The Theory and Practice of Group Psychotherapy (96 page)

Focus of the Inpatient Group: The Here-And-Now.
Throughout this text, I have repeatedly emphasized the importance of here-and-now interaction in the group therapeutic process. I have stressed that work in the here-and-now is the heart of the group therapeutic process, the power cell that energizes the therapy group. Yet, whenever I have visited inpatient wards throughout the country, I have found that groups there rarely focus on here-and-now interaction. Such avoidance of the here-and-now is, in my opinion, precisely the reason so many inpatient groups are ineffective.

If the inpatient group does not focus on the here-and-now, what other options are there? Most inpatient groups adopt a then-and-there focus in which members, following the therapist’s cues, take turns presenting their “back-home problems”—those that brought them into the hospital—while the rest of the group attempts to address those problems with exhortation and advice.
This approach to inpatient group therapy is the least effective way to lead a therapy group and almost invariably sentences the group to failure.

The problems that brought a patient into the hospital are complex and overwhelming. They have generally foiled the best efforts of skilled mental health professionals and will, without question, stump the therapy group members. For one thing, distressed patients are generally unreliable self-reporters: the information they present to the group will invariably be biased and, given the time constraints, limited. The then-and-there focus has many other disadvantages as well. For one thing, it results in highly inequitable time sharing. If much or all of a meeting is devoted to one member, many of the remaining members will feel cheated or bored. Unlike outpatient group members, they cannot even bank on the idea that they have credit in the group—that is, that the group owes them time and attention. Since they will most likely soon be discharged or find themselves in a group composed of completely different members, patients are left clutching worthless IOUs.

Some inpatient groups focus on
ward problems
—ward tensions, staffpatient conflict, housekeeping disputes, and so on. Generally, this is an unsatisfactory mode of using the small group. The average inpatient ward has approximately twenty patients. In any small group meeting, only half the members and one or two staff members will be present; invariably, the patients or staff members discussed will be in the other group. A much better arena for dealing with ward problems is the therapeutic community meeting, in which all patients and staff are present.

Other inpatient groups focus on
common themes
—for example, suicidal ideation, hallucinations, or drug side effects. Such meetings may be of value to some but rarely all members. Often such meetings serve primarily to dispense information that could easily be provided to patients in other formats. It is not the most effective way of using the inherent power of the small group modality.

The clinical circumstances of the inpatient group do not make the here-and-now focus any less important or less advisable. In fact,
the here-and-now focus is as effective in inpatient as in outpatient therapy.
However, the clinical conditions of inpatient work (especially the brief duration of treatment and the group members’ severity of illness) demand modifications in technique. As I mentioned earlier, there is no time for working through interpersonal issues. Instead, you must help patients spot interpersonal problems and reinforce interpersonal strengths, while encouraging them to attend aftercare therapy, where they can pursue and work through the interpersonal issues identified in the group.

The most important point to be made about the use of the here-and-now in inpatient groups is already implicit in the foregoing discussion of support. I cannot emphasize too heavily that the here-and-now is
not synonymous with conflict, confrontation, and critical feedback.
I am certain that it is because of this erroneous assumption that so few inpatient group therapists capitalize on the value of here-and-now interaction.

Conflict is only one, and by no means the most important, facet of here-and-now interaction. The here-and-now focus helps patients learn many invaluable interpersonal skills: to communicate more clearly, to get closer to others, to express positive feelings, to become aware of personal mannerisms that push people away, to listen, to offer support, to reveal oneself, to form friendships.

The inpatient group therapist must pay special attention to the issue of the relevance of the here-and-now. The members of an inpatient group are in crisis. They are preoccupied with their life problems and immobilized by dysphoria or confusion. Unlike many outpatient group members who are interested in self-exploration, in personal growth, and in improving their ability to cope with crisis, inpatients are closed, in a survival mode, and unlikely to apprehend the relevance of the here-and-now focus for their problems.

Therefore, you must provide explicit instruction about its relevance. I begin each group meeting with a brief orientation in which I emphasize that, though individuals may enter the hospital for different reasons, everyone can benefit from examining how he or she relates to other people. Everyone can be helped by learning how to get more out of relationships with others. I stress that I focus on relationships in group therapy because
that is what group therapy does best
.† In the group, there are other members and two mental health experts who are willing to provide feedback about how they see each person in the group relating to others. I also acknowledge that members have important and painful problems, other than interpersonal ones, but that these problems need to be addressed in other therapeutic modalities: in individual therapy, in social service interviews, in couples or marital therapy, or with medication.

Modes of Structure

Just as there is no place in acute inpatient group work for the inactive therapist, there is no place for the nondirective group therapist. The great majority of patients on an inpatient ward are confused, frightened, and disorganized; they crave and require some external structure and stability. Consider the experience of patients newly admitted to the psychiatric unit: they are surrounded by other troubled, irrationally behaving patients; their mental acuity may be obtunded by medication; they are introduced to many staff members who, because they are on a complex rotating schedule, may not appear to have consistent patterns of attendance; they are exposed, sometimes for the first time, to a wide array of therapies and therapists.

Often the first step to acquiring internal structure is exposure to a clearly perceived, externally imposed structure. Anxiety is relieved when one is provided with clear, firm expectations for behavior in a new situation.

In a study of debriefing interviews with newly discharged patients, the overwhelming majority expressed a preference for
group leaders who provided an active structure for the group.
¹⁹
They appreciated a therapist who started the group meeting and who provided crystal-clear direction for the procedure of the group. They preferred leaders who actively invited members to participate, who focused the group’s attention on work, who assured equal distribution of time, who reminded the group of its basic group task and direction. The research literature demonstrates that such leaders obtain superior clinical results.
²⁰

Group leaders can provide structure for the group in many ways: by orienting members at the start of each group; by providing a written description of the group in advance of the meeting, by setting clear spatial and temporal boundaries; by using a lucid, confident personal style; by following a consistent and coherent group procedure.

Spatial and Temporal Boundaries.
The ideal physical arrangement for an inpatient therapy group, as for any type of group, is
a circle of members meeting in an appropriately sized room with a closed door.
Sounds simple, yet the physical plan of many wards makes these basic requirements difficult to meet. Some units, for example, have only one group room and yet must schedule two groups to meet at the same time. In this case, one group may have to meet in a very large, busy general activity room or in an open hallway without clear spatial demarcation. I believe that the lack of clear spatial boundaries vitiates intimacy and cohesiveness and compromises the work of the group; it is far preferable to find some closed space, even if it means meeting off the ward.

Structure is also provided by
temporal stability
. The ideal meeting begins with all members present and punctual, and runs with no interruptions until its conclusion. It is difficult to approximate these conditions in an inpatient setting for several reasons: disorganized patients arrive late because they forget the time and place of the meeting; members are called out for some medical or therapy appointment; members with a limited attention span may ask to leave early; heavily medicated members fall asleep during a session and interrupt the group flow; agitated or panicked patients may bolt from the group.

Therapists must intervene in every way possible to provide maximum stability. They should urge the unit administration to declare the group time inviolable so that group members cannot be called out of the group for
any
reason (not because the group is the most important therapy on the unit, but because these disruptions undermine it, and group therapy, by its nature, has little logistical flexibility). They may ask the staff members to remind disorganized patients about the group meeting and escort them into the room. It should be the ward staff’s responsibility, not the group leaders’ alone, to ensure that patients attend. And, of course, the group therapists should always model promptness.

The problem of bolters—members who run out of a group meeting—can be approached in several ways. First, patients are made more anxious if they perceive that they will not be permitted to leave the room. Therefore, it is best simply to express the hope that they can stay the whole meeting. If they cannot, suggest that they return the next day, when they feel more settled. A patient who attempts to leave the room in midsession cannot, of course, be physically blocked, but there are other options. You may reframe the situation in a way that provides a rationale for putting up with the discomfort of staying: for example, in the case of a person who has stated that he or she often flees from uncomfortable situations and is resolved to change that pattern, you might remind him or her of that resolution. You may comment: “Eleanor, it’s clear that you’re feeling very uncomfortable now. I know you want to leave the room, but I remember your saying just the other day that you’ve always isolated yourself when you felt bad and that you want to try to find ways to reach out to others. I wonder if this might not be a good time to work on that by simply trying extra hard to stay in the meeting today?” You may decrease her anxiety by suggesting that she simply be an observer for the rest of the session, or you may suggest that she change her seat to a place that feels more comfortable to her—perhaps next to you.

Groups led for higher-level patients may be made more stable by a policy that prohibits latecomers from entering the group session. This policy, of course, is only effective with an optional group. It may present problems for therapists who feel uncomfortable with being strict gatekeepers; it runs against the grain of traditional clinical training to refuse admission to clients who want therapy. Of course, this policy creates resentment in clients who arrive at a meeting only a few minutes late, but it also conveys to them that you value the group time and work and that you want to get the maximum amount of uninterrupted work each session. The group may employ a five-minute window for late arrivals with the door open, but once the door is closed, the meeting should not be interrupted. Debriefing interviews with recently discharged patients invariably reveal that they resent interruptions and approve of all the therapists’ efforts to ensure stability.
²¹
Latecomers who are denied entrance to the group may sulk for an hour or two but generally will be punctual the following day.

Therapist Style.
The therapist also greatly contributes to the sense of structure through personal style and presence.† Confused or frightened patients are reassured by therapists who are firm, explicit, and decisive, yet who, at the same time, share with patients the reasons for their actions. Many long-term outpatient group therapists allow events to run their course and then encourage the examination and integration of the event. Inpatient groups, however, are disrupted repeatedly by major events. Members are often too stressed and vulnerable to deal effectively with such events and are reassured if therapists act decisively and firmly. If, for example, a manic patient veers out of control and monopolizes the group’s time, it is best to intervene and prevent the patient from obstructing the group work in that session. You may, for example, tell the patient that it is time to be quiet and to work on listening to others, or, if the patient is unable to exercise any control, you may escort him or her from the room. Generally, it is excellent modeling for therapists to talk about their ambivalent feelings in such a situation. They may, for example, share both their conviction that they have made the proper move for the welfare of the entire group and their great discomfort at assuming an authoritarian pose.

At other times, the group may engage in long discussions that the inpatient therapist realizes are not effective and do not constitute effective work. Again, the therapist has options, including waiting and then analyzing the resistance. However, in inpatient groups it is far more efficient to be direct—for example, to interrupt the group with some explicit message such as, “I have a sense that this topic is of much interest to several of the people in the room, but it seems to me that you could easily have this discussion outside the group. I want to suggest that there might be a more valuable way to use the group time. Groups are much more helpful if we help members learn more about how they relate and communicate with others, and I think it would be better if we could get back to . . . ”—here you would supply some clear alternative.