The Theory and Practice of Group Psychotherapy (66 page)

Group factors include the consequences of subgrouping, poor compositional match of clients, scapegoating, member-member impasses, or unresolved conflict. The therapists also play a role: they may select members too hurriedly, they may not prepare members adequately, they may not attend to building group cohesion, or they may be influenced by unresolved countertransference reactions.

Preventing Dropouts.
As I discussed earlier, the two most important methods of decreasing the dropout rate are proper selection and comprehensive pretherapy preparation. It is especially important that in the preparation procedure, the therapist make it clear that periods of discouragement are to be expected in the therapy process. Clients are less likely to lose confidence in a therapist who appears to have the foreknowledge that stems from experience. In fact, the more specific the prediction, the greater its power. For example, it may be reassuring to a socially anxious and phobic individual to anticipate that there will be times in the group when he will wish to flee, or that he will dread coming to the next meeting. The therapist can emphasize that the group is a social laboratory and suggest that the client has the choice of making the group yet another instance of failure and avoidance or, for the first time, staying in the group and experimenting, in a low-risk situation, with new behaviors. Some groups contain experienced group members who assume some of this predictive function, as in the following case:

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One group graduated several members and was reconstituted by adding five new members to the remaining three veteran members. In the first two meetings, the old members briefed the new ones and told them, among other things, that by the sixth or seventh meeting some member would decide to drop out and then the group would have to drop everything for a couple of meetings to persuade him to stay. The old members went on to predict which of the new members would be the first to decide to terminate. This form of prediction is a most effective manner of ensuring that it is not fulfilled.

Despite painstaking preparation, however, many clients will consider dropping out. When a member informs a therapist that he or she wishes to leave the group, a common approach is to urge the client to attend the next meeting to discuss it with the other group members. Underlying this practice is the assumption that the group will help the client work through resistance and thereby dissuade him or her from terminating. This approach, however, is rarely successful. In one study of thirty-five dropouts from nine therapy groups (with a total original membership of ninety-seven clients), I found that
every one of the dropouts had been urged to return for another meeting, but not once did this final session avert premature termination.
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Furthermore, there were no group continuers who had threatened to drop out and were salvaged by this technique, despite considerable group time spent in the effort. In short, asking the client who has decided to drop out to return for a final meeting is usually an ineffective use of group time.

Generally, the therapist is well advised to see a potential dropout for a short series of individual interviews to discuss the sources of group stress. Occasionally an accurate, penetrating interpretation will keep a client in therapy.

• Joseph, an alienated client with schizoid personality disorder, announced in the eighth meeting that he felt he was getting nowhere in the group and was contemplating termination. In an individual session, he told the therapist something he had never been able to say in the group—namely, that he had many positive feelings toward a couple of the group members. Nevertheless, he insisted that the therapy was ineffective and that he desired a more accelerated and precise form of therapy. The therapist correctly interpreted Joseph’s intellectual criticism of the group therapy format as a rationalization: he was, in fact, fleeing from the closeness he had felt in the group. The therapist again explained the social microcosm phenomenon and clarified for Joseph that in the group he was repeating his lifelong style of relating to others. He had always avoided or fled intimacy and no doubt would always do so in the future unless he stopped running and allowed himself the opportunity to explore his interpersonal problems in vivo. Joseph continued in the group and eventually made considerable gains in therapy.

In general the therapist can decrease premature termination by attending assiduously to early phase problems. I will have much to say later in this text about self-disclosure, but for now keep in mind that outliers—excessively active members and excessively quiet members—are both dropout risks. Try to balance self-disclosure. It may be necessary to slow the pace of a client who too quickly reveals deeply personal details before establishing engagement. On the other hand, members who remain silent session after session may become demoralized and increasingly frightened of self-disclosure.

Negative feelings, misgivings, and apprehensions about the group or the therapeutic alliance must be addressed and not pushed underground. Moreover, the expression of positive affects should also be encouraged and, whenever possible, modeled by the therapist.
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Inexperienced therapists are particularly threatened by the client who expresses a wish to drop out. They begin to fear that, one by one, their group members will leave and that they will one day come to the group and find themselves alone in the room. (And what, then, do they tell their group supervisor?) Therapists for whom this fantasy truly takes hold cease to be therapeutic to the group. The balance of power shifts. They feel blackmailed. They begin to be seductive, cajoling—anything to entice the clients back to future meetings. Once this happens, of course, any therapeutic leverage is lost entirely.

After struggling in my own clinical work with the problem of group dropouts over many years, I have finally achieved some resolution of the issue. By shifting my personal attitude, I no longer have group therapy dropouts. But I do have group therapy throwouts! I do not mean that I frequently ask members to leave a therapy group, but I am perfectly prepared to do so if it is clear that the member is not working in the group. I am persuaded (from my clinical experience and from empirical research findings) that group therapy is a highly effective mode of psychotherapy. If an individual is not going to be able to profit from it, then I want to get that person out of the group and
into a more appropriate mode of therapy
, and bring someone else into the group who will be able to use what the group has to offer.

This method of reducing dropouts is more than a specious form of bookkeeping; it reflects a posture of the therapist that increases the commitment to work. Once you have achieved this particular mental set, you communicate it to your clients in direct and indirect ways. You convey your confidence in the therapeutic modality and your expectation that each client will use the group for effective work.

Removing a Client from a Group.
Taking a client out of a therapy group is an act of tremendous significance for both that individual and the group. Hence it must be approached thoughtfully. Once a therapist determines that a client is not working effectively, the next step is to identify and remove all possible obstacles to the client’s productive engagement in the group. If the therapist has done everything possible yet is still unable to alter the situation, there is every reason to expect one of the following outcomes: (1) the client will ultimately drop out of the group without benefit (or without further benefit); (2) the client may be harmed by further group participation (because of negative interaction or the adverse consequences of the deviant role—see chapter 8); or (3) the client will substantially obstruct the group work for the remaining group members. Hence, it is folly to adopt a laissez-faire posture:
the time has come to remove the client from the group.

How? There is no adroit, subtle way to remove a member from a group. Often the task is better handled in an individual meeting with the client than in the group. The situation is so anxiety-provoking for the other members that generally the therapist can expect little constructive group discussion; moreover, an individual meeting reduces the member’s public humiliation. It is not helpful to invite the client back for a final meeting to work things through with the group: if the individual were able to work things through in an open, nondefensive manner, there would have been no need to ask him or her to leave the group in the first place. In my experience, such final working-through meetings are invariably closed, nonproductive, and frustrating.

Whenever you remove a client from the group, you should expect a powerful reaction from the rest of the group. The ejection of a group member stirs up deep levels of anxiety associated with rejection or abandonment by the primal group. You may get little support from the group, even if there is unanimous agreement among the members that the client should have been asked to leave. Even if, for example, the client had developed a manic reaction and was disrupting the entire group, the members will still feel threatened by your decision.

There are two possible interpretations the members may give to your act of removing the member. One interpretation is rejection and abandonment: that is, that you do not like the client, you resent him, you’re angry, and you want him out of the group and out of your sight. Who might be next?

The other interpretation (the correct one, let us hope) is that you are a responsible mental health professional acting in the best interests of that client and of the remaining group members. Every individual’s treatment regimen is different, and you made a responsible decision about the fact that this form of therapy was not suited to a particular client at this moment. Furthermore, you acted in a professionally responsible manner by ensuring that the client will receive another form of therapy more likely to be helpful.

The remaining group members generally embrace the first, or rejection, interpretation. Your task is to help them arrive at the second interpretation. You may facilitate the process by making clear the reasons for your actions and sharing your decisions about future therapy for the extruded client, such as individual therapy with you or a referral to a colleague. Occasionally, the group may receive the decision to remove a member with relief and appreciation. A sexually abused woman described the extrusion of a sadistic, destructive male group member as the first time in her life that the “people in charge” were not helpless or blind to her suffering.

The Departing Member: Therapeutic Considerations.
When a client is asked to leave or chooses to leave a group, the therapist must endeavor to make the experience as constructive as possible. Such clients ordinarily are considerably demoralized and tend to view the group experience as one more failure. Even if the client denies this feeling, the therapist should still assume that it is present and, in a private discussion, provide alternative methods of viewing the experience. For example, the therapist may present the notion of readiness or group fit. Some clients are able to profit from group therapy only after a period of individual therapy; others, for reasons unclear to us, are never able to work effectively in therapy groups. It is also entirely possible that the client may achieve a better fit and a successful course of therapy in another group, and this possibility should be explored. In any case, you should help the removed member understand that this outcome is not a failure on the client’s part but that, for several possible reasons, a form of therapy has proved unsuccessful.

It may be useful for the therapist to use the final interview to review in detail the client’s experience in the group. Occasionally, a therapist is uncertain about the usefulness or the advisability of confronting someone who is terminating therapy. Should you, for example, confront the denial of an individual who attributes his dropping out of the group to his hearing difficulties when, in fact, he had been an extreme deviant and was clearly rejected by the group? As a general principle, it is useful to consider the client’s entire career in therapy. If the client is very likely to reenter therapy, a constructive gentle confrontation will, in the long run, make any subsequent therapy more effective. If, on the other hand, there is little likelihood that the client will pursue a dynamically oriented therapy, there is little point in presenting a final interpretation that he or she will never be able to use or extend. Test the denial. If it is deep, leave it be: there is no point in undermining defenses, even self-deceptive ones, if you cannot provide a satisfactory substitute. Avoid adding insight to injury.
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The Addition of New Members

Whenever the group census falls too low (generally five or fewer members), the therapist should introduce new members. This may occur at any time during the course of the group, but in the long-term group there are major junctures when new members are usually added: during the first twelve meetings (to replace early dropouts) and after twelve to eighteen months (to replace improved, graduating members). With closed, time-limited groups, there is a narrow window of the first 3–4 weeks in which it is possible to add new members, and yet provide them with an adequate duration of therapy.

Timing.
The success of introducing new members depends in part on proper timing: there are favorable and unfavorable times to add members. Generally, a group that is in crisis, is actively engaged in an internecine struggle, or has suddenly entered into a new phase of development does not favor the addition of new members; it will often reject the newcomers or else evade confrontation with the pressing group issue and instead redirect its energy toward them.

Examples include a group that is dealing for the first time with hostile feelings toward a controlling, monopolistic member or a group that has recently developed such cohesiveness and trust that a member has, for the first time, shared an extremely important secret. Some therapists postpone the addition of new members if the group is working well, even when the census is down to four or five. I prefer not to delay, and promptly begin to screen candidates. Small groups, even highly cohesive ones, will eventually grow even smaller through absence or termination and soon will lack the interaction necessary for effective work. The most auspicious period for adding new members is during a phase of stagnation in the group. Many groups, especially older ones, sensing the need for new stimulation, actively encourage the therapist to add members.