are forced to address them. Any work in the here-and-now focuses on building support and connection and on reinforcing new and adaptive behaviors, not on deep interpersonal exploration. Benefits from these group interventions emerge from experiencing social support and connection, finding meaning in the face of adversity, and gaining coping skills.65

A Prototype Group for Medical Illness

Let’s examine a group for women with breast cancer. Breast cancer serves as a compelling illustration for the role of group therapy because of its high prevalence (one in eight women will be diagnosed with breast cancer in their lifetime) and its breadth of concern, ranging from genetic and familial predisposition, to early primary breast cancer (which is often curable), to advanced disease carrying a grave prognosis.66 The model we describe has subsequently been adapted and used broadly. Related group models used to good effect include cognitive-existential group therapy and meaning-based group therapy.67

The Clinical Situation. At the time of the first experimental therapy groups for women with breast cancer in the mid-1970s, women with breast cancer were in serious peril. Surgery was severely deforming and chemotherapy poorly developed. Women whose disease had metastasized had little hope for survival, were often in great pain, and felt abandoned and isolated. They were reluctant to discuss their despair with family members and friends lest they bring them down into despair as well. Moreover, friends and relatives often avoided them, not knowing how best to speak to them. All this resulted in an ever-increasing isolation. Women with advanced breast cancer often felt guilty: the pop psychology of the day frequently made them feel that they were in some manner responsible for their own disease.68

Finally, there was considerable resistance in the medical field to forming a group because of the widespread belief that talking openly about cancer and hearing several women share their pain and fears would only make things worse. It was in this environment that I (IY) first began to work with breast cancer patients.i

Goals for the Therapy Group. My primary goal was to reduce isolation and improve coping. I hoped that bringing together several individuals facing the same illness and encouraging them to share their experiences and feelings would create a supportive social network, destigmatize the illness, and help the members share coping strategies. Many of the women’s closest friends had dropped away, and I hoped to counter that by committing myself and the group to staying with them—to the death if needed.

Modification of Group Therapy Technique. Mixing women with the better prognosis of primary breast cancer with women with the graver prognosis of metastatic disease undermined cohesion because metastatic disease represented the former subgroup’s worst fears. After some experimentation with groups of women with different types and stages of cancer, I concluded that a homogeneous group offered the most support and formed a group of women with metastatic breast cancer that met weekly for ninety minutes. It was an open group with new women joining the group over time, cognizant that others before them had died from the illness.

Support was the most important guiding principle. I wanted each member to experience “presence”—to know others facing the same situation. As one member put it, “I know I’m all alone in my little boat, but when I look and see the lights on all the other boats in the harbor, I don’t feel so alone.”

In order to increase the members’ sense of personal control, I turned over as much of the direction of the of the group as possible to the members. They invited each other to speak, to share their experiences, to express the many dark feelings they could not discuss elsewhere. They validated each member’s concerns, modeled empathy, attempted to clarify confused feelings, and sought to mobilize the resources available in the membership.

For example, if members described their fear of their physicians and their inability to ask their oncologist questions, I encouraged other members to share the ways they had dealt with their physicians. At times, I suggested that a member role-play a meeting with her oncologist. Not infrequently a member invited another group member to accompany her to her medical appointment under the principle that two heads are better than one while under stress. One of the most powerful interventions the women learned was to respond to a rushed appointment with the compellingly simple and effective statement, “Doctor, I know that you are rushed, but if you can give me five more minutes of your time today, it may give me a month’s peace of mind.” No physician would refuse that request.

Members expressing affect, whatever it might be, was a positive experience in the group: the members had too few opportunities elsewhere to express their feelings. They talked about everything: all their macabre thoughts, their fears of death and oblivion, the sense of meaninglessness, the dilemma of what to tell their children, how to plan their funerals. Such discussions served to detoxify some of these fearsome issues. Expressing emotions almost invariably improved the women’s well-being.69

I attempted to be always supportive, never confrontational. The here-and-now, if used at all, always focused on positive feelings between members. Members differed greatly in their coping styles. Some members, for example, wanted to know everything about their illness; others preferred not to inquire too deeply. I never challenged behavior that offered comfort, mindful never to tamper with a group member’s coping style unless I had something far superior to offer. Some groups formed cohesion-building rituals, such as a few minutes of hand-holding meditation or guided imagery at the end of meetings.

Unlike traditional therapy groups, the members were encouraged to have extragroup contacts: phone calls, luncheons, and the like, and even occasional death vigils were part of the ongoing process. Some members delivered moving eulogies at the funerals of other members, fulfilling their pledge never to abandon one another. These eulogies repeatedly demonstrated deep understanding and care of one another.

Many members had overcome panic and despair and found something positive emanating from the confrontation with death. Some spoke of entering a golden period in which they prized and valued life more vividly. Some reprioritized their life activities and stopped doing the things they did not wish to do. Instead they turned their attention to the things that mattered most: loving exchanges with family, the beauty of the passing seasons, discovering creative parts of themselves. One woman noted wisely, “Cancer cures psychoneurosis.” The petty things that used to agonize her no longer mattered. More than one member said she had become wiser but that it was a pity she had to wait until her body was riddled with cancer before learning how to live. How much she wished her children could learn these lessons while they were healthy. Because of these attitudes, they welcomed student observers rather than resenting them. Having learned something valuable from their encounter with death, they could imbue the final part of life with meaning by passing their accrued wisdom on to others, to students, and to their children and group leaders.

An illustration from a group session (led by ML) highlights this:70

> Kathleen, a sixty-five-year-old woman with advanced disease, told the group about enjoying a respite from chemotherapy. Her oncologist encouraged her to use this window of relative well-being wisely. Kathleen recognized that she had a very poor prognosis, but she was feeling better at this moment than she had in months. She even fantasized about taking a last trip to visit her older brother in Ireland. He had a heart condition that prohibited him from traveling to see her, and time was passing for them both.

The group encouraged Kathleen to seize this moment, and she replied that she was obligated to care for her ninety-two-year-old mother-in-law and so could not travel. A sense of resignation fell upon the group until Sue, another group member, jumped in: “Kathleen, you have four adult children in the city. Give them the gift of giving you the gift of looking after their grandmother so that you can take this trip.” It was a brilliant intervention; Kathleen thought for a moment and then endorsed it. She quickly arranged a trip to Ireland. She returned after a lovely visit and expressed deep appreciation to the group members for their wisdom and support. She relapsed shortly after her return and died a few weeks later.

After Kathleen’s death, her children sent a note to the group members thanking them for encouraging this final trip. They loved their mother but were frustrated at how hard it was to repay her for her devotion to them. She always put herself last. By supporting this trip, they felt they had reciprocated her love for them. Though they were sad, the trip eased their grief and helped “balance the books a bit better.” <<

It is important to note that leading such a group is deeply emotionally demanding, and that co-therapy and supervision are highly recommended. Leaders cannot remain distant, as these issues deeply touch the leaders as well as the group members. There is no “us and them.” We are all fellow travelers facing the same existential threats.71

This particular group approach, which is now termed supportive-expressive group therapy (SEGT), has been described in a series of publications.72 It has been taught to many psycho-oncology professionals for use with a range of cancer patients along the continuum of illness.73

This approach has also been used for women with a strong genetic or familial predisposition to develop breast cancer. Reports describe effective homogeneous groups that meet for a course of twelve weekly sessions. The last four meetings may be used as boosters, meeting once monthly for four months, which extends exposure to the intervention to six months. Central concerns in these groups include coping with life’s uncertainty, decisions about prophylactic mastectomy, and shattered illusions of invulnerability. Feelings of loss and grief are prominent, often amplifying the sense of personal risk for breast cancer. Working through these feelings contributes to a better informed, more accurate assessment of one’s personal risk.74

Effectiveness. Outcome research over the past twenty-five years has demonstrated the effectiveness of these groups. Supportive-expressive group therapy for women at risk of breast cancer, women with primary breast cancer, and women with metastatic disease has consistently been shown to reduce the experience of pain and to improve psychological coping and adaptation. The medical profession’s initial apprehensions—that talking about death and dying would make women feel worse or cause them to withdraw from the group—has been thoroughly disconfirmed.75

Can groups for cancer patients increase members’ survival time?76 The first controlled study of groups for women with metastatic breast cancer reported longer survival, but several other studies have consistently failed to replicate those first findings. The original reports spurred hope that we could find a psychoneuroimmunological mechanism to account for a psychosocial intervention prolonging life. Subsequent studies have eliminated neither the controversy nor our wish to find survival benefits. It is likely the case that any impact on survival is the result of the group enhancing social support, reducing isolation for those with limited relationships, promoting health equity, and helping vulnerable individuals access and maintain compliance with difficult treatment regimens. All of the studies, however, show significant positive psychological results: less experience of pain, less psychological distress, better quality of life, and even the capacity to grow personally as one faces the trauma of mortal illness. Even if the group intervention does not prolong life, there is little doubt that it can improve the quality of life for its members.77

ADAPTATION OF CBT AND IPT TO GROUP THERAPY

In this section we describe two widely used models of brief group therapy. Cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) were originally constructed, described, and empirically tested in individual therapy.78 Both are now used as brief group therapy interventions and are accruing good support for their effectiveness.

It is important not to be misled by labels. A review of the current literature on group therapy for women with breast cancer noted that many of the groups identified as CBT were in fact integrative models that synthesized contributions from multiple models.79 This important finding is by no means the exception: it is often the case that effective, well-conducted therapy of purportedly different ideological models shares much in common. One of the major conclusions of the encounter group study was exactly that: The behavior of effective therapists resembled that of effective therapists from other ideological schools far more than it did the behavior of other, less effective practitioners of their own school.80 Why is this so? Likely it is a result of the effective use of the common and evidence-based factors that predict effectiveness across all therapy models and that we have examined throughout this text.81 Good group therapists are committed to being helpful to their clients and not wedded to their model’s ideology.

Cognitive-Behavioral Group Therapy

Group CBT (CBT-G) initially arose from the search for greater clinical efficiency. Cognitive-behavioral therapists used the group venue to deliver individual CBT to a large number of clients simultaneously. Note this important and fundamental difference: CBT therapists were using groups to increase the efficiency of delivering CBT to individual clients, not to tap the unique benefits inherent in group therapy that we have emphasized throughout this text. At first, cognitive-behavioral therapists had a narrow focus: they wanted to provide psychoeducation and cognitive and behavioral skill training. They used the group as a setting to deliver an intervention without harnessing the group as an agent of change. What about peer support, universality, instillation of hope, imitative behavior, altruism, destigmatization, social skills training, and interpersonal learning? They were considered merely backdrop benefits. What about the presence of group process, cohesion, or phases of group development? They represented noise in the system, often interfering with the work of delivering CBT; in fact, some CBT therapists initially raised the concern that the group format diluted the power of CBT.82

We have now passed into a second generation of more sophisticated CBT-G applications in which the essential elements of group life are being acknowledged. CBT-G therapists are productively utilizing groups to deepen learning and experience. Greater attention to the use of the group therapy factors, the development of group cohesion and early client engagement, and a focus on group leadership style have all increased CBT-G’s effectiveness.83 Group cohesion fosters more risk-taking, deeper task engagement, and reduced shame and avoidance. Relationship building and skill development reinforce one another, and the quality of the group experience contributes substantially to the outcome of the group treatment even in skill-focused groups.84

The CBT approach postulates that psychological distress is the result of impaired information-processing and disruption in patterns of social behavioral reinforcement.85 Although thoughts, feelings, and behaviors are of course interrelated, CBT considers one’s thoughts in particular to be central to the process. Often automatic and flying beneath the radar of one’s awareness, one’s thoughts initiate alterations in mood and behavior. CBT therapists attempt to access and illuminate these thoughts through probing, Socratic questioning, and the encouragement of self-examination and rigorous self-monitoring reaching client core beliefs.

What type of core beliefs are uncovered? Core beliefs fall into two main categories—relationships and competence: “Am I worth loving?” and “Can I achieve what I need to confirm my worth?” Integrative therapists have noted that core beliefs are often strongly interpersonal at their center.86 Once these dysfunctional core beliefs (for example, “I am entirely unlovable”) are identified, the next objective of treatment is to restructure them into more adaptive and self-affirming beliefs.

CBT-G has been applied effectively to an array of clinical conditions: acute depression,87 chronic depression,88 chronic dysthymia,89 depression relapse prevention,90 posttraumatic stress disorder (PTSD),91 acute stress,92 eating disorders,93 insomnia,94 somatization and hypochondriasis,95 spousal abuse,96 panic disorder,97 obsessive-compulsive disorder,98 generalized anxiety disorder,99 social phobia,100 anger management,101 schizophrenia (both for negative symptoms, such as apathy and withdrawal, and, positive ones, such as hallucinations),102 perinatal anxiety,103 parent-child groups for childhood anxiety,104 and many other conditions, including medical illnesses.105

Substantial and durable benefits have been regularly reported in these applications. Recent generations of CBT-G in which group therapists pay more attention to group cohesion and group process have been found to be no less effective than individual CBT. CBT-G generally does not have a higher rate of premature termination of therapy. Exposure-based group treatment for PTSD, however, does have a greater frequency of dropouts. Exposure-based treatments require clients to gradually approach their trauma-related memories, feelings, or situations, directly or in imagination. Group members are often so overwhelmed by exposure to traumatic memories that a brief format is likely not feasible. Desensitization must be conducted over a considerable period.106

The application of CBT in groups varies according to the particular needs of the clients in each type of specialty group, but all share certain well-identified features.107 CBT-G is typically homogeneous, time limited, and relatively brief, generally with a course of eight to twenty meetings that last two to three hours.108 Group CBT emphasizes structure, focus, and acquisition of cognitive and behavioral skills. Therapists assign homework between sessions and make it clear that group members are each accountable for advancing their own therapy. The homework is tailored to the concerns of the individual client. It might involve keeping a log of one’s automatic thoughts and how these thoughts relate to mood, or it might involve a behavioral task that challenges avoidance. Gradients of exposure to fearful stimuli can be jointly constructed by the client and group leader and engaged by the client.

The review of the homework is conducted in each group meeting and represents a key difference between group CBT and interactional group therapy: the CBT leader substitutes “cold processing” of the client’s at-home functioning for the “hot processing” that typifies interactional group therapy.109 In other words, the group focuses on clients’ descriptions of their at-home functioning rather than on their real-time functioning in the here-and-now interaction.

Measurement of clients’ distress and progress through self-report questionnaires is ongoing, providing regular feedback that either supports the therapy or signals the need to realign therapy.

The group CBT therapist makes use of a set of strategies and techniques, in various combinations, that clients employ and then discuss together in the group.110 These interventions deconstruct the clients’ difficulties into workable segments and combat their tendency to generalize, magnify, and distort. For example, clients may be asked to:

• Record automatic thoughts. Make overt what is covert; link thoughts to mood and behavior. For example, “I will never be able to meet anyone who will find me attractive; why should I try to date?”

• Challenge automatic thoughts. Challenge negative beliefs; identify distortions in thinking; explore the deeper personal assumptions underlying the automatic thoughts. For example, “How can I actually meet people if I keep refusing invitations to go out for drinks after work?”

• Monitor mood. Explore the relationship between mood and thoughts and behaviors. For example, “I think I started to feel lousy when no one invited me for lunch today.”

• Create an arousal hierarchy. Rank anxiety-generating situations and gradually confront each one, from easiest to hardest. For example, a client with agoraphobia would rank the places that elicit anxiety from the easiest to the most challenging. Going to church on Sunday morning with a spouse might be at the low end of arousal. Going shopping alone at a new mall at night might be at the high end of arousal. Ultimately, gradual exposure desensitizes the client and extinguishes the anxious and avoidant response.

• Monitor activity. Track how time and energy are spent. For example, one might take note of how much time is actually lost to rumination about work competence and how that in turn interferes with completing required tasks.

• Problem-solve. Find solutions to everyday problems. Therapists challenge clients’ belief in their inevitable failure by breaking a problem down into instrumental and workable components. For example, clients may be asked how to balance self-care with care for an ill family member.

• Acquire knowledge through psychoeducation. This might include, for example, education about the physiology of anxiety or the symptoms of the stress response.

• Learn relaxation training. Reduce emotional tension by progressive muscle relaxation, guided imagery, breathing exercises, and meditation. Generally, a meeting or two is devoted to training in these techniques. The objective is to increase the clients’ abilities to step back and reflect on their experience, lessening the tendency to be highly reactive.

• Perform a risk appraisal. Clients examine what feels threatening and what resources they have to meet these threats. This might include, for example, examining the client’s belief that his panic attack is actually a heart attack and reminding him that he can use deep breathing to settle himself effectively.

• Employ guided imagery for exposure. Clients challenge negative attributions about self-worth and the anticipation of rejection that result in avoidance and escape behaviors. They focus instead on constructing positive and healing imagery.

• Anticipate relapse and create a relapse prevention plan. Clients identify potential triggers—both external events and internal assumptions—and the core skills they need to respond to these triggers. They plan and practice for the future.

The group CBT treatment of social phobia is representative.111 Each group consists of five to seven members and meets for twelve sessions of two and a half hours each. Each meeting has a beginning agenda and check-in, a middle working phase, and an end-of-session review. An individual pregroup or postgroup meeting may be used with each member.

The first two group sessions address the clients’ automatic thoughts regarding situations that evoke anxiety. For example, a member might state, “If I speak up, I will certainly make a fool of myself and be ridiculed.” Skills are then taught to challenge these automatic thoughts and errors in logic. For example: “You assume that you will express yourself poorly, and reach the worst outcome possible. But when you voice your concerns here, others have repeatedly told you that you are clear and articulate.”

The middle sessions address each individual’s target goals using homework, in-group role simulations, and behavioral exposure to the source of anxiety. The last few sessions consolidate gains and identify future situations that could trigger a relapse. Imagery can be added to deepen the client’s exposure to the aversive situation.112 In summary, the group leader helps each member to identify dysfunctional thinking, to challenge these thoughts, to restructure thoughts, and to modify behavior.

Group Interpersonal Therapy

Individual interpersonal therapy (IPT), first described by Gerald Klerman, Myrna Weissman and colleagues, has also been adapted for group use.113 In the same way that CBT views psychological dysfunction as a problem of information processing and behavioral reinforcement, IPT views psychological dysfunction as a problem rooted in one’s interpersonal relationships. As the client’s social and interpersonal functioning improve, his or her presenting disorder—for example, depression or binge eating—also improves. Interestingly, this can occur with relatively little specific attention to the actual disorder other than psychoeducation about its nature, course, and impact.114 The improvement in social and interpersonal functioning can have broad positive reverberations that reinforce and sustain improvement in the primary symptoms.

Group IPT (IPT-G) emphasizes the acquisition of interpersonal skills and strategies for dealing with social and interpersonal problems.115 Group applications of IPT-G emerge from the societal drive toward greater efficiency, but it also recognizes the many therapeutic opportunities group members can provide one another in addressing interpersonal dysfunction. These include reducing social isolation, modeling, destigmatization, and supporting treatment compliance and engagement. The first group IPT application was developed for clients with binge eating disorder, but clinical applications have proliferated since then. IPT-G is now used in the treatment of depression, social phobia, postpartum depression, and psychological trauma, among other clinical foci. It has been used effectively as a stand-alone treatment and has been combined with social rhythm interventions for clients with bipolar disorder in order to help with self-regulation of sleep, activity, and exposure to stimulation. It has proven effective in skills training for depressed adolescents with poor school functioning.116 IPT-G can be employed conjointly with pharmacotherapy, either concurrently or sequentially.117

IPT-G’s relevance and efficacy have also been demonstrated in other cultures, where it has been taught effectively to providers who have little prior psychotherapeutic training.118 The World Health Organization has published a manual to support the delivery of IPT-G internationally in under-resourced countries where other depression treatments may be inaccessible. IPT-G’s relational focus makes it a good match across cultures and with diverse populations. It has even been delivered in environments as challenging as displaced persons camps.119

Group IPT closely follows the individual IPT model. A positive, supportive, transparent, and collaborative client-therapist relationship is strongly encouraged. Each client’s interpersonal difficulties are ascertained beforehand in an intensive evaluation of relationship patterns. These are categorized into one or two of four main areas: grief and loss, interpersonal disputes, role transitions, or interpersonal sensitivity. Self-report questionnaires and interpersonal inventories may be used to refine the client’s focus and to measure progress. The most commonly used self-report measurements address the client’s chief areas of distress—mood, trauma, eating behaviors, or interpersonal patterns. One to three goals are identified for each client to help focus the work and to jump-start the group therapy.

A typical course of therapy consists of one or two preliminary individual meetings aimed at building a therapeutic alliance and establishing therapy goals and then eight to twenty-four group meetings of ninety minutes each, with an individual follow-up session three or four months later. Some practitioners also use an individual evaluation meeting after the group has completed half of its sessions. Booster group sessions may be scheduled at regular intervals in the months following the intensive phase of therapy.

The group therapy meeting consists of an initial introduction and orientation phase, a middle working phase, and a final consolidation and review segment.120 Written group summaries (see Chapter 13) may be sent to each group member before the next session.

The first phase of the group, in which members present personal goals, helps to catalyze cohesion and universality. Psychoeducation, interpersonal problem solving, advice, and feedback are provided to each client by the group members and the therapist(s). The ideal posture for the therapist is one of active concern, support, and encouragement. Transference issues are managed rather than explored. Clients are encouraged to analyze and clarify their patterns of communication with figures in their environment but not to work through member-to-member tensions.

What are the differences between group IPT and the interactional, interpersonal model described in this text? In the service of briefer therapy and more limited goals, IPT-G generally de-emphasizes both the here-and-now and the group’s function as a social microcosm. These modifications reduce interpersonal tensions and the potential for disruptive disagreements. (Such conflicts may be instrumental for far-reaching change but may impede the course of brief therapy.) The group, through its supportive and modeling functions, nonetheless becomes an important social network. In some carefully selected instances, group here-and-now interaction may be judiciously employed and linked to the client’s focus and goals, but generally this focus is much less prominent than in the interpersonal group model we have described in this text. As we have noted elsewhere, skillful group leadership regarding an appreciation of group dynamics, group cohesion, group development, and group process play an important role in enhancing effectiveness.121

SELF-HELP GROUPS AND ONLINE SUPPORT GROUPS

The number of participants in self-help groups (SHGs) is staggering. To place some perspective on this, a report antedating the huge expansion of Internet support groups reported that over ten million Americans had participated in one of over five hundred thousand self-help groups in the preceding year and twenty-five million Americans had participated in a self-help group sometime in the past. That study focused exclusively on self-help groups that had no professional leadership. But in fact, more than 50 percent of self-help groups have professional leadership of some sort, which means that a truer measure of participation in self-help groups at that time, even by a conservative estimate, was likely twenty million individuals in the previous year and fifty million overall—figures that far exceed the number of people receiving professional mental health care.122 This trend will only increase in light of consumers’ growing self-awareness, self-assertiveness, access to information online, and difficulty in accessing costly professional care.

Group psychotherapists will regularly encounter clients who participate in SHGs and may at times encourage client participation in self-help groups. SHGs exist for virtually every condition and life challenge and are particularly prominent for mental health concerns and substance use disorders.123 Fortunately, there are many excellent guides and entry points to this vast resource. The National Alliance on Mental Illness (NAMI), for example, each year provides millions of Americans with support, psychoeducation, and online resources by working with five hundred local affiliates. NAMI provides online support groups tailored to particular client concerns. Online self-help clearinghouses such as Mental Health America and the National Mental Health Consumers Self-Help Clearinghouse similarly provide useful guides to the many types of self-help groups available as well as materials, support, and guidance for the development of self-help groups.124

SHGs are proliferating rapidly, but they are certainly not new. In fact, we can readily track an arc from the fraternal organizations of the fourteenth century to the online support groups of today.125 While the means of delivery has changed, the objectives of SHGs have remained consistent. SHGs provide their members with mutual aid and support. This includes a sense of safety and belonging, information sharing, and development of coping strategies. These groups may also help members advocate for change, as exemplified by Mothers Against Drunk Driving (MADD). In such cases, using one’s lived experience to help others can lead to feelings of empowerment and a greater sense of self-efficacy.126

Evaluation of outcomes is difficult, given that SHG membership is often anonymous and records are unreliable. Nonetheless, some systematic studies attest to the efficacy of these groups. Members value the groups highly (sometimes more so than clients’ objective improvement alone would predict) and report improved coping and well-being, greater knowledge of their condition, and reduced use of other health-care services.127

SHGs resemble therapy groups in many ways; the quality of peer leadership and the development of group cohesion are critical. SHGs make extensive use of almost all the group therapeutic factors, most prominently, altruism, cohesiveness, universality, imitative behavior, instillation of hope, and catharsis. But there is one important exception: the therapeutic factor of interpersonal learning plays a far less important role in the self-help group than in the therapy group.

Several factors account for the widespread growth of SHGs. They are open and accessible, offering psychological support to anyone who identifies with the group. Ailments that are underrecognized or unaddressed by the professional health-care system are very likely to generate self-help groups, and in these cases the groups are quite reassuring, helping members accept and normalize their malady.128 Beyond traditional face-to-face SHGs, the Internet promotes connections between isolated individuals who feel unique in their distress. Instead of relying on restricted, perhaps unresponsive local communities, those affected with rare maladies now have access to support from kindred folks from around the world.

Self-help groups emphasize internal rather than external expertise. They draw on the resources available within the group rather than those available from external experts, and this shift is empowering. The members’ shared experience makes them both peers and credible experts. They become providers and consumers of support at the same time, benefiting from both roles: their self-worth rises through altruism, and hope is instilled by contact with others who have surmounted similar problems. Active coping strategies enhance functional outcomes.129

The presence of a professional leader in the SHG may facilitate deeper disclosures by participants.130 These findings have led some researchers to call for more active collaboration between professional health-care providers and the self-help movement. There is a risk, however, that professional status may overshadow the SHG members’ expertise. In any such collaboration, mutual respect and recognition of the value brought by both peer and professional experts is critical.131

Telemental Health Applications

Online mental health platforms include mobile device applications, remote health monitoring, and educational material. Apps and personal devices that provide a stream of personalized feedback about mood and stress aimed at promoting mental health self-awareness and self-care are proliferating daily. Although the feedback these provide is often generic and not individually tailored, there is no question that they can be of benefit.132

The early and technologically simpler (but still popular) online groups that first appeared operate either as real-time groups (synchronous chat lines) or asynchronous groups (bulletin boards). In both formats, members have no video contact but communicate by posting written messages. Facebook groups, for instance, are models of both. Groups may be time limited or ongoing; they may be actively managed through a facilitator’s comments or questions regarding posts; or they may operate without any professional input. They may be of varying and even indeterminant size. If there is professional input from moderators, their responsibility is to coordinate and curate participants’ messages in ways that maximize the functioning of the group.133

An online bulletin board or chat group is a support system that is available 24/7 and allows its members time to rehearse, craft, and fine-tune their narrative.134 That is the good news, and the impact is often profound and positive. The less good news, at times, is that the lack of boundaries may foster regressive online behaviors. Despite its manifest appearance as a kind of therapy group, an online chat group or bulletin board group can be a very large group in cyberspace shaped by large group dynamics and forces. This may include the expression of emotionally powerful, at times unconscious social and cultural forces regarding race, identity, diversity, authority, and inclusion. Participants only know one another through their limited posts, and without deeper interpersonal knowledge, assumptions and projections can easily mount.135 This may encourage posting of attacking or inflammatory responses. Some professional input can reduce the risk of destructive and damaging posts.

A study of 103 participants in an online peer support group message board for depression found that many of the members of the group valued it highly, spending at least five hours engaged with the group online over the preceding two weeks to post messages and respond to others’ posts. Benefits of participation included emotional support and tips about depression treatments. High users of the message board were more likely to experience resolution of their depression. More than 80 percent of the participants also continued to receive in-person professional care. They saw the online group as a supportive adjunct to, rather than as a substitute for, traditional care.136 One participant’s account of her experience describes many of the unique benefits of the online support group:

> I find online message boards to be a very supportive community in the absence of a “real” community support group. I am more likely to interact with the online community than I am with people face to face. This allows me to be honest and open about what is really going on with me. There are lots of shame and self-esteem issues involved in depression, and the anonymity of the online message board is very effective in relieving some of the anxiety associated with “group therapy” or even individual therapy. I am not stating that it is a replacement for professional assistance, but it has been very supportive and helped motivate me to be more active in my own recovery program.137 <<

Posting messages as the vehicle for communication has the serendipitous benefit of facilitating research, as every communication can be examined. An analysis of postings in groups for women with breast cancer demonstrated that members of groups that had trained moderators were more likely to express distressing emotions than members of groups without moderators. Greater emotional expression by participants was associated with reduced depression.138 The moderator, generally a mental health expert, requires skill in facilitation and in activating, containing, and exploring strong emotions. This appears to be as important in online support groups as in face-to-face groups.139

Internet support group participants describe many other unique advantages. Individuals, for example, who are unable to attend face-to-face meetings, because of geographic distance, cost, physical disability, infirmity, or the dearth of professionals in their communities, are now able to participate in a self-help or therapy group.140 Patients with stigmatizing ailments or social anxiety may prefer the relative anonymity of an Internet support group. These groups promote health equity by enhancing access to care. For many people in search of help, an Internet support group is the equivalent of putting a toe in the water in preparation for full immersion in some other therapy endeavor; for others, it is a definitive treatment. Intimacy itself is being redefined favorably in online terms. Haim Weinberg has coined the term “E-ntimacy” to describe the intimacy that online platforms generate.141

Footnotes

i For a full description of the first group I led for cancer patients, see “Travels with Paula” in Momma and the Meaning of Life (New York: HarperCollins, 1999), 15-53.

Chapters 16

Training the Group Therapist

GROUP THERAPY IS A CURIOUS PLANT IN THE GARDEN OF THE psychotherapies. It is hardy: the best available research consistently reports that group therapy is as effective and robust as individual therapy. It also represents a remarkably efficient use of therapist resources.1 It is a Triple E therapy: effective, equivalent to individual therapy, and efficient. Yet it needs constant tending; its perennial fate is to be periodically choked by the same old weeds: prejudices and judgments that it is “superficial,” “dangerous,” or “second-rate—to be used only when individual therapy is unavailable or unaffordable.” We hope the American Psychological Association’s 2018 recognition of group psychotherapy as a designated psychology specialty will alter the landscape, elevating group therapy practice and training to the status it warrants.2

Clients and many mental health professionals continue to underrate and to fear group therapy, and unfortunately those very same attitudes adversely influence group therapy training programs.3 Why? Perhaps because group therapy cannot cleanse itself of the anti-intellectual taint of the antiquated encounter group movement. Perhaps it is because we all wish to be the special and singular object of attention that individual therapy promises. Perhaps because many of our clients have found groups to be their life problem, not the solution. Perhaps many of us prefer to avoid the anxiety inherent in the role of the group leader: greater public exposure of oneself as a therapist, less sense of control, fear of being overwhelmed by the group, too much clinical material to synthesize. Perhaps, too, it is because groups evoke for us unpleasant personal memories of earlier peer group experiences.

The moment demands a whole new generation of well-trained group psychotherapists, and it behooves us to pay careful attention to their education. Training is a lifelong endeavor. Time and experience are not sufficient: deliberate attention to ongoing learning and to feedback on one’s work are required for group therapists to grow and develop.4

In this chapter, we present our views about group therapy training, not only in terms of specific training recommendations but also in the form of an underlying philosophy of training. The approach to group therapy described in this book is based on a synthesis of extensive clinical experience and the best available research evidence. Similar principles apply to the education of group therapists.

Most training programs for mental health professionals focus on individual therapy and do not provide group therapy training, or offer it only as an elective part of the program. In fact, it is not unusual for students to be given excellent individual therapy supervision and then, early in their program, to be asked to lead therapy groups with no specialized guidance whatsoever. Many program directors apparently expect, naïvely, that students will be able somehow to translate their individual therapy training into group therapy skills without meaningful group experience and training. This practice not only invites ineffective group leadership but causes students to devalue the group therapy enterprise.5 The same process occurs in many clinical work settings. Despite group therapy practice being more complex than individual therapy, therapists are routinely thrown into the work without adequate training, and with discouraging results.6

Neophyte group therapists make predictable errors, and without strategies to address these errors, replication of them is likely. Good training helps the developing group therapist to appreciate the complexity of the group and to reflect on the “big picture” of what is happening regarding group process, dynamics, and development. Errors of omission tend to be more prominent than errors of commission in the practice of the beginning group therapist.7

It is essential that mental health training programs appreciate the need for rigorous, well-organized group therapy training and offer programs that match the needs of trainees and their clients. Both the American Group Psychotherapy Association (AGPA) and the American Counseling Association (ACA) have established minimum training standards for group therapy certification that can serve as a template for training. For example, the AGPA’s International Board for Certification of Group Psychotherapists (IBCGP) requires a minimum of fifteen hours of didactic training, three hundred hours of group therapy leadership, and seventy-five hours of group therapy supervision with a group therapist who has met the standards of certification.8 These are the expectations for recognition as a Certified Group Psychotherapist (CGP). Many international organizations have set training standards as well and in addition insist on personal group therapy as a component of core training.9 For many group therapists, experiential training at intensive institutes offered at conferences serves a similar purpose: a personal group experience greatly enhances one’s effectiveness as a group therapist.

Health-care economics force us to recognize that one-to-one psychotherapy cannot possibly meet the pressing mental health needs of the public. Health insurers forecast rapid growth in the use of group therapy, particularly in structured and time-limited groups.10 We believe strongly that psychotherapy training programs that do not acknowledge this and do not expect students to become as fully proficient in group as in individual therapy are failing to meet their responsibilities to the field and to their students.

While we cannot hope to offer a definitive blueprint for a universal training program, we shall, in the following section, discuss the four major components that we consider essential to a comprehensive training program beyond the didactic: observation of experienced group therapists at work, close clinical supervision of students’ maiden groups, a personal group experience, and personal psychotherapeutic work.

OBSERVATION OF EXPERIENCED CLINICIANS

Though it is exceedingly uncommon for students to observe a senior clinician doing individual therapy, the more public nature of group therapy makes it possible for trainees to observe directly. Student therapists derive enormous benefit from watching an experienced group practitioner at work.11 At first, experienced clinicians may feel considerable discomfort while being observed; but once they have taken the plunge, the process becomes comfortable as well as rewarding for all: students, therapists, and group members.12 In one study, trainees who observed ongoing group therapy described it as their most impactful training experience. They reported learning about group leadership and group dynamics as well as how to bear the strong emotions generated by group therapy.13

The format of observation depends, of course, on the physical facilities. We prefer having our students observe our group work through a one-way mirror, but if students’ schedules do not permit them to be present for a ninety-minute group and a postgroup discussion, the group can be videotaped (with client consent) and reviewed at a later time. However, observation is more alive in the moment, noting as well there is a significant difference between live observation through a one-way mirror and being physically present in the group room. If there are only one or two observers, they may sit in the group room outside of the circle without unduly distracting the members. In this model, observers sit silently and decline to respond to any questions group members may pose to them.

Regardless of the format used, the group members must be fully informed about the presence of observers and their purpose. In every instance, observers should be held to the same standard of professionalism regarding confidentiality and ethical conduct as the therapists.14 A clear observers’ contract protects both the clinical and learning environments. If a trainee recognizes or knows a group member, that individual is not permitted to observe.

I (ML) once faced the situation of having a group member, Donna, recognize a student entering the observation room as someone she knew from her neighborhood. Donna was furious at me for this apparent violation and I was flummoxed. Through the one-way mirror, I asked the observer in apparent violation to leave the viewing room immediately, only to learn afterward, in our rehash, that the observer had an identical twin whom Donna knew. My credibility in making that improbable explanation the next week was strained, but ultimately survived intact.

Clients may initially protest feeling like “specimens” when being observed but generally this feeling soon evaporates. We remind clients that observation is necessary for training, that we were trained in that fashion, and that their willingness to permit observers will ultimately be beneficial to the student observers’ clients in the future.

The total length of students’ observation time is generally determined by service and training rotations. If there is sufficient program flexibility, we suggest that observation continue for at least six to ten sessions, which generally provides a sufficient period of time for changes to occur in group development, in interactional patterns, and in perceivable client growth.

The postmeeting discussion is an absolute necessity in training, and there is no better time for the group leaders/teachers to meet with student observers than immediately after the meeting. We prefer to meet for thirty to forty-five minutes, and we use the time in a variety of ways: obtaining the students’ observations, answering their questions about underlying reasons for our interventions, and using the clinical material as a springboard for discussion of fundamental principles of group therapy. Although some introductory didactic sessions are useful, we find that much of the material presented in this book can be best discussed with students when appropriate clinical material arises in an observed group. Theory becomes so much more alive when it is immediately relevant.

The relationship between observers, the group, and the group therapists is important. There will be times when observers may be critical and faulting. The repeated questions of “Why didn’t you…?” may create discomfort for the therapists, but also models openness to learning and feedback. Not infrequently, observers complain of boredom, and therapists may feel some pressure to increase the group’s entertainment quotient. Our experience is that, in general, boredom is inversely related to experience. As students gain experience and sophistication, they come increasingly to appreciate the many subtle, fascinating layers underlying every transaction.

The observation group has a process of its own that may reverberate with themes in the group. Observers may identify with the therapist, or with certain characteristics of the clients that, if explored in the debriefing session, may provide an opportunity to explore such themes as empathy, countertransference, and projective identification. At times, observers develop strong attachments to group members and may express the wish that they were in the group as participants. One observer was so disturbed when one group member verbally attacked another that he shared a fantasy of coming into the group and accosting the offending group member. This admission led to a rich discussion of how to manage intense affects and countertransference.

Group members respond to being observed by students in a range of ways. Like any group event, the different responses resemble a projective test. If all members face the same situation (that is, being observed by students), why do some respond with anger, others with suspicion, and still others with pleasure, even exhilaration? Why such different responses to a common stimulus? The answer, of course, is that each member has a different inner world, and the differing responses facilitate examination of each inner world.

Nonetheless, for the majority of clients, observation is an intrusion. Sometimes the observers may serve as a lightning rod for anxiety arising from other concerns. For example, one group I (ML) led had been observed consistently but suddenly became preoccupied with the observers, growing convinced that they were mocking and ridiculing the members. A group member reported encountering someone in the washroom before the group who smirked at him, and he was convinced this person was an observer. The group members demanded that the observers be brought into the group room to account for themselves. The group’s reaction was so intense that I began to wonder if there had been some breach of trust. As we continued to examine the source of this intensity, it became apparent that the group members were in fact projecting their apprehensions onto the observers. There were impending changes in the group—two senior members had left, and two new additions to the group were imminent—and the real issue was whether the new additions would value the group or deride the process and the members.

Though the most a leader can generally expect from clients is a grudging acceptance of the observers’ presence, there are methods of turning the students’ observations to therapeutic advantage. We remind the group that the observers’ perspectives are valuable to us as the leaders; if appropriate, we may cite some helpful comments observers made after the previous meeting. Some of the observers’ comments may also be incorporated into the written summary of the meeting.

Another, more daring strategy is to invite the group members to be present at the observers’ postmeeting discussion. In Chapter 15 we discussed a model of an inpatient group that regularly included a ten-minute observers’ discussion that the group members observed.15 I (IY) have used a similar format for outpatient groups. I invite members and observers to switch rooms at the end of a meeting so that the clients can view the observers’ and co-therapists’ postgroup discussion through the one-way mirror. My only proviso is that the entire group elect to attend: if only some members attend, the process may be divisive and impede the development of cohesiveness. A significant time commitment is required: forty-five minutes of postgroup discussion after a ninety-minute group therapy session make for a long afternoon or evening. This format has interesting implications for teaching. It teaches students how to be constructively transparent, and it conveys a sense of respect for the client as a full ally in the therapeutic process.

A further benefit is that boredom in the observation room absolutely vanishes: students, knowing they will later take part in the meeting, become more engaged in the process.

A useful adjunct teaching tool may be a group videotape designed to illustrate important aspects of leader technique and group dynamics. We recommend use of three videotape programs—one for outpatient groups, one for inpatients, and one based upon The Schopenhauer Cure.16

CLINICAL SUPERVISION

Supervision is a sine qua non in the education of the group therapist. This book describes our approach to therapy and delineates principles of technique that emerge from the empirical roots of group therapy. But the laborious working-through process that constitutes the bulk of therapy cannot be thoroughly depicted in a text. An infinite number of situations arise, each of which may require a rich, imaginative approach. It is precisely at these points that a supervisor makes a valuable and unique contribution to a student therapist’s education. Because of its central importance in training, supervision has become a major focus of attention in the psychotherapy literature.17

We can conceive of the tasks of psychotherapy supervision as threefold: normative, formative, and restorative. The normative elements include setting the stage administratively and practically for the trainee’s clinical work, supervision, and evaluation. The formative elements include guiding the trainee session to session in the principles that link theory and practice. The restorative elements include supporting the trainee in the face of the challenges of the clinical work: bearing strong emotion, dealing with countertransference, fostering remoralization, and promoting trainee wellness.18

We want our trainees to learn not only how to be effective group therapists but also how to take care of themselves professionally. The work we do is difficult: extensive exposure to the traumatic experiences of our clients can generate feelings of vicarious traumatization. Psychotherapist burnout—the triad of feeling exhausted, disengaged, and ineffective—is a growing concern in our field. Prevention, in the form of engaging in self-care, setting appropriate limits, maintaining collegial connectedness, and redefining professionalism to include personal balance, is preferable to downstream efforts at recovery. Burnout damages the provider and in turn compromises good clinical care.19

What are the characteristics of effective supervision? Supervision first requires the establishment of a supervisory alliance that conveys to the student the ambiance and value of the therapeutic alliance. This encompasses student and supervisor agreement regarding the goals, tasks, and nature of the supervision relationship. Supervision not only conveys technical expertise and theoretical knowledge but also models and transmits the profession’s values and ethics. Accordingly, supervisors must strive for congruence: they should treat their students with the same respect and care that the student should provide to clients. If we want our trainees to treat their clients with respect, compassion, and dignity, then that is how we must treat our trainees.20 Training is enhanced when the hidden curriculum aligns with the manifest curriculum.

The supervisor should focus on the professional and clinical development of the trainee and be alert to any blocks—either from lack of knowledge or from countertransference—that the trainee encounters. A fine balance must be maintained between training and therapy. Anne Alonso suggests that the supervisor should listen like a clinician but speak like a teacher, never crossing the boundary into therapizing the supervisee.21

The most effective supervisors are able to tune in to the trainee, track the trainee’s central concerns, capture the essence of the trainee’s narrative, guide the trainee through clinical dilemmas, and demonstrate personal concern and support. Supervision that is unduly critical, shaming, or closed to the trainee’s principal concerns will not only fail educationally but also dispirit the trainee. The effective supervisor pays careful attention to any emotional reactions to the supervisee’s clinical presentation and uses that as data to deepen his or her understanding of the supervisee and of the clients being presented in supervision.22

How personal and transparent should the supervisor be? The same principles we described for the group therapist in Chapter 7 apply here. The supervisor must be able to identify his or her motivation and the likely impact of personal disclosure in supervision. By revealing their own experiences and clinical challenges, supervisors reduce the power hierarchy and help the trainee see that there is no shame in not having all the answers. What’s more, such a revealing and nondefensive stance will influence the type of clinical material the trainee will bring to supervision. If we expect our clients to accept their imperfections without crushing shame, the principle of acceptance must be echoed in the supervision of the group therapist.

Supervisees report that judicious supervisor disclosure promotes a sense of collegiality and reduces the hierarchy of the relationship.23 I (ML) have at times found it helpful to describe my tendency to avoid aggression, for example. Being the child of Holocaust survivors, I learned from a young age to reduce interpersonal tensions. In my therapy practice I am careful not to enact that avoidance. This supervisory disclosure has been helpful in addressing the difference between the components of countertransference that can be attributed to our client’s impact on us (objective) and that which we bring into our work with our clients (subjective). A cardinal task of psychotherapy training is developing the trainee’s capacity to become self-aware of countertransference, to be able to recognize it, and to harness its therapeutic power.24

Leading a first group is a highly threatening experience for the neophyte group therapist. Until the therapist appreciates how to harness the group forces constructively, he or she may be in a state of group shock, overwhelmed by the clinical material, the public exposure of his or her abilities, and the fear of the group failing to launch. Even conducting psychoeducational groups, with their clear content and structure, can be inordinately challenging to the neophyte.25 In a study of neophyte trainees, researchers compared trainees who had positive and negative group therapy training experiences. Both groups reported high degrees of apprehension and strong, distressing emotional reactions early in the work. One variable distinguished the two groups: the quality of the supervision. Those reporting greater satisfaction with their supervision were far more likely to feel positive about their subsequent group therapy experience than those reporting less satisfaction.26

In another study, my (IY) colleagues and I examined twelve nonprofessionally trained leaders of groups in a psychiatric hospital. Half received ongoing supervision as well as an intensive training course in group leadership; the others received neither. Observers—who did not know which therapists received supervision and which did not—rated the therapists at the beginning of their groups and again six months later. The results indicated not only that the trained therapists had improved, but that the untrained therapists were less skilled at the end of the period than they had been at the beginning.27 Sheer experience, apparently, is not enough. Without ongoing supervision and evaluation, original errors may be reinforced by simple repetition: trainees may lose therapeutic confidence, shrink their range of interventions, and become less effective.

Supervision may be even more important for the neophyte group therapist than for the budding individual therapist because of the inherent stress in the group leader role. We have had many trainees report anxiety-laden dreams just before commencing their first group experience. These are filled with images about being out of control or confronting some threatening group situation. Because they arise so frequently, we routinely inquire about such dreams to depathologize initial trainee anxiety.

It is not only the neophyte who benefits from the support and reflective space that supervision provides. I (ML) was shaken by an experience I had several years ago. It took place in a demonstration group I led at a conference.

> A woman volunteered to join a demonstration group I was leading only to use time in the group to roundly criticize my teaching and group leadership earlier in the day. She left virtually no part of me untouched by her attack. I was overcome with feelings of vulnerability and shame and was acutely aware of the irony that I was to be honored the next day with an award for outstanding contributions to our field.

My task in the demonstration group was to protect this individual from being scapegoated by the other group members, who jumped to my defense. Identifying why she would seek to participate in this group at all remained a puzzle to me in the limited time we had, but it was certainly a signal that more was at play than met the eye. I was affected by her attack, not the least part of which was its public nature, which is of course what happens for our group trainees.

An intervention by a colleague in the audience was very helpful. He texted me after the session, telling me that he had some interesting information to share with me. He, too, was puzzled by this attack, and he approached this woman afterward and inquired why she had been so upset and critical. That led to a conversation about her learning difficulties. It seemed that she was upset that I had used an academic approach to teaching in the morning, rather than being entirely experiential. Because of a learning disability, such academic presentations were “deadening” to her. She elaborated to my colleague that because of her learning disability, she had felt humiliated in every course of study and had completed her training only with significant learning accommodations. He asked her whether she had ever protested this before so powerfully, to which she replied, “Never until today.”

That information helped settle me enormously. It underscored that she had seized an opportunity to do something she had not been able to risk doing in the past. By not rebuking her in the group, I allowed her to feel safe enough to protest—and perhaps to offset her usual feeling of failure by projecting that onto me.

What struck me was that I was an experienced clinician with many years of practice and was on the cusp that week of receiving a significant honor, yet my sense of myself as a therapist and my understanding of my work was roiled by her attack. What was very helpful to me in regaining my equanimity was talking with a trusted colleague who saw what I did not. It was fortunate that in this instance he had additional information regarding “the backstory.”

Supervision often provides that backstory. The supervisor is able to see things beneath what is manifest that the trainee does not yet appreciate. <<

A few practical recommendations may be helpful. First, supervision should be well established before the first group, both to attend to the selection and preparation tasks of group leadership and to address therapist apprehension about starting the group. One supervisory hour per group therapy session is, in our experience, the optimal ratio. It can be logistically challenging to find time for the group, for the co-therapists’ postgroup discussion, and for supervision, but it is wise to hold the supervisory session soon after the group session, preferably the following day. Some supervisors observe the last segment of each meeting and hold the supervisory session immediately thereafter. At the very least, the supervisor must observe one or two sessions at the beginning of supervision and, if possible, an occasional session throughout the year; this enables the supervisor to affix names to faces and also to sample the affective climate of the group.

An added benefit of live observation is that even the most committed trainees will miss important material in their process notes. We have often had the experience of writing five pages of notes while observing a group segment that might be reported by our supervisees in thirty seconds. The move to competency-based health-care provider education demands even greater direct observation of our trainees and the provision of tailored feedback.28 Video recordings may serve this purpose as well (audio recordings, too, though far less satisfactorily).

If too much time elapses between the group meeting and the supervisory session, the events of the group fade; in this case, students are well advised to make detailed postgroup process notes. Therapists develop their own styles of note taking. Our preference is to record up to three major themes for each session. For example: (1) Joaquin’s distress at losing his job and the group’s efforts to offer support; (2) Sharita’s anger at the men in the group; (3) Annabelle’s feelings of inferiority and of not being accepted by the group.

Once this basic framework is in place, other vital data can be added: the transition between themes, each member’s contribution to each of the themes, and therapist interventions and feelings about the meeting as a whole and toward each of the members. Other supervisors suggest that students pay special attention to choice points—a series of critical points in the meeting where action was required of the therapist. Still others make use of client feedback obtained from questionnaires distributed at the end of a group session (see Chapter 13 regarding monitoring of outcome and process).29

A ninety-minute group session provides a wealth of material. If trainees present a narrative of the meeting and discuss each member’s verbal and nonverbal contribution as well as the trainees’ own participation and reactions toward each of the group members, there should be more than enough important material to occupy the supervisory hour. If the trainee quickly runs out of material, or if the supervisor has to scratch hard to learn the events of the meeting, something has gone seriously wrong in the supervisory process. At such times a supervisor would do well to examine his or her relationship with the trainee. Is the student guarded, distrustful, or fearful of being exposed to scrutiny, perhaps more invested in protecting his or her self-esteem than in learning?30

The supervisory session is no less a microcosm than is the therapy group. The supervisor should be able to obtain much information about the therapist’s behavior in a therapy group by attending to the therapist’s behavior in supervision. (Sometimes this phenomenon is referred to as the “parallel process” in supervision.) Important emotions that are felt in any component of the group-therapist-supervisor system are likely to be expressed throughout that system and can be addressed productively in supervision.31

If students lead groups as co-therapy teams (and, as Chapter 13 explains, we recommend that format for neophyte therapists), a process focus in the supervisory hour is particularly rich. It is likely that the relationship of the two co-therapists in the supervisory hour parallels their relationship during the therapy group meetings. Supervisors should attend to such issues as the degree of openness and trust during the supervisory hour. Who reports the events of the meeting? Who defers to whom? Do the co-leaders report two bewilderingly different views of the group? Is there much competition for the supervisor’s attention? The relationship between co-therapists is of crucial importance for the therapy group, and the supervisor is maximally effective by focusing attention on this relationship.

In the ongoing work, the supervisor must explore the student’s verbal and nonverbal interventions and check that they help establish useful group norms. At the same time, the supervisor must avoid making the student so self-conscious that spontaneity is stunted.

Most supervisors will at times tell a supervisee what they themselves would have said at some juncture of the group. It is not uncommon, however, for student therapists to mimic the supervisor’s comments at an inappropriate spot in the following group meeting and then begin the next supervisory session with: “I did what you said, but…” Thus, when we tell a student what we might have said, we often preface our comments with, “Don’t say this at the next meeting, but here’s one way you might have responded…” But at some pivotal points, it can be very helpful to suggest a particular intervention. Here, too, a delicate balance needs to be maintained. Although we are often explicit in supervision about the principles that underpin our interventions, supervision should rarely be prescriptive and never heavy-handed.

Supervision Groups

Many supervisors have, to good effect, expanded the supervisory hour into a continuous case seminar for several trainees, with the group leaders taking turns presenting their group to the entire supervision group. Since it takes time to assimilate data about all the members of a group, we prefer that one group be presented for several weeks before moving on to another. In this format, three to four groups can be followed throughout the year. In our experience this works best with more advanced supervisees.

There are several benefits to providing group therapy supervision in a group format. For one thing, it may be possible for a skillful supervisor to focus on the interaction and the group dynamics of the supervisory group. The participants’ self-reflection on the supervision group can be very instructive in illuminating the dynamics of the therapy groups. The supervisees’ lived experience of risk-taking, of belonging (or not), of feeling shamed or silenced, become powerful portals into the clinical work. Another benefit of group supervision is the presence of peer support, which helps to normalize the developmental challenges of leading therapy groups. The impact of group cohesion and the holding, containing function of the group can also be brought to life.32

Furthermore, accounts of colleagues’ experiences, conceptualizations, and techniques expose trainees to a greater range of group therapy phenomena and broaden their empathic awareness. Trainees also have the opportunity to think like a supervisor or consultant, a skill that will be useful at other points in their careers.33 Feedback about one’s clinical work is often a delicate process. Supervision groups teach members to communicate authentically, respectfully, and empathically.

A group supervision format may also encourage subsequent participation in a peer supervision group by demonstrating the value of peer supervision, consultation, and support.34 The supervision group should not, however, transform itself into a personal growth or therapy group—that group experience involves a substantially different set of norms and expectations.

A Multicultural Orientation and Supervision

Some recent supervision innovations have made good use of the Internet to offer supervision to practitioners living in isolated or distant locales. Facilitated online supervision groups now occur routinely, bringing together trainees from around the world.35 This approach has been a mainstay of training within the Yalom Institute in China. This program, led by Ruthellen Josselson, PhD, and me (ML), has provided ongoing supervision, with translation, of course, to scores of Chinese mental health professionals and trainees.36 Culture plays a crucial role both in training and in psychotherapy. Attitudes about self-expression, emotional expression, and authority are different in the West than in many other parts of the world.

Among the initial challenges we faced in providing training in China was the tendency for our students (and their clients) to defer to authority, to seek conferred wisdom, and to comply without assertion or protest. Therapy and supervision were very top-down, much less collaborative than in the West, and required our constant attention to the impact of cultural norms and expectations on our work together. Even these statements, however, are less true now than when we began our work there ten years ago, reflecting the large cultural shifts rapidly occurring in today’s world.

One of the key messages in supervision and training of psychotherapists and group therapists is this: Understanding culture is central. Therapist multicultural orientation is strongly correlated with significantly better clinical outcomes. The hallmarks of culturally resonant care include cultural humility, the therapist’s openness to new learning without presumption or disrespect; cultural comfort, the therapist’s examination of his or her thoughts and feelings regarding the client’s cultural identities or culturally focused material in therapy; and cultural opportunity, seizing opportunity to discuss cultural issues.37

Within our psychotherapy groups these issues become even more important. Not only is discrimination corrosive to mental health, but the social microcosm of the group provides a unique arena for difficult dialogues about race and privilege that are not often possible in other settings. This is challenging work, fraught with the hazards of unintended adverse events arising from microaggressions that invalidate, diminish, or otherize group members based upon cultural stereotypes. But the group also has the potential to promote healing more broadly in our society and to disrupt the intergenerational transmission of race-based trauma. It is essential work, and the experience of our trainees in supervision will shape their capacity to do this work well. Both a safe space and a brave space need to be preserved in our groups.38

A GROUP EXPERIENCE FOR TRAINEES

For decades, a group experiential component was widely accepted as an integral part of training. Across a range of disciplines, this is much less so today. Although they are still prominent in many psychiatry training programs, some surveys show an overall decline in these training opportunities—part of the de-emphasis on psychological and psychotherapeutic treatments in psychiatry training programs.39 We believe strongly that these training group experiences offer many types of learning not available elsewhere. Members are able to learn at an emotional level what they may previously have known only intellectually. They experience the power of the group—power both to wound and to heal. They learn how important it is to be accepted by the group; what self-disclosure really entails; how difficult it is to reveal your secret world, your fantasies, your feelings of vulnerability, hostility, and tenderness. They learn to appreciate their own strengths as well as their weaknesses. They learn about their own preferred role in the group, about their habitual countertransference responses, and about group-as-a-whole and system issues that lurk in the background of the meetings. They learn about group process and the hazards of oversimplified explanations. Perhaps most striking of all, they learn about the role of the leader by becoming aware of their own dependency and their own often unrealistic appraisal of the leader’s power and knowledge.40 These are the reasons why this form of training continues to be so popular in continuing professional development.

Even experienced practitioners who are being trained in a new model of group therapy benefit greatly when an experiential affective component is added to their didactic training. Personal participation is the most vital way to teach and to learn group process. That is the approach I (ML) and colleagues used in training a national network of group therapists in a multisite trial of supportive-expressive group therapy for women with metastatic breast cancer.41

The most common model is a group composed of other trainees and referred to by any number of terms (T-group, support group, process group, experiential training group, and so on). This may be a short-term group, lasting perhaps a dozen sessions, or an intensive one- or two-day experience. The model we recommend is a process group that meets for sixty to ninety minutes each week for a year.

We have led groups of mental health trainees for over thirty years and, without exception, have found these groups to be highly valuable educationally. Indeed, many psychotherapy students, when reviewing their training programs, have rated their group as the single most valuable experience in their curriculum. A group experience with one’s peers has a great deal to recommend it: members not only learn how to lead a group but also, if the group is led properly, bond with each other. Relationships and communication within the trainee class improve, enriching the entire educational experience. Students always learn a great deal from their peers, and any efforts that potentiate that process increase the value of the program. The group can also play an important role in promoting therapist wellness and self-care.

> In a T-group of psychiatry residents, an older male resident asked an attractive, aloof, younger female resident, Tiffany, why she appeared so distant. Much to his surprise, she welcomed his overture and acknowledged that she knew she had a reputation as “The Ice Queen.” She added that she was isolated and lonely in the residency and hoped to lessen the aura of detachment she conveyed to others. She then disclosed that “the residency is particularly challenging for me because of all the suicidal patients I am caring for; and because my father, also a physician, took his own life after abusing narcotics for some time prior to his death. No one—not my colleagues nor my supervisors—knows that. This is the first I am speaking of it.”

I (ML) paused and checked in with Tiffany to determine how the pace and depth of disclosure felt. Through her tears, she responded that she felt relief and an unburdening. The group was very supportive, thanked her for her courage and trust, and then dove into a deep and meaningful discussion of physician mental health and why suicide rates were so high in the profession. They determined that the least they could offer one another in the residency was a lessening of that isolation and toxic self-reliance. <<

Are there also disadvantages to a group experience? One often hears storm warnings about the possible destructive effects of staff or trainee experiential groups. These are by and large urban myths, and in our experience the warnings are based on irrational premises: for example, that enormous amounts of destructive hostility ensue once a group unlocks suppressive floodgates, or that groups precipitate an enormous invasion of privacy as forced confessionals are wrung one by one from each of the hapless trainees. We know now that responsibly led groups that are clear about norms and boundaries facilitate communication and constructive working relationships.

Should Training Groups Be Voluntary?

An experiential group is always more effective if the participants engage voluntarily and view it not only as a training exercise but as an opportunity for personal growth. Indeed, we prefer that trainees begin such a group with an explicit formulation of what they want to obtain from the experience personally as well as professionally. To this end, it is important that the group be introduced and described to the trainees in such a way that they consider it to be consonant with their personal and professional goals. We prefer to frame the group within the students’ training career by asking them to project themselves into the field of the future. It is, after all, highly probable that mental health practitioners will spend an increasing amount of their time in professional groups—both as members and leaders of treatment teams. Their clients will be in groups as well. To be effective in this role, clinicians of the future will simply have to know their way around groups. They will have to learn how groups work and how they themselves work in groups.

Once an experiential group is introduced as a regular part of a training program, and once the faculty develops confidence in the group as a valuable training adjunct, there is little difficulty in selling it to incoming trainees. Still, programs differ on whether to make the group optional or mandatory. Our experience is that if a group is presented properly, the trainees not only look forward to it with anticipation but experience strong disappointment if for some reason the opportunity for a group experience is withheld.

Nadiya Sunderji, Jan Malat, and I (ML) reviewed several years of data from evaluations of our annual intensive experiential group day model. In this model, sixty to eighty residents meet in groups of eight to ten participants for the day with an experienced leader. Although residents were required to attend twice in the four years of residency, many of them went beyond the requirement. It is a safe learning experience, and the evaluations are uniformly positive. For the study, participants reported that they were much more self-disclosing than they expected to be and that feedback from peers was more valuable than they anticipated. We consistently receive feedback that the day has much personal significance as well as professional value.42 Participants reported the following benefits:

• Gaining firsthand experience as a group participant

• Appreciating the patient’s perspective

• Understanding the difficulty of self-disclosure

• Learning about themselves in a safe setting

• Learning more about their colleagues and making a better connection with them

• Learning about group process and group facilitation techniques

• Improving their skills as group leaders

Who Should Lead Student Experiential Groups?

Directors of training programs should select the leaders for trainee groups with great care. For one thing, the group experience is an extraordinarily influential event in the students’ training career; the leader will often serve as an important role model for the trainees and therefore should have extensive clinical and group experience and the highest possible professional standards. The overriding criteria are, of course, the personal qualities and skill of the leader; a much lesser consideration is the leader’s professional discipline.

We believe that a training group led by a leader skilled in the interactional group therapy model provides the best educational experience.43 Supporting this view is a study of 434 professionals who participated in two-day American Group Psychotherapy Association training groups. Process-oriented groups that emphasized here-and-now interaction resulted in significantly greater learning about leadership and peer relations than groups that were more didactic or structured. The members felt they profited most from an atmosphere in which leaders supported participants, demonstrated techniques, and facilitated an atmosphere in which members supported one another, revealed personal feelings, and took personal risks.44

Is the Training Group a Therapy Group?

This is a vexing question. In training groups of professionals, no other issue is so often used in the service of group resistance. It is wise for leaders to present their views about training versus therapy at the outset of the group. We begin by asking that the members make certain commitments to the group. Each member should be aware of the requirements for membership: a willingness to invest oneself emotionally in the group, to disclose feelings about oneself and the other members, and to explore areas in which one would like to make personal changes.

There is a useful distinction to be made between a therapy group and a therapeutic group. A training group, though it is not a therapy group, is therapeutic in that it offers the opportunity to learn about oneself. By no means, though, is each member expected to do extensive therapeutic work.

The basic contract of the group, in fact, its raison d’être, is training, not therapy. To a great extent, these goals overlap: a leader can offer no better group therapy training than that of an effective therapeutic group. Furthermore, every intensive group experience contains within it great therapeutic potential: members cannot engage in effective interaction, cannot fully assume the role of a group member, cannot get feedback about their interpersonal styles and their blind spots, without some therapeutic spin-off. Yet that is different from a therapy group that assembles for the purpose of accomplishing extensive therapeutic change for each member of the group.

Leader Technique

The leader of a training group of mental health professionals has a demanding job: he or she not only must be a role model, by shaping and conducting an effective group, but must also make certain modifications in technique to deal with the specific educational needs of the group members. Leading these groups can be stressful for the group facilitators. They are exposed to the scrutiny of the group participants (who may also be evaluating the leader’s effectiveness) and may dread a group that becomes defensively avoidant and boring, or, worse yet, a group that becomes unsafe for the trainees.

Nevertheless, our suggestions for leaders of training groups do not deviate from the guidelines for leading groups we have outlined throughout this book. For example, the leader is well advised to retain an interactional, here-and-now focus. It is an error to allow the group to move into a supervisory format where members describe problems they confront in their clinical work: such discussion should be the province of the supervisory hour. Whenever a group is engaged in discourse that can be held equally well in another formal setting, it is failing to capitalize on its unique properties and achieve its full potential. Instead, members can discuss these work-related problems in more profitable, group-relevant ways. For example, they might discuss how it would feel to be the client of a particular member. The group is also an excellent place for two members who happen to work together as co-leaders to work on their relationship.

There are many ways for a leader to use the members’ professional experience in the service of the group work. In a therapy group, the expression and integration of affect and the recognition of here-and-now process are essential but secondary considerations to the primary goal of promoting individual therapeutic change. In a training group of mental health professionals, the reverse is true. There will be many times when the T-group leader will seize an opportunity for explication and teaching that a group therapist would seize for deeper emotional exploration. This rebalancing of emotional activation and cognitive integration is one of two key modifications we have found useful.

The second modification focuses on leader transparency. We are much more likely to show our thinking in these groups. We are also unusually self-disclosing—in effect, we give the members more on us than we have on them. In so doing, we model openness and communicate how unlikely it would be for us to adopt a judgmental stance toward them. Leader transparency offered in the service of training lowers the perceived stakes for the participants by normalizing their concerns.

For example, we have often made transparent statements to the training group in the following vein: “The group has been very slow moving today. When I inquired, you told me that you felt ‘lazy’ or that it was too soon after lunch to work. If you were the leader of a group and heard this, what would you make of it? What would you do?” Or, “Not only are Joanie and Stewart refusing to work on their differences, but others are lining up behind them. What are the options available to me as a leader today?” In a training group, we are inclined, much more than in a therapy group, to explicate group process. In therapy groups, if there is no therapeutic advantage in clarifying group process, we see no reason to do so. In training groups, there is always the superordinate goal of education.

Often process commentary combined with a view from the leader’s seat is particularly useful. For example:

> Let me tell you what I (IY) felt today as a group leader. A half hour ago I felt uncomfortable with the massive encouragement and support everyone was giving Tom. This has happened before, and though it was reassuring, I haven’t felt it was really helpful to Tom. I was tempted to intervene by inquiring about Tom’s tendency to pull this behavior from the group, but I chose not to—partly because I’ve gotten so much flak lately for being nonsupportive. So, I remained silent. I think I made the right choice, since it seems to me that the meeting developed into a very productive one, with some of you getting deeply into your feelings of needing care and support. How do the rest of you see what’s happened today? <<

In a particularly helpful essay, Mark Aveline, an experienced leader of training groups, suggests that the leader has five main tasks:

1. Containment of anxiety through exploration of sources of anxiety in the group and provision of anxiety-relieving group structure

2. Establishment of a therapeutic atmosphere in the group by shaping norms of support, acceptance, and group autonomy

3. Establishing appropriate goals that can be addressed in the time available

4. Moderating the pace so that the group moves neither too fast nor too slowly, so that members do not engage in forced or damaging self-disclosure

5. Ending well45

PERSONAL PSYCHOTHERAPY

A training group rarely suffices to provide all the personal self-exploration a student therapist requires. Few would dispute that personal psychotherapy is necessary for the maturation of the group therapist, and the field at large has long considered personal therapy an indispensable element of personal and professional development. The role of personal psychotherapy for psychotherapists has spawned many studies and surveys.46

A large, early survey of 318 practicing psychologists indicated that 70 percent had entered therapy during their training—often more than one type of therapy: 63 percent in individual therapy (mean = 100 hours); 24 percent in group therapy (mean = 76 hours); 36 percent in couples therapy (mean = 37 hours). What factors influenced the decision to enter therapy? Psychologists were more likely to engage in therapy if they had an earlier therapy experience in their training, if they were dynamically oriented in their practice, and if their practice involved significant amounts of psychotherapy.47 In another survey, over half of psychotherapists entered personal psychotherapy after their training, and over 90 percent reported considerable personal and professional benefit from the experience.48

What about more recent studies? A national survey of 600 nonmedical psychotherapists reported that 85 percent engaged in personal psychotherapy and 90 percent of those who did reported benefits. Top motivations for treatment were relationship distress, depression, pursuit of self-understanding, and dealing with stress or anxiety. Enduring lessons that emerged from personal therapy included the importance of therapist reliability, skill, and empathy. These are the hallmarks of good psychotherapy.

Surveys of psychiatry residents provide another perspective.49 A survey of 400 Canadian psychiatry residents reported that 43 percent pursued therapy while in training. They were motivated by the desire for personal growth, self-understanding, and professional development; one-third sought care because of mental health concerns. The personal and professional impacts were very positive. A comparable US study showed a lower and declining participation rate of 26.5 percent. Here, too, the motivations were a mix of personal need and professional development. Program directors are largely supportive and encouraging of their residents pursuing psychotherapy, but time and cost persist as barriers to access.50

The survey methodology can only inform us of so much due to variable response rates, yet consistent findings emerge: Respondents have great interest in personal therapy and report clear benefit from their therapy. Without doubt, the training environment influences the pursuit of personal therapy among trainees, and more should be done to facilitate that pursuit. It is a grave concern that American psychiatrists today are so much less likely to pursue personal therapy than was the case for the prior generation.51

We both consider our personal psychotherapy experiences during our residencies to be an important part of our training as therapists. Moreover, in later years, I (IY) reentered therapy with therapists of various persuasions, including Gestalt, behavioral, and existential. We urge every student entering the field not only to seek out personal therapy but to do so more than once during their careers—different life stages evoke different issues to be explored. The emergence of personal discomfort is an opportunity for greater self-exploration that will ultimately make us better therapists.52

Both the challenge and the richness of our work lies in our ability to use ourselves as therapeutic agents. Our tools are largely our models and ourselves. Our self-knowledge plays an instrumental role in every aspect of therapy. An inability to perceive our countertransference responses, to recognize our personal distortions and blind spots, or to use our own feelings and fantasies in our work will severely limit our effectiveness.

If you lack insight into your own motivations, you may, for example, avoid conflict in the group because of your proclivity to mute your feelings; or you may unduly encourage confrontation in a search for aliveness in yourself. You may be overeager to prove yourself or to make consistently brilliant interpretations, and thereby disempower the group. You may fear intimacy and prevent open expression of feelings by offering premature interpretations—or do the opposite: overemphasize feelings, make too few explanatory comments, and overstimulate clients, so that they are left in agitated turmoil. You may so need acceptance that you are unable to challenge the group and, like the members, get swept along by the prevailing group current. You may be so devastated by an attack on yourself and so unclear about your presentation of self as to be unable to distinguish the realistic from the transference aspects of the attack.

There is another excellent reason to recommend personal therapy for all psychotherapists. It is an excellent resource for maintaining wellness and reducing the risk of burnout.53

Several training programs have historically encouraged their candidates to participate as bona fide members in a therapy group led by a senior clinician and composed of nonprofessionals seeking personal therapy.54 Advocates of such programs point out the many advantages to being a real member of a therapy group. There is less sibling rivalry than in a group of one’s peers, less need to perform, less defensiveness, and less concern about being judged.

Experience as a full member of a bona fide therapy group is invaluable, and we encourage all trainees to seek such therapy. Unfortunately, the right group can be hard to find. Advocates of personal group therapy for trainees hail from large metropolitan areas (New York, London, Toronto, Geneva). But in smaller urban areas, the availability of personal group therapy is limited. There are simply not enough groups that meet the proper criteria—that is, an ongoing, high-functioning group led by a senior clinician with an eclectic dynamic approach (who, incidentally, is neither a personal nor a professional associate of the trainee).

The use of online groups (see Chapter 14) creates new opportunities for therapists and trainees to join and participate regardless of their location. The online format adds insulation that allows therapists to feel less professionally exposed to colleagues in their local community. The growth of good, reliable, HIPAA-compliant VTC platforms will foster much greater use of this format.

There is one other method of obtaining both group therapy training and personal psychotherapy. For several years, I (IY) led a therapy group for practicing psychotherapists. In fact, for one year, this was a group that we led as co-therapists during ML’s fellowship at Stanford University. It was a straightforward therapy group, not a training group. Admission to the group was predicated on the need and the wish for personal therapy, and members were charged standard therapy group fees. Naturally, in the course of their therapy, the members—most but not all of whom are also group therapists—learn a great deal about the group therapy process.

SUMMARY

The training experiences we have described—observation of an experienced clinician, clinical supervision in group therapy, experiential group participation, and personal therapy—constitute, in our view, the minimum essential components of a program to train group therapists. These build atop a comprehensive education in the theory and underpinnings of group therapy. We recommend that observation, personal therapy, and the experiential group begin very early in the training program, to be followed in a few months by the formation of a group and ongoing supervision. We feel it is wise for trainees to have a clinical experience in which they deal with basic group and interactional dynamics in traditional group therapy before they begin to work with goal-limited groups of highly specialized client populations or with one of the new specialized therapy approaches.

Training is, of course, a lifelong process. Every discipline sets expectations for continuing professional development. We feel strongly that this should not be a perfunctory undertaking, but should reflect a deep commitment to deliberate practice. It is important as well that clinicians maintain contact with colleagues, either informally or through professional organizations such as the American Group Psychotherapy Association (AGPA) or the Association for Specialists in Group Work. For growth to continue, ongoing input is required. Many formats for continued education exist, including reading, working with different co-therapists, teaching, participating in professional workshops, webinars, and having informal discussions with colleagues. Postgraduate personal group experiences are a regenerative process for many. The AGPA offers two-day experiential groups led by highly experienced group leaders at its annual institute, which regularly precedes its annual meeting. Follow-up surveys attest to the value—both professional and personal—of these groups.55 Many of the AGPA’s local affiliate societies offer similar opportunities.

Another format is for practicing therapists to form leaderless support groups. Though, until recently, there has been little in the literature on support groups of mental health professionals, I (IY) can personally attest to their value. For over thirty years I have benefited enormously from membership in a group of ten therapists of my own age and level of experience that meets for ninety minutes every other week. As time went by, several members of the group aged and died, and new members were introduced into the group. Currently, I am the oldest member. Our group has evolved a clear consensus of expectations, goals, and norms to ensure that we stay on track and address our personal issues and our own group process.56 I have greatly benefited from the work of this group, and I recommend such a group to all mental health practitioners.

BEYOND TECHNIQUE

The group therapy training program has the task of teaching students not only how to do but also how to learn. What clinical educators must not convey is a rigid certainty in either our techniques or our underlying assumptions about therapeutic change; the field is far too complex and pluralistic for disciples of unwavering faith. To this end, we believe it is most important that we teach and model a basic research orientation to this work—meaning an open, self-critical, inquiring attitude toward clinical and research evidence. As we have noted earlier, experience alone does not confer effectiveness. Rather, it is what we do with that experience that influences our professional growth.

Recent developments in psychotherapy research underscore this principle. We can all be evidence-based group therapists regardless of our theoretical models. Ultimately, it is the therapist more than the model that produces benefits. We believe the effective therapist is characterized by these key elements: the ability to form strong therapeutic relationships across a range of clients; strong interpersonal skills; professional humility and self-reflection; and a dedication to learning and refining one’s craft.57