The Theory and Practice of Group Psychotherapy (109 page)

Since every training community has some experienced group therapists, this format makes group therapy available to large numbers of mental health professionals. The composition of the group is generally more compatible for the student group therapist in that there is great homogeneity of ego strength. The group is a stranger group; members are all professionals but do not work together (though I have seen therapists with some informal affiliation—for example, sharing the same office suite—participate without complication in the same group). This eliminates many of the competitive problems that occur in groups of students in the same training program. Members are highly motivated, psychologically minded, and generally verbally active. The highly experienced group therapist will find that such groups are not difficult to lead. Occasionally, members may test, judge, or compete with the leader, but the great majority are there for nononsense work and apply their own knowledge of psychotherapy to help the group become maximally effective.

SUMMARY

The training experiences I have described—observation of an experienced clinician, group therapy supervision, experiential group participation, and personal therapy—constitute, in my view, the minimum essential components of a program to train group therapists. (I assume that the trainee has had (or is in the midst of) training in general clinical areas: interviewing, psychopathology, personality theory, and other forms of psychotherapy.) The sequence of the group therapy training experiences may depend on the structural characteristics of a particular training institute. I 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. I feel it is wise for trainees to have a clinical experience in which they deal with basic group and interactional dynamics in an open-ended group of nonpsychotic, highly motivated clients 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. It is important that clinicians maintain contact with colleagues, either informally or through professional organizations such as the American Group Psychotherapy Association or the Association for Specialists in Group Work. For growth to continue, continual input is required. Many formats for continued education exist, including reading, working with different co-therapists, teaching, participating in professional workshops, and having informal discussions with colleagues. Postgraduate personal group experiences are a regenerative process for many. The American Group Psychotherapy Association offers a two-day experiential group, led by highly experienced group leaders, at their annual institute, which regularly precedes their annual meeting. Follow-up surveys attest to the value—both professional and personal—of these groups.
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Another format is for practicing professionals to form leaderless support groups. Although such groups date back to Freud, until recently there has been little in the literature on support groups of mental health professionals. I can personally attest to their value. For over fifteen years I have profited enormously from membership in a group of eleven therapists of my own age and level of experience that meets for ninety minutes every other week. Several members of the group share the same office suite and over the years had observed, somewhat helplessly, as several colleagues suffered, and sometimes fell victim to, severe personal and professional stress. Their unanimous response to the support group has been: “Why on earth didn’t we do this twenty-five years ago?” Such groups not only offer personal and professional support but also remind therapists of the power of the small group and permit a view of the group therapeutic process from the members’ seat. Like all groups, they benefit from a clear consensus of expectations, goals, and norms to ensure that they stay on track and are able to address their own group process.
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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 in our underlying assumptions about therapeutic change: the field is far too complex and pluralistic for disciples of unwavering faith. To this end, I believe it is most important that we teach and model a basic research orientation to continuing education in the field. By research orientation, I refer not to a steel-spectacled chi-square efficiency but instead to an open, self-critical, inquiring attitude toward clinical and research evidence and conclusions—a posture toward experience that is consistent with a sensitive and humanistic clinical approach.

Recent developments in psychotherapy research underscore this principle. For a while there was a fantasy that we could greatly abbreviate clinical training and eliminate variability in therapy outcome by having therapists adhering to a therapy manual. This remains an unrealized fantasy: therapy manualization has not improved clinical outcomes. Ultimately it is the therapist more than the model that produces benefits. Adherence to the nuts and bolts of a psychotherapy manual is a far cry from the skillful, competent delivery of psychotherapy. Many practitioners feel that manuals restrict their natural responsiveness and result in a “herky-jerky” ineffective therapeutic process. Therapist effectiveness has much to do with the capacity to improvise as the context demands it, drawing on both new knowledge and accrued wisdom. Manuals on psychotherapy do not provide that.
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We need to help students critically evaluate their own work and maintain sufficient technical and attitudinal flexibility to be responsive to their own observations. Mature therapists continually evolve: they regard each client, each group—indeed, their whole career—as a learning experience. It is equally important to train students to evaluate group therapy research and, if appropriate, to adapt the research conclusions to their clinical work. The inclusion of readings and seminars in clinical research methodology is thus highly desirable. Although only a few clinicians will ever have the time, funding, and institutional backing to engage in largescale research, many can engage in intensive single-person or single-group research, and all clinicians must evaluate published clinical research. If the group therapy field is to develop coherently, it must embrace responsible, well-executed, relevant, and credible research; otherwise, group therapy will follow its capricious, helter-skelter course, and research will become a futile, effete exercise.

Consider how the student may be introduced to a major research problem: outcome assessment. Seminars may be devoted to a consideration of the voluminous literature on the problems of outcome research. (Excellent recent reviews may serve to anchor these discussions.)
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In addition to seminars, each student may engage in a research practicum by interviewing clients who have recently terminated group therapy.

Once having engaged even to a limited extent in an assessment of change, the student becomes more sensitive and more constructively critical toward outcome research. The problem, as the student soon recognizes, is that conventional research continues to perpetuate the error of extensive design, of failing to individualize outcome assessment.

Clinicians fail to heed or even to believe research in which outcome is measured by before-and-after changes on standardized instruments—and with good reason. Abundant clinical and research evidence indicates that change means something different to each client. Some clients need to experience less anxiety or hostility; for others, improvement would be accompanied by greater anxiety or hostility. Even self-esteem changes need to be individualized. It has been demonstrated that a high self-esteem score on traditional self-administered questionnaires can reflect either a genuinely healthy regard of self or a defensive posture in which the individual maintains a high self-esteem at the expense of self-awareness.
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These latter individuals would, as a result of successful treatment, have lower (but more accurate) self-esteem as measured by questionnaires.

Hence, not only must the general strategy of outcome assessment be altered, but also the criteria for outcome must be reformulated. It may be an error to use, in group therapy research, criteria originally designed for individual therapy outcome. I suspect that although group and individual therapies are equivalent in overall effectiveness, each modality may affect different variables and have a different type of outcome. For example, group therapy graduates may become more interpersonally skilled, more inclined to be affiliative in times of stress, more capable of sustaining meaningful relationships, or more empathic, whereas individual therapy clients may be more self-sufficient, introspective, and attuned to inner processes.
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For years, group therapists have considered therapy a multidimensional laboratory for living, and it is time to acknowledge this factor in outcome research. As a result of therapy, some clients alter their hierarchy of life values and grow to place more importance on humanistic or aesthetic goals; others may make major decisions that will influence the course of their lives; others may be more interpersonally sensitive and more able to communicate their feelings; still others may become less petty and more elevated in their life concerns; some may have a greater sense of commitment to other people or projects; others may experience greater energy; others may come to meaningful terms with their own mortality; and still others may find themselves more adventuresome, more receptive to new concepts and experiences. Complicating matters even more is the fact that many of these changes may be orthogonal to relief of presenting symptoms or to attainment of greater comfort.
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A research orientation demands that, throughout your career as a therapist, you remain flexible and responsive to new evidence and that you live with a degree of uncertainty—no small task. Uncertainty that stems from the absence of a definitive treatment system begets anxiety.

Many practitioners seek solace by embracing the Loreleis of orthodox belief systems: they commit themselves to one of the many ideological schools that not only offer a comprehensive system of explanation but also screen out discrepant facts and discount new evidence. This commitment usually entails a lengthy apprenticeship and initiation. Once within the system, students find it difficult to get out: first, they have usually undergone such a lengthy apprenticeship that abandonment of the school is equivalent to denouncing a part of oneself; and second, it is extremely difficult to abandon a position of certainty for one of uncertainty. Clearly, however, such a position of certainty is antithetical to growth and is particularly stunting to the development of the student therapist.

On the other hand, there are potential dangers in the abrogation of certainty. Anxious and uncertain therapists may be less effective. Deep uncertainty may engender therapeutic nihilism, and the student may resist mastering any organized technique of therapy. Teachers, by personal example, must offer an alternative model, demonstrating that they believe, in accordance with the best evidence available, that a particular approach is effective, but expect to alter that approach as new information becomes available. Furthermore, the teachers must make clear to their students the pride they derive from being part of a field that attempts to progress and is honest enough to know its own limitations.

Practitioners who lack a research orientation with which to evaluate new developments are in a difficult position. How can they, for example, react to the myriad recent innovations in the field—for example, the proliferation of brief, structured group approaches? Unfortunately, the adoption of a new method is generally a function of the vigor, the persuasiveness, or the charisma of its proponent, and some new therapeutic approaches have been extraordinarily successful in rapidly obtaining both visibility and adherents. Many therapists who do not apply a consistent and critical approach to evidence have found themselves either unreasonably unreceptive to all new approaches or swept along with some current fad and then, dissatisfied with its limitations, moving on to yet another.

The critical problem facing group psychotherapy, then, is one of balance. A traditional, conservative sector is less receptive to change than is optimal; the innovative, challenging sector is less receptive to stability than is optimal. The field is swayed by fashion, whereas it should be influenced by evidence. Psychotherapy is a science as well as an art, and there is no place in science for uncritical orthodoxy or for innovation for its own sake. Orthodoxy offers safety for adherents but leads to stagnation; the field becomes insensitive to the zeitgeist and is left behind as the public goes elsewhere. Innovation provides zest and a readily apparent creative outlet for proponents but, if unevaluated, results in a kaleidoscopic field without substance—a field that “rides off madly in all directions.”
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Appendix

Information and Guidelines for Participation in Group Therapy

Group therapy has a long, proven record as a highly effective and useful form of psychotherapy. It is as helpful as, and in some cases more helpful than, individual therapy, particularly when social support and learning about interpersonal relationships are important objectives of treatment. The vast majority of individuals who participate in group therapy benefit from it substantially. Although group therapy is generally highly supportive, you may at times find it stressful.