The Theory and Practice of Group Psychotherapy (59 page)

All of these unrealistic expectations that, unchecked, lead to a rejection or a blighting of group therapy can be allayed by adequate preparation of the client. Before outlining a preparation procedure, I will consider four problems commonly encountered early in the course of the group that may be ameliorated by preparation before therapy begins.

Common Group Problems

1. One important source of perplexity and discouragement for clients early in therapy is
perceived goal incompatibility
. They may be unable to discern the congruence between group goals (such as group integrity, construction of an atmosphere of trust, and an interactional focus) and their individual goals (relief of suffering). What bearing, members may wonder, does a discussion of their personal reactions to other members have on their symptoms of anxiety, depression, phobias, impotence, or insomnia?

2.
A high turnover
in the early stages of a group is, as I have discussed, a major impediment to the development of an effective group. The therapist, from the very first contact with a client, should discourage irregular attendance and premature termination. The issue is more pressing than in individual therapy, where absences and tardiness can be profitably investigated and worked through. In the initial stages of the group, irregular attendance results in a discouraged and disconnected group.

3. Group therapy, unlike individual therapy, often
does not offer immediate comfort
. Clients may be frustrated by not getting enough “airtime” in the first few meetings, they may feel deprived of their specialness,† or they may feel anxious about the task of direct interpersonal interaction. The therapist should anticipate and address this frustration and anxiety in the preparatory procedure. This is a particular challenge for clients who have found individual therapy to be narcissistically gratifying.

4.
Subgrouping and extragroup socializing
, which has been referred to as the Achilles’ heel of group therapy, may be encountered at any stage of the group. This complex problem will be considered in detail in chapter 12. Here it is sufficient to point out that the therapist may begin to shape the group norms regarding subgrouping in the very first contact with the clients.

A System of Preparation

There are many approaches to preparing clients for group therapy. The simplest and most practical in the harried world of everyday clinical practice is to offer the client the necessary information in the pregroup interview (s). I am careful to set aside sufficient time for this presentation. I attempt to see clients at least twice before introducing them into the group. But even if I see someone only once, I reserve at least half the time to address each of the foregoing misconceptions and initial problems of group therapy.

Misconceptions should be explored in detail and each one corrected by an accurate and complete discussion. I share with the client my predictions about the early problems in therapy and present a conceptual framework and clear guidelines for effective group behavior. Each client’s preparation must be individualized according to the presenting complaints, questions and concerns raised in the interview, and level of sophistication regarding the therapy process. Two situations require particular attention from the therapist: the therapy neophyte and the client who presents with cross-cultural issues. The client who has never been in any form of therapy may find group therapy particularly challenging and may require additional pregroup individual preparation.† Clients from other cultures may be particularly threatened by the intimate personal exposure in the group. The pregroup preparation sessions provide the therapist the opportunity to explore the impact of the client’s culture on his or her attitudes, beliefs, and identity and to demonstrate the therapist’s genuine willingness to enter the client’s world.
⁶⁵

I have found a preparatory interview with the following objectives to be of considerable value:

1. Enlist clients as informed allies. Give them a conceptual framework of the interpersonal basis of pathology and how therapy works.

2. Describe how the therapy group addresses and corrects interpersonal problems.

3. Offer guidelines about how best to participate in the group, how to maximize the usefulness of group therapy.

4. Anticipate the frustrations and disappointments of group therapy, especially of the early meetings.

5. Offer guidelines about duration of therapy. Make a contract about attendance in group.

6. Instill faith in group therapy; raise expectations about efficacy.

7. Set ground rules about confidentiality and subgrouping.

Now, to flesh out each of these points in turn.

1. First, I present clients with a brief explanation of the interpersonal theory of psychiatry, beginning with the statement that although each person manifests his or her problems differently
, all who seek help from psychotherapy have in common the basic difficulty of establishing and maintaining close and gratifying relationships with others.
I remind them of the many times in their lives that they have undoubtedly wished to clarify a relationship, to be really honest about their positive and negative feelings with someone and get reciprocally honest feedback. The general structure of society, however, does not often permit such open communication. Feelings are hurt, relationships are ruptured, misunderstandings arise, and, eventually, communication ceases.

2. I describe the therapy group, in simple, clear language, as a social laboratory in which such honest interpersonal exploration is not only permitted but encouraged. If people are conflicted in their methods of relating to others, then a social situation encouraging honest interaction provides a precious opportunity to learn many valuable things about themselves. I emphasize that working on their relationships directly with other group members will not be easy; in fact, it may even be stressful. But it is crucial
because if they can completely understand and work out their relationships with the other group members, there will be an enormous carryover into their outside world:
they will discover pathways to more rewarding relationships with significant people in their life now and with people they have yet to meet.

3. I advise members that the way to use therapy best is to be honest and direct with their feelings in the group at that moment, especially their feelings toward the other group members and the therapists. I emphasize this point many times and refer to it as the core of group therapy. I say that clients may, as they develop trust in the group, reveal intimate aspects of themselves, but that the group is not a forced confessional and that people have different rates of developing trust and revealing themselves. The group is a forum for risk taking, I emphasize, and I urge members to try new types of behavior in the group setting.

4. I predict certain stumbling blocks and warn clients that they may feel puzzled and discouraged in the early meetings. It will, at times, not be apparent how working on group problems and intermember relationships can be of value in solving the problems that brought them to therapy. This puzzlement, I stress, is to be expected in the typical therapy process. I tell them that many people at first find it painfully difficult to reveal themselves or to express directly positive or negative feelings, and I discuss the tendency to withdraw emotionally, to hide feelings, to let others express one’s feelings, to form concealing alliances with others. I also predict that they are likely to develop feelings of frustration or annoyance with the therapist and that they will expect answers that the therapist cannot supply. Help will often be forthcoming from other group members, however difficult it may be for them to accept this fact.

5. For clients entering an open-ended psychotherapy group I emphasize that the therapeutic goals of group therapy are ambitious because we desire to change behavior and attitudes many years in the making. Treatment is therefore gradual and may be long, often with no important change occurring for months. I strongly urge clients to stay with the group and to ignore any inclination to leave the group before giving it a real chance. It is almost impossible to predict the eventual effectiveness of the group during the first dozen meetings. Thus, I urge them to suspend judgment and to make a good-faith commitment of at least twelve meetings before even attempting to evaluate the ultimate usefulness of the group. For clients who are entering a briefer group therapy, I say that the group offers an outstanding opportunity to do a piece of important work that they can build upon in the future. Each session is precious, and it is in their interest and the interest of the other group members to attend each one of the limited number scheduled.

6. It is vitally important for the therapist to raise expectations, to instill faith in group therapy, and to dispel the false notion that group therapy is second-class therapy. Research tells us that clients who enter therapy expecting it to be successful will exert much greater effort in the therapy, will develop a stronger therapeutic alliance, and are significantly more likely to succeed.
⁶⁶
This effect of client pretherapy expectancies is even greater for less structured therapies that may generate more client anxiety and uncertainty.
⁶⁷
In my preparation, therefore, I provide a brief description of the history and development of group therapy—how group therapy passed from a stage during World War II when it was valued for its economic advantages (that is, it allowed psychotherapists to reach a large number of people in need), to its current position in the field, where it clearly has something unique to offer and is often the treatment of choice. I inform clients that psychotherapy outcome studies demonstrate that group therapy is as efficacious as any mode of individual therapy.

7. There are a few ground rules. Nothing is more important than honestly sharing perceptions and feelings about oneself and other members in the group.
Confidentiality
, I state, is as essential in group therapy as it is in any therapist-client relationship. For members to speak freely, they must have confidence that their statements will remain within the group. In my group therapy experience, I can scarcely recall a single significant breach of confidence and can therefore reassure group members on this matter.
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It is important not to corrode client trust regarding confidentiality. However, at the same time, in the spirit of obtaining informed consent for treatment, I also inform the client of my mandatory professional duties to report certain offenses.
⁶⁹
In virtually all jurisdictions the therapist must report situations in which the actions of the client are, or will imminently be, harmful to self or others. Occasionally, members may inquire whether they can relate aspects of the group therapy discussion with a spouse or a confidant. I urge them to discuss only their own experience: the other members’ experiences and certainly their names should be kept in strictest confidence.

In addition to the ground rules of honesty and confidentiality, I make a point of discussing the issue of contacts outside the group between members which, in one form or another, will occur in every psychotherapy group. Two particularly important points must be stressed:

1. The group provides an opportunity for learning about one’s problems in social relationships;
it is not an assembly for meeting and making social friends
. On the contrary, if the group is used as a source of friends it loses its therapeutic effectiveness. In other words, the therapy group teaches one
how to
develop intimate, long-term relationships, but it does not
provide
these relationships. It is a bridge, not the destination. It is not life but a dress rehearsal for life.

2. If by chance or design, however, members
do
meet outside the group, it is their responsibility to discuss the salient aspects of that meeting inside the group. It is particularly useless for therapists to prohibit extragroup socializing or, for that matter, to declare any injunctions about client behavior. Almost invariably during the therapy, group members will engage in some outside socializing and in the face of the therapist’s prohibition may be reluctant to disclose it in the group. As I shall elaborate in the next chapter, extragroup relationships are not harmful per se (in fact, they may be extremely important in the therapeutic process);
what impedes therapy is the conspiracy of silence that often surrounds such meetings.

An approach of injunction and prohibition merely draws group members into the issue of rule setting and rule breaking. It is far more effective to explain at length why certain actions may interfere with therapy. With subgrouping, for example, I explain that friendships among group members often prevent them from speaking openly to one another in the group. Members may develop a sense of loyalty to a dyadic relationship and may thus hesitate to betray the other by reporting their conversations back to the group. Yet such secrecy will conflict with the openness and candor so essential to the therapy process.
The primary task of therapy group members is, I remind them, to learn as much as possible about the way each individual relates to each other person in the group.
All events that block that process ultimately obstruct therapy. Occasionally group members may wish to make a secret disclosure to the group leader. Almost always it is best that the disclosure be shared with the group. Group leaders must never, in advance, agree to secrecy but instead promise to use discretion and their best clinical judgment.