The Theory and Practice of Group Psychotherapy (105 page)

The history of group therapy has been too thoroughly described in other texts to warrant repetition here.
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A rapid sweep will reveal the basic trends. Joseph Hersey Pratt, a Boston internist, is generally acknowledged to be the father of contemporary group therapy. Pratt treated many patients with advanced tuberculosis, and, recognizing the relationship between psychological health and the physical course of tuberculosis, Pratt undertook to treat the person rather than the disease. In 1905, he designed a treatment regimen that included home visits, diary keeping by patients, and weekly meetings of a tuberculosis class of approximately twenty-five patients. At these classes, the diaries were inspected, weight gains were recorded publicly on a blackboard, and testimonials were given by successful patients. A degree of cohesiveness and mutual support developed that appeared helpful in combating the depression and isolation so common among patients with tuberculosis.

During the 1920s and 1930s, several psychiatrists experimented with group methods. In Europe, Adler used group methods because of his awareness of the social nature of human problems and his desire to provide psychotherapeutic help to the working classes.
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Lazell, in 1921, met with groups of patients with schizophrenia in St. Elizabeths Hospital in Washington, D.C., and delivered lectures on schizophrenia.
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Marsh, a few years later, used groups for a wide range of clinical problems, including psychosis, psychoneurosis, psychophysiological disorders, and stammering.
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He employed a variety of techniques, including didactic methods such as lectures and homework assignments as well as exercises designed to promote considerable interaction; for example, members were asked to treat one another; or all were asked to discuss such topics as one’s earliest memory, ingredients of one’s inferiority complex, night dreams, and daydreams. In the 1930s, Wender used analytic group methods with hospitalized nonpsychotic patients, and Burrows and Schilder applied these techniques to the treatment of psychoneurotic outpatients. Slavson, who worked with groups of disturbed children and young adolescents, exerted considerable influence in the field through his teaching and writing at a time when group therapy was not yet considered an effective therapeutic approach. Moreno, who first used the term group therapy, employed group methods before 1920 but has been primarily identified with psychodrama, which he introduced into America in 1925.
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These tentative beginnings in the use of group therapy were vastly accelerated by the Second World War, when the enormous numbers of military psychiatric patients and the scarcity of trained psychotherapists made individual therapy impractical and catalyzed the search for more economic modes of treatment.

During the 1950s, the main thrust of group therapy was directed toward using groups in different clinical settings and with different types of clinical problems. Theoreticians—Freudian, Sullivanian, Horneyan, Rogerian—explored the application of their conceptual framework to group therapy theory and practice.

The T-group and the therapy group thus arose from different disciplines; and for many years, the two disciplines, each generating its own body of theory and technique, continued as two parallel streams of knowledge, even though a few leaders straddled both fields and, in different settings, led both T-groups and therapy groups. The T-group maintained a deep commitment to research and continued to identify with the fields of social psychology, education, and organizational development.

Therapy Group and Encounter Group: First Interchanges

In the 1960s, there was some constructive interchange between the group therapy and the sensitivity training fields. Many mental health professionals participated in some form of encounter group during their training and subsequently led encounter groups or applied encounter techniques to their psychotherapeutic endeavors. Clinical researchers learned a great deal from the T-group research methods; T-groups were commonly used in the training of group therapists
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and in the treatment program of chronically hospitalized patients.
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Some clinicians referred their individual therapy patients to a T-group for opening-up (just as, later, in the 1980s, some clinicians referred their patients to large group awareness training programs, such as est and Lifespring).
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But later, as the T-group evolved into the flamboyant encounter group that claimed to offer “group therapy for normals” and claimed that “patienthood is ubiquitous,” an acrimonious relationship developed between the two fields. Disagreements arose about territorial issues and the true differences in the goals of encounter and therapy groups.

Encounter group leaders grew even more expansive and insisted that their group participants had a therapeutic experience and that in reality there was no difference between personal growth and psychotherapy (in the language of the time, between “mind expansion” and “head shrinking”). Furthermore, it became evident that there was much overlap: there was much similarity between those seeking psychotherapy and those seeking encounter experiences. Thus, many encounter group leaders concluded that they were, indeed, practicing psychotherapy—a superior, more efficient type of psychotherapy—and advertised their services accordingly.

The traditional mental health field was alarmed. Not only were psychotherapists threatened by the encroachment on their territory, but they also considered encounter groups reckless and potentially harmful to participants. They expressed concerns about the lack of responsibility of the encounter group leaders, their lack of clinical training, and their unethical advertising that suggested that months, even years of therapy could be condensed into a single intensive weekend. Polarization increased, and soon mental health professionals in many areas launched campaigns urging their local governments to pass legislation to regulate encounter group practice, to keep it out of schools, and to hold leaders legally responsible for untoward effects.

In part the vigorous response of the mental health profession was an irrational reaction, but it was also appropriate to certain excesses in some factions of the encounter field. These excesses issued from a crash-program mentality, successful in such ventures as space exploration and industrialization, but a reductio ad absurdum in human relations ventures. If something is good, more must be better. If self-disclosure is good in groups, then total, immediate, indiscriminate self-disclosure in the nude must be better. If involvement is good, then prolonged, continuous, marathon involvement must be better. If expression of feeling is good, then hitting, touching, feeling, kissing, and fornicating must be better. If a group experience is good, then it is good for everyone—in all stages of the life cycle, in all life situations. These excesses were often offensive to the public taste and could, as research has indicated, be dangerous to some participants.

Since that period of acrimony and polarization decades ago, the established fields of therapy and the usurping encounter group field are no longer the same. Although the encounter group movement with all its excesses, grandiosity, and extravagant claims has come and gone,
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it has nonetheless influenced contemporary group therapy. The inventiveness, research attitude and expertise, sophisticated leadership, and training technology of the pioneer encounter group leaders have left an indelible mark on our field.

Chapter 17

TRAINING THE GROUP THERAPIST

G
roup therapy is a curious plant in the garden of psychotherapy. It is hardy: the best available research has established that group therapy is effective, as robust as individual therapy.
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Yet it needs constant tending; its perennial fate is to be periodically choked by the same old weeds: “superficial,” “dangerous,” “second-rate—to be used only when individual therapy is unavailable or unaffordable.”

Clients and many mental health professionals continue to underrate and to fear group therapy, and unfortunately those very same attitudes adversely influence group therapy training programs. Group therapy has not often been accorded academic prestige. The same situation prevails in clinics and hospital administration hierarchies: rarely does the individual who is most invested in group therapy enjoy a position of professional authority.

Why? Perhaps because group therapy cannot cleanse itself of the anti-intellectual taint of the encounter group movement, or because of the intrinsic methodological obstacles to rigorous, truly meaningful research. Perhaps it is because we therapists share the client’s wish to be the special and singular object of attention that individual therapy promises. Perhaps many of us prefer to avoid the anxiety inherent in role of the group leader—greater public exposure of oneself as a therapist, less sense of control, fear of being overwhelmed by the group, more clinical material to synthesize. Perhaps it is because groups evoke for us unpleasant personal memories of earlier peer group experiences.
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Attempts to renew interest in group therapy have always worked—but only for brief periods. An initial wave of renewed enthusiasm for group therapy is followed by neglect, and soon all the old weeds crowd in once again. The moment demands a whole new generation of well-trained gardeners, and it behooves us to pay careful attention to the education of beginning group therapists and to our own continuing professional development.

In this chapter, I present my views about group therapy training, not only in specific recommendations for a training curriculum but also in the form of general considerations concerning an underlying philosophy of training. The approach to therapy described in this book is based on both clinical experience and an appraisal of the best available research evidence. Similarly, in the educational process, a clinical and a research orientation are closely interrelated: the acquisition of an inquiring attitude to one’s own work and to the work of others is necessary in the development of the mature therapist.

Many training programs for mental health professionals are based on the individual therapy model and either do not provide group therapy training or offer it as an elective part of the program. Despite clear acknowledgment that the practice of group therapy will continue to grow, recent surveys show that most academic training programs fall short in the actual provision of group training. In fact, it is not unusual for students to be given excellent intensive individual therapy supervision and then, early in their program, to be asked to lead therapy groups with no specialized guidance whatsoever. Many program directors apparently expect, naively, that students will be able somehow to translate their individual therapy training into group therapy skills without meaningful group experiential or clinical exposure. This not only provides inadequate leadership but causes students to devalue the group therapy enterprise.
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It is essential that mental health training programs appreciate the need for rigorous, well-organized group training programs and offer programs that match the needs of trainees. Both the American Group Psychotherapy Association (AGPA) and the American Counseling Association have established training standards for group therapy certification that can serve as a template for training. For example, the AGPA’s National Registry of Certified Group Psychotherapists requires a minimum of 12 hours of didactic training, 300 hours of group therapy leadership, and 75 hours of group therapy supervision with a group therapist who has met the standards of certification.
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The crisis in medical economics and the growth of managed health care force us to recognize that one-to-one psychotherapy cannot possibly suffice to meet the pressing mental health needs of the public. Managed care leaders also forecast rapid growth in the use of group therapy, particularly in structured and time-limited groups.
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It is abundantly clear that, as time passes, we will rely on group approaches ever more heavily. I believe that any psychotherapy training program that does not acknowledge this and does not expect students to become as fully proficient in group as in individual therapy is failing to meet its responsibilities to the field.

Every program has its own unique needs and resources. While I cannot hope to offer a blueprint for a universal training program, I shall, in the following section, discuss the four major components that I consider essential to a comprehensive training program beyond the didactic: (1) observation of experienced group therapists at work, (2) close clinical supervision of students’ maiden groups, (3) a personal group experience, and (4) personal psychotherapeutic work.

OBSERVATION OF EXPERIENCED CLINICIANS

Student therapists derive enormous benefit from watching an experienced group practitioner at work.† It is exceedingly uncommon for students to observe a senior clinician doing individual therapy. The more public nature of group therapy makes it often the only form of psychotherapy that trainees will ever be able to observe directly. At first, experienced clinicians may feel considerable discomfort while being observed; but once they have taken the plunge, the process becomes comfortable as well as rewarding for all parties: students, therapists, and group members.

The format of observation depends, of course, on the physical facilities. I prefer having my students observe my group work through a one-way mirror, but if students’ schedules do not permit them to be present for a ninety-minute group and a postgroup discussion, I videotape the meeting and replay segments in a shorter seminar with the students. This procedure requires a greater time investment for the therapist and greater discomfort for the members because of the presence of the camera. If there are only one or two observers, they may sit in the group room without unduly distracting the members, but I strongly recommend that they sit silently outside the group circle and decline to respond to questions that group members may pose to them.