The Theory and Practice of Group Psychotherapy (58 page)

To some extent, the optimal group size is a function of the duration of the meeting: the longer the meeting, the larger the number of participants who can profitably engage in the group. Thus, many of the marathon therapy groups of past years had as many sixteen members. Groups such as Alcoholics Anonymous and Recovery, Inc. that do not focus on interaction may range from twenty to eighty. 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 the didactic imparting of information about anxiety and stress reduction.
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Similar findings have been reported in the treatment of panic disorder and agoraphobia.
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The large-group format has also been used with cancer patients, often with training in stress reduction and self-management of illness symptoms and medical treatment side effects. These groups may contain forty to eighty participants meeting weekly for two hours over a course of six weeks.
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If you think of the health care system as a pyramid, large groups of this type are part of the broad base of accessible, inexpensive treatment 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.
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A range of therapeutic factors may operate in these groups. Large homogeneous groups normalize, destigmatize, activate feelings of universality, and offer skills and knowledge that enhance self-efficacy. AA groups use inspiration, guidance, and suppression; the large therapeutic community relies on group pressure and interdependence to encourage reality testing, to combat regression, and to instill a sense of individual responsibility toward the social community.

Group size is inversely proportional to interaction. One study investigated the relationship between group size and the number of different verbal interactions initiated between members in fifty-five inpatient therapy groups. The groups ranged in size from five to twenty participants. A marked reduction in interactions between members was evident when group size reached nine members, and another when it reached seventeen members. The implication of the research is that, in inpatient settings, groups of five to eight offer the greatest opportunity for total client participation.
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Several studies of non-therapy groups suggest that as the size of a group increases, there is a corresponding tendency for members to feel disenfranchised and to form cliques and disruptive subgroups.
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Furthermore, only the more forceful and aggressive members are able to express their ideas or abilities.
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A comparison of twelve-member and five-member problem-solving groups indicates that the larger groups experience more dissatisfaction and less consensus.
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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. 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 to assemble one group.

Some therapists prefer to see the client several times in individual sessions in order to build a relationship that will keep members in the group during early periods of discouragement and disenchantment. It is my clinical impression that the more often clients are seen 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 members is their mutual identification with a shared person: the therapist. Keep in mind that the purpose of the individual pregroup sessions is to build a therapeutic alliance. To use the sessions primarily for anamnestic purposes is not a good use of clinical time; it suggests to the client that anamnesis is central to the therapy process.

One other overriding task must be accomplished in the pregroup interview or interviews:
the preparation of the client for group therapy
. If I had to choose the one area where research has the greatest relevance for practice, it would be in the preparation of clients for group therapy.
There is highly persuasive evidence that pregroup preparation expedites the course of group therapy.
Group leaders must achieve several specific goals in the preparatory procedure:

• Clarify misconceptions, unrealistic fears, and expectations

• 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

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 managed health care systems 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 a number of clients that greatly exceeds the number of staff therapists.

Let us examine some surveys of public beliefs about group therapy. A study of 206 college students consisting of students seeking counseling and a comparable number of psychology students identified three common misconceptions:

1. Group therapy is unpredictable or involves a loss of personal control—for example, groups may coerce members into self-disclosure.

2. Group therapy is not as effective as individual therapy because effectiveness is proportional to the attention received from the therapist.

3. Being in a group with many individuals with significant emotional disturbance is in itself detrimental.
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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. Concerns cited included the fear of ridicule and shame, the lack of confidentiality, and the fear of being made worse through some form of contagion. What are some of the sources of this strong antigroup bias? For many clients seeking therapy, difficulties with their peer and social group or family is
the
problem. Hence, groups in general are distrusted, and the individual therapy setting is considered the protected, safe, and familiar zone. This is particularly the case for those with no prior experience in therapy.
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In general, the media and fictional portrayals of group therapy are vastly inaccurate and often portray therapy groups in a mocking, ridiculing fashion.
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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, stimulate envy or are deemed to be the “weakest link.”
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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 the efficacy of group therapy.
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Lack of exposure in one’s training is part of the problem, but the strength of resistances to remedying these training shortfalls suggest 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.

In addition to evaluative misconceptions, clients usually harbor procedural misconceptions and unrealistic interpersonal fears. Many of these are evident in the following dream, which 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 decided on the cookies and proceeded to go to the group. I asked directions to the room where the group was to meet, 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 went into the group. When I had been looking for the room, I had encountered many people from my past, many people whom I had gone to school with and many people whom I had known for a number of years. The group was very large, and about forty or fifty people were milling around the room. The members of the group included members of my family—most specifically, two of my brothers. Each member of the group was required to stand in front of a large audience and say what they thought was their difficulty and why they were there and what their problems were. The whole dream was
very anxiety-provoking, and the business of being late and the business of having a large number of people was very distracting.

Several themes are abundantly clear in this dream. The client anticipated the first group meeting with considerable dread. Her concern about being late reflected a fear of being excluded or rejected by the group. Furthermore, since she was starting in a group that had already been meeting for several weeks, she feared that the others had progressed too far, that she would be left behind and could never catch up. (She could not find a room with an “A” marked on it.) She dreamed that the group would number forty or fifty. Concerns about the size of the group are common; members fear that their unique individuality will be lost as they become one of the mass. Moreover, clients erroneously apply the model of the economic distribution of goods to the group therapeutic experience, assuming that the size of the crowd is inversely proportional to the goods received by each individual.

The dream image of each member confessing problems to the group audience reflects one of the most basic and pervasive fears of individuals entering a therapy group: the horror of having to reveal oneself and to confess shameful transgressions and fantasies to an alien audience. What’s more, members imagine a critical, scornful, ridiculing, or humiliating response from the other members. The experience is fantasized as an apocalyptic trial before a stern, uncompassionate tribunal. The dream also suggests that pregroup anticipation resulted in a recrudescence of anxiety linked to early group experiences, including those of school, family, and play groups. It is as if her entire social network—all the significant people and groups she had encountered in her life—would be present in this group. (In a metaphorical sense, this is true: to the degree that she had been shaped by other groups and other individuals, to the degree that she internalized them, she would carry them into the group with her since they are part of her character structure; furthermore, she would, transferentially, re-create in the therapy group her early significant relationships.)

It is clear from the reference to room 129 (an early schoolroom in her life) that the client was associating her impending group experience with a time in her life when few things were more crucial than the acceptance and approval of a peer group. Furthermore, she anticipated that the therapist would be like her early teachers: an aloof, unloving evaluator.

Closely related to the dread of forced confession is the concern about confidentiality. The client anticipated that there would be no group boundaries, that every intimacy she disclosed would be known by every significant person in her life. Other common concerns of individuals entering group therapy, not evident in this dream, include a fear of mental contagion, of being made sicker through association with ill comembers. Often, but not exclusively, this is a preoccupation of clients with fragile ego boundaries who lack a solid, stable sense of self.

The anxiety about regression in an unstructured group and being helpless to resist the pull to merge and mesh with others can be overwhelming. In part, this concern is also a reflection of the self-contempt of individuals who project onto others their feelings of worthlessness. Such dynamics underlie the common query, “How can the blind lead the blind?” Convinced that they themselves have nothing of value to offer, some clients find it inconceivable that they might profit from others like themselves. Others fear their own hostility. If they ever unleash their rage, they think, it will engulf them as well as others. The notion of a group where anger is freely expressed is terrifying, as they think silently, “If others only knew what I really thought about them.”