Selecting Clients and Composing Groups PDF

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Selecting Clients and Composing Groups G OOD GROUP THERAPY BEGINS WITH GOOD...

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Selecting Clients and Composing Groups G OOD GROUP THERAPY BEGINS WITH GOOD CLIENT SELECTION. Clients improperly assigned to a therapy group are unlikely to benefit from their therapy experience. Furthermore, a poorly composed group may not be helpful to its members or may even disintegrate early in its life. It is therefore understandable that contemporary psychotherapy researchers are actively examining how best to match clients to psychotherapy groups according to their specific characteristics.1 In this chapter we begin by considering both the research evidence bearing on selection and the clinical methods of determining whether a given individual is a suitable candidate for group therapy. We next address the question of group composition: once it has been decided that a client is a suitable group therapy candidate, into which specific group should he or she go? Group therapy is complex, and at every step of the way the group leader should be guided by this question: What must I do to ensure the success of this group? We focus particularly on a specific type of group therapy: the heterogeneous outpatient group pursuing the ambitious goals of symptomatic relief and characterological change. However, many of the general principles we discuss have relevance to 1 of 78 12/16/2024, 3:29 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... other types of groups as well, including the brief problem-oriented group.2 Here, as elsewhere in this book, we provide the reader with fundamental group therapy principles coupled with strategies for adapting these principles to a wide variety of clinical situations. (We will discuss some more specialized clinical situations in Chapter 15.) We would only refer a client to group therapy if we believe that this would be an effective form of treatment for that individual. We start therefore with observations about the benefits of group therapy. Research consistently shows that group therapy is a potent modality producing significant benefit to its participants.3 It also indicates that group therapy offers unique benefits that in certain situations may make it more helpful than individual therapy. The evidence for the effectiveness of group therapy is so persuasive that some experts advocate that group therapy be utilized as the primary model of contemporary psychotherapy, though they also acknowledge that it is a more complex treatment that requires therapists have specific training.4 Individual therapy may be preferable for clients who require active clinical management, or when relationship issues are less important and personal insight and depth understanding are particularly important.5 Group therapy is superior to individual therapy in providing social learning and in helping clients develop social support and improve social 2 of 78 12/16/2024, 3:29 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... networks, factors of great importance for clients with substance use disorders.6 Clients with a medical illness acquire coping skills better in therapy with a group of peers than in individual therapy.7 Adding group therapy to the treatment of women who are survivors of childhood sexual abuse provides benefits beyond individual therapy: it results in reduced shame and greater empowerment and psychological well-being.8 Of course, personal choice matters. Clients tend to do better when they engage the type of therapy they prefer: a therapy that matches their expectations.9 We also recognize that clients may be reluctant to engage in group therapy for a host of reasons that the group leader will need to address as part of the selection and preparation process—an issue we will discuss later in this chapter.10 Predicting which clients will do best in group therapy and which are better referred to another form of therapy is not a simple matter. Each client is different, and decisions about treatment must be tailored to the individual. Our inclusion and exclusion criteria are best viewed as general guidelines, and even experienced clinicians are often surprised by who does much better or much worse than expected.11 Our limited clinical capacity to evaluate who will do well, and how our clients are actually doing, is part of the rationale for incorporating more empirical measurement in our clinical care.12 In many instances, the variables that seem to forecast a client’s failure in 3 of 78 12/16/2024, 3:29 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... group therapy can be offset by thorough preparation, through empathic therapist responsiveness, and by securing a fit with a group that is better suited to that particular client at that point in the client’s treatment trajectory. We want to get this process as right as possible to safeguard the client’s care and to avoid the impact on the entire group of a member who is a poor fit. CRITERIA FOR EXCLUSION Question: How do group clinicians select clients for group psychotherapy? Answer: The great majority of clinicians do not select for group therapy. Instead, they deselect. Given a pool of clients, experienced group therapists determine that certain people cannot possibly work in a therapy group and should be excluded. And then they proceed to accept all the other clients. That approach seems crude. We would all prefer the selection process to be more elegant, more finely tuned. But, in practice, it is far easier to specify exclusion than inclusion criteria; one characteristic may be sufficient to exclude an individual, whereas a more complex profile must be delineated to justify inclusion. Mistakes in selection are costly not only to the individual client but to the entire group. Here is a major guideline: We can predict that clients will fail in group therapy if they are unable to participate in the primary task of the group, be it for logistical, intellectual, psychological, or interpersonal 4 of 78 12/16/2024, 3:29 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... reasons. There is considerable and consistent clinical consensus13 that clients are poor candidates for a heterogeneous outpatient therapy group if they have a significant brain injury,14 are paranoid,15 somatizing,16 addicted to drugs or alcohol,17 acutely psychotic,18 or antisocial.19 More recent studies using validated questionnaires like the Group Selection Questionnaire (GSQ) or the Group Therapy Questionnaire (GTQ) echo this clinical consensus and expand it by indicating that a certain degree of interpersonal skill is required to work in an interpersonal group.20 An additional important point: if clients have no expectation of the group being of value, there is little chance of a successful outcome, and the therapeutic alliance—the alignment of client and therapist about the goals and tasks and quality of the therapeutic relationship—is undermined from the start.21 These considerations are even more compelling for brief, time-limited groups, which are particularly unforgiving of poor client selection. What traits must a client possess to participate in a dynamic, interactional therapy group? Members must have a capacity and willingness to examine their interpersonal behaviors, to self- disclose, to reflect psychologically on themselves and others, to give and receive feedback, and to have some capacity and willingness to engage with the other group members. Unsuitable clients are those who tend to construct an interpersonal role 5 of 78 12/16/2024, 3:29 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... that is rigid and that would prove detrimental to themselves as well as to the group. For such clients the group becomes a venue for re-creating and reconfirming maladaptive patterns. Antisocial clients are exceptionally poor candidates for interactional group therapy. Although early in therapy they may be influential and active members, they will eventually manifest their basic inability to relate, often with considerable dramatic and destructive impact, as the following clinical example illustrates: > Felix, a highly intelligent thirty-five-year- old man with a history of alcoholism and impoverished, exploitative interpersonal relationships, was added with two other new clients to an ongoing group that had been reduced to three by the recent graduation of members. The group had shrunk so much that it seemed in danger of collapsing, and the therapists were eager to reestablish its size. They realized that Felix was not an ideal candidate, but they had few referrals and decided to take the risk. In addition, they were intrigued by his stated determination to change his lifestyle. (Many antisocial individuals are forever “reaching a turning point in life.”) By the third meeting, Felix had become the social and emotional leader of the group. He seemed to feel more acutely and suffer more deeply than the other members. He presented the group, as he had the 6 of 78 12/16/2024, 3:29 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... therapists, with a largely fabricated account of his background and current life situation. By the fourth meeting, as the therapists learned later, he had seduced one of the female members, and in the fifth meeting he spearheaded a discussion of the group’s dissatisfaction with the brevity of the meetings. He proposed that the group, with or without the permission of the therapists, meet more often, perhaps at one of the members’ homes, without the therapists. By the sixth meeting, Felix had vanished, without notifying the group. The therapists learned later that he had suddenly decided to take a two-thousand-mile bicycle trip, hoping to sell an article about it to a magazine. Sandra, a divorced sixty-year-old woman, was referred by her psychiatrist to a newly forming interpersonal thirty-two-session group. She had a history of intense social isolation and a significant problem with hoarding. So great was her shame about hoarding that she had avoided any discussion of it even in a homogeneous group focused on hoarding. She skipped meetings and refused to participate when she did attend. Sandra was referred this time to an interpersonal group with the hope of reducing her anxious avoidance and intense social isolation. She would continue in individual treatment as well. In the first pregroup assessment meeting, what jumped out to me (ML) were all the reasons her group therapy would likely fail again. Sandra evinced many of the factors we have just reviewed: an odd and eccentric presentation with mismatched clothes, intense social avoidance, a sense of shame about the hoarding and unwillingness to talk about it, and interpersonal rigidity. We also discussed her failure in prior group therapy. She was, however, persuasive in the pregroup assessment, articulating that she was determined not to fail this group as she had done with prior groups. Moreover, as the interview progressed, despite the first impression she made, I found Sandra engaging. We determined together that the focus of 27 of 78 12/16/2024, 3:29 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... her group work would be engaging other members and managing the emotions that would emerge. She agreed that no matter the nature of her distress, she would speak of it in the group. To her credit, she began the first session talking about her wish not to fail or flee. She described her life-long expectation of interpersonal catastrophes and her dread of rejection, humiliation, and shame. The other group members appreciated her openness and courage. There were a few early crises that prompted Sandra to email after meetings asking if she should continue in the group. She was concerned about her misinterpretation of others’ actions, her overreaction to group events, and her great fear that the other members would ask her to leave. In each such instance, however, the group and I offered support. She attended thirty of the thirty-two meetings and graduated as a valued member of the group, feeling “human among other humans.”43 Jake, a fifty-eight-year-old single man, believed that the group was very helpful to others but not to him. He declared that he was just much less interested in relationships than the others in the group. He had been in foster care throughout much of his childhood, shuttled from one family to another and, as an adult, he believed relationships were always motivated by self- interest. Despite Jake’s regular attendance and our (ML) apparent agreement about his core issues, little progress was made. Though the group continued to be encouraging and respectful, Jake, after several months, wished the group well and left. Later, in a state of some desperation, he asked for a referral to individual therapy, which ultimately proved more helpful. George, a thirty-eight-year-old man referred to group therapy by his female individual therapist, struggled with his anger and his avoidance of tenderness or dependence that he traced back to the physical abuse he suffered at the hands of his brutal father. (George was also described in Chapter 2 [“Attack First”].) When his young son’s physical playfulness and roughhousing became frightening to him, he sought individual therapy because of his concern that he, too, would become an abusive father. At first the individual therapy progressed well, but soon his therapist became uneasy with George’s crude and aggressive sexual declarations to her. She became particularly concerned when George suggested that he could best express his gratitude to her through sexual means. Stymied in working this through, yet reluctant to end the therapy because of George’s other gains, the therapist referred him to a therapy group, hoping that the concurrent group and individual format would clarify and dilute the intensity of the transference and countertransference. The group provided both support and challenge, and George’s treatment was able to proceed effectively in 39 of 78 12/16/2024, 3:29 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... both venues. Connie, a woman in her forties, was referred by her family physician for group therapy because of her social anxiety, dysthymia, and interpersonal isolation. Immediately on entering the office, she told me (ML) she had a “bone to pick” with me. “How could you leave a message on my answering machine calling me ‘Connie’ and yourself ‘Dr. Leszcz’? Don’t you understand 51 of 78 12/16/2024, 3:29 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... the power imbalance that promotes? Haven’t you heard of feminism and empowerment? Do you treat all the women you know like this, or only your clients?” I was at first jolted and a bit irritated, but after a few moments’ reflection, I considered that she indeed had a point, and I apologized for the wording of my message. Later in the session, as we developed rapport, I returned to her anger about my phone message. She described feeling regularly devalued and bulldozed into silence. It reminded her of the way her father and her ex-husband had treated her. “So how did you feel about my response to your anger?” I asked. “A bit surprised. Almost shocked. I’m not used to apologies from men.” This gave us a useful interpersonal behavior forecast for the group. I suggested to Connie that she may be inclined initially to relate to the group members in the same way that she did with me, but she did have a choice. She could make the group experience yet another in a series of angry disappointments, or she could engage a process of learning and understanding that could interrupt this interpersonal sequence. Anne, a sixty-year-old single woman, was referred by her family doctor for an evaluation for group therapy. She worked in IT, lived alone, and felt safe in her solitude. She described herself as “friendly enough” at work, and she made token appearances at office social functions, eagerly counting down the time until it was acceptable to leave. She was an expert at escape behaviors. She had recently dislocated her shoulder, however, and her struggle coping with that injury forced her to confront her 56 of 78 12/16/2024, 3:29 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... extreme social isolation. She became frightened: without friends, social groups, or anyone to call for help, she realized she had to change and sought therapy. Anne reported no other emotional distress. Of note, she had once had a severe drinking problem, for which she had been successfully treated in residential care twenty-five years earlier. She had had two courses of individual therapy for several years each when she was in her forties, but had little good to say about either therapy or therapists. She acknowledged growing up with a terrifying and emotionally abusive father. She had not been physically or sexually abused, but that threat always loomed large, and it had led her to adopt a defensive policy of “keep my head down and my mouth shut,” which she did with great expertise. The results of Anne’s self-report questionnaires confirmed the clinical picture: Anne was a person with a strongly dismissive, avoidant attachment style. She had experienced significant early life adversity, and she now regarded relationships as dangerous and not worth the risk of engagement. After I (ML) shared my formulation and impressions, Anne expressed particular interest in the traumatic roots of her difficulties. Although she did not have symptoms of psychological trauma in the 57 of 78 12/16/2024, 3:29 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... form of flashbacks, intense anxiety symptoms, or hyperarousal, she showed significant interpersonal consequences of early life exposure to physical threat and emotional abuse. At the same time, she recognized that the isolation was unhealthy for her over the long term, and she acknowledged fears of returning to alcohol. She was eager to learn, and her motivation for engagement in group therapy seemed to build as we were able to focus on how group therapy worked. What seemed most helpful to Anne was understanding that the group would be a safe, cohesive environment and would be led by able therapists who would allow her to proceed at a pace that felt safe. The objective of her group work would be to liberate herself from the fear engendered by her father that had influenced all her relationships. The group would aim to increase her zone of safety in relationships, first within the group and then hopefully outside the group. We talked as well about her propensity to distance herself in relationships, acknowledging that the risk for her would be to dismiss others in the group or flee when afraid. In contrast, I noted that her openness and her risk-taking with me boded well for her participation in group therapy. Alicia, a twenty-nine-year-old woman with prominent narcissistic personality difficulties, was evaluated for group therapy. She was professionally successful but interpersonally isolated, and experienced chronic dysthymia that was only partially ameliorated with antidepressants. When I (IY) saw her for a pregroup consultation, I experienced her as brittle, explosive, highly demanding, and devaluing of others. In many ways, Alicia’s difficulties echoed those of another woman, Lisa, who had just quit the group (thereby creating the opening for which Alicia was being evaluated). Lisa’s intense, domineering need to be at the center of the group, coupled with an exquisite vulnerability to feedback, had paralyzed the group members, and her departure had been met with clear relief by 73 of 78 12/16/2024, 3:29 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... all. At another time, this group and Alicia could have been a constructive fit. So soon after Lisa’s departure, however, it was very likely that Alicia’s characteristic style of relating would trigger strong responses of “here we go again,” reawakening feelings that group members had just painfully processed. An alternative group for Alicia was recommended.