The Theory and Practice of Group Psychotherapy (94 page)

The inpatient group’s effectiveness, often its very existence, is heavily dependent upon administrative backing. If the ward medical director and the clinical nursing coordinator are not convinced that the group therapy approach is effective, they are unlikely to support the group program and will undermine the prestige of the therapy groups in many ways: they will not assign staff members to group leader positions on a regular schedule, they will not provide supervision, nor even schedule group sessions at a convenient, consistent time. Therapy groups on such wards are rendered ineffective. The group leaders are untrained and rapidly grow demoralized. Meetings are scheduled irregularly and are often disrupted by members being yanked out for individual therapy or for a variety of other hospital appointments.†

Is this state of affairs an
intrinsic, immutable
problem? Absolutely not! Rather, it is an
extrinsic, attitudinal
problem and stems from a number of sources, especially the professional education of the ward administrators. Many psychiatric training programs and nursing schools do not offer a comprehensive curriculum in group therapy (and virtually no programs offer sound instruction in inpatient group psychotherapy). Hence, it is completely understandable that ward directors will not invest ward resources and energy in a treatment program about which they have little knowledge or faith. Without a potent psychosocial therapeutic intervention, inpatient wards rely only on medication and the work of the staff is reduced to custodial care. But I believe that these attitudes can change: it is difficult to ignore the research that demonstrates the effectiveness of inpatient group therapy.
⁸
The ramifications of a foundering group program are great. A well-functioning group program can permeate and benefit the milieu as a whole, and the small group should be seen as a resource to the system as a whole.
⁹

Sometimes the debate about the role of group therapy on the inpatient unit has nothing to do with the effectiveness of the therapy but in actuality is a squabble over professional territory. For many years, the inpatient therapy group has been organized and led by the psychiatric nursing profession. But what happens if the ward has a medical director who does not believe that psychiatric nurses (or occupational therapists, activity therapists, or recreational therapists) should be practicing psychotherapy? In this instance, the group therapy program is scuttled, not because it is ineffective but to safeguard professional territory.

The professional interdisciplinary struggles about psychotherapy—now involving a number of nonmedical disciplines: psychology, nursing, and master’s-level counselors and psychologists—need to be resolved in policy committees or staff meetings. The small therapy group must not be used as a battleground on which professional interests are contested.

In addition to these extrinsic, programmatic problems, the acute inpatient ward poses several major
intrinsic
problems for the group therapist. There are two particularly staggering problems that must be faced by every inpatient group therapist:
the rapid turnover of patients on inpatient wards and the heterogeneity of psychopathology.

Rapid Client Turnover.
The duration of psychiatric hospitalization has inexorably shortened. On most wards, hospital stays range from a few days to a week or two. This means, of course, that the composition of the small therapy group will be highly unstable. I led a daily group on an inpatient unit for five years and rarely had the identical group for two consecutive meetings—almost never for three.

This appears to be an immutable situation. The group therapist has little influence on ward admission and discharge policy. In fact, more and more commonly, discharge decisions are based on fiscal rather than clinical concerns. Nor is there any reason to suspect that this situation will change in the foreseeable future. The revolving-door inpatient unit is here to stay, and even as the door whirls ever faster, clinicians must keep their primary focus on the client’s treatment, doing as much as they can within the imposed constraints.
¹⁰

Heterogeneity of Pathology.
The typical contemporary psychiatric inpatient unit (often in a community general hospital) admits patients with a wide spectrum of pathology: acute schizophrenic psychosis, decompensated borderline or neurotic conditions, substance abuse, major affective disorders, eating disorders, post-traumatic stress disorders, and situational reactions.

Not only is there a wide diagnostic spread, but there are also broad differences in attitudes toward, and capacity for, psychotherapy: many patients may be unmotivated; they may be psychologically unsophisticated; they may be in the hospital involuntarily or may not agree that they need help; they often are not paying for therapy; they may have neither introspective propensity nor inner-directed curiosity about themselves. They seek relief, not growth.

The presence of these two factors alone—
the brief duration of treatment and the range of psychopathology
—makes it evident that a radical modification of technique is required for the inpatient therapy group.

Consider how these two intrinsic clinical conditions violate some of the necessary conditions of group therapy I described earlier in this text. In chapter 3, I stressed the crucial importance of stability of membership. Gradually, over weeks and months, the sense of cohesiveness—a major therapeutic factor—develops, and participants often derive enormous benefit from the experience of being a valued member of an ongoing, stable group. How, then, to lead a whirligig group in which new members come and go virtually every session?

Similarly, in chapter 9, I stressed the importance of composing a group carefully and of paying special attention to avoiding deviants and to selecting members with roughly the same amount of ego strength. How, then, to lead a group in which one has almost no control over the membership, a group in which there may be floridly psychotic individuals sitting side by side with better-functioning, integrated members?

In addition to the major confounding factors of rapid patient turnover and the range of psychopathology, several other intrinsic clinical factors exert significant influence on the functioning of an inpatient psychotherapy group.

Time.
The therapist’s time is very limited. Generally, there is no time to see a patient in a pregroup interview to establish a relationship and to prepare the person for the group. There is little time to integrate new members into the group, to work on termination (someone terminates the group almost every meeting), to work through issues that arise in the group, or to focus on transfer of learning.

Group Boundaries.
The group boundaries are often blurred. Members are generally in other groups on the ward with some or many of the same members. Extragroup socializing is, of course, the rule rather than the exception: patients spend their entire day together. The boundaries of confidentiality are similarly blurred. There can be no true confidentiality in the small inpatient group: patients often share important small group events with others on the ward, and staff members freely share information with one another during rounds, nursing reports, and staff meetings. In fact it is imperative that the small inpatient group boundary of confidentiality be elastic and encompass the entire ward rather than being confined to any one group within that ward. Otherwise the small group becomes disconnected from the unit.†

The Role of the Group Leader.
The role of inpatient group leaders is complex since they may be involved with clients throughout the day in other roles. Their attendance may often be often erratic. Group leaders are frequently psychiatric nurses who, because of the necessity of weekend, evening, and night coverage, are on a rotating schedule and often cannot be present at the group for several consecutive meetings.

Therapist autonomy is limited in other ways as well. For example, therapists have, as I shall discuss shortly, only limited control over group composition. They often have no choice about co-therapists, who are usually assigned on the basis of the rotation schedule. Each client has several therapists at the same time. Inpatient group therapists usually feel more exposed than their outpatient colleagues. Difficulties in the group will be readily known by all. Lastly, the pace of the acute inpatient ward is so harried that there is little opportunity for supervision or even for postmeeting discussion between therapists.

Formulation of Goals

Once you have grasped these clinical facts of life of the inpatient therapy group and differentiated intrinsic from extrinsic factors, it is time to ask this question:
Given the many confounding intrinsic factors that influence (and hobble) the course of the inpatient group, what can the group accomplish?
What are reasonable goals of therapy—goals that are attainable by the inpatient clinical population in the available time?

Let us start by noting that the goals of the acute inpatient group are
not identical to those of acute inpatient hospitalization.
The goal of the group is not to resolve a psychotic depression, not to decrease psychotic panic, not to slow down a patient with mania, not to diminish hallucinations or delusions. Groups can do none of these things. That’s the job of other aspects of the ward treatment program—primarily of the psychopharmacological regimen. To set these goals for a therapy group is not only unrealistic but it sentences the group to failure.

So much for what the inpatient group cannot do. What
can
it offer? I will describe six achievable goals:

1. Engaging the patient in the therapeutic process

2. Demonstrating that talking helps

3. Problem spotting

4. Decreasing isolation

5. Being helpful to others

6. Alleviating hospital-related anxiety

1. Engaging the patient in the therapeutic process

The contemporary pattern of acute psychiatric hospitalization—brief but repeated admissions to psychiatric wards in general hospitals—can be more effective than longer hospitalization only if hospitalization is followed with adequate aftercare treatment.
¹¹
Furthermore, there is persuasive evidence that group therapy aftercare is a particularly efficacious mode of aftercare treatment—more so than individual aftercare therapy.
¹²

A primary goal of inpatient group therapy emerges from these findings—namely, to engage the patient in a process that he or she perceives as constructive and supportive and will wish to continue after discharge from the hospital. Keep in mind that for many patients, the inpatient psychotherapy experience is their first introduction to therapy. If the group therapy experience is sufficiently positive and supportive to encourage them to attend an aftercare group, then—all other factors aside—the inpatient therapy group will have served a very important function.

2. Demonstrating that talking helps

The inpatient therapy group helps patients learn that talking about their problems is helpful. They learn that there is relief to be gained in sharing pain and in being heard, understood, and accepted by others. From listening to others, members also learn that others suffer from the same type of disabling distress as they do—one is not unique in one’s suffering. In other words, the inpatient group introduces members to the therapeutic factors of cohesiveness and universality.

3. Problem spotting

The duration of therapy in the inpatient therapy group is far too brief to allow clients to work through problems. But the group can efficiently help clients spot problems that they may, with profit, work on in ongoing individual therapy, both during their hospital stay and in their post-discharge therapy. By providing a discrete focus for therapy, which clients value highly,
¹³
inpatient groups increase the efficiency of other therapies.

It is important that the groups identify problems with some therapeutic handle—problems that the client perceives as circumscribed and malleable (not problems such as chronic unhappiness, depression, or suicidal inclinations that are too generalized to offer a discrete handhold for therapy). The group is most adept at helping members identify problems in their mode of relating to other people. It is the ideal therapy arena in
which to learn about maladaptive interpersonal behavior
. Emily’s story is a good illustration of this point.

• Emily was an extremely isolated young woman who was admitted to the inpatient unit for depression. She complained that she was always in the position of calling others for a social engagement. She never received invitations; she had no close girl friends who sought her out. Her dates with men always turned into one-night stands. She attempted to please them by going to bed with them, but they never called for a second date. People seemed to forget her as soon as they met her. During the three group meetings she attended, the group gave her consistent feedback about the fact that she was always pleasant and always wore a gracious smile and always seemed to say what she thought would be pleasing to others. In this process, however, people soon lost track of who Emily was. What were her own opinions? What were her own desires and feelings? Her need to be eternally pleasing had a serious negative consequence: people found her boring and predictable.

A dramatic example occurred in her second meeting, when I forgot her name and apologized to her. Her response was, “That’s all right, I don’t mind.” I suggested that the fact that she didn’t mind was probably one of the reasons I had forgotten her name. In other words, had she been the type of person who would have minded or made her needs more overt, then most likely I would not have forgotten her name. In her three group meetings, Emily identified a major problem that had far-reaching consequences for her social relationships outside: her tendency to submerge herself in a desperate but self-defeating attempt to capture the affection of others.