The Theory and Practice of Group Psychotherapy (101 page)

A typical course of therapy consists of one or two preliminary individual meetings and eight to twenty group meetings of ninety minutes each, with an individual follow-up session three or four months later; some practitioners use a midgroup individual evaluation meeting. Group meetings may also be scheduled as booster sessions at regular intervals in the months following the intensive phase of therapy.

The group therapy consists of an initial introduction and orientation phase, a middle working phase, and a final consolidation and review segment.
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Written group summaries (see chapter 14) 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. 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, group IPT generally deemphasizes 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 nonetheless becomes an important social network, through its supportive and modeling functions. In some carefully selected instances, group here-and-now interaction may be employed and linked to the client’s focus and goals.

SELF-HELP GROUPS AND INTERNET SUPPORT GROUPS

A contemporary focus on specialized groups would be incomplete without considering self-help groups and their youngest offspring—Internet support groups.

Self-Help Groups

The number of participants in self-help groups is staggering. A 1997 study that antedates Internet support groups reported that 10 million Americans had participated in a self-help group in the preceding year, and a total of 25 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. 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 is 20 million individuals in the previous year and 50 million overall—figures that far exceed the number of people receiving professional mental health care.
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Although it is difficult to evaluate the effectiveness of freestanding self-help groups, given that membership is often anonymous, follow-up is difficult, and no records are kept, some systematic studies attest to the efficacy of these groups. Members value the groups, report improved coping and well-being, greater knowledge of their condition, and reduced use of other health care facilities.
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These findings have led some researchers to call for a much more active collaboration between professional health care providers and the self-help movement. Is there a way that self-help groups can effectively address the widening gap between societal need and professional resources?
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One important advance is the number of active self-help clearinghouses accessible online or by phone that have emerged to guide consumers to the nearly 500 diverse types of self-help groups in operation. Examples include the American Self-Help Clearinghouse and the National Mental Health Consumers Self-Help Clearinghouse.

Self-help groups have such high visibility that it is barely necessary to list their various forms. One can scarcely conceive of a type of distress, behavioral aberration, or environmental misfortune for which there is not some corresponding group. The roster, far larger than the psychopathologies described in DSM-IV-TR, includes widespread groups such as AA, Recovery, Inc., Compassionate Friends (for bereaved parents), Mended Hearts (for clients with heart disease), Smoke Enders, Weight Watchers, Overeaters Anonymous, and highly specialized groups such as Spouses of Head Injury Survivors, Gay Alcoholics, Late-Deafened Adults, Adolescent Deaf Children of Alcoholics, Moms in Recovery, Senior Crime Victims, Circle of Friends (friends of someone who has committed suicide), Parents of Murdered Children, Go-Go Stroke Club (victims of stroke), Together Expecting a Miracle (adoption support). Some self-help groups transform into social action and advocacy groups as well, such as MADD (Mothers Against Drunk Driving).

Although the self-help groups resemble that of the therapy group, there are some significant differences. The self-help group makes extensive use of almost all the therapeutic factors—especially 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.
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It is rare for a group to be able to focus significantly and constructively on the here-and-now without the participation of a well-trained leader. In general, self-help groups differ from therapy groups in that they have far fewer personality interpretations, less confrontation, and far more positive, supportive statements.
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Most self-help groups employ a consistent, sensible cognitive framework that the group veterans who serve as the group’s unofficial leaders can easily describe to incoming members. Although members benefit from universality and instillation of hope, those who actively participate and experience stronger cohesiveness are likely to benefit the most.
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What accounts for the widespread use and apparent efficacy of self-help groups? They are open and accessible, and they offer psychological support to anyone who shares the group’s defining characteristics. They emphasize
internal
rather than
external
expertise—in other words, the resources available in the group rather than those available from external experts. The members’ shared experience make them both peers and credible experts. Constructive comparisons, even inspiration, can be drawn from one’s peers in a way that does not happen with external experts. Members are simultaneously providers
and
consumers of support, and they profit from both roles—their self-worth is raised through altruism, and hope is instilled by their contact with others who have surmounted problems similar to theirs. Pathology is deemphasized and dependency reduced. It is well known that passive and avoidant coping diminish functional outcomes. Active strategies, such as those seen in self-help groups, enhance functional outcome.
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Ailments that are not recognized or addressed by the professional health care system are very likely to generate self-help groups. Because these groups effectively help members accept and normalize their malady, they are particularly helpful to victims of stigmatizing ailments.
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Groups for substance use disorders are doubtless the most widely found self-help groups. More than 100,000 AA groups exist around the world in over 150 countries.
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The twelve-step model is not only used in AA, but variants of it are used by many other professional providers and by many other self-help groups, such as Narcotics Anonymous, Overeaters Anonymous, Sex Addicts Anonymous, and Gamblers Anonymous. Although some members have misgivings about AA’s spiritual focus, research shows that a lack of a personal commitment to spirituality does not interfere with treatment effectiveness.
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Although twelve-step groups do not use professional leadership, many other self-help groups (perhaps more than half) have a professional leader who is active in the meeting or serves in an advisory or consultant capacity. Occasionally a mental health professional will help launch a self-help group and then withdraw, turning over the running of the group to its members.
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Any mental health professional serving as a consultant must be aware of the potential dangers in too strenuous a demonstration of professional expertise: the self-help group does better if the expertise resides with the members.

A final note: group therapists should not look at the self-help group movement as a rival but as a resource. As I have discussed in chapter 14, many clients will benefit from participation in both types of group experience.

Internet Support Groups

Just a few years ago, the idea of Internet virtual group therapy seemed the stuff of fantasy and satire. Today, it is the real-life experience of millions of people around the world. Consider the following data: 165,640,000 Americans are Internet users; 63,000,000 have sought health information online; 14,907,000 have participated in an online symposium at some time,
and in a recent polling a remarkable 1,656,400 participated in an Internet support group the preceding day!
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Internet support groups take the form of
synchronous
, real-time groups (not unlike a chat line) or
asynchronous
groups, in which members post messages and comments, like a bulletin board. Groups may be time limited or of indeterminate duration. In many ways they are in a state of great flux: it is too early in their evolution for clear structures or procedures to have been established. Internet support groups may be actively led, moderated, or run without any peer or professional executive input. If moderators are used, their responsibility is to coordinate, edit, and post participants’ messages in ways that maximize therapeutic opportunity and group functioning.
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How can we account for this explosive growth? Internet support group participants and providers have described many advantages. Many individuals, for example, wish to participate in a self-help group but are not able to attend face-to-face meetings because of geographic distance, physical disability, or infirmity. Clients with stigmatizing ailments or social anxiety may prefer the relative anonymity of an Internet support group. For many people in search of help, it is the equivalent of putting a toe in the water, in preparation for full immersion in some therapy endeavor. After all, what other support system is available 24/7 and allows its members time to rehearse, craft, and fine-tune their stories so as to create an ideal, perhaps larger-than-life narrative?
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A recent experience as a faculty member in a month-long American Group Psychotherapy Association online training symposium was eyeopening. The program was an asynchronous (that is, bulletin board model) moderated virtual group for mental health professionals on the treatment of trauma. More than 2,000 people around the world signed up, although only a small fraction posted messages. The experience was vital and meaningful, and the faculty, like many of the participants, thought much about the postings during the day and eagerly checked each night to read the latest informative or evocative posting. Although we never met face to face, we indeed became a group that engaged, worked, and terminated.

Internet support groups have several intrinsic problems. The current technology is still awkward and lacks reliability and privacy safeguards. Members may, intentionally or through oversight, post inaccurate messages. Identities and stories may be fictionalized. Communication of emotional states may be limited or distorted by the absence of nonverbal cues. Some experts worry that the Internet contact may deflect members from much-needed professional care or squeeze out actual support in the lives of some participants.
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Keep in mind, too, that a group is a group and Internet groups do have a process. They are not immune to destructive norms, antigroup behavior, unhealthy group pressures, client overstimulation, and scapegoating.
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There are ethical concerns about professional involvement in Internet support groups.
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Professionals who serve as facilitators need to clarify the nature of their contract, how they will be paid for their services, and the limits of their responsiveness online to any emergencies. They must obtain informed consent, acknowledge that there are limits to confidentiality, and provide a platform for secure communication. In addition they must identify each participant accurately and be certain of how to contact each person, and they must indicate clearly how they themselves can be reached in an emergency. Keep in mind geographic limits with regard to licensure and malpractice insurance. A therapist licensed in one state may not be legally able to treat a client residing in another state.
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Many questions about Internet support groups clamor for attention. Are they effective? If so, is it the result of a particular intervention approach or of more general social support and interaction? Can face-to-face group models translate to an online format? What are the implications for health care costs? What kind of special training do online therapists require? Can therapists communicate empathy in prose as readily as in face-to-face interaction?

Although Internet support groups are at an early stage of development, some notable preliminary findings have emerged. In many ways, such groups lend themselves well to research. The absence of nonverbal interaction may be a disadvantage clinically, but it is a boon for the researcher, since everything (100 percent of the interaction) that goes on in the group is in written form and hence available for analysis.