The Theory and Practice Of Group Psychotherapy PDF

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Creating the Group O NCE THE CLIENTS FOR A THERAPY GROUP ARE SEL...

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Creating the Group O NCE THE CLIENTS FOR A THERAPY GROUP ARE SELECTED, group therapists must turn their attention to launching the group.1 First, therapists must secure an appropriate meeting place and make a number of practical decisions about the structure of their group: its size and life span, the admission of new members, the frequency of meetings, and the duration of each session. Considerations for leading psychotherapy groups online will be discussed in Chapter 14. In addition to the therapy group itself we must also consider a second “group”—the group of colleagues who will refer clients; the administrators who support the structure required for success; and the third-party payer, insurer, or managed care organization that may be paying for the treatment.2 Good collaboration with this second group is essential to the success of the therapy group. Groups that meet under the auspices of an organization (for example, a community agency or hospital clinic) may be affected by that organization’s culture, level of stability, and attitudes toward psychotherapy.3 In private practice, many practitioners publicize their clinical work and their models of therapy through the use of engaging websites and social 1 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... media. Although marketing may feel commercial at first, it is merely the contemporary version of professional networking. A professional presence on Facebook, Twitter, LinkedIn, YouTube, and Instagram can inform prospective referral sources and clients of your group therapy offerings. Workshops for group therapists on using social media to help grow their practices have become popular.4 Publicizing one’s work is more than self- promotion. Clinicians have a responsibility to educate the public, destigmatize group therapy, and build strong clinical practice organizations with well-trained clinicians who are properly credentialed, ideally as Certified Group Psychotherapists (CGPs).5 They must urge third- party payers to attend to the robust empirical research supporting group therapy’s effectiveness. The recognition of group psychotherapy as a designated professional specialty by the American Psychological Association will elevate the status of group therapy and underscore the importance of proper group therapy training and continued professional development.6 Many colleagues and administrators unfamiliar with group therapy tend to devalue it until they are educated about its effectiveness and its equivalence to individual therapy in outcome. Our clinical and administrative colleagues also need to understand that group therapy is a complex treatment to deliver and requires therapist expertise. Many college counseling centers, for example, have a 2 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... group therapy coordinator who is responsible for informing referral sources and prospective clients about the efficacy and mechanics of therapy groups. It is constructive to have a group therapy champion in institutional settings.7 SETTING AND STRUCTURE Group meetings may be held in any room that affords privacy and freedom from distractions. In institutional settings, the therapist must negotiate with the administration to establish an inviolate time and space for the therapy group. The first step of a meeting is to form a circle so that members can all see one another. To be avoided are seating arrangements that block members’ views of one another, such as long, rectangular tables, or sofas that seat three or four people. If members are absent, most therapists prefer to remove the empty chairs and form a tighter circle to foster cohesion. If the group session is to be videotaped or observed through a one-way mirror by trainees, the group members’ permission must be obtained in advance and ample opportunity provided for discussion of the procedure. Written consent is essential if any audiovisual recording is planned, even if it is to be used only for supervision purposes. A group that is observed usually seems to forget about the observation after a few sessions, unless there are unresolved group issues about trust, power, or safety. If only one or two students are regular observers, we suggest seating 3 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... them in the room but outside of the group circle. This avoids the intrusion of the mirror and allows the students to sample more of the group affect, which inexplicably is often filtered out by the mirror. Observers should be cautioned to remain silent and to resist any attempts by group members to engage them in the discussion. (See Chapter 16 for further discussion about group observation.) Open and Closed Groups The leader determines if the group is to be open or closed. A closed group, once begun, shuts its gates; accepts no new members, except perhaps within the first two or three sessions; and meets for a predetermined length of time. An open group, by contrast, maintains a consistent size by replacing members as they leave the group. Groups may have a predetermined life span—for example, groups in a college counseling service may plan to meet only through the academic year. In other settings, many open groups continue indefinitely, even though every couple of years there may be a complete turnover of group membership—at times including leadership changes. We know of therapy groups in psychotherapy training centers that have endured for twenty or thirty years and are bequeathed every year or two by a graduating therapist to an incoming student therapist. Open groups tolerate changes in membership better if there is some consistency in leadership. One way to achieve this in the training setting is for the group to have co-therapists, and when the senior co-therapist leaves, the remaining therapist 4 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... continues as the senior group leader and a new co- therapist joins.8 Such continuity maintains the culture and cohesion of the group. Most closed groups are briefer therapy groups that meet weekly for eight months or less. A longer closed group may have difficulty maintaining membership stability. Invariably, members drop out, move away, or face some unexpected scheduling incompatibility. Groups do not function well if they become too small, and new members must be added lest the group perish from attrition. For that reason, we advise starting closed groups with nine or ten members so that a core of six or seven is likely to remain in the group until its conclusion. A long-term closed-group format is feasible in a setting that assures considerable stability, such as a prison, a military base, and occasionally an outpatient group in which all members are concurrently in individual psychotherapy with the group leader (see Chapter 13). Some therapists lead a closed group for six months, at which time members evaluate their progress and decide whether to commit themselves to another six months.9 Some intensive partial hospitalization programs begin with an intensive phase of closed group therapy, which is followed by an extended, open group therapy aftercare maintenance phase. The closed phase emphasizes common concerns and acquisition of fundamental skills. The open phase aims to reduce relapse, reinforces the gains made during the intensive phase, and helps clients apply their gains more broadly in their own social 5 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... environments. Some clients may attend monthly booster group sessions indefinitely. This model has worked well in the treatment of substance abuse, trauma, and geriatric depression.10 Size of the Group What is the optimal size for a successful therapy group? Our own experience and a consensus of the clinical literature suggest that the ideal size of a cohesive interactional therapy group is seven or eight members, with an acceptable range of five to nine members.11 Louis Ormont reported good success with a group size as large as twelve to fourteen members, a model employed by some practitioners of the modern group analytic model.12 And the smallest size of an effective group? When a group is reduced to four or fewer members, it often ceases to operate as a group; member interaction diminishes, and therapists can find themselves engaged in individual therapy within the group. A small group is manageable over a short period due to vacations and absences, but in the long run, members disengage; many of the advantages of a group, especially the opportunity to interact and analyze one’s interactions with a large variety of individuals, are compromised. Small groups become passive, suffer from stunted development, and frequently develop a negative group image.13 Obviously, the group therapist must replace members quickly, but appropriately. If new members are unavailable, 6 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... therapists do better to meld two small groups rather than to continue limping along with insufficient membership in both. Acknowledging that a group has too few members to flourish emancipates the clients and therapist for new therapeutic opportunities. The upper limit of therapy group members is determined by sheer economic principles. As the group increases in size, less and less time is available for the working through of any individual’s problems. If members do not feel they are at the center of the group, cohesion will suffer. Subgrouping may emerge as clients try to find some way to reduce their sense of isolation in the group.14 Since it is likely that one, or possibly two, clients will drop out of the group in the course of the initial meetings, many therapists start a new group with eight to ten members. Starting with a group size much larger than ten in anticipation of dropouts may become a self-fulfilling prophecy. Some members will quit because the group is simply too large for them to participate productively. Larger groups of twelve to sixteen members may meet productively in day hospital settings, because each member is likely to have many other therapeutic opportunities over the course of each week. Alcoholics Anonymous and other twelve- step groups that do not focus on interpersonal interaction (these groups in fact discourage interpersonal feedback and label it as crosstalk; see Chapter 13) may range from twenty to eighty 7 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... participants. Psychoeducational groups for conditions such as generalized anxiety may meet effectively with twenty to thirty participants; these groups actively discourage individual disclosure and interaction, relying instead on imparting information about anxiety and stress reduction.15 Similar findings have been reported in the treatment of panic disorder and agoraphobia as well as a range of other conditions.16 The large-group format has also been used with cancer patients, often accompanied by training in stress reduction and self-management of illness symptoms or medical treatment side effects. These groups may contain forty to eighty participants meeting weekly for two hours over a course of six weeks.17 If we think of the health-care system as a pyramid, large groups of this type are part of the broad base of accessible, inexpensive treatments at the system’s entry level. For many, this provision of knowledge and skills is sufficient. Clients who require more assistance may move up the pyramid to more focused or intensive interventions.18 A range of therapeutic factors may operate in these groups. Large homogeneous groups accept, humanize, normalize, destigmatize, activate feelings of universality, and offer skills and knowledge that enhance self-efficacy. AA groups offer inspiration, guidance, and practical tools for dealing with the challenges of a sober life. Altruism also plays a role—helping others reinforces self-esteem and deepens a personal sense of mastery. 8 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Duration and Frequency of Meetings For many years, the length of a psychotherapy session has been static: the fifty-minute individual hour and the eighty- to ninety-minute group therapy session were part of the entrenched wisdom of the field. Most group therapists agree that, even in well-established groups, at least sixty minutes is required for the warm-up interval and for the unfolding and working through of the major themes of the session. There is also some consensus among therapists that after about two hours, the session reaches a point of diminishing returns: the group becomes weary, repetitious, and inefficient. Moreover, therapists appear to function best in segments of eighty to ninety minutes; with longer sessions therapists often become fatigued and less effective. Although the frequency of meetings varies from one to five times a week, the overwhelming majority of groups meet once weekly. It is often logistically difficult to schedule multiple weekly outpatient group meetings, and few therapists have led an outpatient group that meets more than once a week. But, were it possible, we would choose to meet with groups twice weekly: such groups are more intense, the members continue to work through issues raised in the previous session, and the entire process takes on the character of a continuous meeting. Some therapists meet twice weekly for two or three weeks at the start of a time-limited group to launch the group and turbocharge its intensity before moving to a once- weekly model.19 9 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Weekly sessions promote a greater therapeutic connection, whereas groups meeting less frequently have difficulty maintaining an interactional focus and instead tend to focus on life events and crisis resolution. Less frequent meetings are less efficient and result in lengthened treatment.20 Set a meeting time that facilitates group members’ attendance. Group therapists in private practice recognize the demands of consistently working some evenings as a fact of life. In efforts to achieve “time-efficient therapy,” group leaders have experimented with many aspects of the frame of therapy, but none more than the duration of the meeting.21 Back in the heyday of encounter groups in the 1960s and 1970s, therapists held weekly meetings that lasted four, six, even eight hours—a protocol that now seems both worrisome and wondrous. Some group therapists referred their entire group for a weekend with another therapist or, more commonly, conducted a marathon meeting with their own group sometime during the course of therapy. The objective was to accelerate therapy by exhausting group members and mobilizing group pressure to wear down member resistance and promote deeper and deeper disclosure. The time-extended format was later adapted by such commercial enterprises as EST (Erhard Seminars Training) or Lifespring. Today, these large group awareness training programs have virtually disappeared.22 The therapists who still regularly or periodically 10 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... hold time-extended group meetings represent a small minority of practitioners. There have been occasional recent reports of intensive, and effective, retreat weekends for various conditions, such as substance abuse, panic disorder, PTSD, and bulimia.23 These approaches consist of a comprehensive program that includes group therapy and psychoeducation but not the intensive confrontation and fatigue characteristic of the marathon approach. Some therapists augment weekly group therapy for clients with cancer with an intensive weekend retreat for skill building, reflection, and meditation. Mindfulness group therapies often supplement weekly sessions with one or two full-day weekend meetings. But the purpose is intensive meditational practice rather than wearing down clients’ ego defenses.24 We make reference to the marathon movement not because it has much current usage, or to pay homage to it as a chapter in the history of psychotherapy, but because of what it reveals about how therapists make clinical practice decisions. Over the past several decades, our field has been taken by storm through a series of ideological and stylistic fads. Reliance on the fundamentals of our work and on well-constructed systematic research is the best bulwark against being swept along and zealously embracing and then quickly discarding the fashion of the day. Highly extravagant claims about the effectiveness of marathon group therapy were widely publicized at the time but were based entirely on anecdotal reports of various 11 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... participants or on questionnaires distributed shortly after the end of a meeting—an exceedingly unreliable approach to evaluation. In fact, any outcome study based solely on interviews, testimonials, or client self-administered questionnaires obtained immediately at the end of the group is of questionable value. At no other time is the client more loyal, more grateful, and less objective about a group than at termination, when there is a powerful tendency to recall and to express only positive, tender feelings. Experiencing and expressing negative feelings about the group at this point would be unlikely for at least two reasons: (1) there is strong group pressure at termination to participate in positive testimonials—few group participants, as Solomon Asch has shown, can maintain their objectivity in the face of apparent group unanimity;25 and (2) members reject critical feelings toward the group at this time to avoid a state of cognitive dissonance. In other words, once an individual invests considerable emotion and time into a group and develops strong positive feelings toward other members, it becomes difficult to question the value or activities of the group. Is it possible, as is sometimes claimed, that a time-extended meeting accelerates the maturation of a therapy group, and that it increases openness, intimacy, and cohesiveness, thus facilitating insight and therapeutic breakthroughs? My (IY) colleagues and I studied this question and found that marathon sessions at the start of a course of group therapy did not favorably influence the 12 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... communication patterns in subsequent meetings.26 In fact, there was a trend in the opposite direction: after the six-hour meetings, the groups appeared to engage in less here-and-now interaction. The influence of the six-hour meeting on cohesiveness was quite interesting. In the three groups that held a six-hour initial meeting, there was a trend toward decreased cohesiveness in subsequent meetings. In the three groups that held a six-hour eleventh meeting, however, there was a significant increase in cohesiveness in subsequent meetings. Thus, timing is a consideration: it is entirely possible that, at a particular juncture in the course of a group, a time-extended session may help increase member involvement in the group. These results showed that cohesiveness can be accelerated but not brought into being by time-extended meetings. The marathon group phenomenon makes us mindful of the issue of transfer of learning. There is no question that the time-extended group can evoke powerful affect and can encourage members to experiment with new behavior. But does a change in one’s behavior in the group invariably beget a change in one’s outside life? Clinicians have long known that change in the therapy session is not tantamount to therapeutic success. Change, if it is to be consolidated, must be carried over into important outside interpersonal relationships and endeavors and tested again and again in these natural settings. Of course, therapists wish to accelerate the process of change, but the evidence suggests that it is the duration, consistency, and frequency of treatment that is 13 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... central to therapy’s effectiveness. The transfer of learning is laborious and demands a certain irreducible amount of time—even more so for individuals who have had chronic mood, characterological, and interpersonal difficulties.27 Consider, for example, a male client who, because of his early experience with an authoritarian, distant, and harsh father, tends to see other males, especially those in a position of authority, as having similar qualities. In the group he may have an entirely different emotional experience with a male therapist and perhaps with some of the male members. What has he learned? Well, for one thing he has learned that not all men are frightening bastards—at least there are one or two who are not. Of what lasting value is this experience to him? Probably very little unless he can generalize the experience to future situations. He must learn how to differentiate among people so as not to perceive all men in a predetermined manner. Once he is able to make the necessary discriminations, he must learn how to go about forming relationships on an egalitarian, distortion- free basis. For the individual whose interpersonal relationships have been impoverished and maladaptive, these are formidable and lengthy tasks that often require the continual testing and reinforcement available in the long-term therapeutic relationship. BRIEF GROUP THERAPY 14 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Brief group therapy has become an important and widely used therapy format. Third-party insurers and therapists as well strive relentlessly for briefer, less expensive, and more efficient forms of therapy.i A survey of managed care administrators responsible for the health care of over seventy- three million participants noted that they were interested in the use of more groups but favored brief, problem-homogeneous, structured groups.28 Other factors also favor brief therapy. For example, many geographic locations have high service demands and low availability of mental health professionals; here, brevity translates into greater access to services. College counseling centers use a wide range of brief, tailored group therapies to meet the growing mental health needs of their student clients.29 Brief group therapy can also play a key role in a stepped care model: as a starting point, or setting the stage for further therapy, or sufficient in itself. How long is “brief”? Some clinicians define brief as sixteen to twenty-five sessions, and others as fifty or sixty meetings.30 Inpatient groups, with rapid turnover, may be thought of as having a life span of a single session. The research on cohesion suggests twelve sessions as the shortest duration for an effective brief therapy group.31 Twelve sessions also appears to be the minimum “dose” required to ensure that at least 50 percent of clients in therapy will improve.32 Alternately, we can offer a functional rather than a temporal definition: A brief group is the shortest group life span that 15 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... can achieve some specified goal—hence the felicitous term “time-efficient group therapy.”33 A group dealing with an acute life crisis, such as a job loss, might last four to eight sessions, whereas a group addressing major relationship loss, such as divorce or bereavement, might require twenty or more. A group for dealing with a specific symptom complex, such as eating disorders or sexual abuse victims, might last eighteen to twenty-four sessions. A “brief” group with the goal of changing enduring characterological problems might last twenty or more sessions.34 There are promising approaches that are even briefer, often eight sessions, and utilize intensive preparation to identify a specific interpersonal focus for each group member to work on in the group.35 Explorations into the “dose-effect” of individual psychotherapy shed some light on the question of duration of therapy as it relates to patterns of improvement. This research looks at patterns of improvement over time for clients with a range of clinical concerns.36 Although no comparable dose- effect research in group therapy has been reported, it seems reasonable to assume that there are similar patterns of response to group therapy. Researchers note that clients who normally cope well but who are facing a crisis generally require a small number of therapy hours to achieve significant improvement. Often eight sessions or fewer are sufficient to return many clients to their precrisis level. The vast majority of clients with more chronic difficulties require about fifty to 16 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... sixty sessions to improve, and those with significant personality disturbances require even more. The greater the impairment in trust and the earlier in one’s development the individual has suffered loss or trauma, the greater the likelihood that brief therapy will be insufficient. Many clients with chronic depression who show initial improvement require a longer continuation phase of therapy to reduce the risk of relapse. Failure of prior brief therapies is also often a sign of the need for a longer therapy.37 The reality that many of our clients need longer treatments is often neglected and clients are often undertreated. The actual measurement of client progress coupled with regular objective feedback about the client’s experience of therapy can aid in determining how much therapy is sufficient (see Chapter 13).38 Whatever the precise length of therapy, all brief psychotherapy groups share many common features. They all strive for efficiency; they contract for a discrete set of goals and attempt to stay focused on goal attainment; they tend to stay in the present (with either a here-and-now focus or a “there-and-now” recent-problem-oriented focus); they draw attention to the temporal restrictions to accelerate client engagement; they emphasize the transfer of learning from the group to the real world; their composition is often homogeneous for some problem, symptomatic syndrome, or life experience; and they focus more on interpersonal than on intrapersonal concerns.39 Pregroup preparation, clarity about goals, attention to client 17 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... culture and identity, and a clear therapeutic focus are of particular importance in brief group therapy.40 For some clients a brief course of group therapy may be the entire treatment, whereas for others it may be considered an installment of treatment—an opportunity to do a piece of important work, which may or may not require other installments in the future.41 It is important that we recognize both the power and the limits of brief group therapy. Keep in mind that if the brief group therapy has been effective, it is likely that client gains will continue to consolidate after active therapy ends.42 When leading a brief therapy group, a group therapist is wise to heed these general principles: The brief group is not a truncated long-term group.43 Group leaders must have a different mental set: they must clarify goals, focus the group, manage time, and be active and efficient. Since group members tend to deny their group’s temporal limits, leaders of brief groups must act as group timekeeper, periodically reminding the group how much time has passed and how much remains. The leader should regularly make comments such as: “This is our twelfth meeting. We’re two-thirds done, but we still have six more sessions. It might be wise to spend a few minutes today reviewing what we’ve done, what goals remain, and how we should 18 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... invest our remaining time. Let’s make sure we leave as little unsaid and undone as possible.” Leaders must attend to the transfer of learning by encouraging clients to apply what they have learned in the group to their situations outside the group. They must emphasize that treatment is intended to set change in motion, but not necessarily to complete the process within the confines of the scheduled treatment. Leaders should attempt to turn the disadvantages of time limitations into an advantage. Since the time-limited therapy contributions of Carl Rogers, we have known that imposed time limits may increase efficiency and energize the therapy.44 Also, the fixed, imminent ending may be used to heighten awareness of the existential dimensions of life: time is not eternal; the immediate encounter matters; the ultimate responsibility rests within, not without: there will be no magic solution to problems.45 This approach counters the posture of resistance common to clients of “What can we do in so short a time?” and is useful in even the briefest of groups. Keep in mind that the official name of the group does not determine the work of therapy. Just because the group is made up 19 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... of recently divorced individuals or survivors of sexual abuse does not mean that the focus of the group is “divorce” or “sexual abuse.” It is far more effective for the group’s focus to be interactional, directed toward those aspects of divorce or abuse that have ramifications in the here-and-now of the group. For example, clients who have been abused can work on their shame, their rage, their reluctance to ask for help, their distrust of authority (often focused upon the leaders), and their difficulty in establishing intimate relationships. Groups of recently divorced members will work most profitably not by a prolonged historical focus on what went wrong in their marriages but by examining each member’s problematic interpersonal issues as they manifest in the here-and-now of the group. Members must be helped to recognize and change these patterns so that they do not impair future relationships. This may feel like an unnatural focus for clients seeking support and comfort and therefore should be anticipated and addressed in the pregroup preparation sessions. Processing within the here-and-now (“hot processing”) is more powerful than processing external relationships outside of the group (“cold processing”).46 20 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Effective group therapists should be flexible and use all means available to increase efficacy. Techniques from cognitive or behavioral therapy may be incorporated into the interactional group to alleviate symptomatic distress. For example, the leader of a group for binge eating may recommend that members explore the relationship between their moods and their eating in a written journal, or log their food consumption, or meditate to reduce emotional distress. But by no means is this the sole approach available: brief group work that focuses on the interpersonal concerns that reside beneath the food-related symptoms is as effective as brief group work that targets the disordered eating directly.47 In other words, therapists can think of symptoms as issuing from disturbances in interpersonal functioning and alleviate the symptom by repairing the interpersonal disturbances. Time is limited, but leaders must not make the mistake of trying to save time by abbreviating the pregroup individual session. On the contrary, leaders must exercise particular care in preparation and selection.48 The most important single error made by busy clinics is to screen new clients by phone and immediately introduce them 21 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... into a group without an individual screening or preparatory session. Such an approach undermines the client’s alliance with the group leader and hampers the development of group cohesion. Brief groups are less forgiving of errors than long-term groups. When the life of the group is only, say, twelve sessions, and two or three of those sessions are consumed by attending to an unsuitable member who then drops out (or must be asked to leave), the cost is very high: the development of the group is obstructed, levels of trust and cohesion are slower to develop, and a significant proportion of the group’s precious time and effectiveness is sacrificed. Use the pregroup individual meeting not only for standard group preparation but also to help clients reframe their problems and sharpen their goals so as to make them suitable for brief therapy.49 Some group therapists will use the first group meeting to ask each client to present his or her interpersonal issues and treatment goals as a way of jump-starting the group.50 Some clinicians have sought creative ways to bridge the gap between brief and longer-term treatment. One approach is to follow the brief group with booster group sessions scheduled at 22 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... greater intervals, perhaps monthly, for another six months.51 Another approach offers clients a brief group but provides them with the option of signing on for another series of meetings. One program for clients with chronic illness consists of a series of twelve-week segments with a two-week break between segments.52 Members may enter a segment at any time until the sixth week, at which time the group becomes a closed group. A client may attend one segment and then choose at some later point to enroll for another segment. The program has the advantage of keeping all clients, even the long-term members, goal-focused. Are brief groups effective? Outcome research on brief group therapy has increased substantially, and for many clients, the answer is a clear yes. We summarize only a few notable findings here and encourage readers to examine the comprehensive summary of this literature published by the American Group Psychotherapy Association and other comprehensive reviews.53 An analysis of forty-eight reports of brief therapy groups (both cognitive-behavioral and dynamic/interpersonal) for the treatment of depression demonstrated that groups that met, on average, for twelve sessions produced significant clinical improvement: group members were almost three times more likely to improve than clients waiting for treatment.54 Furthermore, therapy groups add substantially to the effect of pharmacotherapy in the treatment of depression.55 Both expressive-interpretive groups and supportive 23 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... groups for clients with loss and grief have been proven effective.56 Meta-analyses and reviews also confirm that brief group therapy is effective for clients with binge eating disorders or with panic disorder.57 Clients with borderline personality disorder reported improvement in mood and behavior at the end of twenty-five sessions.58 Brief group therapy is also effective in the psychological treatment of the medically ill. It improves coping and stress management, reduces mood and anxiety symptoms, and improves self- care.59 How do brief and longer-term group therapy compare? A well conducted comparative trial of brief versus longer-term group analytic therapy (twenty sessions vs. eighty sessions) showed remarkable and equivalent effectiveness across a range of clinical difficulties. The briefer treatment also had much lower dropout rates. The researchers noted that the brief group therapy was more challenging to deliver well and required much higher levels of therapist activity. Not surprisingly, however, clients with personality disorders benefited more from the longer-term treatment.60 In sum, research demonstrates the effectiveness of brief group therapy.61 We can lead brief groups with confidence; we know there is much we can offer clients in the brief format. But clients with evidence of chronic psychological or characterological difficulties and a history of failed brief therapies require a longer-term group. Don’t 24 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... be swept away by the powerful contemporary push for efficiency at the expense of client need. One of the architects of the NIMH Collaborative Treatment of Depression Study, one of the largest psychotherapy trials ever conducted, raised a caution that our field has likely oversold the power of brief psychotherapy.62 PREGROUP MEETINGS AND PREPARATION FOR GROUP THERAPY There is great variation in clinical practice regarding individual sessions with clients prior to group therapy. Some therapists, after seeing prospective clients once or twice in selection interviews, do not meet with them individually again, whereas others continue individual sessions until the client starts in the group. If several weeks are required to accumulate sufficient members, the therapist is well advised to continue to meet with each member periodically to prevent significant attrition. At the very least we recommend a follow- up meeting closer to the start of the group, which is also an ideal time for a preparation session. Even in settings with plenty of appropriate group therapy referrals, it is important to maintain client momentum and interest. One way to do this is to set a firm start date for the group and then focus energetically on recruitment and assessment. A group leader may need to invest twenty to twenty- five hours in selection and preparation to assemble one group. It is always time well spent. 25 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... It is our clinical impression that the more often clients are seen by their group leader before entering the group, the less likely they are to terminate prematurely from the group. Often the first step in the development of bonds among group members is their mutual identification with the therapist. Keep in mind that the purpose of the individual pregroup sessions is to build a therapeutic alliance in which client and therapist agree about the goals and tasks of group therapy as well as the nature of the relationship they hope to develop. This, in turn, sets the stage for the development of group cohesion. One other overriding task must be accomplished in the pregroup interview or interviews: the preparation of the client for group therapy. If we had to choose the one area where research has the greatest relevance for practice, this would be it: There is highly persuasive evidence that pregroup preparation plays a very positive—even an essential—role in the course of group therapy. Group leaders must achieve several specific goals in the preparatory procedure: Clarify misconceptions and unrealistic fears about group therapy Anticipate and diminish the emergence of problems in the group’s development Provide clients with a cognitive structure that facilitates effective group participation Generate realistic and positive expectations about the group therapy 26 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Challenge clients’ stigmatizing myths and negative assumptions about group therapy Misconceptions About Group Therapy Certain misconceptions and fears about group therapy are so common that if the client does not mention them, the therapist should point them out as potential problems. Despite powerful research evidence on the efficacy of group therapy, many people still believe that group therapy is second- rate. Clients may think of group therapy as cheap therapy—an alternative for people who cannot afford individual therapy or a way for insurers to increase profits. Others regard it as diluted therapy because each member has only twelve to fifteen minutes of the therapist’s time each week. Still others believe that the raison d’être of group therapy is to accommodate more clients with fewer therapists. Such misunderstandings continue to pose a challenge for many clients, even in the current era of greater public attention regarding mental health. Let us illustrate by examining some representative surveys of public beliefs about group therapy. A number of surveys of individuals seeking mental health care, including college students and community members, identify common concerns and misconceptions:63 Group therapy is wild and unpredictable and involves a loss of personal control—for example, groups may coerce members into 27 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... uncomfortable self-disclosure. Group therapy is not as effective as individual therapy because effectiveness is proportional to the attention received from the therapist. Group therapy generates greater risk of feelings of shame and rejection. Being in a group with many individuals with significant emotional disturbance is in itself detrimental and can worsen the mental health of vulnerable individuals. Individual therapy is widely preferred to group therapy, particularly by men. Culture plays a role as well. Clients from non-Western and collectivist traditions may be apprehensive about public displays of emotion or of personal need. Fear of shame may be crippling.64 A British National Health Service study of sixty-nine moderately distressed clients seeking therapy reported that more than 50 percent declared that they would not enter group therapy even if no other treatment were available. Clients feared ridicule and shame, the lack of confidentiality, and being made worse through some form of contagion. What are some of the sources of this strong antigroup bias? For many of our clients, the natural groups that have been part of their lives have usually been “part of the problem,” not “part of the solution.” The client’s initial reaction to the idea of participating in group therapy may be recollections of bullying and 28 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... marginalization. Hence, groups in general are distrusted, and the individual therapy setting is considered a more protected, safe, and familiar zone. This is particularly the case for those with no prior experience in therapy.65 In general, the media and fictional portrayals of group therapy are vastly inaccurate, often portraying therapy groups in a mocking, ridiculing fashion.ii Reality television shows may also play a role. They speak to our unconscious fears of being exposed and extruded from our group because we are found to be defective, deficient, or are deemed to be the “weakest link.”66 Whatever their sources, such misconceptions and apprehensions must be countered; otherwise these strong negative expectations may make successful group therapy outcome unlikely. Nor are these unfavorable expectations limited to the general public or to clients. A survey of psychiatric residents found similar negative attitudes toward group therapy.67 Lack of exposure in psychiatry training programs is part of the problem, but the strength of resistance to remedying these training shortfalls suggests that antigroup attitudes may be deeply rooted and even unconscious. Thus, it should not surprise us to find such attitudes within institutional and administrative leadership. The biological- psychological split in current psychiatry fuels these kinds of prejudices as the field polarizes between a focus on the brain and a focus on the mind, as though these were disconnected in the 29 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... experience of our clients.68 Furthermore, the challenge of learning to lead groups is significant, and human nature often leads us to devalue that which makes us anxious.69 In addition to evaluative misconceptions, clients usually harbor procedural misconceptions and unrealistic interpersonal fears. Many of these are evident in the following dream that a client reported at her second pregroup individual session shortly before she was to attend her first group meeting: > I dreamed that each member of the group was required to bring cookies to the meeting. I went with my mother to buy the cookies that I was to take to the meeting. We had great difficulty deciding which cookies would be appropriate. In the meantime, I was aware that I was going to be very late to the meeting, and I was becoming more and more anxious about getting there on time. We finally selected the cookies and proceeded to go to the group. I asked directions to the room and was told that it was meeting in room 129A. I wandered up and down a long hall in which the rooms were not numbered consecutively and in which I couldn’t find a room with an “A.” I finally discovered that 129A was located behind another room and entered. While looking for the room, I had encountered many people from my past, schoolmates and folks I had known for 30 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... years. The group was large: about forty or fifty people were milling about. I saw members of my family—most specifically, two of my brothers. Each member had to stand up and talk about their problems. The whole dream was very anxiety-provoking— especially being late and the huge number of people in the group. After going through the content of the preparation session, Shelley, a fifty-year- old woman with a history of chronic depression and social anxiety, commented, “I so appreciate your diligence around the entry and preparation for people into the group. I take it as a sign of how serious an undertaking this is, and it increases my sense of hope about it helping me; I feel valued and cared for.” The co-therapists welcomed her spontaneous feedback and noted that she was already addressing her 46 of 57 12/16/2024, 3:38 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... stated goals of taking more interpersonal risks and moving into the center of her life from the sidelines she typically inhabits. In the very next hour, the two therapists had a preparation session with Norma, a forty-year-old single mother, also with chronic depression, who characteristically adopted a harsh, judgmental stance. She expected people to fall short and to disappoint her. Her dismissive and irritable stance throughout the preparation session was palpable, and when we asked her how the session was for her, she responded with, “Why are you wasting time doing this? You haven’t told me anything that I can’t read myself in the handout. Why all the rigmarole?” The co-therapists both felt rebuked and diminished but recalled that Norma had stated that one of her goals in therapy was “learning what I do that pisses off so many people around me.” One of the therapists commented that Norma seemed irritated with them, and Norma apologized for being so critical, stating that she realized the therapists were trying to be helpful. She also requested that they not just give her feedback about what she did wrong, but also try to help her change.