The Theory and Practice of Group Psychotherapy (97 page)

Group Session Protocol.
One of the most potent ways of providing structure is to build into each session a
consistent, explicit sequence
. This is a radical departure from traditional outpatient group therapy technique, but in specialized groups it makes for the most efficient use of a limited number of sessions, as we shall see later when we examine cognitive-behavioral therapy groups. In the inpatient group, a structured protocol for each session has the advantage not only of efficiency but also of ameliorating anxiety and confusion in severely ill patients. I recommend that rapid-turnover inpatient groups take the following form.

1.
The first few minutes.
This is when the therapist provides explicit structure for the group and prepares the group members for therapy. (Shortly, I will describe a model group in which I give a verbatim example of a preparatory statement.)

2.
Definition of the task.
The therapist attempts in this phase to determine the most profitable direction for the group to take in a particular session. Do not make the error of plunging in great depth into the first issue raised by a member, for, in so doing, you may miss other potentially productive agendas. You may determine the task in a number of ways. You may, for example, simply listen to get a feel of the urgent issues present that day, or you may provide some structured exercise that will permit you to ascertain the most valuable direction for the group to take that day (I will give a description of this technique later).†

3.
Filling the task.
Once you have a broad view of the potentially fertile issues for a session, you attempt, in the main body of the meeting, to address these issues, involving as many members as possible in the group session.

4.
The final few minutes.
The last few minutes is the summing-up period. You indicate that the work phase is over, and you devote the remaining time to review and analysis of the meeting. This is the self-reflective loop of the here-and-now, in which you attempt to clarify, in the most lucid possible language, the interaction that occurred in the session. You may also wish to do some final mopping up: you may inquire about any jagged edges or ruffled feelings that members may take out of the session or ask the members, both the active and the silent ones, about their experience and evaluation of the meeting.

Disadvantages of Structure
. Several times in this text, I have remonstrated against excessive structure. For example, in discussing norm setting, I urged that the therapist strive to make the group as autonomous as possible and noted that an effective group takes maximum responsibility for its own functioning. I have also suggested that an excessively active therapist who structures the group tightly will create a dependent group; surely if the leader does everything for the members, they will do too little for themselves. As noted in chapter 14, empirical research demonstrates that leaders who provide excessive structure may be positively evaluated by their members, but their groups fail to have positive outcomes. Again,
leader behavior that is structuring in nature
(total verbal activity and amount of managerial behavior)
is related in curvilinear fashion to positive outcome
(both at the end of the group and at the six-month follow-up).
²²
In other words, the rule of the golden mean prevails:
too much or too little leader structuring is detrimental to growth.

Thus, we face a dilemma. In many brief, specialized groups, we must provide structure; but if we provide too much, our group members will not learn to use their own resources. This is a major problem for the inpatient group therapist who must, for all the reasons I have described, structure the group and yet avoid infantilizing its members.

There is a way out of this dilemma—a way so important that it constitutes a fundamental principle of therapy technique in many specialized groups.
The leader must structure the group so as to encourage each member’s autonomous functioning.
If this principle seems paradoxical wait! The following model of an inpatient group will clarify it.

The Higher-Level Group: A Working Model

In this section I describe in some detail a format for the higher-level functioning inpatient group. Keep in mind that my intention here, as throughout this chapter, is not to provide a blueprint but to illustrate an approach to the modification of group therapy technique. My hope, thus, is not that you will attempt to apply this model faithfully to your clinical situation but that it will serve
to illustrate the general strategy of modification and will assist you in designing an effective model for the specific clinical situations you face.
²³

I suggest that an optional group be held for higher-level clients,
^ah
meeting three to five times a week for approximately seventy-five minutes. I have experimented with a variety of models over the years; the model I describe here is the most effective one I have found, and I have used it for several hundred inpatient group therapy sessions. This is the basic protocol of the meeting:

Orientation and Preparation.
The preparation of patients for the therapy group is no less important in inpatient than in outpatient group therapy. The time frame, of course, is radically different. Instead of spending twenty to thirty minutes preparing an individual for group therapy during an individual session, the inpatient group therapist must accomplish such preparation in the first few minutes of the inpatient group session. I suggest that the leader begin every meeting with a simple and brief introductory statement that includes a description of the ground rules (time and duration of meeting, rules about punctuality), a clear exposition of the purpose of the group, and an outline of the basic procedure of the group, including the sequence of the meeting. The following is a typical preparatory statement:

I’m Irv Yalom and this is Mary Clark. We’ll co-lead this afternoon therapy group, which meets daily for one hour and fifteen minutes beginning at two o’clock. The purpose of this group is to help members learn more about the way they communicate and relate to others. People come into the hospital with many different kinds of important problems, but one thing that most individuals have in common here is some unhappiness about the way some of their important relationships are going.

There are, of course, many other urgent problems that people have, but those are best worked on in some of your other forms of therapy. What this kind of group does best of all is to help people understand more about their relationships with others. One of the ways we can work best is to focus on the relationships that exist between the people in this room. The better you learn to communicate with each of the people here, the better it will become with people in your outside life. Other groups on our unit may emphasize other approaches.

It’s important to know that observers are present almost every day to watch the group through this one-way mirror. [Here, point toward the mirror and also toward the microphone if appropriate, in an attempt to orient the patient as clearly as possible to the spatial surroundings.] The observers are professional mental health workers, often medical or nursing students, or other members of the ward staff.

We begin our meetings by going around the group and checking with each person and asking each to say something about the kinds of problems they’re having in their lives that they’d like to try to work on in the group. That should take fifteen to thirty minutes. It is very hard to come up with an agenda during your first meetings. But don’t sweat it. We will help you with it. That’s our job. After that, we then try to work on as many of these problems as possible. In the last fifteen minutes of the group, the observers will come into the room and share their observations with us. Then, in the last few minutes, we check in with everyone here about how they size up the meeting and about the leftover feelings that should be looked at before the group ends. We don’t always get to each agenda fully each meeting, but we will do our best. Hopefully we can pick it up at the next meeting and you may find also that you can work on it between sessions.

Note the basic components of this preparation: (1) a description of the ground rules; (2) a statement of the purpose and goals of the group; (3) a description of the procedure of the group (including the precise structure of the meeting). Some inpatient therapists suggest that this preparation can be partly communicated to patients outside of the group and should be even more detailed and explicit by, for example, including a discussion of blind spots, supportive and constructive feedback (providing illustrative examples), and the concept of the social microcosm.
²⁴

Personal Agenda Setting.
The second phase of the group is the elaboration of the task. The overriding task of the group (from which the various goals of the group emanate) is to help each member explore and improve his or her interpersonal relationships. An efficient method of task definition is a structured exercise that asks each member to formulate a brief personal agenda for the meeting. The agenda must be realistic and doable in the group that day. It must focus on interpersonal issues and, if possible, on issues that in some way relate to one or more members in the group.

Formulating an appropriate agenda is a complex task. Patients need considerable assistance from the therapist, especially in their first couple of meetings. Neophyte therapists may also find this challenging at first. Each patient is, in effect, asked to make a personal statement that involves three components: (1) an acknowledgment of the wish to change (2) in some interpersonal domain (3) that has some here-and-now manifestation. Think about this as an evolution from the general to the specific, the impersonal to the personal, and the personal to the interpersonal. “I feel unhappy” evolves into “I feel unhappy because I am isolated,” which evolves into “I want to be better connected,” which evolves into “. . . with another member of the group.” Notwithstanding the many ways patients can begin their exposition, there are no more than eight to ten basic agendas that express the vast majority of patient concerns: wanting to be less isolated, more assertive, a better communicator, less bottled up, closer with others, more effective in dealing with anger, less mistrustful, or better known to others, or wanting to receive specific feedback about a characteristic or aspect of behavior. Having these examples in mind may make it easier for therapists to help patients create a workable focus.

Patients have relatively little difficulty with the first two aspects of the agenda but require considerable help from the therapist in the third—that is, framing the agenda in the here-and-now. The third part, however, is less complex than it seems, and the therapist may move any agenda into the here-and-now by mastering only a few basic guidelines.

Consider the following common agenda: “I want to learn to communicate better with others.” The patient has already accomplished the first two components of the agenda: (1) he or she has expressed a desire for change (2) in an interpersonal area. All that remains is to move the agenda into the here-and-now, a step that the therapist can easily facilitate with a comment such as: “Please look around the room. With whom in the group do you communicate well? With whom would you like to improve your communication?”

Another common agenda is the statement, “I’d like to learn to get closer to people.” The therapist’s procedure is the same: thrust it into the here-and-now by asking, “Who in the group do you feel close to? With whom would you like to feel closer?” Another common agenda is: “I want to be able to express my needs and get them met. I keep my needs and pain hidden inside and keep trying to please everybody.” The therapist can shift that into the here-and-now by asking: “Would you be willing to try to let us know today what you need?” or “What kind of pain do you have? What would you like from us?”

Nota bene
, the agenda is generally
not
the reason the patient is in the hospital. But, often unbeknownst to the patient, the agenda may be an underlying or contributory reason. The patient may have been hospitalized because of substance abuse, depression, or a suicide attempt. Underlying such behaviors or events, however, there are almost invariably important tensions or disruptions in interpersonal relationships.

Note also that the therapist strives for agendas that are gentle, positive, and nonconfrontational. In the examples just cited of agendas dealing with communication or closeness, I made sure of inquiring first about the positive end of the scale.

Many patients offer an agenda that directly addresses anger: for example, “I want to be able to express my rage. The doctors say I turn my anger inward and that causes me to be depressed.” This agenda must be handled with care. You do
not
want patients to express anger at one another, and you must reshape that agenda into a more constructive form.

I have found it helpful to approach the patient in the following manner: “I believe that anger is often a serious problem because people let it build up to high levels and then are unable to express it. The release of so much anger would feel like a volcano exploding. It’s frightening both to you and to others. It’s much more useful in the group to work with
young anger
, before it turns into red anger. I’d like to suggest to you that today you focus on young anger—for example, impatience, frustration, or very minor feelings of annoyance. Would you be willing to express in the group any minor flickerings of impatience or annoyance when they first occur—for example, irritation at the way I lead the group today?”