The Theory and Practice of Group Psychotherapy (56 page)

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 ambulatory group meetings, and most therapists have never led an outpatient group that meets more than once a week. But if I had my choice, I would meet with groups twice weekly: such groups have a greater intensity, 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 turbocharge the intensity and launch the group more effectively.
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Avoid meeting too infrequently. Groups that meet less than once weekly generally have considerable difficulty maintaining an interactional focus. If a great deal has occurred between meetings in the lives of the members, such groups have a tendency to focus on life events and on crisis resolution.

The Time-Extended Group.
In efforts to achieve “time-efficient therapy,”
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group leaders have experimented with many aspects of the frame of therapy, but none more than the duration of the meeting. Today’s economically driven climate pressures therapists to abbreviate therapy, but the opposite was true in the 1960s and 1970s, the heyday of the encounter groups (see chapter 16), when group therapists experimented boldly with the length of meetings. Therapists held weekly meetings that lasted four, six, even eight hours. Some therapists chose to meet less frequently but for longer periods—for example, a six-hour meeting every other week. Individual therapists often referred their clients to a weekend time-extended group. 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 “marathon group” was widely publicized during that time in U.S. magazines, newspapers, and fictionalized accounts.† It met for a prolonged session, perhaps lasting twenty-four or even forty-eight hours, with little or no time permitted for sleep. Participants were required to remain together for the entire designated time. Meals were served in the therapy room, and sleep, if needed, was snatched during quick naps in the session or in short scheduled sleep breaks. The emphasis of the group was on total self-disclosure, intensive interpersonal confrontation, and affective involvement and participation. Later the time-extended format was adapted by such commercial enterprises as est and Lifespring; today, these large group awareness training programs have virtually disappeared.
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Proponents of the time-extended group claimed that it accelerated group development, intensified the emotional experience, and efficiently condensed a lengthy course of therapy into a day or a weekend.† The emotional intensity and fatigue resulting from lack of sleep was also thought to accelerate the abandonment of social facades. The results of marathon group therapy reported in the mass media and in scientific journals at the time were mind-boggling, exceeding even today’s claims of the personality-transforming effects of new miracle drugs: “Eighty percent of the participants undergo significant change as the result of a single meeting”;
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“ninety percent of 400 marathon group members considered the meeting as one of the most significant and meaningful experiences of their lives”;
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“marathon group therapy represents a breakthrough in psychotherapeutic practice”;
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“the marathon group has become a singular agent of change which allows rapidity of learning and adaptation to new patterns of behavior not likely to occur under traditional arrangements”;
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“if all adults had been in a marathon, there would be no more war; if all teenagers had been in a marathon, there would be no more juvenile delinquency”;
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and so on.

Yet despite these claims, the marathon movement has come and gone. The therapists who still regularly or periodically hold time-extended group meetings represent a small minority of practitioners. Though there have been occasional recent reports of intensive, and effective, retreat weekends for various conditions ranging from substance abuse to bulimia,
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these enterprises consist of a comprehensive program that includes group therapy, psychoeducation, and clear theory rather than a reliance on the intensive confrontation and fatigue characteristic of the marathon approach. This approach is also used today to augment weekly group therapy for clients with cancer, in the form of an intensive weekend retreat for skill building, reflection, and meditation.
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Nonetheless, it is important to inform ourselves about the marathon movement—not because it has much current usage, nor to pay homage to it as a chapter in the history of psychotherapy, but because of what it reveals about how therapists make decisions about clinical practice. Over the past several decades, psychotherapy in general and group therapy in particular have been taken by storm by a series of ideological and stylistic fads. Reliance on the fundamentals and on well-constructed research is the best bulwark against will-o’-the-wisp modes of therapy dominated by the fashion of the day.

Many therapeutic fads come and go so quickly that research rarely addresses the issues they raise. Not so for the time-extended meeting, which has spawned a considerable research literature. Why? For one thing, the format lends itself to experimentation: it is far easier to do outcome research on a group that lasts, say, one day than on one that lasts for six months: there are fewer dropouts, fewer life crises, no opportunities for subjects to obtain ancillary therapy. Another reason is that time-extended groups arose in an organization (the National Training Laboratories—see chapter 16) that had a long tradition of coupling innovation and research.

The highly extravagant claims I quoted above were based entirely on anecdotal reports of various 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 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 Asch
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has shown, can maintain their objectivity in the face of apparent group unanimity; 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 in a group and develops strong positive feelings toward other members, it becomes difficult to question the value or activities of the group. To do so thrusts the individual into a state of uncomfortable dissonance.

Research on marathon groups is plagued with a multitude of design defects.
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Some studies failed to employ proper controls (for example, a non–time-extended comparison group). Others failed to sort out the effects of artifact and other confounding variables. For example, in a residential community of drug addicts, an annual marathon group was offered to rape survivors. Because the group was offered only once a year, the participants imbued it with value even before it took place.
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The rigorous controlled studies comparing differences in outcome between time-extended and non–time-extended groups conclude that there is no evidence for the efficacy of the time-extended format. The positive results reported in a few studies were unsystematic and evaporated quickly.
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Is it possible, as is sometimes claimed, that a time-extended meeting accelerates the maturation of a therapy group, that it increases openness, intimacy, and cohesiveness and thus facilitates insight and therapeutic breakthroughs? My colleagues and I studied the effect of a six-hour meeting on the development of cohesiveness and of a here-and-now, interactive communicational mode.
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We followed six newly formed groups in an ambulatory mental health program for the first sixteen sessions. Three of the groups held a six-hour first session, whereas the other three held a six-hour eleventh session.
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We found that
the marathon session did not favorably influence the communication patterns in subsequent meetings.
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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. Hence, the results showed that cohesiveness can be accelerated but not brought into being by time-extended meetings.

During the 1960s and 1970s, many therapists referred individual therapy patients to weekend marathon groups; in the 1980s, many sent patients to intensive large-group awareness training weekends (for example, est and Lifespring).
Is it possible that an intensive, affect-laden time-extended group may open up a client who is stuck in therapy?
My colleagues and I studied thirty-three such clients referred by individual therapists for a weekend encounter group. We assigned them to one of three groups: two affect-evoking gestalt marathons and a control group (a weekend of meditation, silence, and tai chi).
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Six weeks later, the experimental subjects showed slight but significant improvement in their individual therapy compared to the control subjects. By twelve weeks, however, all differences had disappeared, and
there were no remaining measurable effects on the process of individual therapy.

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, that 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 the duration of treatment is more influential than the number of treatments.
The transfer of learning is laborious and demands a certain irreducible amount of time.
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Consider, for example, a male client who, because of his early experience with an authoritarian, distant, and harsh father, tends to see all 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. As a result of the group, the individual learns that at least
some
men in positions of authority can be trusted. But which ones? He must learn how to differentiate among people so as not to perceive all men in a predetermined manner. A new repertoire of perceptual skills is needed. 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

Brief group therapy is rapidly becoming an important and widely used therapy format. To a great extent, the search for briefer forms of group therapy is fueled by economic pressures. Managed care plans and HMOs strive relentlessly for briefer, less expensive, and more efficient forms of therapy.
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A survey of managed care administrators responsible for the health care of over 73 million participants
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noted that they were interested in the use of more groups but favored brief, problem-homogeneous, and structured groups. In the same survey, a range of therapists favored process, interpersonal, and psychodynamic group therapy without arbitrary time restrictions. 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.